Evaluation of the Reliability and Reproducibility of the Roussouly Classification for Lumbar Lordosis Types / Avaliação da confiabilidade e reprodutibilidade da classificação de Roussouly para os tipos de lordose lombar

Abstract Objective The present study aims to determine the intra- and inter-rater reliability and reproducibility of the Roussouly classification for lumbar lordosis types. Methods A database of 104 panoramic, lateral radiographs of the spine of male individuals aged between 18 and 40 years old was used. Six examiners with different expertise levels measured spinopelvic angles and classified lordosis types according to the Roussouly classification using the Surgimap software (Nemaris Inc., New York, NY, USA). After a 1-month interval, the measurements were repeated, and the intra- and inter-rater agreement were calculated using the Fleiss Kappa test. Results The study revealed positive evidence regarding the reproducibility of the Roussouly classification, with reasonable to virtually perfect (0.307-0.827) intra-rater agreement, and moderate (0.43) to reasonable (0.369) inter-rater agreement according to the Fleiss kappa test. The most experienced examiners showed greater inter-rater agreement, ranging from substantial (0.619) to moderate (0.439). Conclusion The Roussouly classification demonstrated good reliability and reproducibility, with intra- and inter-rater agreements at least reasonable, and reaching substantial to virtually perfect levels in some situations. Evaluators with highest expertise levels showed greater intra and inter-rater agreement.

Resumo Objetivo Determinar a confiabilidade e reprodutibilidade intra- e interavaliadores da classificação dos tipos de lordose lombar de Roussouly. Métodos Foram utilizadas 104 radiografias panorâmicas da coluna vertebral em incidência de perfil, de banco de dados, de indivíduos do sexo masculino com idade entre 18 e 40 anos. Utilizando o software Surgimap (Nemaris Inc., Nova York, NY, EUA), seis examinadores com diferentes níveis de experiência aferiram os ângulos espinopélvicos e classificaram o tipo de lordose de acordo com a classificação de Roussouly. Após um intervalo de 1 mês, as mensurações foram realizadas novamente, sendo calculadas as concordâncias intra- e interavaliadores através do teste Kappa de Fleiss. Resultados O estudo demonstrou evidências positivas em relação à reprodutibilidade da classificação de Roussouly, com teste Kappa de Fleiss para concordância intraavaliador entre razoável à quase perfeita (0,307-0,827), e interavaliador entre moderada (0,43) e razoável (0,369). Os examinadores mais experientes apresentaram maior concordância interavaliador, variando entre substancial (0,619) e moderada (0,439). Conclusão A classificação de Roussouly, demonstrou boa confiabilidade e reprodutibilidade, tendo em vista que a concordância intra- e interavaliadores foi considerada no mínimo razoável, podendo atingir os níveis de substanciais à quase perfeitos em algumas situações. Os avaliadores com maior nível de experiência apresentaram maior concordância intra- e interavaliadores.

Subthalamic Stimulation for Camptocormia in Parkinson's Disease: Association of Volume of Tissue Activated and Structural Connectivity with Clinical Effectiveness.

BACKGROUND: Deep brain stimulation of the subthalamic nucleus (STN-DBS) has been reported to be effective for camptocormia in Parkinson's disease (PD). However, the association between clinical effectiveness and the stimulated volumes or structural connectivity remains unexplored. OBJECTIVE: To investigate the effectiveness of STN-DBS for treating camptocormia in PD and its association with volumes of tissue activated (VTA) and structural connectivity. METHODS: We reviewed video recordings of patients who had undergone STN-DBS. The total and upper camptocormia (TCC and UCC) angles were measured to quantify changes in camptocormia. The Movement Disorders Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) was used to assess motor symptoms. Pre- and postoperative brain images were collected for modeling volume of VTA and structural connectivity using Lead-DBS software. RESULTS: Participants included 36 patients with PD (8 with TCC-camptocormia and 2 with UCC-camptocormia) treated with bilateral STN-DBS. After surgery, patients showed a significant improvement in postural alignment at follow-up (mean follow-up duration: 6.0±2.2 months). In the entire sample, higher structural connectivity to the right supplementary motor area (SMA) and right lateral premotor cortex along the dorsal plane (PMd) was associated with larger postsurgical improvements in axial signs and TCC angles after stimulation was turned on. In patients diagnosed with camptocormia, larger improvement in camptocormia angles after STN-DBS was associated with a larger VTA overlap with STN (R = 0.75, p = 0.032). CONCLUSION: This study suggests that both VTA overlap with STN and structural connectivity to cortical motor regions are associated with the effectiveness of STN-DBS for managing camptocormia in PD.

Impact of Spinopelvic sagittal alignment on the surgical outcomes of dropped head syndrome: a multi-center study.

BACKGROUND: Most of the previous studies about the surgical treatment of dropped head syndrome (DHS) are small case series, and their primary outcome measures were cervical alignment parameters. Therefore, little is known about the associations between pre- and postoperative global sagittal alignment in the whole spine and the clinical outcomes of the surgical treatment of DHS. In this study, we investigated the surgical outcomes of DHS, including correction of cervical and global spinal sagittal alignment. METHODS: This study was a retrospective observational study. Fifteen patients with DHS who had undergone correction surgery were enrolled. Surgical outcomes, including complications and implant failures, were investigated. We assessed cervical alignment parameters as well as spinopelvic global alignment parameters, including pelvic incidence (PI), lumbar lordosis (LL), and C7-sacral sagittal vertical axis (SVA). We examined the changes in these parameters using pre- and posoperative whole spine lateral radiographs. The parameters were compared between the failure and nonfailure groups. RESULTS: Recurrence of sagittal imbalance and horizontal gaze difficulty was observed in 6 cases (40%). In all, 3 cases (20%) exhibited a distal junctional failure and required multiple surgeries with extension of fusion. Of all the radiographic parameters compared between the failure and nonfailure groups, significant differences were only observed in pre and postoperative SVA and PI-LL. CONCLUSIONS: Our results suggest that the global sagittal alignment parameters, including PI-LL and SVA, were different between the patients with failure and non failure, and these parameters might have notable impacts on surgical outcomes. Surgeons should consider PI-LL and SVA while determining the surgical course for patients with DHS.

Peripheral nerve pathology in VAPB-associated amyotrophic lateral sclerosis with dysautonomia in a Chinese family.

Mutations of the vesicle-associated membrane protein-associated protein B (VAPB) gene have been identified in familial amyotrophic lateral sclerosis (ALS) with dysautonomia. Here we report the peripheral nerve pathology in ALS with dysautonomia caused by the p.Pro56Ser mutation of the VAPB gene in a Chinese family. The clinical features in all patients were camptocormia, fasciculation, and weakness in all limbs. Two patients developed symptoms of dysautonomia, including abdominal bloating, orthostatic hypotension, constipation, frequent urination, decreased sweating, and burning feet. Electromyography showed widespread neuropathic damage. The sympathetic skin response was absent in the soles of the feet. Sural nerve biopsy revealed loss of nerve fibers, especially unmyelinated fibers. Electron microscopy revealed regional loss of unmyelinated fibers with numerous collagen pockets. This report indicates that VAPB-associated ALS may be accompanied by multifocal autonomic nerve damage.

Inflammatory Events in Patients with Sagittal Imbalance through Platelet-Associated Inflammation.

AIM: To determine whether platelet-associated inflammation parameters (PAIP) could be useful for evaluating inflammation in sagittal imbalance (SI) by investigating its relationship with pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL) and thoracic kyphosis (TK). MATERIAL AND METHODS: The study included 57 patients (19 males, 38 females) who were diagnosed with SI and 44 healthy control subjects. Spinal sagittal balance was evaluated using digitalized-standing lumbar lateral radiographs of the patients. All parameters including SS, PI, LL and PT were evaluated through from the lateral radiographs. RESULTS: In the analysis, Mean Platelet Volume (MPV) (10.6 ± 0.9; p < 0.0001), Platelet Distribution Width (PDW) (12.7 ± 2.2; p < 0.001) and Platelet Distribution Width (RDW) (41.9 ± 4.4; p < 0.0001) were observed to be much higher in the SI than in the control. The neutrophil-lymphocyte ratio (NLR) was higher in the SI group (p=0.033), and no difference was determined in respect of the platelet-lymphocyte ratio (PLR) (p > 0.05). The PT had a positive correlation with hospital length of stay in SI patients (r=0.655; p=0.008). MPV showed a strong positive correlation with comorbidity (r=0.715; p=0.001). A positive correlation was determined between NLR and PLR (r=0.692; p=0.002), and between MPV and RDW (r=0.788; p=0.001). No correlation was determined between the PAIP and radiological measurements (PI, PT, SS) that were used for SI. CONCLUSION: The results suggest that the neurosurgical approach should cover not only the sagittal parameters and their angles but also PAIP showing inflammatory events originating from platelets.

Can knee flexion contracture affect cervical alignment and neck tension? A prospective self-controlled pilot study.

BACKGROUND CONTEXT: The coordination of the alignment between the lower extremities and cervical spine helps to achieve balance and horizontal gaze during standing and walking. Malalignment in any segment can disturb the global balance, causing compensation in another segment. Knee flexion contracture (KFC) can cause spine inclination with increased C7 tilt or C7 SVA (sagittal vertical axis). Cervical alignment and the posterior muscles are essential for maintaining the horizontal gaze which is closely related to neck tension (NT). PURPOSE: This study aimed to determine whether KFC can affect cervical alignment and its potential effects on the posterior muscles and NT. DESIGN: A prospective pilot study was carried out in preoperative (pre-op) and postoperative (post-op) phases. PATIENT SAMPLE: This study included 22 consecutive patients with KFC and 12 control subjects in our department who agreed to participate from between August 1, 2018 and February 28, 2019 in our department. OUTCOME MEASURES: Visual analog scale (VAS) and neck disability index (NDI) were used. The sagittal alignment parameters and cervical range of motion (ROM) were measured on radiographic images, and included the C0-C2 lordosis (C0-2L), C2-C7 lordosis (C2-7L), C2 SVA, C7 SVA, T1 slope, thoracic kyphosis, lumbar lordosis (LL), pelvic tilt, sacral slope, and knee flexion angle (KA). Surface electromyography-based flexion-relaxation ratio (FRR) and ultrasound-based shear wave elastography (SWE) were performed. METHODS: The control group was matched for age, sex, and body mass index with the KFC group. Patients in the KFC group underwent arthroscopic surgery to correct knee alignment. Comparisons between pre-op and post-op phases were performed using paired sample t tests, comparisons between KFC and control groups were performed using independent samples t tests. The correlation analysis between the parameters was performed using Spearman analysis. Funding for this study was provided by the National Natural Science Foundation of China (60,000 USD), Beijing Municipal Administration of Hospitals Incubating Program (50,000 USD), and Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (20,000 USD). There were no conflicts of interest associated with this study. RESULTS: The average follow-up time for this pilot study was 11.4±1.5 days. Pre-op, the KFC group had higher KA, T1S, C7 SVA, C2 SVA, C0-2L, SWE, VAS, and NDI compared with the control group, but all of these parameters were decreased significantly post-op. The LL, FRR of splenius capitis (FRRsc), and ROM of the KFC group pre-op were lower than the control group, and all of these were increased significantly post-op. There were no differences in pelvic tilt, sacral slope, C2-7 L, or TK between the KFC and control groups, or in FRR of splenius capitis (FRRutr) between pre-op and post-op phases. KA had strong correlations with LL (r=-0.83), which correlated well with C7 SVA (r=-0.75). C7 SVA correlated strongly with C2 SVA (r=0.79), which also correlated strongly with C0-2 L (r=0.76). C0-2 L correlated well with FRRsc (r=-0.65) and SWEsc (r=0.72), and both of them correlated well with VAS (r=-0.54, r=0.71) and NDI (r=-0.57, r=0.76). ROM correlated well with FRRsc (r=0.71), SWEsc (r=-0.74), VAS (r=-0.66), and NDI (r=-0.66). CONCLUSIONS: KFC may cause spine inclination and craniocervical malalignment, leading to NT and ROM reduction. The results of this pilot study may be helpful in guiding further studies concerning KFC and NT.

DEXA sensitivity analysis in patients with adult spinal deformity.

BACKGROUND: Adult spinal deformity (ASD) is a debilitating condition that commonly requires surgical intervention. However, ASD patients may also present with osteoporosis, predisposing them to surgical complications and failure of instrumentation. As a result, proper detection of low bone mineral density (BMD) is critical in order to ensure proper patient care. Typically dual-energy x-ray absorptiometry (DEXA) scans are performed on the hip and spine. Unfortunately, in ASD patients, the latter is often inaccurate PURPOSE: In this study, we consider the value of obtaining a forearm DEXA scan in addition to a hip scan in patients suffering from ASD and osteoporosis in order to accurately detect low BMD. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Patient data between 2016 and 2018 from a single academic medical center was utilized. Two hundred eighty-six patients met the initial search criteria. OUTCOME MEASURES: No outcomes measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included T-scores across various anatomic locations and diagnoses relating to low bone density (ie, osteopenia and osteoporosis). METHODS: This retrospective study examines patients that underwent DEXA studies between 2016 and 2018 and were previously diagnosed with both osteoporosis and adult spinal deformity. For each patient, age, gender, body mass index, and smoking history were noted, as well as whether there was long-term prednisone use. T-scores from both the forearm and hip were recorded and analyzed. Diagnoses from hip DEXA scans were compared with those obtained from forearm scans to identify which region was more sensitive in detecting low BMD. From this data, the frequency of a missed diagnosis, due to reliance on hip or spine T-scores for detection of low BMD, was extrapolated. No external funding source was received in support of this study. RESULTS: Two hundred eighty-six patients matched the initial search criteria. Only 68% had one T-score value. However, 24.8% of patients had data for both the hip and forearm, whereas 7.1% had data for the forearm, hip, and spine. Among the 85 patients with more than one anatomical site of study, the forearm was more sensitive than the hip in its ability to detect osteopenia or osteoporosis 41.2% of the time. A two-tailed t test showed no statistically significant difference between hip T-scores and forearm T-scores. However, for more than 17% of patients, the forearm allowed clinicians to detect osteoporosis or osteopenia in a setting where using only the hip data would have missed such a diagnosis. CONCLUSIONS: Clinicians need to ensure they survey at least two locations when conducting DEXA studies before precluding a diagnosis of osteopenia or osteoporosis. All ASD patients being evaluated for low bone density should receive DEXA scans that survey at least the hip and the forearm. Misdiagnoses can be costly in the setting of ASD. They occur frequently when only a single hip scan is relied upon to assess BMD.

The Importance of C2 Slope, a Singular Marker of Cervical Deformity, Correlates With Patient-reported Outcomes.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: To define a simplified singular measure of cervical deformity (CD), C2 slope (C2S), which correlates with postoperative outcomes. SUMMARY OF BACKGROUND DATA: Sagittal malalignment of the cervical spine, defined by the cervical sagittal vertical axis (cSVA) has been associated with poor outcomes following surgical correction of the deformity. There has been a proliferation of parameters to describe CD. This added complexity can lead to confusion in classifying, treating, and assessing outcomes of CD surgery. METHODS: A prospective database of CD patients was analyzed. Inclusion criteria were cervical kyphosis>10°, cervical scoliosis>10°, cSVA>4 cm, or chin-brow vertical angle >25°. Patients were categorized into two groups and compared based on whether the apex of the deformity was in the cervical (C) or the cervicothoracic (CT) region. Radiographic parameters were correlated to C2S, T1 slope (T1S) and 1-year health-related quality-of-life outcomes as measured by the EuroQol 5 Dimension questionnaire (EQ5D), modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and the Neck Disability Index (NDI). RESULTS: One hundred four CD patients (C = 74, CT = 30; mean age 61 yr, 56% women, 42% revisions) were included. CT patients had higher baseline cSVA and T1S (P < 0.05). C2S correlated with T1 slope minus cervical lordosis (TS-CL) (r = 0.98, P < 0.001) and C0-C2 angle, cSVA, CL, T1S (r = 0.37-0.65, P < 0.001). Correlation of cSVA with C0-C2 was weaker (r = 0.48, P < 0.001). At 1-year postoperatively, higher C2S correlated with worse EQ-5D (r = 0.28, P = 0.02); in CT patients, higher C2S correlated with worse NDI, modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and EQ5D (all r > 0.5, P≤0.05). Using linear regression, moderate disability by EQ5D corresponded to C2S of 20°(r = 0.08). For CT patients, C2S = 17° corresponded to moderate disability by NDI (r = 0.4), and C2S = 20° by EQ5D (r = 0.25). CONCLUSION: C2S correlated with upper-cervical and subaxial alignment. C2S correlated strongly with TS-CL (R = 0.98, P < 0.001) because C2S is a mathematical approximation of TS-CL. C2S is a useful marker of CD, linking the occipitocervical and cervico-thoracic spine. C2S defines the presence of a mismatch between cervical lordosis and thoracolumbar alignment. Worse 1-year postoperative C2 slope correlated with worse health outcomes. LEVEL OF EVIDENCE: 3.

A novel radiographic classification of severe spinal curvatures exceeding 100°: the Omega (Ω), gamma (γ) and alpha (α) deformities.

PURPOSE: For spine curvatures with Cobb angles > 100°, curve classification and characterization become more difficult with conventional radiographs. 3-D computerized axial tomography scans add relevant information to categorize and describe a new classification to aid preoperative assessment in communication and patient evaluation. The purpose of this study is to describe a radiographic classification system of curves exceeding 100°. METHODS: A consecutive series of patients with curves exceeding 100° underwent a full spine radiographic review using conventional radiographs and 3-D CT. A descriptive analysis was performed to categorize curves into 4 main types (1, 2, 3 and 4) and 6 subtypes (1C, 1S, 1CS, 2P, 2D and 2PD) based on the location of the Cobb angle of the major scoliotic and kyphotic deformity as well as the location of the upper/lower end vertebra relative to the apical vertebra. RESULTS: A total of 98 patients met the inclusion criteria. There were 51 males and 47 females with an average age of 17.8 ± 4.5 years. The diagnosis included idiopathic (48); congenital (24); neuromuscular (4); and neurofibromatosis (2). The mean major coronal and sagittal Cobb (kyphosis) were 131.2° ± 23.4° and 154 ± 45.6, respectively. The classification scheme yielded 4 main types (1, 2, 3 and 4) and 6 subtypes under types 1 and 2 (1C, 1S, 1CS, 2P, 2D and 2PD). CONCLUSIONS: Our study describes a novel method of classifying severe spinal curvatures exceeding 100° using erect AP/lateral radiographs and 3-D CT reconstructive images. We hope that the descriptive analysis and classification will expand our understanding of these complex deformities. These slides can be retrieved under Electronic Supplementary Material.

Characteristics and risk factors for proximal junctional kyphosis in adult spinal deformity after correction surgery: a systematic review and meta-analysis.

There are still controversies on characteristics and risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients. The objective of this study is to explore the characteristics and risk factors for PJK in ASD. A systematic online search in databases including PubMed, EMBASE, Web of Science, and the Cochrane Library was performed to identify eligible studies. OR and weight mean difference with 95% CI were used to evaluate characteristics and risk factors. A total of 31 studies were finally included. ASD patients with PJK had larger proximal junctional angle (PJA), thoracic kyphosis (TK), pelvic incidence minus lumbar lordosis (PI-LL), and sagittal alignment. Age, female gender, and low BMD/osteoporosis were demographic risk factors for PJK. Using hooks at upper instrumented vertebra (UIV) and the selection of UIV above T8 could reduce the occurrence of PJK, while pelvic fixation was significantly associated with increased occurrence of PJK. Preoperative LL, preoperative pelvic tilt (PT), preoperative LL-TK, preoperative PI-LL, preoperative sagittal vertical axis (SVA), preoperative global spine alignment (GSA), postoperative PJA, change in PJA, postoperative TK, change in LL, change in SVA, and postoperative GSA were identified as risk factors for PJK. In conclusion, PJK patients had larger PJA, larger TK, smaller PI-LL, and larger sagittal alignment. Older female ASD patients with low BMD/osteoporosis are more likely to suffer from PJK. We recommend the following: (1) using hooks at UIV; (2) UIV should be chosen above T8, and pelvic fixation should be avoided if possible; (3) ideal correction of sagittal alignment should be performed to prevent the occurrence of PJK.

Surgical risk stratification based on preoperative risk factors in adult spinal deformity.

BACKGROUND CONTEXT: Corrective surgery for adult spinal deformity (ASD) improves health-related quality of life but has high complication rates. Predicting a patient's risk of perioperative and late postoperative complications is difficult, although several potential risk factors have been reported. PURPOSE: To establish an accurate, ASD-specific model for predicting the risk of postoperative complications, based on baseline demographic, radiographic, and surgical invasiveness data in a retrospective case series. STUDY DESIGN/SETTING: Multicentered retrospective review and the surgical risk stratification. PATIENT SAMPLE: One hundred fifty-one surgically treated ASD at our hospital for risk analysis and model building and 89 surgically treated ASD at 2 other our hospitals for model validation. OUTCOME MEASURES: HRQoL measures and surgical complications. METHODS: We analyzed demographic and medical data, including complications, for 151 adults with ASD who underwent surgery at our hospital and were followed for at least 2years. Each surgical risk factor identified by univariate analyses was assigned a value based on its odds ratio, and the values of all risk factors were summed to obtain a surgical risk score (range 0-20). We stratified risk scores into grades (A-D) and analyzed their correlations with complications. We validated the model using data from 89 patients who underwent ASD surgery at two other hospitals. RESULTS: Complications developed in 48% of the patients in the model-building cohort. Univariate analyses identified 10 demographic, physical, and surgical risk indicators, with odds ratios from 5.4 to 1.4, for complications. Our risk-grading system showed good calibration and discrimination in the validation cohort. The complication rate increased with and correlated well with the risk grade using receiver operating characteristic curves. CONCLUSIONS: This simple, ASD-specific model uses readily accessible indicators to predict a patient's risk of perioperative and postoperative complications and can help surgeons adjust treatment strategies for best outcomes in high-risk patients.

Mutant MAPK7-Induced Idiopathic Scoliosis is Linked to Impaired Osteogenesis.

BACKGROUND/AIMS: Three rare MAPK7 variants that predispose individuals to adolescent idiopathic scoliosis have previously been identified. However, the mechanism underlying the effects of the mutations remain unknown. METHODS: Human mesenchymal stem cells (hMSCs) were isolated from both patients and healthy volunteer donors, and MAPK7 expression was detected by western blotting and real-time quantitative PCR (RT-qPCR). Zebrafish embryos were injected with mapk7 morpholinos or co-injected with morpholinos and wild-type (WT) MAPK7 messenger RNA (mRNA) at the one-cell stage, followed by calcein staining to evaluate bone formation. hMSCs were transfected with MAPK7 small interfering RNAs and osteogenesis was induced for 14 days. Alizarin red staining was performed and osteoblast markers were detected by western blotting and RT-qPCR. Since RPS6KA3 is a downstream target of MAPK7 and plays an important role in the osteogenesis, zebrafish embryos were then injected with rps6ka3 morpholinos, or co-injected with rps6ka3 or mapk7 morpholinos and WT RPS6KA3 mRNA at the one-cell stage. RESULTS: MAPK7 expression in the patient group was much lower than in the control group. Morpholino-induced mapk7 knockdown in zebrafish embryos led to body curvature, which was significantly reversed by WT MAPK7 mRNA. Calcein staining revealed that mapk7-knockdown delayed the ossification of the vertebrae. MAPK7 silencing in hMSCs impaired osteogenesis and downregulated osteoblast marker expression. Morpholino-induced rps6ka3-knockdown in zebrafish embryos led to body curvature, which was reversed by WT RPS6KA3 mRNA. Interestingly, RPS6KA3 mRNA also partially reversed the phenotype induced by mapk7 morpholinos. CONCLUSION: Impaired osteogenesis is linked to mutant MAPK7-induced idiopathic scoliosis , and RPS6KA3 may play an important role in this process.

Radiologic features of dropped head syndrome in the overall sagittal alignment of the spine.

PURPOSE: Dropped head syndrome (DHS) is a rare clinical entity which is defined as a chin-on-chest deformity in the standing or sitting position, resulting from sagittal imbalance of the cervical region. The purpose of the present study was to clarify the radiologic features of DHS in the overall sagittal alignment of the spine. We also investigated the changes in sagittal alignment after correction surgery for DHS. METHODS: Twenty DHS patients [1 male and 19 female, with an average age of 78.9 years (range 59-88)] with a main complaint of horizontal gaze disorder were enrolled in this study. Spino-pelvic lateral radiographs in the free-standing clavicle position were taken of all patients. Parameters such as sagittal vertical axis (SVA), C2-7 angle, clivo-axial angle (CAA), C2-7 SVA, T1 slope, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured, and the radiologic features of DHS in the overall sagittal alignment of the spino-pelvis were investigated. Eight patients underwent correction surgery, and the parameter changes between pre- and post-operative radiographs were also examined. RESULTS: DHS appeared to have two distinct types: SVA+ and SVA-. Seven of 20 cases were SVA+, and 13 were SVA-. The radiologic parameters in which we found statistically significant differences between the groups were: 80.2 ± 68 and -44.5 ± 40 (SVA), 42.1 ± 16.8 and 18.4 ± 11.4 (T1 slope), and 21.1 ± 19.2 and 44.2 ± 19.8 (LL) in SVA+ and SVA-, respectively. After surgical intervention, T1 slope and LL appeared to approach normal in the SVA- group, because compensation at downward spine was no longer necessary. In SVA+ group, although the patients gained horizontal gaze after surgery, abnormality of the sagittal alignment in the whole spine remained, because compensation in the thoracic and lumbar spine was still insufficient. CONCLUSIONS: The present study has indicated that radiologic feature of DHS in the sagittal alignment of the overall spino-pelvis can be categorized into two types: SVA+ and SVA-.

The Risk of Curve Progression and Surgery in African Americans With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective clinical cohort study. OBJECTIVE: To determine if certain risk factors (age, curve magnitude, skeletal maturity, gender, and curve pattern) traditionally associated with curve progression and surgical intervention in the general population apply equally to African Americans. SUMMARY OF BACKGROUND DATA: Currently, information is limited on the role that a patient's race plays in the risk of curve progression of adolescent idiopathic scoliosis (AIS), and existing studies have conflicting results. METHODS: Retrospective search of records identified patients who were African American, had been diagnosed with AIS, had a major curve Cobb angle of 10 degrees or more, and had at least two clinical visits with spinal radiographs at least 90 days apart to determine the risk factors for surgical treatment, and 2 years apart to determine the risk factors for curve progression. Patients with a medical condition likely to cause scoliosis were excluded. RESULTS: Of 738 African American patients with AIS, 223 were assessed for surgical risk factors, and 72 were assessed for curve progression risk factors. Fifty-six (29.17%) had progression of the major coronal curve, and 38 (17.04%) underwent surgery. Age at presentation and curve magnitude at presentation were significant risk factors for surgical intervention. Curve magnitude at presentation was a significant risk factor for curve progression. No significant relationships were found for gender or curve type as they relate to surgical intervention or curve progression. CONCLUSION: Age and curve magnitude at presentation were significantly associated with surgery, as is true in other scoliosis populations. Curve magnitude at presentation was associated with curve progression. In contrast to studies in other populations, however, no significant association was observed between curve progression and age at presentation, curve type, or gender, or between surgery and curve type or gender. LEVEL OF EVIDENCE: Level III, prognostic cohort study.

Minimally invasive percutaneous nephrolithotomy guided by ultrasonography to treat upper urinary tract calculi complicated with severe spinal deformity

ABSTRACT Objective: To report our experience of minimally invasive percutaneous nephrolithotomy(MPCNL) in managing upper urinary tract calculi complicated with severe spinal deformity. Materials and Methods: Between August 2001 to December 2012, 16 upper urinary calculi in 13 patients with severe spinal deformity were treated by MPCNL. Preoperative investigation of the respiratory function, evaluation of anatomy by intravenous urography (IVU) and CT scan, and preoperative kidney ultrasonagraphy with simulation of the percutaneous puncture were performed in all patients. The percutaneous puncture was guided by ultrasonography. Results: A total of 19 MPCNL procedures were performed in 16 kidneys, with an average 1.2 procedures in each kidney. Three kidneys needed two sessions of MPCNL, and 2 kidneys needed combined treatment with retrograde flexible ureterscopic lithotripsy. All procedures were successfully completed with no major complications during or after surgery. The mean (range) operative duration was 67 (20-150) min and the mean postoperative haemoglobin drop was 1.0 (0.2-3.1) g/dL. Complete stone-free status was achieved in 14 kidneys. At a mean follow-up of 48(3-86) months, recurrence of small lower calyx stone was detected in one patient. Recurrent UTI was documented by urine culture in two patients and managed with sensitive antibiotics. Conclusion: PCNL for patients with severe spinal deformities is challenging. Ultrasonography-assisted puncture can allow safe and successfully establishment of PCN tract through a narrow safety margin of puncture and avoid the injury to the adjacent organs. However, the operation should be performed in tertiary centers with significant expertise in managing complex urolithiasis.

Minimally invasive percutaneous nephrolithotomy guided by ultrasonography to treat upper urinary tract calculi complicated with severe spinal deformity.

OBJECTIVE: To report our experience of minimally invasive percutaneous nephrolithotomy(MPCNL) in managing upper urinary tract calculi complicated with severe spinal deformity. MATERIALS AND METHODS: Between August 2001 to December 2012, 16 upper urinary calculi in 13 patients with severe spinal deformity were treated by MPCNL. Preoperative investigation of the respiratory function, evaluation of anatomy by intravenous uro¬graphy (IVU) and CT scan, and preoperative kidney ultrasonagraphy with simulation of the percutaneous puncture were performed in all patients. The percutaneous puncture was guided by ultrasonography. RESULTS: A total of 19 MPCNL procedures were performed in 16 kidneys, with an ave¬rage 1.2 procedures in each kidney. Three kidneys needed two sessions of MPCNL, and 2 kidneys needed combined treatment with retrograde flexible ureterscopic lithotripsy. All procedures were successfully completed with no major complications during or after surgery. The mean (range) operative duration was 67 (20-150) min and the mean postoperative haemoglobin drop was 1.0 (0.2-3.1) g/dL. Complete stone-free status was achieved in 14 kidneys. At a mean follow-up of 48(3-86) months, recurrence of small lower calyx stone was detected in one patient. Recurrent UTI was documented by urine culture in two patients and managed with sensitive antibiotics. CONCLUSION: PCNL for patients with severe spinal deformities is challenging. Ultra¬sonography-assisted puncture can allow safe and successfully establishment of PCN tract through a narrow safety margin of puncture and avoid the injury to the adjacent organs. However, the operation should be performed in tertiary centers with significant expertise in managing complex urolithiasis.

Surgical considerations for major deformity correction spine surgery.

Spinal deformity is defined as abnormality in alignment, formation, or curvature of one or more segments of the spine. Its characteristic clinical presentation and radiographic appearance differ according to patient age and the underlying cause. The most common deformity in the pediatric population is adolescent idiopathic scoliosis, whereas in adults many patients present with de novo deformity secondary to degenerative disease. Although the specific goals differ between patients, the broad aims include restoration of regional and global alignment, decompression of neural elements as necessary, and establishment of a solid fusion. Surgeons perform deformity correction by various approaches and techniques to achieve the desired correction while minimizing perioperative risk.

Is deltoid muscle biopsy useful in isolated camptocormia? A prospective study.

BACKGROUND AND PURPOSE: Camptocormia is a marked anterior curvature of the thoracolumbar spine that may be caused by parkinsonism, amyotrophic lateral sclerosis (ALS), myasthenia gravis (MG) and muscle disease. The interest of a systematic muscle biopsy has not been evaluated until now. In our study, the aim was to prospectively evaluate the proportion of patients with isolated camptocormia without ALS, MG and parkinsonism who have an underlying myopathy. METHODS: Twenty consecutive patients (75% female, mean age 70 years) with isolated camptocormia were enrolled in a single centre in this 5-year prospective study. ALS, MG and parkinsonism had been excluded in all cases. A left deltoid muscle biopsy was performed in all patients and processed with standard techniques for histology and immunohistochemistry. Additional biochemical and genetic studies were performed when pathological analysis was consistent with myopathy. RESULTS: A myopathy was identified in seven patients (35%). Three patients presented with mitochondrial myopathy, including two patients harbouring a heterozygous POLG gene pathogenic variant and one patient with a heterozygous RRM2B gene pathogenic variant. Two patients presented with an inflammatory myopathy, including one with anti-PM/Scl antibodies. One patient presented with facioscapulohumeral muscular dystrophy and one patient with an MYH7 gene-related myofibrillar myopathy. No obvious myopathy was found in the 13 remaining cases. DISCUSSION: In this prospective study, an underlying myopathy was found in 35% of patients with isolated camptocormia. These results suggest that a muscle biopsy should be systematically performed in patients with isolated camptocormia when ALS, MG and parkinsonism have been excluded.

Anterior Column Realignment (ACR) in Adult Sagittal Deformity Correction: Technique and Review of the Literature.

STUDY DESIGN: The anterior column realignment (ACR) procedure was retrospectively reviewed. OBJECTIVE: To review surgical technique, complication avoidance, case examples, and published results on ACR. SUMMARY OF BACKGROUND DATA: For surgical correction of sagittal imbalance, three column osteotomies (3CO) have traditionally been employed for large degrees of correction at a single segment. However, 3CO procedures are technically challenging and carry high morbidity rates. ACR was developed as a less invasive procedure for restoring segmental lordosis. METHODS: The ACR surgical technique is reviewed. ACR involves either a lateral, trans-psoas or anterior retroperitoneal approach to sectioning the anterior longitudinal ligament/annulus and placing a hyperlordotic cage. ACR usually also involves a second stage posterior column osteotomy. Three case examples are presented. A review of literature on ACR papers was completed. RESULTS: Twelve papers met inclusion criteria. Ten to 27° of segmental lordosis were reported with use of hyperlordotic cages. 19° increase in mean intradiscal angle was reported when ACR was combined with posterior column osteotomy, 13° more than lateral lumbar interbody fusion alone without a hyperlordotic implant. Reported complication rates ranged from 18 to 47%. The most common minor complications were transient hip flexion weakness (9.3%) and transient paresthesia or dysesthesia (12%). There were few reports of major complications, such as bowel perforation (n = 1) or vascular injury (n = 1). Motor deficit was reported in 11 of 75 cases, lower than reported rates for 3CO. CONCLUSION: ACR is an emerging, less invasive technique for correction of sagittal deformity ACR has similar restorative capacity as other techniques with same or lower complication rates. LEVEL OF EVIDENCE: 4.

The Correlation Between Restoration of Lumbar Lordosis and Surgical Outcome in the Treatment of Low-grade Lumbar Degenerative Spondylolisthesis With Spinal Fusion.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To investigate the relationship between the restoration of the lumbar lordosis (LL) and the surgical outcome of patients undergoing spinal fusion for low-grade lumbar degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Correlation between low back pain and the loss of LL in the treatment of low-grade lumbar degenerative spondylolisthesis has seldom been reported. METHODS: Between May 2005 and July 2011, 59 patients with low back pain and neurogenic claudication due to low-grade lumbar degenerative spondylolisthesis underwent spinal decompression and fusion by a senior surgeon. Ten patients were lost to follow-up. The mean age of the remaining 49 patients (10 men and 39 women) was 64.0 years (range, 47-88 y). Patients were categorized on the basis of the spino-pelvic posture: type 1 [pelvic incidence (PI)<45 degrees] (n=12), type 2 (45 degrees≤PI≤60 degrees) (n=24), and type 3 (PI>60 degrees) (n=13). The LL restoration ratio was calculated by the actual LL divided by the predicted LL. The clinical results were evaluated using a visual analogue scale and the Oswestry Disability Index. Postoperative 36-inch spinal films were used to assess the sagittal balance. RESULTS: The mean follow-up period was 43.2 months (range, 28-62 mo). Forty-eight patients showed significant improvement with respect to visual analogue scale and Oswestry Disability Index regardless of whether the LL was restored higher or lower. Postoperative 36-inch spinal films showed the C7 plumb line to be within an average of 4.4 cm (range, 0.6-5.6 cm) from the posterior-superior corner of the S1 vertebrae. CONCLUSIONS: Patients with smaller PI tended to be restored higher, and those patients with a larger PI were more likely to be restored lower. For patients with normal sagittal balance, the surgical outcomes in the treatment of low-grade lumbar degenerative spondylolisthesis with spinal fusion are not correlated with restoration of the LL.