Cervical spine alignment following surgery for adolescent idiopathic scoliosis (AIS): a pre-to-post analysis of 81 patients.

BACKGROUND: Several studies have emphasized the importance of restoring thoracic kyphosis (TK) in the setting of AIS, but very few have discussed changes in cervical spine alignment following surgery. Aim of this study was to evaluate reciprocal cervical alignment change after modification of global and regional thoracolumbar alignment with surgery in the setting of adolescent idiopathic scoliosis (AIS). METHODS: Baseline and 2-yrs follow-up radiographs of AIS patients (n = 81) were analysed measuring cervical parameters (upper cervical: C2-C0, McGregor Slope; lower cervical: C2-C7, C2-C7 sagittal vertical axis (SVA), C2-T3, C2-T3SVA, C2-T1Harrison (C2-T1Ha), T1 Slope (T1S)), thoracic, lumbar, pelvic and global alignment parameters. Post-operatively, patients were grouped twice; based on changes in TK and SVA. Cervical alignment was compared between groups. Pearson correlation was conducted to examine the relationship between changes in TK, SVA, and cervical alignment. RESULTS: Stratification by change in TK, revealed significant alteration of lower cervical alignment T1S [p < 0.001]), C2-T3 [p = 0.019], C2-T1Ha [p = 0.043]), but there was no reciprocal change in the upper cervical spine. Stratification by SVA revealed a significant coexisting change in the lower cervical spine (T1S [p < 0.001], C2-C7SVA [p = 0.034], C2-T3 [p = 0.023], C2-T3SVA [p = 0.001]). SVA change was not associated to a change in the upper cervical spine. The correlation analysis showed that with a post-operative increase in TK, the cervical spine became more lordotic. Changes in TK were significantly correlated with: ΔT1S, ΔC2-C7, ΔC2-T3, and ΔC2-T3SVA. Similarly, increased cervical kyphosis was found when SVA was decreased post-operatively. Furthermore, there was a significant correlation between change of SVA and both ΔC2-T3 and ΔC2-T3SVA. CONCLUSIONS: In surgically treated AIS patients, changes in global and regional alignment of the thoracolumbar and cervical spinal segments exhibit interdependence. Thus, surgical planning with regard to sagittal deformity in AIS patients should account for the post-operative impact on cervical alignment.

The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND: Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION: Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS: Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS: 47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m2). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001). DISCUSSION AND CONCLUSION: Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE: Level III.

Normative spino-pelvic sagittal alignment of Lebanese asymptomatic adults: Comparisons with different ethnicities.

BACKGROUND: Normative values of sagittal alignment are used as references for the diagnosis and treatment of spinal pathologies. There are currently no reference values for the normative sagittal alignment of Lebanese subjects. The objective is to describe normative values of full body sagittal alignment parameters in asymptomatic Lebanese adults and to compare the sagittal alignment of this population to that of populations of various origins. METHODS: Included subjects were aged 18 to 28 years old. Each subject underwent a full body biplanar X-ray exam with measurement of spine, pelvis and lower limb parameters of sagittal alignment. The sagittal alignment of the Lebanese population was compared to that of other ethnicities, previously reported in the literature, using one-way ANOVA. RESULTS: Ninety-two asymptomatic Lebanese young adult volunteers (48 males, 44 females, age=21.5±2.2 years) were enrolled in this study. The mean curvature in the cervical spine was kyphotic (-4.3°) in women, while it was lordotic in men (5.4°). Men were found to be significantly more kyphotic than women (-58.3° vs. -53.0°; p<0.01) but both sexes were found to have similar lordosis (61.6°) and pelvic incidence (52.0°). Lebanese subjects had intermediate pelvic incidence compared to other ethnicities but showed significantly higher thoracic kyphosis (p<0.01) and lumbar lordosis (p<0.01) compared to all other ethnicities. CONCLUSIONS: This study established reference normative values for young adult Lebanese subjects. Most women were found to have kyphotic cervical spines. The sagittal alignment of Lebanese subjects differed significantly compared to that of other ethnicities. LEVEL OF EVIDENCE: Level IV - cross sectional study.

Clinical and stereoradiographic analysis of adult spinal deformity with and without rotatory subluxation.

INTRODUCTION: In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose. HYPOTHESIS: 3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact. MATERIAL AND METHODS: One hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed. RESULTS: RS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia. DISCUSSION: In this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management. LEVEL OF EVIDENCE: 4, retrospective study.