Does the use of postoperative brace help preventing mechanical complications following adult deformity surgery?

PURPOSE: There is scarce information regarding the effectiveness of postoperative braces in decreasing mechanical complications and reinterventions following adult deformity surgery. METHODS: Retrospective matched cohort study from a prospective adult deformity multicenter database. We selected operated patients, fused to the pelvis, > 6 instrumented levels, and minimum 2 year follow-up. Three hundred and eighty patients were separated into two groups (Brace-3 months TLSO-vs No Brace) and then matched controlling for age, gender and frailty. We studied demographic, intraoperative, and postoperative spinopelvic parameters. Both groups were compared regarding complications and reinterventions in the first 2 postoperative years, using univariate and multivariate logistic regression analysis. RESULTS: We finally analyzed 359 matched patients, mean age of 65.3 ± 8.9 years, frailty-index (0.43 ± 0.15), and mostly females (84%). 224 patients wore a postoperative brace (B) and 135 didn't (NoB). They showed no difference in intraoperative variables and postoperative spinopelvic alignment. They differed (P < 0.05) in: Pelvic incidence (B:58° ± 13 vs NoB:54.5° ± 13); BMI (B:25.8 ± 4 vs NoB:27.4 ± 5); upper instrumented vertebra (B:81.7% T8-L1 vs NoB:72.6% T8-L1), and the use of multiple rods (B:47.3% vs NoB:18.5%). Univariate analysis showed a higher rate of mechanical complications and reinterventions when not using a brace. As well as higher NRS-back and leg pain at 6 weeks. However, multivariate analysis selected the use of multiple rods as the only independent factor protecting against mechanical complications (OR: 0.38; CI 95% 0.22-0.64) and reinterventions (OR: 0.41; CI 95% 0.216-0.783). CONCLUSION: After controlling for potential confounders, our study could not identify the protective effect of postoperative braces preventing mechanical complications and reinterventions in the first two postoperative years.

Revision surgery following long lumbopelvic constructs for adult spinal deformity: prospective experience from two dedicated databases.

PURPOSE: Pan Lumbar Arthodesis (PLA) are often required for Adult Spinal Deformity (ASD) correction, reducing significantly the compensatory capacity in case of postoperative sagittal malalignment. Few papers have investigated outcomes and complications in this vulnerable subset of patients. The objective of this study was to assess revision surgery rate for PLA in ASD, its risk factors and impact on clinical outcomes. METHODS: Retrospective multicenter review of prospective ASD data from 7 hospitals covering Europe and Asia. ASD patients included in two prospective databases having a posterior instrumentation spanning the whole lumbar region with more than 2-years of follow-up were reviewed. Demographic, surgical, radiographic parameters and Health-Related Quality of Life (HRQoL) scores were analyzed. Univariate and multivariate regression models analyzed risk factors for revision surgery as well as surgical outcomes. Patients with Early versus Late and PJK versus Non-PJK mechanical complications were also compared. RESULTS: Out of 1359 ASD patients included in the database 589 (43%) had a PLA and 357 reached 2-years mark. They were analyzed and compared to non-PLA patients. Average age was 67 and 82% were females. 100 Patients (28.1%) needed 114 revision surgeries (75.4% for mechanical failures). Revised patients were more likely to have a nerve system disorder, higher BMI and worst immediate postoperative alignment (as measured by GAP Parameters). These risk factors were also associated with earlier mechanical complications and PJK. Deformity and HRQoL parameters were comparable at baseline. Non-revised patients had significantly better clinical outcomes at 2-years (SRS 22 scores, ODI, Back pain). Multivariate analysis could identify nerve system disorder (OR 4.8; CI 1.8-12.6; p = 0.001), postoperative sagittal alignment (GAP Score) and high BMI (OR 1.07; CI 1.01-1.13; p = 0.004) as independent risk factors for revisions. CONCLUSIONS: Revision surgery due to mechanical failures is relatively common after PLA leading to worse clinical outcomes. Prevention strategies should focus on individualized restoration of sagittal alignment and better weight control to decrease stress on these rigid constructs in non-compliant spines. Nerve system disorders independently increase revision risk in PLA. LEVEL OF EVIDENCE II: Prognosis.

Relationship between pelvic incidence-adjusted relative spinopelvic parameters, global sagittal alignment and lower extremity compensations.

PURPOSE: In response to sagittal malalignment, compensatory spinal and lower extremity mechanisms are recruited. Thoracolumbar realignment surgery has been shown to yield reciprocal changes in these compensations. Thus, whole-body radiographic assessment has come to the fore. This study aimed to evaluate the relationship between spinopelvic parameters and lower extremity compensation angles and to examine their coupled change with deformity correction. METHODS: This was a multicenter retrospective analysis of patients who had ≥ 4 levels posterior fusion, whole-body radiographs, and ≥ 2 years follow-up. Relative Pelvic Version (RPV), Relative Lumbar Lordosis (RLL), Relative Spinopelvic Alignment (RSA), Femoral Obliquity Angle (FOA), Knee Flexion Angle (KFA) and Global Sagittal Axis (GSA) were measured preoperatively and 6 week postoperatively. Kruskal-Wallis tests were performed to assess the relation of relative spinopelvic parameters to global sagittal alignment and lower extremity compensation angles. Spearman's correlations were performed to assess correlations of pre-to-postoperative changes. RESULTS: 193 patients (156F, 37 M) were included. The mean age was 57.2 ± 16.6 years. The mean follow-up duration was 50.6 (24-90) months. On average, 10.3 ± 3.8 levels were fused. Among the cohort, 124 (64.2%) had a sacral or sacroiliac fixation, and 43 (22.3%) had 3-column osteotomies. Preoperative FOA, KFA and GSA significantly differed between RPV, RLL and RSA categories. Significant weak-to-strong correlations were observed between spinopelvic parameters, global sagittal alignment and lower extremity compensation angles (rho range: - 0.351 to 0.767). CONCLUSIONS: PI-adjusted relative spinopelvic parameters significantly correlated with measurements of the lower extremity compensation. Postoperative changes in RPV, RLL and RSA reflected changes in FOA, KFA and GSA. These measurements may serve as a valuable proxy for surgical planning when whole-body imaging is not available.

Combined anterior-posterior versus all-posterior approaches for adult spinal deformity correction: a matched control study.

PURPOSE: Anterior approaches are gaining popularity for adult spinal deformity (ASD) surgeries especially with the introduction of hyperlordotic cages and improvement in MIS techniques. Combined Approaches provide powerful segmental sagittal correction potential and increase the surface area available for fusion in ASD surgery, both of which would improve overall. This is the first study directly comparing surgical outcomes between combined anterior-posterior approaches and all-posterior approach in a matched ASD population. METHODS: This is a retrospective matched control cohort analysis with substitution using a multicenter prospectively collected ASD data of patients with > 2 year FU. Matching criteria include: age, American Society of Anesthesiologists Score, Lumbar Cobb angle, sagittal deformity (Global tilt) and ODI. RESULTS: In total, 1024 ASD patients were available for analysis. 29 Combined Approaches patients met inclusion criteria, and only 22 could be matched (1:2 ratio). Preoperative non-matched demographical, clinical, surgical and radiological parameters were comparable between both groups. Combined approaches had longer surgeries (548 mns vs 283) with more blood loss (2850 ml vs 1471) and needed longer ICU stays (74 h vs 27). Despite added morbidity, they had comparable complication rates but with significantly less readmissions (9.1% vs 38.1%) and reoperations (18.2% vs 43.2%) at 2 years. Combined Approaches achieved more individualised and harmonious deformity correction initially. At the 2 years control, Combined Approaches patients reported better outcomes as measured by COMI and SRS scores. This trend was maintained at 3 years. CONCLUSION: Despite an increased initial surgical invasiveness, combined approaches seem to achieve more harmonious correction with superior sagittal deformity control; they need fewer revisions and have improved long-term functional outcomes when compared to all-posterior approaches for ASD deformity correction.

Compensatory mechanisms recruited against proximal junctional kyphosis by patients instrumented from the thoracolumbar junction to the iliac.

PURPOSE: The compensatory mechanisms recruited by un-instrumented patients against sagittal imbalance are well documented. However, there is a lack of information regarding instrumented patients. MATERIAL AND METHODS: We performed a retrospective analysis of data collected prospectively in a multicenter adult spinal deformity database. We included patients suffering PJK/PJF after (T8-L2) to iliac instrumentation with minimum two-year follow-up. We measured quantitative sagittal spinopelvic and qualitative sagittal distribution parameters in the immediate postoperative period (6w) and at the time of PJK/PJF appearance. We analyzed how these parameters changed comparing these two time points with univariate and multivariate logistic regression analyses. RESULTS: A total of 69 patients were included. Two different patterns at PJK/PJF were found: 36 patients activated compensation (defined as an increase in pelvic retroversion (ΔRPV > 5º), and 33 did not (ΔRPV < 5º). The difference in behavior relied mostly on the amount of not surgically restored pelvic rotation at 6w (OR: 0.6; CI95%: 0.4-9.2; P = 0.017). Non-compensators had less rotation reserve (PTx100/PI = 33.9% vs 47.8%;P < 0.001) associated with worse 6w relative pelvic version and lower lumbar arc restoration, worse 6w relative sagittal alignment and GAP-score, compared with compensators (P < 0.001). Compensators' response was based on pelvic retroversion, causing lower lumbar arc decrease, lumbar apex caudal migration, and upper lumbar arc posterior inclination. Despite compensation, a thoracic kyphosis increase in both upper and lower arches gradually evolved into a PJK/PJF. Non-compensators did not react to PJK/PJF, which forced them into kyphosis from the lumbar apex and extending cranially, mainly throughout the upper thoracic arc. CONCLUSIONS: In patients fused from the TL junction to the iliac, those having greater postoperative pelvic rotation reserve showed greater capacity to recruit compensatory mechanisms against PJK/PJF.

Effect of lumbar pedicle subtraction osteotomy level on lordosis distribution and shape.

PURPOSE: Little is known about the qualitative results (postoperative upper/lower lumbar arches distribution and lumbar apex or inflection point positioning) of lumbar pedicle subtraction osteotomies (L-PSO) depending on the level of L-PSO. METHODS: We conducted a retrospective analysis of prospectively collected data of adult deformity patients undergoing single-level L-PSO. We analyzed several variables in preoperative and postoperative sagittal radiographs: L-PSO level, Roussouly classification (R-type), inflection point (InfP), lumbar apex (LApex), spinopelvic parameters, lordosis distribution index (LDI = L4-S1/L1-S1), and number of levels in the lordosis (NVL). Comparisons between PSO levels were performed to determine lordosis distribution and sagittal shape using ANOVA test and Chi-squared statistics. RESULTS: A total of 126 patients were included in this study. L5-PSO mainly increased the lower lumbar arch, thereby increasing LDI. L4 increased upper/lower arches similarly. PSOs at and above L3 increased the upper lumbar arch, thereby decreasing LDI (P < 0.001). L4-PSO added 1 vertebra into the lordosis (NVL = + 1.2 ± 2.2). PSOs above L3 added 2 vertebrae into the lordosis (NVL = + 2.3 ± 1.4). Overall P = 0.007. PSOs above L4 shifted the LApex cranially in 70% of the cases (mean 1.12 levels) and the InfP in 85% of the cases (mean 2.4 levels). L5-PSO shifted the LApex caudally in 70% of the cases (mean - 1.1 levels) and the InfP in 50% of the cases (mean - 1.6 levels). Overall P < 0.006. The L-PSO level was not associated with a specific Roussouly-type P > 0.05. CONCLUSIONS: The level of L-PSO influenced upper/lower lumbar arches distribution, and lumbar apex and inflection point positioning. The correct level should be chosen based on the individual assessment of each patient.

Adult spinal deformity surgical decision-making score. Part 2: development and validation of a scoring system to guide the selection of treatment modalities for patients above 40 years with adult spinal deformity.

PURPOSE: We aimed to develop and internally validate a scoring system, the adult spinal deformity surgical decision-making (ASD-SDM) score, to guide the decision-making process for ASD patients aged above 40 years. METHODS: A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation set and was internally validated in a validation set. The performance of the ASD-SDM score for predicting surgical management was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 702 patients were included for analysis in the present study. The scoring system developed based on 562 patients, ranging from 0 to 12 points, included five parameters: leg pain scored by the numerical rating scale; pain and self-image domains in the Scoliosis Research Society-22 score; coronal Cobb angle; and relative spinopelvic alignment. Surgical indication was graded as low (score 0 to 4), moderate (score 5 to 7), and high (score 8 to 12) groups. In the validation set of 140 patients, the AUC for predicting surgical management according to the ASD-SDM score was 0.797 (standard error = 0.037, P < 0.001, 95% confidence interval = 0.714 to 0.861), and in the low, moderate, and high surgical indication groups, 23.7%, 43.5%, and 80.4% of the patients, respectively, were treated surgically. CONCLUSIONS: The ASD-SDM score demonstrated reliability, with higher scores indicating a higher probability of surgery. This index could aid in the selection of surgery for ASD patients in clinical settings. These slides can be retrieved under Electronic Supplementary Material.

Prediction of satisfaction after correction surgery for adult spinal deformity: differences between younger and older patients.

PURPOSE: Achieving an adequate level of patient's satisfaction with results is one of the goals of adult spinal deformity (ASD) surgery. However, it is unclear whether the same factors affect satisfaction in all patient populations. Patients' age influences the postoperative course and prevalence of complications after ASD surgery. The purpose of this study was to determine the factors predicting satisfaction 2 years after ASD surgery in younger and older patients. METHODS: A total of 119 patients under 40 years old, 155 patients 40 to 65 years old, and 148 patients over 65 years old at surgery who were followed for a minimum of 2 years after surgery were included. Multivariate analysis was used to determine independent related factors with maximum AUC for satisfaction 2 years after surgery in each group. A propensity-matched cohort under equivalent demographic and clinical characteristics was used to confirm the results. RESULTS: Logistic regression analyses revealed satisfaction among the under-40 group corresponded to prior spine surgery, complications, and self-image. That among the 40-to-65 group corresponded to neurologic complication, revision surgery, pain, and sagittal vertical axis restoration. Among the over-65 group satisfaction correlated with revision surgery, standing ability, and lumbar lordosis index restoration. Propensity score matching confirmed that sagittal alignment correction led to substantial satisfaction. CONCLUSIONS: In younger patients, avoiding complications and improving patients' self-image were essential for substantial satisfaction levels. In older patients, revision, standing ability, as well as sagittal spinopelvic alignment restoration, were the key factors. Surgeons should consider the differences in goals of each patient.

Mental health status and sagittal spinopelvic alignment correlate with self-image in patients with adult spinal deformity before and after corrective surgery.

PURPOSE: Preoperative patient self-image (SI) in adult spinal deformity (ASD) is the most relevant factor for surgical decision-making. Postoperative SI has an important role in a patient's satisfaction with surgery. However, few studies are available to describe these variables. The aim was to investigate the factors that correlate with SI before and 2 years after ASD surgery. METHODS: This study was a retrospective review of prospectively collected multicentric data. Patients who underwent ASD surgery with a minimum follow-up of 2 years were enrolled (n = 391). They were divided into high-SI and low-SI groups, both preoperatively and postoperatively, according to SRS-22R SI/appearance subdomain scores at baseline and at 2 years, respectively. Independently related factors for SI were determined using logistic regression analysis. RESULTS: Crucial factors for SI at baseline were the scores on the SRS-22R function/activity (OR: 2.61), SRS-22R mental health (OR: 2.63) subdomains, and relative spinopelvic alignment (RSA, OR: 0.95). SF-36 MCS (OR: 1.07) at baseline as well as sagittal vertical axis (SVA, OR: 0.99) at 2 years, and complications (OR: 0.44) were independent predictive factors for SI at 2 years. The patients who transitioned from the preoperative low-SI group to the postoperative high-SI group achieved larger global sagittal alignment restoration and had lesser complications than those who did not. CONCLUSIONS: Mental status and sagittal spinopelvic alignment are key determinants of SI. The results indicate that considering mental status, preventing complications, and global sagittal alignment, restoration is crucial for achieving substantial SI scores after ASD surgery. These slides can be retrieved under Electronic Supplementary Material.

Adult spinal deformity surgical decision-making score : Part 1: development and validation of a scoring system to guide the selection of treatment modalities for patients below 40 years with adult spinal deformity.

PURPOSE: We aimed to develop and internally validate a simple scoring system: the adult spinal deformity (ASD) surgical decision-making (ASD-SDM) score, which is specific to the decision-making process for ASD patients aged below 40 years. METHODS: A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation cohort and was internally validated in a validation cohort. The accuracy of the ASD-SDM score was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 316 patients were randomly divided into derivation (253 patients, 80%) and validation (63 patients, 20%) cohorts. A 10-point scoring system was created from four variables: self-image score in the Scoliosis Research Society-22 score, coronal Cobb angle, pelvic incidence minus lumbar lordosis mismatch, and relative spinopelvic alignment, and the surgical indication was graded into low (score 0-4), moderate (score 5-7), and high (score 8-10) surgical indication groups. In the validation cohort, the AUC for selecting surgical management according to the ASD-SDM score was 0.789 (SE 0.057, P < 0.001, 95% CI 0.655-0.880). The percentage of patients treated surgically were 21.1%, 55.0%, and 80.0% in the low, moderate, and high surgical indication groups, respectively. CONCLUSIONS: The ASD-SDM score, to the best of our knowledge, is the first algorithm to guide the decision-making process for the ASD population and could be one of the indices for aiding the selection of treatment for ASD. These slides can be retrieved under Electronic Supplementary Material.

Development of predictive models for all individual questions of SRS-22R after adult spinal deformity surgery: a step toward individualized medicine.

PURPOSE: Health-related quality of life (HRQL) instruments are essential in value-driven health care, but patients often have more specific, personal priorities when seeking surgical care. The Scoliosis Research Society-22R (SRS-22R), an HRQL instrument for spinal deformity, provides summary scores spanning several health domains, but these may be difficult for patients to utilize in planning their specific care goals. Our objective was to create preoperative predictive models for responses to individual SRS-22R questions at 1 and 2 years after adult spinal deformity (ASD) surgery to facilitate precision surgical care. METHODS: Two prospective observational cohorts were queried for ASD patients with SRS-22R data at baseline and 1 and 2 years after surgery. In total, 150 covariates were used in training machine learning models, including demographics, surgical data and perioperative complications. Validation was accomplished via an 80%/20% data split for training and testing, respectively. Goodness of fit was measured using area under receiver operating characteristic (AUROC) curves. RESULTS: In total, 561 patients met inclusion criteria. The AUROC ranged from 56.5 to 86.9%, reflecting successful fits for most questions. SRS-22R questions regarding pain, disability and social and labor function were the most accurately predicted. Models were less sensitive to questions regarding general satisfaction, depression/anxiety and appearance. CONCLUSIONS: To the best of our knowledge, this is the first study to explicitly model the prediction of individual answers to the SRS-22R questionnaire at 1 and 2 years after deformity surgery. The ability to predict individual question responses may prove useful in preoperative counseling in the age of individualized medicine. These slides can be retrieved under Electronic Supplementary Material.

Decision-making factors in the treatment of adult spinal deformity.

PURPOSE: We aimed to elucidate the factors for the decision-making process in the treatment of adult spinal deformity (ASD), including sagittal parameters, that impact health-related quality of life (HRQOL). METHODS: A multicenter prospective ASD database was retrospectively reviewed. The demographic data, HRQOL, and radiographic measures were analyzed using multivariate analyses in younger (≤ 50 years) and older (> 50 years) age groups. RESULTS: This study included 414 patients (134 surgical and 280 nonsurgical; mean age 30.7 years) in the younger age group and 575 patients (323 surgical and 252 nonsurgical; mean age 65.8 years) in the older age group. Worse HRQOL measures drove surgical treatment, both in younger and older patients. The SRS-22 self-image score was the most differentiating domain, both in the younger and older age groups, and an additional significant factor in the older age group was pain and disability. Coronal deformity drove surgical treatment for the younger age group; however, older surgical patients were less likely to have coronal malalignment. Sagittal parameters were associated with the decision-making process. Greater pelvic incidence minus lumbar lordosis mismatch in the younger age group and smaller lumbar lordosis index in the older age group were most correlated with the decision to undergo surgery. CONCLUSIONS: Aside from the HRQOL measures and coronal deformity, sagittal parameters were identified as significant factors for the decision-making process in the ASD population, and the lack of lumbar lordosis in relation to pelvic incidence was a strong driver to pursue surgical treatment. These slides can be retrieved under Electronic Supplementary Material.

The impact of deep surgical site infection on surgical outcomes after posterior adult spinal deformity surgery: a matched control study.

PURPOSE: The impact of deep surgical site infection (SSI) on surgical outcomes after adult spinal deformity (ASD) surgery is still unclear. We aimed to study the morbidity of SSI in ASD and its impact on deformity correction and functional outcome. METHODS: Prospective multicenter matched-cohort study including consecutively enrolled ASD patients. Patients developing SSI were matched to similar controls in terms of age, gender, ASA, primary or revision, extent of fusion, and use of tri-columnar osteotomies. Preoperative parameters, surgical variables, and complications were recorded. Deformity parameters and Health Related Quality of Life (HRQoL) scores were obtained preoperatively and at 6, 12, and 24 months. Independent t test and Fischer's exact test were used for comparisons. RESULTS: 444 surgical ASD patients with more than 2 years of follow-up were identified. 20 sustained an acute SSI and 60 controls were accordingly matched. No differences were observed between groups in preoperative radiological and HRQoL variables confirming comparable groups. SSI patients had longer hospital stay and more mechanical complications including proximal junctional kyphosis. Infection was associated with more unrelated complications and revisions. Deformity correction was maintained equally at the different time intervals. One death was related to SSI. SSI patients had worse overall HRQoL status at 1 year and were less likely to experience improvement. However, no significant differences were recorded thereafter. CONCLUSION: SSI significantly affects the first postoperative year after posterior ASD surgery. It is associated with more complications, unrelated revisions, and worst quality of life. However it's negative impact seems to be diluted by the second postoperative year as differences in HRQoL scores between the two groups decrease. These slides can be retrieved under Electronic Supplementary material.

Are sagittal spinopelvic radiographic parameters significantly associated with quality of life of adult spinal deformity patients? Multivariate linear regression analyses for pre-operative and short-term post-operative health-related quality of life.

PURPOSE: To evaluate the association in ASD patients between spinopelvic sagittal parameters and health-related quality of life (HRQL), adjusted for demographic and surgical variables. METHODS: We constructed multiple linear regression models to investigate pre-operative (PreOp) and 6-month post-operative (PostOp) HRQL as assessed by the Oswestry Disability Index (ODI), with sagittal parameters as independent variables adjusted for potential confounders, such as age, sex, body mass index, past spine surgery, types of surgical treatment, and complications. RESULTS: A total of 204 patients (164 women, 40 men, mean age 53.1 years) were included in this study. In multivariate models for PreOp ODI, no significant association was observed between PreOp HRQL and sagittal parameters when adjusted for covariates. Interestingly, age, sex, American Society of Anesthesiologists score, and body mass index were still significantly associated with PreOp HRQL. In contrast to PreOp analysis, there was a significant association between PostOp worse HRQL (higher ODI) and positive T1 sagittal tilt (T1ST: the angle between a line drawn from the center of the femoral head axis to the midpoint of the T1 vertebral body and a vertical line). Sagittal vertical axis had a weaker association with HRQL than T1ST. PostOp ASD patients lose flexibility in the fused spinal segment, and might be predisposed to symptoms related to spinal sagittal malalignment due to limited compensatory ability to maintain a balanced standing posture. Interestingly, in patients with sagittal imbalance, low pelvic tilt (PT) of <20 was significantly associated with PostOp worse HRQL; this suggests that lack of pelvic compensatory ability can cause significant disability after ASD surgery. CONCLUSIONS: Pre-operatively, the impact of sagittal parameters on HRQL was not as strong as reported in the previous studies that used univariate analysis. Not only sagittal parameters, but also the pre-operative patient's general condition should be carefully reviewed when considering indication for ASD surgery. In contrast, although this is a short-term follow-up study, PostOp HRQL was significantly associated with sagittal parameters. When ASD surgery has been indicated, restoration of spinal sagittal alignment is certainly important for PostOp HRQL.

Sagittal malalignment has a significant association with postoperative leg pain in adult spinal deformity patients.

PURPOSE: To evaluate the association between spinopelvic sagittal parameters and leg pain in patients with adult spinal deformity (ASD) after adjusting for demographic and surgical variables. METHODS: A multicenter prospective ASD database (European Spine Study Group) was retrospectively reviewed. The characteristics (age, sex, body mass index, comorbidity, history of spine surgery, and radiographical coronal and sagittal parameters) of patients with preoperative and 6-month postoperative leg pain (PostLP; numerical rating scale score ≥5) were analyzed using univariate and multivariate analyses. RESULTS: In this study, 204 patients (164 women and 40 men; mean age 53.1 years) were included. Fifty-three percent of the patients had preoperative leg pain (PreLP). The patients with PreLP had significantly worse sagittal parameters and less coronal Cobb angle than those with less leg pain; however, this association disappeared after adjustment for covariates. The PreLP of the ASD patients was successfully treated surgically in most cases; however, 24 % of the patients still had unexpected residual leg pain. Postoperative sagittal malalignment (sagittal vertical axis ≥40 mm, T1 sagittal tilt ≥0°, pelvic tilt ≥30°) was a significant risk factor of PostLP even after adjusting for covariates. CONCLUSIONS: Leg pain in patients with ASD was significantly associated with sagittal malalignment especially after surgical treatments. As these patients lose flexibility in the fused spinal segment, they can only depend on the remaining compensatory mechanisms below the pelvis (e.g., the hips and knees) to maintain a balanced posture. This may lead to a predisposition of these patients to postoperative leg symptoms related to spinal sagittal malalignment.

Safety and efficacy of osteotomies in adult spinal deformity: what happens in the first year?

PURPOSE: Spinal surgery for adult spinal deformity (ASD) may require the use of osteotomies, which may have high complication rates (up to 80 %). These may be expected to affect health-related quality of life (HRQOL) in the early postoperative phase but little is known about the clinical course of these patients in the first year following surgery. The aim of the study is to evaluate the radiological results and HRQOL in patients undergoing a spinal osteotomy for ASD within the first year following surgery with special reference to the effect of complications. METHODS: From a prospective multicenter ASD database, patients who had undergone a Smith-Petersen osteotomy (SPO), pedicle substraction osteotomy (PSO), vertebral column resection (VCR) or any combination of these were reviewed for radiological sagittal alignment parameters [sagittal vertical axis (SVA), global tilt, lumbar lordosis, T2-sagittal tilt (ST)] as well as HRQOL [Oswestry Disability Index (ODI), short form-36 items (SF-36) Physical Component Score (PCS), SF-36 mental CS (MCS), Scoliosis Research Society (SRS)-22 questionnaire (SRS-22) subtotal] preoperatively and at the 6th- and 12th-month follow-ups with special reference to complications classified as major (life threatening or requiring additional surgery) and minor and their effects on HRQOL. RESULTS: 121 patients (85 F, 36 M) with a total of 71 SPOs, 45 PSOs and 13 VCRs were evaluated. Osteotomy resulted in correction of the major coronal Cobb angle from 43.0 ± 3.7° to 24.8 ± 2.8° (p < 0.001) and the SVA from 69.0 ± 10.3 to 52.4 ± 6.6 mm (p = 0.001). Other radiological parameters showed no significant changes. Remarkable improvements in HRQOL scores with a strong age effect (p ≤ 0.01), for all instruments except SF-36 MCS, were found. Most of these HRQOL improvements have been achieved within the first 6 months. A total of 114 complications (59 major, 55 minor) that had a lesser effect on the age-adjusted HRQOL scores (p < 0.05) (except for the SF-36 PCS) and 1 death were observed. CONCLUSIONS: Osteotomies were moderately effective in radiological improvement but resulted in a significant increase in HRQOL. They were associated with a high rate of complications but these had no/minimal effect on the clinical outcome. Contrary to the general perception, the greatest improvements in HRQOL were seen to take place during the first 6 months after surgery, even in the presence of complications.

Sagittal alignment of cervical spine in adult idiopathic scoliosis.

PURPOSE: Alignment of the cervical spine (CS) in adolescent idiopathic scoliosis (IS) as well as in asymptomatic adult populations has recently been studied and described as being less lordotic in the adolescent IS population. However, few studies have examined the sagittal alignment of the CS in adult IS or its association with other radiological variables and clinical relevance. The aim of this study is to analyse the sagittal alignment of CS in adult IS and its association with age, alignment of the thoracic, lumbar and global spinal column as well as health-related quality of life (HRQOL) parameters. METHODS: A retrospective review of prospectively collected data from a multicenter database was performed. Of 468 consecutive adult IS patients, 213 were included in the study; the remainder were excluded due to poor quality X-rays where the CS was not properly visible, or previous surgery. X-rays were measured for the following CS parameters: [Cranial base-C2 (C0-C2) lordosis, C2-C7 lordosis, thoracic (T1) slope, thoracic inlet angle (TIA) and odontoid (Od)-T1 offset using a measurement software]. These measurements were then evaluated for possible associations with patient age and with pre-existing alignment parameters and HRQOL scores using Pearson correlation tests. RESULTS: The average and standard deviations for CS alignment parameters were 32.3° ± 10.2° for C0-C2; 5.7° ± 14.1° for C2-C7; 23.9° ± 11.3° for T1 slope, 70.5° ± 14.7° for TIA and 20.8° ± 16.5° for Od-T1 offset. CS alignment showed a significant (p < 0.05) correlation with age, T kyphosis and several other sagittal alignment parameters such as sagittal vertical axis (SVA), global tilt and T1 sagittal tilt, but not with the HRQOL parameters. CONCLUSION: The sagittal alignment of the CS in adult IS is less lordotic than the normal average while less kyphotic than that of IS of a younger age. It correlates with age, thoracic kyphosis and some global sagittal alignment parameters. These findings suggest that CS alignment is likely a component of the global sagittal alignment strongly affected by thoracic kyphosis, and most probably does not affect HRQOL by itself.

The reunion with my patients: their journey and experience 30 years after their intervention for adolescent idiopathic scoliosis via CD instrumentation.

PURPOSE: Our objective was to collect the experience and current attitude of those patients, now adults, operated on for adolescent idiopathic scoliosis (AIS) more than 25 years ago with CD instrumentation (CDI). METHODS: Prospective qualitative cross-sectional study with interpretive phenomenological analysis approach of AIS patients operated in a single center with CDI between 1985 and 1995. Patients underwent a semi-structured interview with their original surgeon. Seven agreed themes were open for conversation, and several subthemes emerged related to their experience during their journey in life. Filed notes were recorded and transcribed verbatim. We used the method of content, semantic and pragmatic analysis. RESULTS: We contacted 103 patients, 100 agreed to participate. Mean age was 47.5 ± 3.3, mean follow-up was 30.9 ± 2.7 years. Three fundamental concerns stood out: discomfort with self-image; low back pain with daily activities; and lack of spinal flexibility. 50% were engaged in continuous physical exercise, and only some referred limitations with load-bearing work. Patients commonly described negative memories of the conservative treatment, but positive memories of the surgical process. In general, there was a good adaptation to social life (occupation, social and family relationships). Two-thirds were married, and 65 women had offspring. A frequent concern was the excess of radiographs over the years, and three developed breast cancer. CONCLUSIONS: Factors such as dissatisfaction with self-image, low back pain, and spine stiffness were relevant to patients throughout their journeys. Despite this, the great majority were satisfied with the treatment received, which allowed them to lead an integrated life in society. LEVEL OF EVIDENCE: Level II.

Which sagittal plane assessment method is most predictive of complications after adult spinal deformity surgery?

PURPOSE: Different methods of sagittal alignment assessment compete for predicting adverse events after adult spinal deformity (ASD) surgery. We wanted to study which method provides greater benefit. METHODS: Retrospective study of 391 patients operated for ASD, with > 6 instrumented levels, fused to the pelvis, and 2 years of follow-up. Three alignment methods were analyzed 6-week postoperatively: (1) Roussouly mismatch; (2) GAP score/GAP categories; (3) T4-L1-Hip axis. Binary logistic regression generated models that best predict the following adverse events: mechanical complications (MC): in general and isolated (PJK, PJF, rod breakage); reinterventions (in general and after MC); and readmissions. ROC/AUC analysis was also implemented. In a second regression round, we added different variables that were selected on univariate analysis-demographic, surgical, and radiographic-to complete the models. RESULTS: The best predictor parameters in most models were T4-L1PA mismatch and GAP score; we could not prove a predictive ability of the Roussouly mismatch. The T4-L1PA mismatch best predicted general MC, PJK, PJK + PJF, and readmission, while the GAP score best predicted PJF and reinterventions (for MC and for any complication). However, the variance explained by these models was limited (Nagelkerke's R2 = 0.031-0.113), with odds ratios ranging from 1.070 to 1.456. ROC curves plotted an AUC between 0.57 and 0.70. Introducing additional variables (demographic, surgical, and radiographic) improved prediction in all the models (Nagelkerke's R2 = 0.082-0.329) and allowed predicting rod breakage. CONCLUSION: The T4-L1-Hip axis and GAP score show potential in predicting adverse events, surpassing the Roussouly method. Despite partial efficacy in complication anticipation, recognizing postoperative sagittal alignment as a key modifiable risk factor, the crucial need arises to integrate diverse variables, both modifiable and non-modifiable, for enhanced predictive accuracy. LEVEL OF EVIDENCE: Level IV.