Sagittal alignment of diverse mechanical complications following adult spinal deformity surgery.

PURPOSE: To compare the sagittal alignment of patients with diverse mechanical complications (MCs) following adult spinal deformity (ASD) surgery with that of patients without MCs. METHODS: A total of 371 patients who underwent ASD surgery were enrolled. The sagittal spinopelvic parameters were measured preoperatively and at the 6-month and last follow-up, and the global alignment and proportion (GAP) score was calculated. The subjects were divided into non-MC and MCs groups, and the MCs group was further divided into rod fracture (RF), screw breakage (SB), screw dislodgement (SD) and proximal junctional kyphosis (PJK) subgroups. RESULTS: Preoperatively, the RF group had greater thoracolumbar kyphosis (TLK) and relative upper lumbar lordosis (RULL); the SB group had the largest pelvic incidence (PI) and lumbar lordosis (LL); the SD group had the least global sagittal imbalance; and the PJK group had the highest thoracic kyphosis (TK), TLK and RULL. At the last follow-up, the RF and SB groups featured a large PI minus LL (PI-LL), while the PJK group featured a prominent TK; all the MCs subgroups had sagittal malalignment and a higher GAP score, and the SB group had the most severe cases. Logistic regressions showed that the relative spinopelvic alignment (RSA) score was correlated with RF, SB and SD, while the RSA and age scores were associated with PJK. CONCLUSION: Each patient with MCs had individual characteristics in the sagittal plane following ASD surgery, which may be helpful to understand the pathophysiology of poor sagittal alignment with its subsequent MCs and guide an eventual revision strategy.

Proximal junctional kyphosis after adult spinal deformity operated patients with long fusion to the pelvis. Does the type of proximal anchor matter?

PURPOSE: To assess, in a large population of Adult Spinal Deformity (ASD) patients, the true interest of varying the upper anchors as a protective measure against Proximal Junctional Kyphosis (PJK), by analyzing and comparing 2 groups of patients defined according to their proximal construct. Another objective of the study is to look for any other factors, radiological or clinical, that would affect the occurrence of the proximal failure. METHODS: Retrospective review of a prospective ASD database collected from 5 centers. Inclusion criteria were age of at least 18 years, presence of a spinal deformity with instrumentation from T12 or above to the pelvis, with minimum 2 years of follow-up. Demographic data, spinopelvic parameters, functional outcomes and complications were collected. Multiple logistic regression analysis was performed to identify the risk factors that would affect the occurrence of PJK. RESULTS: 254 patients were included. 166 in the group "screws proximally" (SP) and 88 in the group "hooks proximally" (HP). There was no difference between both groups for PJK (p = 0.967). The occurrence of PJK was rather associated with greater age and BMI, higher preoperative kyphosis, worst preoperative SRS22 and SF36 scores, greater postoperative Sagittal Vertical Axis (SVA), coronal malalignment and kyphosis. CONCLUSION: The use of proximal hooks was not effective to prevent PJK after ASD surgery, when compared to proximal screws. Worse preoperative functional outcomes and worse postoperative sagittal and also coronal malalignment were the main drivers for the occurrence of PJK regardless the type of proximal implant.

Calculation of the minimal clinically important difference in operated patients with adult spine deformity: advantages of the ROC method and significance of prevalence in threshold selection.

PURPOSE: The Minimal Clinically Important Difference (MCID) is crucial to evaluate management outcomes, but different thresholds have been obtained in different works. Part of this variability is due to measurement error and influence of the database, both essential for calculating the MCID. The aim of this study was to introduce the association of the ROC method in the anchor-based MCID calculation for ODI, SRS-22r, and SF-36, to objectively set the threshold for the anchor-based MCID in an adult spine deformity (ASD) population. METHODS: Multicentric study based on a prospective database of consecutively operated ASD patients. An anchor question was used to assess patients' quality of life after surgery. Different approaches were used to calculate the MCID and then compared: SEM (Standard Error of Measurement), MDC (Minimal Detectable Change), and anchor-based MCID with ROC method. RESULTS: 516 patients were included. Those who responded with 6 and 7 to the anchor question were considered improved. The MCID ranges obtained with the ROC method exhibited the lowest variability. Prediction error rates ranged from 31% (SRS-22r) to 41% (SF-36 MCS). The MCID ranges spanned between 12 and 15 for ODI, 0.6 and 0.73 for SRS-22r, 6.62 and 7.41 for SF-36 PCS, and between 2.69 and 5.63 for SF-36 MCS. CONCLUSION: The ROC method proposes an MCID range with error rate, and can objectively determine the threshold for distinguishing improved and non-improved patients. As the MCID correlates with the utilized database and error of measurement, each study should compute its own MCID for each PROM to allow comparison among different publications. LEVEL OF EVIDENCE: II.

Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series.

PURPOSE: Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery. METHODS: A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity. RESULTS: Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted. CONCLUSION: 95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

Domino connector for thoracic pedicle subtraction osteotomy reduction: surgical technique and patient series.

PURPOSE: Different techniques have been previously described to close the pedicle subtraction osteotomy (PSO) site for correction of sagittal malalignment; the use of a side-to-side domino connector as a correction tool in the thoracic spine has not been specifically studied. METHODS: Twenty adult patients who underwent single-level thoracic PSO from T1 to T12 were included and retrospectively reviewed (two centers). Preoperative and postoperative full-body X-rays, perioperative data, clinical data and complications were recorded with a minimum 2 years of follow-up. Surgical technique and the nuances in using the domino connector were described in detail. RESULTS: Patients had a mean age of 40y; 40% were female. Two different techniques involving the domino were applied for closure of the PSO site depending on the type of kyphosis (smooth vs. angular deformity). Both techniques provided significant correction of the local kyphosis (from 48° to 18°) with reciprocal reduction of compensatory cervical lordosis (from 37.6° to 18.6°, p < 0.01) in upper thoracic PSO or lumbar lordosis (from 74.5° to 46.6°, p < 0.01) in lower thoracic PSO. Four patients presented postoperative complications that resolved (hemothorax, GI bleeding), and two patients presented transient neurological deficit. Oswestry Disability Index score improved in the majority of the patients (from 32.7 to 22.5, p < 0.05). There were no pseudarthroses, symptomatic instrumentation breakage, or surgical site infection. CONCLUSION: Use of a side-to-side domino connector in combination with two different rod cantilever techniques is effective for the reduction of thoracic pedicle subtraction osteotomy achieving satisfactory radiological and clinical outcome.

Rod angulation does not reflect sagittal curvature in adult spinal deformity surgery: comparison of lumbar lordosis and rod contouring.

STUDY DESIGN: A retrospective study. OBJECTIVE: Relationship between rod and spinal shape in the sagittal plane in adult spinal deformity (ASD) surgery. BACKGROUND: Corrective surgery for adult spinal deformity (ASD) involves the use of contoured rods to correct and modify the spinal curvatures. Adequate rod bending is crucial for achieving optimal correction. The correlation between rods and spinal shape in long constructs has not been reported previously. METHODS: We conducted a retrospective analysis of a prospective, multicenter database of patients who underwent surgery for ASD. The inclusion criteria were patients who underwent pelvic fixation and had an upper instrumented vertebra at or above T12. Pre- and post-operative standing radiographs were used to assess lumbar lordosis at the L4S1 and L1S1 levels. The angle between the tangents to the rod at the L1, L4, and S1 pedicles was calculated to determine the L4S1 and L1S1 rod lordosis. The difference between the lumbar lordosis (LL) and the rod lordosis (RL) was calculated as ΔL = LL-RL. The correlation between this difference (ΔL) and various characteristics was analyzed using descriptive and statistical methods. RESULTS: Eighty-three patients were included in the study, resulting in 166 analyzed differences (ΔL) between the rod and spinal lordosis. The values for rod lordosis were found to be both greater and lesser than those of the spine but were mostly lower. The range for total ΔL was -24 °-30.9 °, with a mean absolute ΔL of 7.8 ° for L1S1 (standard deviation (SD) = 6.0) and 9.1 ° for L4S1 (SD = 6.8). In 46% of patients, both rods had a ΔL of over 5 °, and over 60% had at least one rod with a ΔL difference of over 5 °. Factors found to be related to a higher ΔL included postoperative higher lumbar lordosis, presence of osteotomies, higher corrected degrees, older age, and thinner rods. Multivariate analysis correlated only higher postoperative L1S1 lordosis with higher ΔL. No correlation was found between a higher ΔL and sagittal imbalance. CONCLUSIONS: Variations between spinal and rod curvatures were observed despite the linear regression correlation. The shape of the rod does not seem to be predictive of the shape of the spine in the sagittal plane in ASD long-construct surgeries. Several factors, other than rod contouring, are involved in explaining the postoperative shape of the spine. The observed variation calls into question the fundamentals of the ideal rod concept.

Adherence to the Obeid coronal malalignment classification and a residual malalignment below 20 mm can improve surgical outcomes in adult spine deformity surgery.

PURPOSE: Coronal balance is a major factor impacting the surgical outcomes in adult spinal deformity (ASD). The Obeid coronal malalignment (O-CM) classification has been proposed to improve the coronal alignment in ASD surgery. Aim of this study was to investigate whether a postoperative CM < 20 mm and adherence to the O-CM classification could improve surgical outcomes and decrease the rate of mechanical failure in a cohort of ASD patients. METHODS: Multicenter retrospective analysis of prospectively collected data on all ASD patients who underwent surgical management and had a preoperative CM > 20 mm and a 2-year follow-up. Patients were divided in two groups according to whether or not surgery had been performed in adherence to the guidelines of the O-CM classification and according to whether or not the residual CM was < 20 mm. The outcomes of interest were radiographic data, rate of mechanical complications and Patient-Reported Outcome Measures. RESULTS: At 2 years, adherence to the O-CM classification led to a lower rate of mechanical complications (40 vs. 60%). A coronal correction of the CM < 20 mm allowed for a significant improvement in SRS-22 and SF-36 scores and was associated with a 3.5 times greater odd of achieving the minimal clinical important difference for the SRS-22. CONCLUSION: Adherence to the O-CM classification could reduce the risk of mechanic complications 2 years after ASD surgery. Patients with a residual CM < 20 mm showed better functional outcomes and a 3.5 times greater odd of achieving the MCID for the SRS-22 score.

The Obeid-coronal malalignment classification is reliable and helps guiding decision-making and surgical management of adult spinal deformities: letter to the editor of BMC Musculoskeletal Disorders.

A recently published article by Zhang et al. in BMC Musculoskeletal Disorders reported that the classification of coronal deformity based on preoperative global coronal malalignment for adult spinal deformity is questionable. The aim of the paper was to specifically discredit the Obeid-Coronal Malalignment (O-CM) classification. In this correspondence, we thought it judicious to clarify misunderstood concepts by the authors. We highlight several limitations of their study, and explain the deep interest of the classification from our perspective in order to avoid misleading the readers. Overarching, we aim to help the colleagues through a constructive rather than destructive approach to better understand the foundations of a coronal malalignment classification.

Domino connector is an efficient tool to improve lumbar lordosis correction angle after pedicle subtraction osteotomy for adult spinal deformity.

PURPOSE: To compare the radiological outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either a domino connector was applied for osteotomy correction or not. METHODS: Retrospective review of a prospective, multicenter adult spinal deformity database (5 sites). Inclusion criteria were adult patients who underwent PSO between L3 and L5 with a minimum follow-up of 2 years. Among 1243 patients in the database, 79 met the inclusion criteria, 41 in the no-domino (ND) group and 38 in the domino (D) group. The domino technique consisted of using 2 parallel rods connected by a domino on one side of the PSO in order to achieve gradual and controlled compression at the osteotomy site. Demographic data, operative parameters, spinopelvic parameters and complications were collected. RESULTS: Demographic data and operative parameters were globally similar between both groups, and they showed a comparable preoperative sagittal malalignment. Segmental lordosis improved by 22° and 31° (p < 0.05) and L1S1 lordosis improved by 23° and 32° (p < 0.05) in the ND and D group, respectively. The use of multiple rods was similar between the groups (58% vs. 57%). Also, mechanical complications rate was globally similar between both groups with no statistically significant difference (22% vs. 28.9%). CONCLUSION: Domino connector is a safe, powerful and efficient tool for pedicle subtraction osteotomy site closure. It improved the lumbar lordosis correction angle with an acceptable rate of complications.

Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up.

PURPOSE: The objective of this retrospective study was to provide the radiographic outcomes and complications for pedicle subtraction osteotomy (PSO) performed at the low lumbar spine, i.e., L4 or L5 for ASD patients with fixed sagittal malalignment. METHODS: ASD patients who underwent L4 or L5 PSO with a minimum 2-year follow-up were included. Preoperative and postoperative radiographs, and complications were collected. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), thoracic kyphosis (TK), sagittal vertical axis (SVA), spinal lordosis (SL) ratio and global tilt (GT) on standing long-cassette radiographs. RESULTS: A total of 102 patients from 2 spinal centers were analyzed. 66 patients underwent PSO at L4 and 36 patients at L5. From preoperatively to the final follow-up, significant improvements occurred in LL (from - 31° to - 52°), SVA (from 13 to 5 cm), and GT (from 44° to 27°) (all, p < 0.05). 12 patients had transient neurological deficits, and 8 patients had persistent neurological deficit. 23 patients underwent revision for PJK (2), pseudarthrosis (10), neurological deficit (2), epidural hematoma (1), or deep surgical site infection (8). No PJK was observed in any of the patients with L5 PSO. CONCLUSIONS: PSO at the level of L4 or L5 remains a challenging technique but with an acceptable rate of complications and revisions. It enables correction of fixed sagittal malalignment in ASD patients with a globally satisfactory outcome. In comparison with L4 PSO, L5 PSO patients did not show PJK as a mechanical complication. Distal lumbar PSO at the level of L5 may represent one of the factors that may help preventing the proximal junctional kyphosis complication.

Static and dynamic sagittal lumbar apex: a new concept for the assessment of lumbar lordosis distribution in spinal deformity.

PURPOSE: Sagittal lumbar apex has been demonstrated to be a key parameter in sagittal plane morphology. Our aim was to understand its behavior with postural changes, analyzing two different concepts of lumbar apex. MATERIALS AND METHODS: Prospective observational study with a cohort of patients presenting sagittal malalignment identified from a monocenter database of adult spinal deformities (ASD). Inclusion criteria were age > 30 years, SVA > 40 mm, and/or PT > 20. All patients had full-spine EOS radiographs in 2 different positions: (P1: natural position) and position 2 (P2: compensated position). Sagittal alignment, spinopelvic values, and two different methods of assessing lordosis apex location were analyzed in both P1 and P2 positions. Changes between P1 and P2 were compared using a paired t test with a significance level at p < 0.05. RESULTS: Twenty-five patients were recruited (21 women and 4 men). The mean age was 64.8 years (range 21-79). The patient's main compensation was based on an increase in the femoral shaft angle, and pelvic retroversion, with a subsequent decrease in sacral slope, and therefore of the lower lumbar arc. When the lumbar apex was calculated as the most anterior point touching the vertical line in a lateral radiograph, postural compensation changes modified its location usually shifting it to a more caudal position. When the lumbar apex was assessed as the most distant point of the global lumbar lordosis, its position remained stable regardless of compensation. CONCLUSIONS: Postural changes can modify the location of the lumbar apex when understanding its location as the cornerstone of sagittal plane harmonic distribution. This concept can be useful as an additional sign to assess compensation. However, if the lumbar apex was calculated as the angular point of the global lordosis, its position remained stable regardless of postural changes. This concept can help to mold lumbar lordosis in ASD surgery. LEVEL OF EVIDENCE IV: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

The short-term impact of COVID-19 pandemic on spine surgeons: a cross-sectional global study.

PURPOSE: The outbreak of COVID-19 erupted in December 2019 in Wuhan, China. In a few weeks, it progressed rapidly into a global pandemic which resulted in an overwhelming burden on health care systems, medical resources and staff. Spine surgeons as health care providers are no exception. In this study, we try to highlight the impact of the crisis on spine surgeons in terms of knowledge, attitude, practice and socioeconomic burden. METHODS: This was global, multicentric cross-sectional study on 781 spine surgeons that utilized an Internet-based validated questionnaire to evaluate knowledge about COVID-19, availability of personal protective equipment, future perceptions, effect of this crisis on practice and psychological distress. Univariate and multivariate ordinal logistic regression analyses were used to evaluate the predictors for the degree of COVID-19 effect on practice. RESULTS: Overall, 20.2%, 52% and 27.8% of the participants were affected minimally, intermediately and hugely by COVID-19, respectively. Older ages (ß = 0.33, 95% CI 0.11-0.56), orthopedic spine surgeons (ß = 0.30, 95% CI 0.01-0.61) and those who work in the private sector (ß = 0.05, 95% CI 0.19-0.61) were the most affected by COVID-19. Those who work in university hospitals (ß = - 0.36, 95% CI 0.00 to - 0.71) were affected the least. The availability of N95 masks (47%) and disposable eye protectors or face shields (39.4%) was significantly associated with lower psychological stress (p = 0.01). Only 6.9%, 3.7% and 5% had mild, moderate and severe mental distress, respectively. CONCLUSION: While it is important to recognize the short-term impact of COVID-19 pandemic on the practice of spine surgery, predicting where we will be standing in 6-12 months remains difficult and unknown. The COVID-19 crisis will probably have an unexpected long-term impact on lives and economies.

Multiple-rod constructs in adult spinal deformity surgery for pelvic-fixated long instrumentations: an integral matched cohort analysis.

PURPOSE: Multiple-rod constructs (Multi-Rod: extra rods for additional pillar support) are occasionally used in adult spinal deformity (ASD) surgery. We aimed to compare and analyze the general outcome of multi-rod constructs with a matched two-rod cohort, to better understand the differences and the similitudes. METHODS: This is a retrospective matched cohort study including patients with ASD that underwent surgical correction with long posterior instrumentation (more than five levels), pelvic fixation and a minimum 1-year follow-up. Matching was considered with demographical data, preoperative radiographical parameters, preoperative clinical status [health-related quality-of-life (HRQoL) scores] and surgical characteristics (anterior fusion, decompression, rod material, osteotomies). Postoperative radiographical and clinical parameters, as well as complications, were obtained. Univariate and multivariate analysis was performed regarding postoperative improvement, group variables comparison and parameters correlation. RESULTS: Thirty-three patients with multi-rod construct and 33 matched with a two-rod construct were selected from a database with 346 ASD-operated patients. Both groups had a significant improvement with surgical management in the radiographical and HRQoL parameters (p < 0.001). Differences between groups for the postoperative radiographical, clinical and perioperative parameters were not significant. Rod breakage was more frequent in the two-rod group (8 vs 4, p = 0.089), as well as the respective revision surgery for those cases (6 vs 1 p = 0.046). Risk factors related to revision surgery were greater kyphosis correction (p = 0.001), longer instrumentation (p = 0.037) and greater sagittal vertical axis correction (p = 0.049). CONCLUSION: No major disadvantage on the use of multi-rod construct was identified. This supports the benefit of using multi-rod constructs to avoid implant failure. 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.

A new classification for coronal malalignment in adult spinal deformity: a validation and the role of lateral bending radiographs.

PURPOSE: Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. METHODS: Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. RESULTS: Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. CONCLUSIONS: Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

Opioids and analgesics use after adult spinal deformity surgery correlates with sagittal alignment and preoperative analgesic pattern.

PURPOSE: To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period. METHODS: In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed. RESULTS: Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P < 0.05) postoperatively. While the minimal group had the best pre- and postoperative HRQOL scores, the NSAID group demonstrated the best improvement in HRQOL. Only the minimal group displayed continued improvement from 6 months to 1 year. 90%, 65% and 40% of minimal, NSAID and narcotic groups of patients, respectively, no longer took any analgesics at 1 year postoperatively. Alternatively, 36% of patients in the narcotics group continued to take narcotics at 1 year. Residual malalignment increased NSAIDs consumption in different groups at 1 year. CONCLUSION: This study evaluated the analgesics use after ASD surgery in relation to the clinical and radiological outcomes. Despite important postoperative opioids consumption in the narcotics group, clinical outcome yet improved. Malalignment parameters demonstrated a predictive value in regard to NSAIDs' usage. These slides can be retrieved under Electronic Supplementary Material.

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.

Dual iliac screws in spinopelvic fixation: a systematic review.

PURPOSE: The classical spinopelvic fixation includes 1 iliac screw on each side. The purpose of this study is to specify the indications of the "dual iliac screw" (DIS) construct, i.e., when to put 2 iliac screws on each side, to describe its biomechanical advantages, and to define its related technical aspects. METHODS: A primary search on Medline through PubMed distribution was performed, with the use of the terms "pelvic fixation" or "spinopelvic" or "lumbo-iliac" and the terms "dual iliac screw" or "double iliac screw." English papers corresponding to the inclusion criteria were analyzed regarding the specific indications of the DIS construct and its surgical technique and advantages. RESULTS: Eleven papers were identified according to the research criteria and included in this review. Three main indications were identified for the DIS technique according to three types of pathologies: in adult deformities when a long construct is needed in an osteoporotic patient or when correction requires three-column osteotomy of the sacrum; in trauma when a U-shaped fracture-dislocation of the sacrum is involved; in sacral tumors when a sacrectomy is performed or when destructive metastatic lesions of the sacrum require palliative surgical treatment. Biomechanically, the DIS technique proved to have higher construct stiffness in terms of compression and torsion. CONCLUSION: In specific cases, affecting different areas of spinal diseases, the DIS technique is more advantageous, when compared to the "single iliac screw" version, as it would provide a stronger and safer fixation at the base of the spinopelvic construct. These slides can be retrieved under Electronic Supplementary Material.

Management of a pseudarthrosis with sagittal malalignment in a patient with ochronotic spondyloarthropathy.

PURPOSE: Ochronotic spondyloarthropathy is an uncommon disease, and its association to sagittal malalignment in the context of a pseudarthrosis has never been described. METHODS: We present the case of a 56-year-old female, who underwent previously L4L5 laminectomy for central canal stenosis and started later on to complain of progressively severe low back pain with a significant forward imbalance while walking. X-rays showed non-compensated sagittal malalignment due to thoracolumbar kyphosis, CT scan revealed multilevel central intradiscal calcifications with important vacuum disc at L4L5, and MRI showed T1 and T2 hypointensity signal at the same level with bone marrow oedema. Alkaptonuric ochronosis was suspected and confirmed by the presence of homogentisic acid in the urine, and the diagnosis of L4L5 pseudarthrosis with associated severe sagittal malalignment in the context of ochronotic spondyloarthropathy was established. RESULTS: The patient underwent surgery with a posterior-only approach with a long-segment pedicle screw construct from T10 to the pelvis with a 360° fusion with a cage at L4L5. Samples taken from the disc and ligaments confirmed the diagnosis of ochronotic spondyloarthropathy macroscopically and microscopically. She could walk on day 2 with a satisfactory clinical and radiological result at 2 years. CONCLUSION: This is the first case in the literature to describe a post-laminectomy pseudarthrosis leading to a significant sagittal malalignment in a patient with ochronotic spondyloarthropathy. Management of such a case is challenging as the spine is partially ankylosed; therefore, a long construct is advisable to avoid ankylosing disorders related complications.

Classification of coronal imbalance in adult scoliosis and spine deformity: a treatment-oriented guideline.

INTRODUCTION: In adult spinal deformity (ASD), sagittal imbalance and sagittal malalignment have been extensively described in the literature during the past decade, whereas coronal imbalance and coronal malalignment (CM) have been given little attention. CM can cause severe impairment in adult scoliosis and ASD patients, as compensatory mechanisms are limited. The aim of this paper is to develop a comprehensive classification of coronal spinopelvic malalignment and to suggest a treatment algorithm for this condition. METHODS: This is an expert's opinion consensus based on a retrospective review of CM cases where different patterns of CM were identified, in addition to treatment modifiers. After the identification of the subgroups for each category, surgical planning for each subgroup could be specified. RESULTS: Two main CM patterns were defined: concave CM (type 1) and convex CM (type 2), and the following modifiers were identified as potentially influencing the choice of surgical strategy: stiffness of the main coronal curve, coronal mobility of the lumbosacral junction and degeneration of the lumbosacral junction. A surgical algorithm was proposed to deal with each situation combining the different patterns and their modifiers. CONCLUSION: Coronal malalignment is a frequent condition, usually associated to sagittal malalignment, but it is often misunderstood. Its classification should help the spine surgeon to better understand the full spinal alignment of ASD patients. In concave CM, the correction should be obtained at the apex of the main curve. In convex CM, the correction should be obtained at the lumbosacral junction. These slides can be retrieved under Electronic Supplementary Material.