The Importance of Pelvic Obliquity in Assessing Spinal Coronal Alignment: Normative Values, Demographic, and Radiographic Correlations.

STUDY DESIGN: Prospective, cross-sectional study. OBJECTIVE: In a geographically diverse population of asymptomatic volunteers, we sought to report the incidence of pelvic obliquity (PO), establish normative values of PO across patient factors, and assess the correlation of PO with radiographic parameters. SUMMARY OF BACKGROUND DATA: PO is defined as the misalignment of the pelvis and can be assessed through several anatomic landmarks. Significant PO, whether caused by leg-length discrepancy or not, can lead to coronal malalignment which causes severe pain and disability. Significant emphasis has been placed on achieving appropriate sagittal alignment in recent decades; however, a greater understanding of coronal alignment is needed, and PO is a crucial aspect of evaluating the coronal plane in adult spinal deformity patients. METHODS: Asymptomatic adult volunteers, ages 18-80 years, enrolled patients from 5 countries (France, Japan, Singapore, Tunisia, and the United States) in the "multiethnic alignment normative study" cohort (IRB 201812144). The included volunteers had no known spinal disorder(s), no significant neck or back pain (Visual Analog Scale: ≤2; Oswestry Disability Index: ≤20), and no abnormal alignment (Cobb ≤20°). PO was measured in the frontal plane as the distance between the highest points of each acetabulum, calculated along the vertical axis in millimeters (mm). The incidence of PO was defined as PO ≥10 mm. Kruskal-Wallis, Wilcoxon rank-sum, Pearson correlation, and linear regression were used. RESULTS: A total of 467 patients were included, and PO values by age, sex, body mass index, and country were provided. The overall incidence of PO ≥10 mm was 4.3%, and a nonsignificant trend toward increased PO with age was seen ( P = 0.077). No significant differences were seen in PO between sex, ethnicity, or body mass index groups. No significant correlation existed between PO and other commonly used coronal radiographic measurements. CONCLUSION: PO ≥10 mm occurred in 4.3% of asymptomatic volunteers. Despite the importance of recognizing PO in preventing coronal malalignment, PO did not seem to be associated with other radiographic and demographic information, which underscores the importance of intentionally assessing for any PO before surgery. These results in an asymptomatic population provide a foundation for studying PO in patients with spinal pathology.

Do Grip Strength Dynamometer Readings Improve After Cervical Spine Surgery?

STUDY DESIGN: Retrospective, cohort study. OBJECTIVES: Hand function can be difficult to objectively assess perioperatively. In patients undergoing cervical spine surgery by a single-surgeon, we sought to: (1) use a hand dynamometer to report pre/postoperative grip strength, (2) distinguish grip strength changes in patients with radiculopathy-only vs myelopathy, and (3) assess predictors of grip strength improvement. METHODS: Demographic and operative data were collected for patients who underwent surgery 2015-2018. Hand dynamometer readings were pre/postoperatively at three follow-up time periods (0-3 m, 3-6 m, 6-12 m). RESULTS: 262 patients (mean age of 59 ± 14 years; 37% female) underwent the following operations: ACDF (80%), corpectomy (25%), laminoplasty (19%), and posterior cervical fusion (7%), with 81 (31%) patients undergoing multiple operations in a single anesthetic setting. Radiculopathy-only was seen in 128 (49%) patients, and myelopathy was seen 134 (51%) patients. 110 (42%) had improved grip strength by ≥10-lbs, including 69/128 (54%) in the radiculopathy-only group, and 41/134 (31%) in the myelopathy group. Those most likely to improve grip strength were patients undergoing ACDF (OR 2.53, P = .005). Patients less likely to improve grip strength were older (OR = .97, P = .003) and underwent laminoplasty (OR = .44, 95% CI .23, .85, P = .014). Patients undergoing surgery at the C2/3-C5/6 levels and C6/7-T1/2 levels both experienced improvement during the 0-3-month time range (C2-5: P = .035, C6-T2: P = .015), but only lower cervical patients experienced improvement in the 3-6-month interval (P = .030). CONCLUSIONS: Grip strength significantly improved in 42% of patients. Patients with radiculopathy were more likely to improve than those with myelopathy. Patients undergoing surgery from the C2/3-C5/6 levels and the C6/7-T1/2 levels both significantly improved grip strength at 3-month postoperatively.

The Posterior Cranial Vertical Line: A Novel Radiographic Marker for Classifying Global Sagittal Alignment.

OBJECTIVE: To define a novel radiographic measurement, the posterior cranial vertical line (PCVL), in an asymptomatic adult population to better understand global sagittal alignment. METHODS: We performed a multicenter retrospective review of prospectively collected radiographic data on asymptomatic volunteers aged 20-79. The PCVL is a vertical plumb line drawn from the posterior-most aspect of the occiput. The horizontal distances of the PCVL to the thoracic apex (TA), posterior sagittal vertical line (PSVL, posterosuperior endplate of S1), femoral head center, and tibial plafond were measured. Classification was either grade 1 (PCVL posterior to TA and PSVL), grade 2 (PCVL anterior to TA and posterior to PSVL), or grade 3 (PCVL anterior to TA and PSVL). RESULTS: Three hundred thirty-four asymptomatic patients were evaluated with a mean age of 41 years. Eighty-three percent of subjects were PCVL grade 1, 15% were grade 2, and 3% were grade 3. Increasing PCVL grade was associated with increased age (p < 0.001), C7-S1 sagittal vertical axis (SVA) (p < 0.001), C2-7 SVA (p < 0.001). Additionally, it was associated with decreased SS (p = 0.045), increased PT (p < 0.001), and increased knee flexion (p < 0.001). CONCLUSION: The PCVL is a radiographic marker of global sagittal alignment that is simple to implement and interpret. Increasing PCVL grade was significantly associated with expected changes and compensatory mechanisms in the aging population. Most importantly, it incorporates cervical alignment parameters such as C2-7 SVA. The PCVL defines global sagittal alignment in adult volunteers and naturally distributes into 3 grades, with only 3% being grade 3 where the PCVL lies anterior to the TA and PSVL.

Morphological description of sagittal lumbar spinal alignment using curve magnitude, span, and apex-the multiethnic alignment normative study (MEANS).

BACKGROUND CONTEXT: Current definition of lumbar lordosis uses the L1-S1 angle. Prevailing classification of sagittal spinal morphology, derived from a young adult population, classifies the spine into four subtypes defined by their sacral slope (SS) and curve morphology. PURPOSE: To describe physiological sagittal alignment of the lumbar spine across age groups using three main parameters that dictate the lumbar curve: angular magnitude, span, and apex. STUDY DESIGN: A large, multicenter, cross-sectional radiographic comparison study. PATIENT SAMPLE: Four hundred sixty-eight healthy, asymptomatic subjects aged 18 to 80 years from five countries (184 males, 284 females; 98 France, 119 Japan, 79 Singapore, 80 Tunisia, 92 USA, mean age 40.61±14.99 years). OUTCOME MEASURES: Sagittal lumbar profile subtypes clustered based on lumbar curve angular magnitude (ie, Cobb angle of the lumbar lordosis), span, and apex, and described by sagittal radiographic parameters. METHODS: Subjects underwent whole-body low-dose EOS stereoradiographs. Comparisons between conventional L1-S1 lumbar lordosis (cLL) and true lumbar lordosis (tLL, defined by the inflection-S1 angle) were conducted. Using the K-means clustering algorithm, lumbar curve angular magnitude, span and apex were used to classify sagittal spinal morphology into subtypes, stratified across age groups. Further univariate and multivariate analyses were conducted to compare radiographic parameters across subtypes, and identify predictors for the lumbar curve's angular magnitude, span and apex. RESULTS: Mean cLL was -57.27±11.37°, and tLL was -62.62±10.76°. Using tLL, instead of cLL, to describe sagittal spinal morphology, we found significant differences in terms of angular magnitude of the lumbar curve, the median thoracolumbar inflection vertebral level and pelvic incidence-lumbar lordosis mismatch Multivariate analysis found a larger SS, more positive T9 tilt, and more kyphotic T4-T12 predictive for a more lordotic tLL, while a larger overhang distance predicted for a less lordotic tLL (p-values<.001). In addition, a larger T9 tilt, less lordotic L1-L5 and smaller PT were predictors of a more caudal thoracolumbar inflection and lumbar apical vertebral levels (p-values<.001). Sagittal lumbar profiles of subjects age<30 years, 30≤age<60 years and age≥60 years, could be classified into 4, 6, and 3 subtypes, respectively. CONCLUSIONS: Sagittal lumbar profile subtypes vary across age groups, with more homogenous morphologies at the extremes of ages. Improved understanding of the morphological evolution of sagittal spinal profiles with age in asymptomatic individuals will help guide future individualized surgical treatment.

The Lumbosacral Fractional Curve vs Maximum Coronal Cobb Angle in Adult Spinal Deformity Patients with Coronal Malalignment: Which Matters More?

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: In patients undergoing adult spinal deformity (ASD) surgery we sought to: 1) report preoperative and postoperative lumbosacral fractional (LSF) curve and maximum coronal Cobb angles and 2) determine their impact on radiographic, clinical, and patient-reported outcomes (PROs). METHODS: A single-institution cohort study was undertaken. The LSF curve was the cobb angle between the sacrum and most tilted lower lumbar vertebra. Coronal/sagittal vertical axis (CVA/SVA) were collected. Patients were compared between 4 groups: 1) Neutral Alignment (NA); 2) coronal malalignment only (CM); 3) Sagittal malalignment only (SM); and 4) Combined-Coronal-Sagittal-Malalignment (CCSM). Outcomes including postoperative CM, postoperative coronal vertical axis, complications, readmissions, reoperation, and PROs. RESULTS: A total of 243 patients underwent ASD surgery with mean total instrumented levels of 13.5. Mean LSF curve was 12.1±9.9°(0.2-62.3) and mean max Cobb angle was 43.0±26.5° (0.0-134.3). The largest mean LSF curves were seen in patients with CM (14.6°) and CCSM (13.1°) compared to NA (12.1°) and SM (9.5°) (p=0.100). A higher LSF curve was seen in patients with fusion to the sacrum and instrumentation to the pelvis (p=0.009), and a higher LSF curve was associated with more TLIFs (p=0.031). Postoperatively, more TLIFs were associated with greater amount of LSF curve correction (p<0.001). Comparing the LSF and the max Cob angle among Qiu types, the highest mean max Cobb angle was in Qiu Type B patients (p=0.025), whereas the highest mean LSF curve was in Qiu Type C patients (p=0.037). Moreover, 82.7% of patients had a LSF curve opposite the max Cobb angle. The LSF curve was larger than the max Cobb angle in 22/243 (9.1%) patients, and most of these 22 patients were Qiu Type A (59.1%). Regarding correction, the max Cobb angle achieved more correction than the LSF curve, judged by the percent improved from preop (54.5% Cobb vs. 46.5% LSF, p=0.025) in patients with max cobb>20° and LSF curve >5°. The LSF curve underwent greater correction in Qiu Type C patients (9.2°) compared to Type A (5.7°) and Type B (5.1°) (p=0.023); however, the max Cobb angle was similarly corrected among Qiu Types: Type A 21.8°, Type B 24.6°, and Type C 25.4° (p=0.602). Minimal differences were seen comparing the preop/postop/change in LSF curve and max Cobb angle regarding postop CM, postop CVA, complications, readmissions, reoperation, and PROs. CONCLUSIONS: The LSF curve was highest in patients with CM, CCSM, and Qiu Type C curves. Most patients had a LSF curve opposite the max Cobb angle. The max Cobb angle was more often corrected than the LSF curve. The LSF curve underwent greater correction among Qiu Type C patients, whereas the max Cobb angle was similarly corrected among all Qiu Types. No clear trend was seen regarding postoperative complications and PROs between the LSF curve and max Cobb angle.

Living with a C2-Sacrum Spinal Fusion: Surgical Outcomes and Quality of Life in Patients Fused from C2 to the Sacrum.

STUDY DESIGN: Single center, retrospective cohort study. OBJECTIVES: Little is known about the surgical outcomes and quality of life in patients with C2-sacrum posterior spinal fusion (PSF). Though it is thought to be a "final" construct, it remains unknown how patients fare postoperatively. We sought to evaluate the surgical outcomes and quality of life of patients after C2-sacrum PSF. METHODS: Consecutive patients undergoing C2-Sacrum PSF from 2015-2020 by 4 surgeons at a single institution were included. The study time period for each patient began after their index operation that led to the C2-sacrum fusion. Dates of surgery, complications, reoperations, patient reported outcomes (PROs) including EuroQol 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) questionnaires, and activities of daily living (ADL) questions were collected and analyzed. Descriptive statistics, paired t-tests, student t-tests, and linear regression were used. RESULTS: Of the 23 patients who underwent C2-sacrum PSF, 6 patients (26%) required a total of 10 reoperations after a mean of 1.5 years (range 0-4 years) after C2-sacrum PSF. Five reoperations were for mechanical failure; 3 for wound complications/infection; and 2 for instrumentation and spinous process prominence. PROs were collected on 18 patients with mean follow-up of 2.4 years (range .5-4.5) after their C2-sacrum PSF. At 6-months, both SRS-22 and ODI scores improved significantly after C2-sacrum PSF (SRS: 57.5 to 76.3, P = .0014; ODI: 47.0 to 31.7, P = .013). Similarly, at a mean 2.4 years postoperatively, mean ODI improved significantly (47.0 to 30.4, P = .0032). Six patients (33%) had minimal symptoms (ODI <20). The median postoperative EQ-5D score was .74 (range .19 to 1.0), which compares favorably to patients with hip/knee osteoarthritis (EQ-5D .63) and diabetes mellitus (DM) (EQ-5D .69) and hypertension (HTN). In terms of activities of daily living (ADL), 10 patients (56%) exercised regularly-a mean 4.5 days/week. 11 (61%) could do light aerobic activity (e.g. stationary bike). 10 (55%) were able to play with children/grandchildren as desired. Eight patients (44%) hiked, and 2 (11%) drove independently. 11 (61%) could tolerate short air-travel comfortably. Of the 17 patients who could toilet and perform basic hygiene preoperatively, 16 (94%) were able to do so postoperatively. CONCLUSION: Though C2-sacrum PSF is thought to be a "final" construct, approximately 1 in 4 patients require subsequent operations. However, C2-sacrum PSF patients had a significant improvement in SRS and ODI scores by 6 months postop. Over 60% of patients were regularly performing light aerobic activity 2 years after their C2-sacrum PSF. EQ-5D suggests that this population fares better than those with degenerative hip/knee arthritis and similarly to those with common chronic conditions like DM and HTN.

Rod fractures after multi-rod constructs in adult spinal deformity patients fused to the sacrum/pelvis: where do they occur and why?

PURPOSE: (1) To describe the use of multi-rod constructs (MRCs) in adult spinal deformity (ASD) surgery, (2) to report rod fractures occurring at MRC sites, and (3) to evaluate risk factors for rod fractures. METHODS: A single-center, retrospective cohort study was conducted of patients undergoing ASD surgery with these inclusion criteria: minimum 2-year follow-up, MRCs used, ≥ 10-level fusion, and fused to sacrum/pelvis. The primary outcome was rod fracture. Univariate/multivariate logistic regression was performed controlling for age, kickstand rod usage, number of rods across the lumbosacral junction (LSJ), and the amount of coronal/sagittal Cobb correction. RESULTS: Among 57 patients undergoing ASD surgery with MRCs, mean age was 60 ± 11 years. With respect to MRCs, 32 (56%) patients had 3 rods, 18 (32%) had 4, and 7 (12%) had 5. Rods crossing the LSJ were most often three (63%), followed by four (25%) and five (5%) rods. Nine (16%) patients experienced rod fractures with eight (89%) patients having no more than three rods crossing the LSJ. A coronal correction > 30 mm was more often seen in patients with rod fracture (p = 0.030), while an SVA correction > 50 mm was not significantly different (p = 0.608). Multivariate logistic regression revealed that the amount of coronal correction was significantly associated with rod fracture (OR 1.03, 95% CI 1.01-1.07, p = 0.044), as was achieving a coronal correction > 30 mm (OR 7.72, 95% CI 1.17-51.10, p = 0.034), with no association between the amount of sagittal correction obtained and rod fracture. CONCLUSION: This study found that greater coronal correction was associated with an increased odds of rod fracture. We suggest adding at least four rods across the LSJ cephalad to the interbody fusions to avoid rod fractures in these high demand areas. LEVEL OF EVIDENCE: III.

Postoperative coronal malalignment after adult spinal deformity surgery: incidence, risk factors, and impact on 2-year outcomes.

PURPOSE: To evaluate the incidence, risk factors, and patient-reported outcomes (PROs) of adult spinal deformity (ASD) patients with postoperative coronal malalignment. METHODS: A single-institution, retrospective cohort study of ASD patients undergoing ≥ 6 level fusions from 2015 to 2019 was undertaken. The primary outcome was postoperative coronal malalignment, defined as C7-coronal vertical axis (CVA) > 3 cm. Secondary outcomes included: complications, readmissions, reoperations, and 2-year PROs. RESULTS: A total of 243 ASD patients undergoing spinal surgery had preoperative and immediate postoperative measurements, and 174 patients (72%) had 2-year follow-up. Mean age was 49.3 ± 18.3yrs and mean instrumented levels was 13.5 ± 3.9. Mean preoperative CVA was 2.9 ± 2.7 cm, and 90 (37%) had preoperative coronal malalignment. Postoperative coronal malalignment occurred in 43 (18%) patients. Significant risk factors for postoperative coronal malalignment were: preoperative CVA (OR 1.21, p = 0.001), preoperative SVA (OR 1.05, p = 0.046), pelvic obliquity (OR 1.21; p = 0.008), Qiu B vs. A (OR 4.17; p = 0.003), Qiu C vs. A (OR 7.39; p < 0.001), lumbosacral fractional (LSF) curve (OR 2.31; p = 0.021), max Cobb angle concavity opposite the CVA (OR 2.10; p = 0.033), and operative time (OR 1.16; p = 0.045). Postoperative coronal malalignment patients were more likely to sustain a major complication (31% vs. 14%; p = 0.01), yet no differences were seen in readmissions (p = 0.72) or reoperations (p = 0.98). No significant differences were seen in 2-year PROs (p > 0.05). CONCLUSIONS: Postoperative coronal malalignment occurred in 18% of ASD patients and was most associated with preoperative CVA/SVA, pelvic obliquity, Qiu B/C curves, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite side of the CVA. Postoperative coronal malalignment was significantly associated with increased complications but not readmission, reoperation, or 2-year PROs.

Predicting Bone Health Using Machine Learning in Patients undergoing Spinal Reconstruction Surgery.

STUDY DESIGN: Retrospective study of data collected prospectively. OBJECTIVE: The goal of this study is to create a predictive model of preoperative bone health status in adult patients undergoing adult spinal reconstructive (ASR) surgery using machine learning (ML). SUMMARY OF BACKGROUND DATA: Despite understanding that bone health impacts spine surgery outcomes, spine surgeons lack the tools to risk stratify patients preoperatively to determine who should undergo bone health screening. An ML approach mines patterns in data to determine the risk for poor bone health in ASR patients. MATERIALS AND METHODS: Two hundred and eleven subjects over the age of 30 with dual energy X-ray absorptiometry scans, who underwent spinal reconstructive surgery were reviewed. Data was collected by manual and automated collection from the electronic health records. The Weka software was used to develop predictive models for multiclass classification of healthy, osteopenia, and osteoporosis (OPO) bone status. Bone status was labeled according to the World Health Organization (WHO) criteria using dual energy X-ray absorptiometry T scores. The accuracy, sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. The model was evaluated on a test set of unseen data for generalizability. RESULTS: The prevalence of OPO was 23.22% and osteopenia was 52.61%. The random forest model achieved optimal performance with an average sensitivity of 0.81, specificity of 0.95, and AUC of 0.96 on the training set. The model yielded an averaged sensitivity of 0.64, specificity of 0.78, and AUC of 0.69 on the test set. The model was best at predicting OPO in patients. Numerous patient features exhibited predictive value, such as body mass index, insurance type, serum sodium level, serum creatinine level, history of bariatric surgery, and the use of medications such as selective serotonin reuptake inhibitors. CONCLUSION: Predicting bone health status in ASR patients is possible with an ML approach. Additionally, data mining using ML can find unrecognized risk factors for bone health in ASR surgery patients.

Patients With Coronal Malalignment Undergoing Adult Spinal Deformity Surgery: Does Coronal Alignment Change From Immediately Postoperative to 2-years?

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The objectives were to: (1) characterize the changes in coronal vertical axis (CVA) after adult spinal deformity (ASD) surgery from immediate postoperative to 2-years postoperative, and (2) assess for predictors of CVA change from immediate postoperative to 2-years postoperative. SUMMARY OF BACKGROUND DATA: It is unknown whether coronal correction obtained immediately postoperative accurately reflects long-term coronal alignment. MATERIALS AND METHODS: A retrospective, single-institution registry was queried for patients undergoing ASD surgery from 2015-2019, including patients undergoing ≥6-level fusions with preoperative coronal malalignment (CM), defined as CVA≥3 cm. A clinically significant change in CVA was defined a priori as ≥1 cm. Radiographic variables were obtained preoperatively, immediately postoperative, and at 2-years postoperative. RESULTS: Of 368 patients undergoing ASD surgery, 124 (33.7%) had preoperative CM, and 64 (17.0%) completed 2-years follow-up. Among 64 patients, mean age was 53.6±15.4 years. Preoperatively, absolute mean CVA was 5.4±3.1 cm, which improved to 2.3±2.0 cm ( P <0.001) immediately postoperative and 2.2±1.6 cm ( P <0.001) at 2-years. The mean change in CVA from preoperative to immediately postoperative was 2.2±1.9 cm (0.3-14.4). During the immediate postoperative to 2-years interval, 29/64 (45.3%) patients experienced a significant change of CVA by ≥1 cm, of which 22/29 (76%) improved by a mean of 1.7 cm and 7/29 (24%) worsened by a mean of 3.5 cm. No preoperative or surgical factors were associated with changed CVA from immediately postoperative to 2-years. CONCLUSION: Among 64 patients undergoing ASD surgery with preoperative CM, 45.3% experienced a significant (≥1 cm) change in their CVA from immediately postoperative to 2-years postoperative. Of these 29 patients, 22/29 (76%) improved, whereas 7/29 (24%) worsened. Although no factors were associated with undergoing a change in CVA, this information is useful in understanding the evolution and spontaneous coronal alignment changes that take place after major ASD coronal plane correction.

Myelopathic Patients Undergoing Severe Pediatric Spinal Deformity Surgery Can Improve Neurologic Function to That of Non-Myelopathic Patients by 1-Year Postoperative.

STUDY DESIGN: Multi-center, prospective, observational cohort. OBJECTIVE: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes. METHODS: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy). RESULTS: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up. CONCLUSION: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

OBJECTIVE: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval. STUDY DESIGN: Retrospective Cohort. METHODS: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed. RESULTS: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved (P < .001). In all patients, the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; P < .001). Subgroup analysis: ≥55 years had an improved median ODI (18 vs. 8; P = .047) and an improved percent achieving ODI MCID (73% vs. 84%, P = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; P = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; P = .032). CONCLUSIONS: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.

What Radiographic and Clinical Factors Ultimately Necessitate a C2-Sacrum Instrumented Posterior Spinal Fusion?

OBJECTIVE: /Hypothesis: Patients undergoing C2-sacrum PSF have unique medical histories and multiple prior operations over an extended period. DESIGN: Single center, retrospective cohort. METHODS: Consecutive C2-sacrum PSF patients operated on by 4 surgeons at a single-center from 2015-2020 were reviewed. Demographics, comorbidities, indications, surgical history, and radiographic parameters were collected. RESULTS: 23 patients underwent C2-sacrum PSF. 13 (57%) were male, and 21 (91.3%) were adults. Mean age at time of first spine surgery was 44 years (range 5-71) and 53 years (range 14-72) at the time of C2-sacrum PSF. Six patients (26%) had osteoporosis, and 6 patients (26%) had neurologic comorbidities-including Parkinson's disease (4), cerebral palsy (1), and Brown Sequard syndrome (1). Four (17%) had connective tissue disease. Two patients underwent C2-sacrum PSF as an index procedure: (1) 67M with myelomatous fractures and 124° of cervicothoracic kyphosis; (2) 28F with severe Marfan syndrome with 140° thoracic scoliosis and 130° thoracic kyphosis. The remaining 21 (91%) underwent C2-sacrum PSF as a revision following prior spinal surgeries on average, 4 previous surgeries (range 1-13) over 10.5 years (range .3-37.4). Indications for the remaining 21 C2-sacrum PSF revision procedures included 17 (81%) for kyphosis (5 of whom also had significant coronal deformity), 1 (5%) for only coronal malalignment, 2 (10%) for instrumentation failure, and 1 (5%) for myelopathy. CONCLUSIONS: 91% (21/23) of patients requiring C2-sacrum PSF were treated as revisions of prior fusions, with a mean of 4 prior surgeries over 10 years. Over 80% of these patients underwent C2-sacrum PSF to address kyphosis. 26% had neurologic conditions, and 26% had osteoporosis.

Risk of distal junctional kyphosis in scheuermann's kyphosis is decreased by selecting the LIV as two vertebrae distal to the first lordotic disc.

PURPOSE: To determine whether (1) distal junctional kyphosis (DJK) is decreased by selecting the stable sagittal vertebra (SSV), versus the vertebra below the 1st lordotic disc (1stLD), as the lowest instrumented level (LIV); (2) DJK is decreased if the LIV is two versus one vertebrae distal to the 1stLD. METHODS: A multi-institution prospective database was queried for SK patients who underwent posterior-only instrumentation and fusion with > 2 year follow-up. DJK was defined as > 10° change in the distal junctional angle postoperative from the preoperative junctional angle. Statistical analysis was performed using t test, chi-square test and logistic regression. RESULTS: Of 94 patients included, 38 (40%) developed radiographic DJK. 31 (39%) patients in whom the LIV was at or distal to the SSV developed DJK, whereas 7 (47%) in whom the LIV was proximal to the SSV developed DJK. 20 (59%) patients in whom the LIV was one vertebra below and 10 (22%) in whom the LIV was two vertebrae below the 1stLD developed DJK. Logistic regression demonstrated a significant increase in DJK development if the LIV was one vertebra below the 1stLD (OR = 3.2 (1.28-8.18)). There was not a significant relationship between DJK development and LIV position relative to the SSV. CONCLUSION: In SK surgery, LIV selection/fusion to two vertebrae below the 1stLD decreased the development of DJK. A significant relationship was not found between DJK development and location of distal fusion level in regards to the SSV, possibly due to the small number of patients who had LIV proximal to SSV.

Age and Gender Based Spinopelvic and Regional Spinal Alignment in Asymptomatic Adult Volunteers: Results of the Multi-Ethnic Alignment Normative Study (MEANS).

BACKGROUND: Spinal alignment can have a significant impact on a patient's overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex. MATERIALS AND METHODS: Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. RESULTS: MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was -0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was -5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤-10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)-0.2 (age) ( r =0.75). CONCLUSIONS: LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL. LEVEL OF EVIDENCE: Level II-prospective cohort study.

Age- and Gender-based Global Sagittal Spinal Alignment in Asymptomatic Adult Volunteers: Results of the Multiethnic Alignment Normative Study (MEANS).

STUDY DESIGN: Multicenter Cohort. OBJECTIVE: Assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender. SUMMARY OF BACKGROUND DATA: Our understanding of ideal sagittal alignment is still evolving. The Multiethnic Alignment Normative Study (MEANS) investigated skeletal alignment of the largest multiethnic cohort of asymptomatic adult volunteers. We aim to assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender. MATERIALS AND METHODS: Asymptomatic volunteers between the ages of 18-80 years were enrolled prospectively and then analyzed retrospectively from six different centers. Volunteers included reported no significant neck or back pain, nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. RESULTS: MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. The average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. LL did not show significant differences across the five age groups. TK showed a significant difference based on age ( P <0.0001). Sagittal vertical axis increased across age groups from -14.2 mm in young adults to 17.0 mm in patients >64. Similar trend was seen for T1 pelvic angle with a mean of 5.0° in young adults and 13.7° in those older than age 64. Knee flexion increased across age groups without a significant change in odontoid-knee distance which is a surrogate for the center of the head aligned over the knees. CONCLUSIONS: In asymptomatic volunteers, sagittal alignment parameters showed a slow and steady change across age groups exemplified by an increase in TK. However, LL did not show a significant decrease across age groups. Volunteers used compensatory mechanisms such as slight pelvis retroversion, knee flexion, and neck extension to maintain an aligned sagittal posture with their head centered over their knees (odontoid-knee). LEVEL OF EVIDENCE: 3.

Worse Preoperative Disability is Predictive of Improvement in Disability After Complex Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Few previous studies have examined the relationship between preoperative disability and patient outcomes after complex adult spinal deformity surgery. In this study, we hypothesized that patients with worse preoperative disability would be more likely achieve a clinically significant improvement in their symptoms after surgery. METHODS: Demographics, comorbidities, surgical data, and health related survey results were analyzed from a consecutive series of adults (≥18 years old) who underwent spinal deformity correction, instrumentation, and fusion. Patients included had 6 or more levels fused and their surgery performed at single institution between 2015 and 2018 with minimum 2 year follow up. RESULTS: A total of 108 patients met inclusion criteria. Bivariate analysis demonstrated the following as having a greater probability of reaching minimum clinically important difference (MCID) at 2 years postoperatively: >50th percentile Oswestry Disability Index (ODI) score (ODI >36), cardiac comorbidities, and use of pelvic fixation, pedicle subtraction osteotomy, and transforaminal lumbar interbody fusion. Conversely, baseline Scoliosis research society score (SRS) >50th percentile (SRS ≥62) and use of vertebral column resection (VCR) were significant predictors of not reaching MCID at 2 years. On logistic regression analysis, >50th percentile ODI score (ODI >36) was identified as the only independent predictor of achieving MCID. CONCLUSIONS: Patients with greater disability, independent of other preoperative or surgical factors, are more likely to have clinically significant improvement in their daily functioning after complex deformity surgery. For patients who undergo surgical intervention for severe or progressive deformity, including VCR, MCID might be an ineffective outcome measure.

Evaluation of coronal alignment from the skull using the novel orbital-coronal vertical axis line.

OBJECTIVE: When treating patients with adult spinal deformity (ASD), radiographic measurements evaluating coronal alignment above C7 are lacking. The current objectives were to: 1) describe the new orbital-coronal vertical axis (ORB-CVA) line that evaluates coronal alignment from cranium to sacrum, 2) assess correlation with other radiographic variables, 3) evaluate correlations with patient-reported outcomes (PROs), and 4) compare the ORB-CVA with the standard C7-CVA. METHODS: A retrospective cohort study of patients with ASD from a single institution was undertaken. Traditional C7-CVA measurements were obtained. The ORB-CVA was defined as the distance between the central sacral vertical line and the vertical line from the midpoint between the medial orbital walls. The ORB-CVA was correlated using traditional coronal measurements, including C7-CVA, maximum coronal Cobb angle, pelvic obliquity, leg length discrepancy (LLD), and coronal malalignment (CM), defined as a C7-CVA > 3 cm. Clinical improvement was analyzed as: 1) group means, 2) minimal clinically important difference (MCID), and 3) minimal symptom scale (MSS) (Oswestry Disability Index < 20 or Scoliosis Research Society-22r Instrument [SRS-22r] pain + function domains > 8). RESULTS: A total of 243 patients underwent ASD surgery, and 175 had a 2-year follow-up. Of the 243 patients, 90 (37%) had preoperative CM. The mean (range) ORB-CVA at each time point was as follows: preoperatively, 2.9 ± 3.1 cm (-14.2 to 25.6 cm); 1 year postoperatively, 2.0 ± 1.6 cm (-12.4 to 6.7 cm); and 2 years postoperatively, 1.8 ± 1.7 cm (-6.0 to 11.1 cm) (p < 0.001 from preoperatively to 1 and 2 years). Preoperative ORB-CVA correlated best with C7-CVA (r = 0.842, p < 0.001), maximum coronal Cobb angle (r = 0.166, p = 0.010), pelvic obliquity (r = 0.293, p < 0.001), and LLD (r = 0.158, p = 0.006). Postoperatively, the ORB-CVA correlated only with C7-CVA (r = 0.629, p < 0.001) and LLD (r = 0.153, p = 0.017). Overall, 155 patients (63.8%) had an ORB-CVA that was ≥ 5 mm different from C7-CVA. The ORB-CVA correlated as well and sometimes better than C7-CVA with SRS-22r subdomains. After multivariate logistic regression, a greater ORB-CVA was associated with increased odds of complication, whereas C7-CVA was not associated with any of the three clinical outcomes (complication, readmission, reoperation). A larger difference between the ORB-CVA and C7-CVA was significantly associated with readmission and reoperation after univariate and multivariate logistic regression analyses. A threshold of ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes. CONCLUSIONS: The ORB-CVA correlated well with known coronal measurements and PROs. ORB-CVA was independently associated with increased odds of complication, whereas C7-CVA was not associated with any outcomes. A ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes.

Three-Dimensional Assessment of Vertebral Derotation in Adolescent Idiopathic Scoliosis: Review of a Surgical Technique and Its Success in Achieving Derotation in the Instrumented and Uninstrumented Spine.

BACKGROUND: Three-dimensional (3D) imaging represents a novel way to assess surgical derotation maneuvers in adolescent idiopathic scoliosis (AIS). OBJECTIVE: To assess the following in patients with AIS undergoing derotation surgery with Lenke type 1/2 curves using 3D imaging: (1) the primary outcome of thoracic apical vertebral rotation (T-AVR) and (2) secondary outcomes of thoracic kyphosis (TK), lumbar AVR (L-AVR), and rotation of each thoracic/lumbar vertebrae. METHODS: A retrospective, pilot study of type 1/2 AIS patients from 2017 to 2018 was performed. All patients received posterior pedicle screw/rod constructs with consistent direct vertebral derotational maneuvers and received full length SterEOS imaging with 3D reconstruction. The primary outcome of interest was T-AVR. Secondary outcomes included TK, L-AVR, and rotation at each thoracic/lumbar vertebrae. RESULTS: Fifteen patients (mean age 15.7 ± 1.2 years, 67.0% female) were studied. The mean preoperative/postoperative Cobb angle of the major curve was 51.8° ± 14.9° (range 39.8-62.0) and 11.0° ± 5.1° (range 3.7-20.7). Mean level fused was 10.5 ± 1.2. The primary outcome of T-AVR showed significant improvement (13.8° ± 12.5° vs 9.2° ± 8.6°, P = .015) after surgery, along with secondary outcome of TK (T1-12/T4-12, P = .008/.027). Significant spontaneous rotational improvement was seen in L-AVR (P = .016). Significant improvement was also seen in 11 of 17 (64.7%) individual vertebrae (T3-8/T11-L3) (P < .05). CONCLUSION: In Lenke Type 1/2 AIS patients undergoing surgical derotation and fusion, 3D imaging techniques captured improvements in rotation. Significant postoperative improvement was seen in T-AVR, TK, L-AVR, and rotation of the individual vertebrae T3-8/T11-L3. These pilot results warrant the study of 3D imaging in all patients with AIS and other scoliosis populations.

Determining the relationship between preoperative mental health scores and postoperative outcomes in adult spinal deformity surgeries.

OBJECTIVE: The objective of this study was to examine the relationship between the mental health domain of the refined 22-item Scoliosis Research Society Outcome Questionnaire (SRS) and various postoperative outcome measures in the adult spinal deformity (ASD) population. Given the scale and involved nature of deformity surgery, some surgeons have proposed that preoperative mental health scores (MHSs) may assist in screening out poor surgical candidates. In this study, the authors aimed to further assess the SRS MHS as a preoperative metric and its association with postoperative outcomes and to comment on its potential use in patient selection and optimization for ASD surgery. METHODS: The authors conducted a retrospective study of 100 consecutive patients who had undergone primary or revision ASD surgery at a single academic institution between 2015 and 2019. Each patient had a minimum 2-year follow-up. Patients were categorized on the basis of their baseline mental health per the SRS mental health domain, with a score < 4 indicating low baseline mental health (LMH) and a score ≥ 4 indicating high baseline mental health (HMH). Baseline and follow-up SRS and Oswestry Disability Index scores, surgical procedures, lengths of stay, discharge locations, intraoperative or postoperative complications, and other outcome metrics were then compared between the HMH and LMH groups, as well as these groups stratified by an age ≤ 45 and > 45 years. RESULTS: Among patients aged ≤ 45 and those aged > 45, the LMH group had significantly worse baseline health-related quality-of-life (HRQOL) metrics in nearly all domains. The LMH group also had an increased median estimated blood loss (EBL; 1200 vs 800 ml, p = 0.0026) and longer average surgical duration (8.3 ± 2.8 vs 6.9 ± 2.6 hours, p = 0.014). Both LMH and HMH groups had significant improvements in nearly all HRQOL measures postoperatively. Despite their worse preoperative HRQOL baseline, patients in the LMH group actually improved the most and reached the same HRQOL endpoints as those in the HMH group. CONCLUSIONS: While patients with lower baseline MHSs may require slightly longer hospital courses or more frequent discharges to rehabilitation facilities, these patients actually attain greater absolute improvements from their preoperative baseline and surprisingly have the same postoperative HRQOL metrics as the patients with high MHSs, despite their poorer starting point. This finding suggests that patients with LMH may be uniquely positioned to substantially benefit from surgical intervention and improve their HRQOL scores and thus should be considered for ASD surgery to an extent similar to patients with HMH.