Implementing an infection control checklist May not be effective in reducing the incidence of surgical site infections in spinal surgery.

Background: Surgical site infections (SSI) in instrumented spine surgery remains as a major complication with increased morbidity. Although implementation of surgical safety checklists has been reported to lower the rates of SSI, reproducibility of these remain unclear. Objective: The specific aim of this study was to explore the results of implementation of a SSI control protocol in regard to its efficacy in decreasing the rate of SSI. Methods: A total of 140 instrumented spinal surgery cases between 2018 and 2021 were divided into two groups as Group 1 (checklist implemented) and Group 2 (control) and these were compared regarding SSI rates, patient rand surgery related factors, laboratory findings and infecting microorganisms. Results: Ten SSIs were encountered in Group 1 (20.8%), whereas only nine in Group 2 (9.8%). Although not statistically significant (p > .05), these results highly favor the non-checklist implemented group regarding the development of SSI. A definitive infective microorganism could be identified in five out of 10 SSI in Group 1 and 6 out of nine in Group 2. Whereas only three out of 11 (27.3%) involved Gr (+) agents, rest of eight out of 11 (72.7%) involved Gr (-) agents. Discussion: A failure in decreasing the SSI rate through the implementation of a SSI prevention checklist may be due to several factors pertaining to the study design, patient characteristics and the Gr (-) dominance in SSIs in our center. Nevertheless, this suggests that checklist implementation to prevent SSI in instrumented spine surgery may not be effective in all contexts.

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.

Ideal sagittal profile restoration and ideal lumbar apex positioning play an important role in postoperative mechanical complications after a lumbar PSO.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To determine the influence of postoperative ideal lordosis distribution and ideal sagittal harmony on mechanical complications in patients undergoing one-level lumbar pedicle subtraction osteotomy (L-PSO). Many variables have been associated with mechanical complications after L-PSO. However, the impact of restoring the ideal inflexion point, lumbar apex, and sagittal shape is still underexplored. METHODS: Analyzed risk factors were: age and patient-related variables, PSO level, interbody cages, rod material/diameter, number of rods, upper instrumented vertebra, lower instrumented vertebra, PI-LL mismatch, global tilt (GT), postoperative level of lumbar apex (LApex), postoperative level of inflexion point (InfxP), and postoperative type of Roussouly sagittal profile (R-type). These last variables were compared to ideal (based on pelvic incidence). Univariate and multivariate analyses were performed to identify risks for mechanical complications with a minimum 2-year follow-up. RESULTS: A total of 87 patients were included. Mean follow-up was 4.5 ± 1.7 years. 40.2% of the patients suffered postoperative mechanical complications (7 PJK, 4 PJF, 18 pseudoarthrosis/rod breakage, 6 screw pullout). Mean time for complications was 584 ± 416 days from surgery. Univariate analysis showed that age (63 vs 57 years; P = 0.04), BMI (28.1 vs 25.9; P = 0.024), preoperative-GT (50.7° vs 38.7°; P < 0.001), postoperative-GT (28.9° vs 23.4°; P = 0.018), postoperative LApex location mismatched from ideal (77.8% vs 22.2%; P = 0.036), and postoperative R-type mismatched from ideal (67.6% vs 22.6%; P < 0.001) were significantly related to mechanical complications. The independent factors selected by multivariate analysis were: postoperative R-type mismatched from ideal OR 11.3 (95% CI 3.9-32.6; P < 0.001), age OR 1.05 (95% CI 1-1.1; P = 0.03), and LApex matching OR 0.5 (95% CI 0.27-0.97; P = 0.04). The further the LApex was from its ideal position, the higher the risk of mechanical complications (P = 0.036). CONCLUSIONS: Over other multiple suspected risk factors, proper lumbar apex position and ideal sagittal shape restoration played an important role in postoperative mechanical complications after L-PSO. LEVEL OF EVIDENCE: III.

Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications.

PURPOSE: There are still no data proving whether restoring the ideal sagittal profile (according to Roussouly classification) in adult scoliosis (AS) patients leads to any additional benefit, especially regarding mechanical complications. METHODS: Retrospective analysis of operated AS patients recorded in a prospective multicenter database. Demographic and radiographic (preoperative and 6-week postoperative) data were analyzed. Patients with and without mechanical complications were compared looking especially at the surgical restoration of the ideal (based on Pelvic Incidence) sagittal profile. Univariate and multivariate analysis was performed to identify causes of mechanical complications at 2-year minimum follow-up. RESULTS: Ninty-six AS patients were analyzed. Thirty-nine patients suffered a mechanical complication (18 PJK, 11 pseudoarthrosis, 10 screw pull-out), and 57 patients had no mechanical complications. Postoperatively, 72% of patients not matching the ideal Roussouly-type suffered mechanical complications compared to 15% of matched patients (P < 0.001). Univariate analysis showed that older patients 64.9 ± 13 versus 40.7 ± 15.6 years (P < 0.001), higher postoperative Global Tilt (27° vs. 14.7°) and Pelvic Tilt (25° vs. 16°) (P < 0.001), upper instrumented vertebra at the thoracolumbar junction (62% vs. 21%) (P < 0.001), fixation to the Iliac (76% vs. 6%) (P < 0.001), and postoperative Roussouly-type mismatch (72% vs. 15%) (P < 0.001) significantly increased the rate of mechanical complications. Multivariate logistic regression analysis selected: postoperative Roussouly-type mismatch (OR = 41.9; 95%CI = 5.5-315.7; P < 0.001), iliac instrumentation (OR = 19.4; 95%CI = 2.6-142.5; P = 0.004), and age (OR = 1.1; 95%CI = 1.02-1.16; P = 0.004), as the most important variables. CONCLUSIONS: Adult scoliosis surgery should restore the ideal Roussouly sagittal profile to decrease the rate of mechanical complications, especially in patients older than 65, instrumented to the pelvis. These slides can be retrieved under Electronic Supplementary Material.

Impact of Adult Scoliosis on Roussouly Sagittal Shape Classification.

STUDY DESIGN: A retrospective analysis of data collected prospectively in an adult spine deformity multicenter database. OBJECTIVE: The aim of this study was to determine the impact of adult scoliosis (AS) on the type of Roussouly sagittal shape in terms of classification applicability, scoliosis modification of a patient theoretical sagittal shape, and coronal-sagittal deformity associations. SUMMARY OF BACKGROUND DATA: Roussouly described a four-type sagittal shape classification in healthy individuals, which has been also applied to patients with degenerative spinal disease. However, it remains uncertain if its principles can be applied to AS patients. METHODS: AS patients recorded in a prospective multicenter database of adult spinal deformity were included. Preoperative sagittal radiographs were analyzed using the KEOPS software to measure pelvic parameters, global sagittal alignment, and the various criteria used for the Roussouly classification. The different sagittal shape types were compared using the Chi-square and McNemars tests, and analysis of variance with Bonferroni correction. RESULTS: The classification was applicable to all of the 190 analyzed AS patients. In addition to Roussouly criteria, two parameters helped differentiate the different shapes: T10-L2 angle (24°â€Š±â€Š19 type-1; 14°â€Š±â€Š15 type-2; 3°â€Š±â€Š15 type-3; 0.4°â€Š±â€Š14 type-4; P < 0.001), and lordosis distribution index (90% ±â€Š17 type-1; 83% ±â€Š16 type-2; 73% ±â€Š21 type-3; 63% ±â€Š16 type-4; P < 0.001). AS changed the theoretical shape in 34% of the patients (P < 0.001). Curve etiology and curve pattern were not associated with any particular type of sagittal shape (P > 0.05). Type-1 was associated with older patients (P = 0.02), degenerative curves (P = 0.02), and greater PI-LL mismatch (P = 0.012). Types 3 to 4 were associated with younger age and idiopathic etiology (P < 0.001). CONCLUSION: Roussouly four-type sagittal shape classification could be applied to AS patients. AS modified the theoretical type in one of every three patients. No particular association was found between the sagittal types and specific coronal deformities. Sagittal shape recognition in patients with AS will help restore the appropriate theoretical shape through surgery, which can eventually lead to better surgical outcomesLevel of Evidence: 2.

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.

External validation of the adult spinal deformity (ASD) frailty index (ASD-FI).

PURPOSE: To assess the ability of the recently developed adult spinal deformity frailty index (ASD-FI) to predict odds of perioperative complications, odds of reoperation, and length of hospital stay after adult spinal deformity (ASD) surgery using a database other than the one used to create the index. METHODS: We used the ASD-FI to calculate frailty scores for 266 ASD patients who had minimum postoperative follow-up of 2 years in the European Spine Study Group (ESSG) database. Patients were enrolled from 2012 through 2013. Using ASD-FI scores, we categorized patients as not frail (NF) (< 0.3 points), frail (0.3-0.5 points), or severely frail (SF) (> 0.5 points). Multivariable logistic regression, adjusted for preoperative and surgical factors such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and odds of major complications, odds of reoperation, and length of hospital stay. RESULTS: We categorized 135 patients (51%) as NF, 90 patients (34%) as frail, and 41 patients (15%) as SF. Overall mean ASD-FI score was 0.29 (range 0-0.8). The adjusted odds of experiencing a major intraoperative or postoperative complication (OR 4.5, 95% CI 2.0-10) or having a reoperation (OR 3.9, 95% CI 1.7-8.9) were higher for SF patients compared with NF patients. Mean hospital stay was 2.1 times longer (95% CI 1.8-2.4) for SF patients compared with NF patients. CONCLUSIONS: Greater patient frailty, as measured by the ASD-FI, is associated with longer hospital stays and greater odds of major complications and reoperation. These slides can be retrieved under Electronic Supplementary Material.

Impact of Iliac Instrumentation on the Quality of Life of Patients With Adult Spine Deformity.

STUDY DESIGN: Retrospective comparative analysis of data collected prospectively in an adult spine deformity (ASD) multicenter database. OBJECTIVE: To evaluate the impact of the iliac screws on the quality of life of ASD patients compared with those instrumented above the pelvis (L5/S1/S2). SUMMARY OF BACKGROUND DATA: The impact on patient's daily activities and functions, of immobilizing the sacroiliac joint with iliac screws for the treatment of ASD is still underexplored. METHODS: Inclusion criteria were ASD patients with a long arthrodesis of at least eight levels and whose lowest instrumented vertebrae (LIV) were L5 or below. We analyzed the following preoperative and 2 years' follow-up variables: age, Cobb angle, coronal and sagittal alignment, number of instrumented levels, Oswestry Disability Index (ODI), Core Outcome Measures Index (COMI), Scoliosis Research Society-22 (SRS-22), and Short Form 36 (SF-36) questionnaires. Statistical analysis was performed with Mann-Whitney U test, and Wilcoxon test. RESULTS: A total of 129 patients were included, and separated into two groups: "Iliac Yes," with the LIV at the Ilium (N = 104), and "iliac No," with the LIV at L5/S1/S2 (N = 25). Patients instrumented with Iliac screws were older (x = 66 vs. 56 yr, P = 0.008), and had lower Cobb magnitude (x = 31° vs. 45°, P = 0.019). No statistically significant differences were found in the health related quality of life (HRQOL) questionnaires prior to surgery or at 2-years' follow up. The "Iliac Yes" group significantly improved all radiographic and HRQOL scores parameters 2 years after surgery (P < 0.005). While the "Iliac No" group failed to significantly improve (coronal balance, sagittal vertical axis, SF-36 Physical functioning, SF-36 General health, and COMI) (P > 0.05) CONCLUSION.: ASD patients instrumented with iliac screws significantly improved all their HRQOL questionnaires 2 years after surgery. The 2 years' postoperative HRQOL scores were similar in both groups, regardless of the sacroiliac joint immobilization. Therefore, with the currently available tools, we cannot state that iliac instrumentation has a negative influence on patient's quality of life. LEVEL OF EVIDENCE: 4.

Impact of early unanticipated revision surgery on health-related quality of life after adult spinal deformity surgery.

BACKGROUND CONTEXT: Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes. PURPOSE: The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery. DESIGN: This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database. PATIENT SAMPLE: The present study included 280 patients from a multicenter international prospective database. OUTCOME MEASURE: Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work. METHODS: Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models. RESULTS: Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group. CONCLUSIONS: Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.

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.

Function and Clinical Symptoms are the Main Factors that Motivate Thoracolumbar Adult Scoliosis Patients to Pursue Surgery.

STUDY DESIGN: A retrospective two-cohort comparative analysis of data collected prospectively in an adult deformity multicenter database. OBJECTIVE: The aim of this study was to define the radiographic and clinical parameters that motivate adult thoracolumbar (TL) scoliosis patients to undergo surgery. SUMMARY OF BACKGROUND DATA: TL curves are a primary concern in adulthood, and it is necessary to establish why patients are motivated to seek surgical intervention. METHODS: Patients with only main TL/lumbar (TL/L) idiopathic curves were included, defined as Schwab type L curves and Schwab type D curves in which thoracic curves were <40° and the difference between the TL/L-MT Cobb was ≥15°. Demographic data, health-related quality of life (HRQOL) questionnaires, and 14 different radiological preoperative parameters were assessed. Surgical versus conservative cohorts were compared with the Student t test, Chi-square, and the Mann-Whitney U test. RESULTS: A total of 184 patients met the inclusion criteria. Ninety-four were treated conservatively (C), while 90 underwent surgery (S). No differences were found between groups in terms of demographic or radiographic preoperative data. Age (C: 57.5 ±â€Š18 vs. S: 54.2 ±â€Š18 yr; P = 0.18), coronal TL/L Cobb (C: 52.3°â€Š±â€Š15 vs. S: 50.6°â€Š±â€Š13; P = 0.61), and sagittal alignment (SVA C: 3.1 cm ±â€Š5.7 vs. S: 4.9 cm ±â€Š6.4; P = 0.054) were similar. No differences were found in pelvic parameters (pelvic incidence, pelvic tilt, sacral slope), apical translation, coronal balance, lumbar rotatory subluxation, or lumbar lordosis. However, significant differences were found in HRQOL questionnaires. Surgical patients initially had worse COMI scores (C: 4.6 ±â€Š2.3 vs. S: 6 ±â€Š2.3; P = 0.001), worse ODI scores (C: 27.7 ±â€Š16 vs. S: 38.9 ±â€Š20; P = 0.000), worse SF-36 physical (C: 40.9 ±â€Š8.5 vs. S: 36 ±â€Š9.5; P = 0.001) and mental scores (C: 45.8 ±â€Š12 vs. S: 42.2 ±â€Š11.8; P = 0.032), and worse SRS-22 scores in all domains with mean values under 3.1 points (range = 2.4-3.1). In both SF-36 physical and SRS-22 function, differences between groups were higher than the minimum clinically important difference. CONCLUSION: After analyzing a large multicenter database, we found that only clinical factors-particularly function impairment-motivated adult TL scoliosis patients to undergo surgery. Demographic and radiographic parameters did not seem to influence decision-making. LEVEL OF EVIDENCE: 3.

Untreated Thoracic Curve in Adult Idiopathic Scoliosis: What Are Patients' Concerns?

STUDY DESIGN: Retrospective two-cohort comparative analysis of data collected prospectively. OBJECTIVES: To analyze a cohort of patients with untreated thoracic curves of an adult multicenter deformity database [European spine study group (ESSG)], describe patient characteristics and concerns, and establish the rate and motivations for surgical intervention. SUMMARY OF BACKGROUND DATA: Idiopathic thoracic curves have a significant clinical and socioeconomic impact during adolescence. However, little attention has been given to adult thoracic scoliosis. The complaints of patients that have reached adulthood with an untreated thoracic curve are still not well studied. METHODS: The database of 1,142 prospective consecutive adult patients with deformity was searched to identify patients with untreated thoracic idiopathic curves: Schwab Type T curves, and Schwab Type D with thoracolumbar/lumbar (TL/L) curves <40° and a difference between main thoracic (MT) and the TL/L ≥15°. Demographic data, different radiologic preoperative parameters, and health-related quality of life questionnaires were assessed. RESULTS: Forty-two patients met inclusion criteria, showing the following characteristics: age, 30.9 ± 12.5 years; thoracic Cobb, 55.6 ± 10.8°; lumbar Cobb, 28.1 ± 7.3°; sagittal vertical axis, 2.9 ± 19.3 cm; Core Outcome Measures Index (COMI), 4 ± 2.5; Oswestry Disability Index (ODI), 20.4 ± 17.4; Scoliosis Research Society-22 questionnaire (SRS-22) subtotal, 3.6 ± 0.7; 36-Item Short Form Health Survey (SF-36) mental health, 46.1 ± 10.1; SF-36 physical health, 47.3 ± 11.1. Only 13 of these patients underwent surgery. Compared with nonoperated patients, they were younger (24.3 ± 7.3 vs. 33.8 ± 13.4 years; p = .009), had larger MT curves (58.7° ± 9.6 vs. 50.6° ± 8.3; p = .012), and had worse SRS-22 self-image scores (2.9 ± 0.8 vs. 3.5 ± 0.8; p = .042). No patients older than 50 years underwent surgery, despite having worse SRS-22 function (3.0 ± 0.9 vs. 4.1 ± 0.9, p = .032) and worse ODI scores (42.4 ± 19.9 vs. 18.7 ± 18.0, p = .026). CONCLUSIONS: Very few adult deformity patients sought treatment because of untreated thoracic scoliotic curve. The probability of undergoing surgery was low (13/42), and it was associated with youth, curve magnitude, and poor self-image. The rate of surgical treatment of the thoracic curve appears to diminish with age, despite its being associated with poorer function and greater disability in the older patient.

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.