Factors Associated with Improved Quality of Life Outcomes in Patients Undergoing Surgery for Adult Spinal Deformity.

STUDY DESIGN: Retrospective longitudinal cohort study. OBJECTIVE: This study aimed to elucidate factors affecting the likelihood of achieving minimum clinically important difference (MCID) to patient-reported outcomes defined by the Scoliosis Research Society-22r (SRS-22r) among patients with adult spinal deformity (ASD) who underwent extensive corrective fusion surgery from the thoracic spine to the pelvis. SUMMARY OF BACKGROUND DATA: Achieving MCID for SRS-22r parameters was a measure of surgical efficacy. Patient characteristics and surgical and radiographic factors that affect the likelihood of achieving MCID for SRS-22r parameters are unknown. METHODS: Data from patients with ASD who underwent extensive corrective fusion surgery from the thoracic spine to the pelvis during 2010 to 2016 were retrospectively reviewed. Data from a total of 167 patients with ≥2 years of follow-up were included. Multivariate analysis was used to investigate factors associated with the likelihood of achieving MCID for each of the SRS-22r domains (Function, Pain, Subtotal) 2 years after surgery. The following MCID values were used: 0.90 for Function, 0.85 for Pain, and 1.05 for the Subtotal. RESULTS: MCID achievement rate was 36.5% for Function, 46.1% for Pain, and 44.3% for the Subtotal domain. In multivariate analysis, preoperative SRS-22r Function (odds ratio [OR] = 0.204, 95% confidence interval [CI] 0.105-0.396) increased the likelihood of achieving MCID for SRS-22r Function. Preoperative SRS-22r Subtotal (OR = 0.211, 95% CI, 0.107-0.413), preoperative pelvic tilt (OR = 1.072, 95% CI, 1.012-1.136), preoperative pelvic incidence minus lumbar lordosis (OR = 0.965, 95% CI, 0.934-0.997), and postoperative sagittal vertical axis (OR = 0.985, 95% CI, 0.974-0.995) affected the likelihood of achieving MCID for the SRS-22r Subtotal. CONCLUSION: Patients with poor preoperative health-related quality of life were more likely to achieve improvement in SRS-22r parameters after extensive corrective fusion surgery for ASD. Achieving postoperative sagittal alignment increased the likelihood of achieving MCID for the SRS-22r Subtotal domain.Level of Evidence: 3.

Lumbar Muscle Fat Content Has More Correlations with Living Quality than Sagittal Vertical Axis in Elderly Patients with Degenerative Lumbar Disorders.

PURPOSE: As the most poorly tolerated and debilitating form of spinal malalignment, sagittal imbalance is becoming an increasingly recognized cause of pain and disability in adults. However, there is evidence showing that sagittal imbalance has a weak or no correlation with health-related quality-of-life (HRQoL) outcomes. The objective of this study was to describe the direct factor associated with HRQoL in terms of Oswestry Disability Index (ODI) assessment. PATIENTS AND METHODS: This study retrospectively evaluated the clinical and radiographic information of 179 elderly patients with degenerative lumbar disorders and suboptimal sagittal standing posture (sagittal vertical axis>50 mm). Patient-reported outcomes were assessed using ODI. Patients with ODI≥40% were assigned to Group D (disability), while those with ODI<40% were assigned to Group ND (non-disability). RESULTS: Compared with Group ND (n=104), patients in Group D (n=75) had greater thoracolumbar kyphosis, pelvic incidence-lumbar lordosis (PI-LL), sagittal vertical axis (SVA), T1 pelvic angle, and fat infiltration, and smaller LL and muscle mass ratio. Pearson analysis revealed a high correlation between the percentage of fat infiltrated and ODI (r=768, P<0.01) and moderate correlation between SVA and ODI (r=0.408, P<0.001). Linear regression results indicated that fat infiltration was an independent factor associated with ODI. ODI significantly correlated with SVA in patients with major fat infiltration (r=0.328, P=0.001), while having no correlation with SVA in those with moderate or minor fat infiltration (r=0.083, P=0.464). CONCLUSION: Lumbar muscle fat infiltration is an independent factor associated with the living quality in terms of ODI assessment in the elderly population with degenerative lumbar disorders, which has more correlations with ODI scores than the sagittal imbalance. The relationship between HRQoL outcomes and sagittal imbalance depends on the quality of lumbar muscle.

Effect of Perioperative Mental Status on Health-related Quality of Life in Patients With Adult Spinal Deformities.

STUDY DESIGN: A retrospective study. OBJECTIVE: We aimed to evaluate the impact of mental status on the clinical outcomes of patients with adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Limited information is currently available on how preoperative mental status affects postoperative health-related quality of life (HRQOL) in patients with ASD. METHODS: We enrolled 165 patients with ASD who underwent corrective surgery at a single university hospital between March 2010 and September 2015. We compared Scoliosis Research Society-22r (SRS-22r) and Oswestry Disability Index (ODI) scores using various x-ray parameters at these time points: preoperative period and postoperative 2 years. Additionally, to determine the associations between perioperative complications and mental health disorders, we examined these x-ray parameters: lumbar lordosis, thoracic kyphosis, sacral slope, pelvic incidence, pelvic tilt, sagittal vertical axis (SVA), and T1 pelvic angle (TPA). RESULTS: We found correlations between the preoperative SRS-22r total score and preoperative ODI (r = -0.692, P < 0.01) and postoperative ODI (r = -0.443, P < 0.01). Preoperative SRS-22r mental domain correlated with preoperative ODI (r = -0.561, P ≤ 0.01) and postoperative ODI (r = -0.315, P ≤ 0.01). Perioperative (preoperative and postoperative) SRS-22r mental domain did not correlate with the postoperative x-ray parameters except for SVA and TPA. Postoperative mental health correlated with early infection (P < 0.05), hematoma (P < 0.05), deep vein thrombosis (P < 0.05), and delirium (P < 0.05). Regression analysis revealed that preoperative SRS-22r mental health score correlated with preoperative ODI (P < 0.001) and postoperative ODI (P < 0.001). The regression coefficient number between preoperative SRS-22r mental health score and perioperative (preoperative and postoperative) ODI improved from -17.3 to -10.2 from preoperative to postoperative periods. CONCLUSION: Diminished preoperative mental health worsened postoperative HRQOL. Perioperative complications influence postoperative mental status and HRQOL; hence, screening preoperative mental health is important. LEVEL OF EVIDENCE: 3.

Correlation between body image perception and spinopelvic parameters in ankylosing spondylitis.

OBJECTIVE: To identify relationships between spinopelvic parameters and body image perception in ankylosing spondylitis (AS). METHODS: The study and control groups comprised 107 AS patients (18 women and 89 men) and 40 controls. All underwent anteroposterior and lateral radiography of whole spine, including hip joints, and completed clinical questionnaires. The radiographic parameters examined were sagittal vertical axis, sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, thoracic kyphosis, spinosacral angle (SSA), and spinopelvic angle (SPA). The Trunk appearance scale (TAPS), and the Scoliosis Research Society 22 appearance questionnaire (SRSapp) were administered to evaluate body image perception. RESULTS: The patient and control groups were found to differ significantly in terms of sagittal vertical axis, sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, SSA, and SPA. However, no significant intergroup difference was observed for thoracic kyphosis (p > .05). Correlation analysis revealed significant relationships between radiographic parameters and body image perception. Multiple regression analysis was performed to identify predictors of body image perception scores, and the results obtained revealed age, SSA, and SPA significantly predicted SRSapp scores and that age and SSA predicted TAPS scores. CONCLUSIONS: AS patients and normal controls were found to differ significantly in terms of sagittal spinopelvic parameters. Correlation analysis revealed significant relationships between radiographic parameters and body image perception. In particular, age, SSA, and SPA were found to be significant predictors of body image perception scores in AS patients.

Long-Term Minimum Clinically Important Difference in Health-Related Quality of Life Scores After Instrumented Lumbar Interbody Fusion for Low-Grade Isthmic Spondylolisthesis.

BACKGROUND: Despite its growing popularity, no comparative studies have explored the minimum clinically important difference (MCID) of health-related quality of life scores following lumbar interbody fusion (LIF) performed on a single-level adult low-grade isthmic spondylolisthesis (LGIS). OBJECTIVE: The purpose of this study is to investigate factors related to MCID of health-related quality of life scores following instrumented LIF performed on a single-level adult LGIS. METHODS: Consecutive patients who underwent instrumented LIF for single-level LGIS were reviewed. The inclusion criteria were adult patients who underwent L4-5 or L5-S1, underwent anterior lumbar interbody fusion or transforaminal lumbar interbody fusion with a posterior screw fixation, and had a minimum 36-month postoperative follow-up period. MCID was defined as having an improved score of visual analog scale (VAS) back and leg pain >3 and Oswestry Disability Index (ODI) >12. Patients were subdivided into groups named "achievement" (A) and "nonachievement" (N) depending on their postoperative MCID for each health-related quality of life score category. RESULTS: One-hundred and five patients met the inclusion criteria. The overall achievement of MCID for VAS back, leg, and ODI was 80%, 73.3%, and 82.9%. MCID-VAS leg and ODI were less achieved at the L5-S1 level than at the L4-5 level. Postoperatively, disk height was higher and segmental lordosis (SL) was lower in group A of MCID-VAS leg. SL was lower in group A of MCID-ODI. CONCLUSIONS: We postulate that excessive SL does not affect lumbar lordosis; rather, it can result in lowering posterior disk height. The decrease in posterior DH may lead to a decreased foraminal height that, in turn, can lead to nerve root compression. Proper restoration of disk height and bone fusion is more important than restoration of more segmental lordosis or slip reduction for isthmic spondylolisthesis.

The Lumbar Pelvic Angle, the Lumbar Component of the T1 Pelvic Angle, Correlates With HRQOL, PI-LL Mismatch, and it Predicts Global Alignment.

STUDY DESIGN: Prospective multicenter analysis of adult spinal deformity (ASD) patients. OBJECTIVE: The aim of this study was to introduce the lumbar pelvic angle (LPA), a novel parameter of spinopelvic alignment. SUMMARY OF BACKGROUND DATA: The T1 pelvic angle (TPA), a measure of global spinopelvic alignment, correlates with health-related quality of life (HRQOL), but it may not be measureable on all intraoperative x-rays. In patients with previous interbody fusion at L5-S1, the plane of the S1 endplate can be blurred, creating error in pelvic incidence and lumbar lordosis (PI-LL) measure. The LPA is more readily measured on intraoperative imaging than the TPA. METHODS: ASD patients were included with either coronal Cobb angle >20°, sagittal vertical axis (SVA) >5 cm, thoracic kyphosis >60°, or pelvic tilt (PT) >25°. Measures of disability included Oswestry Disability Index (ODI), Scoliosis Research Society (SRS), and Short Form (SF)-36. Baseline and 2-year follow-up radiographic and HRQOL outcomes were evaluated. Linear regressions compared LPA with radiographic parameters and HRQOL. RESULTS: A total of 852 ASD patients (407 operative) were enrolled (mean age 53.7). Baseline LPA correlated with PI-LL (r = 0.79), PT (r = 0.78), TPA (r = 0.82), and SVA (r = 0.61) (all P < 0.001). PI-LL, LPA, and TPA correlated with ODI (r = 0.42/0.29/0.45), SF-36 physical component score (-0.43/-0.28/-0.45) SRS (-0.354/-0.23/-0.37) with all P < 0.001. At 2 years' follow-up, LPA correlated with PI-LL (r = 0.77), PT (r = 0.78), TPA (r = 0.83), and SVA (r = 0.57) (all P < 0.001). Categorizing patients by increasing LPA (<7°; 7°-15°; >15°) revealed progressive increases in all HRQOL, PI-LL (-3.2°/12.7°/32.4°), and TPA (9.7°/20.1°/34.6°) with all P < 0.001. Moderate disability (ODI = 40) corresponded to LPA 10.1°, PI-LL 12.6°, and TPA 20.6°. Mild disability (ODI = 20) corresponded to LPA 7.2°, PI-LL 4.2°, and TPA 14.7°. CONCLUSION: LPA correlates with TPA, PI-LL, and HRQOL in ASD patients. LPA can be used as an intraoperative tool to gauge correction with a target LPA of <7.2°. LPA predicts global alignment, as it correlates with baseline and 2-year TPA and SVA. Along with the cervical-thoracic pelvic angle and TPA, LPA completes the fan of spinopelvic alignment. LEVEL OF EVIDENCE: 3.

[The psycho-social impact of the locomotor deformations in school-aged child]. / Impactul PSIHO-social la copilul de vârsta scolara suferind de deformatii ale aparatului locomotor.

Depending on their severity, congenital or acquired, the deformations of the locomotor system affect more or less the child's mental status. Adolescence is the time when their impact is most important. When the physical, mental or functional suffering become a disability, professional and psycho-social integration problems occur. The role of the team treating such a patient is to orientate him toward a specific job corresponding to his abilities, while the social services must support him in achieving this goal. The psychotherapist is the most important person in his fight against depression and, more important, suicide.

The significance of correlation of radiographic variables and MOS short-form health survey for clinical decision in symptomatic low back pain patients.

OBJECTIVES: To assess any correlation between SF-36 scores and several lateral roentgenographic variables of the lumbar spine, both in low back pain patients and asymptomatic volunteers. The clinical relevance of the method proposed in this study to make a surgical strategy on the basis of distinct lateral roentgenographic parameters and conversely was assessed by independent radiologists and physicians. METHODS: One hundred asymptomatic male volunteers, used as controls and an equal number of age-, height- and weight- comparable consecutive patients with chronic low back pain were examined both roentgenographically and with the SF-36 questionnaire. The roentgenographic variables measured were: lumbar lordosis, sacral inclination, L1 to S1 vertebral inclination, L4-S1 distal lordosis, disc index, and L1 to L5 vertebral index. These variables were correlated with the eight SF-36 items both in patients and controls. Both sensitivity and specificity of the method were calculated to assess the impact of subjectivity on the clinical decision. RESULTS: Low back patients showed significantly lower scores than their asymptomatic counterparts, in physical role limitations (P<0.01), severity of bodily pain (P<0.01), interference of bodily pain (P<0.01) and mental health (P<0.001). In the controls, general health, physical functioning, social functioning, and role limitations displayed a statistically significant correlation with age, height, weight, lumbar lordosis, sacral inclination, inclination of L1,L3 & L5-vertebra, L1 to L5-vertebral index and L1-L2, L3-L4, L4-L5 and L5-S1 disc index. In LBP-patients previous general health, physical functioning, role limitations, social functioning, bodily pain were significantly correlated with age, height, L1-and L2-inclination, distal lordosis, L5-index, and disc index L4-L5, and L5-S1. Although the consensus between either radiologists suggesting a strategy on the basis of roentgenographic data only or between physicians based on only SF-36 data was significant (P<0.001), there was no consensus in clinical decision between physicians and radiologists. Clinical decision based on matched SF-36 and roentgenographic data made either by radiologists or surgeons showed significant correlations (P<0.001). However, both sensitivity and specificity of our method to make a clinical decision on the basis of radiology were low: 0.48 and 0.36 respectively. CONCLUSIONS: SF-36 scores were correlated with distinct lateral roentgenographic variables of the lowermost lumbar spine (L4-S1) in low back patients, and of the whole lumbar spine in asymptomatic individuals. Clinical decision should not be taken on the basis of radiological evidence of pathology because clinical decision seems to be more accurate when is taken on the basis of combined SF-36 and roentgenographic data. However, clinical examination is mandatory to SF-36 questionnaire and radiographic analysis.

Abdominal proptosis: a case report.

A case history of abdominal swelling of psychological origin is described. The clinical presentation and psychogenic pathogenesis of the disorder provide a differentiation from pseudocyesis. The psychodynamics of this case are discussed emphasizing the conflict involving strong elements of pre-oedipal aggressivity towards the father image.