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Shen Y, Sardar ZM, Greisberg G, Katiyar P, Malka M, Hassan F, Reyes J, Zuckerman SL, Marciano G, Lombardi JM, Lehman RA, Lenke LG. Practical Methods of Assessing Coronal Alignment and Outcomes in Adult Spinal Deformity Surgery: A Comparative Analysis. Spine (Phila Pa 1976) 2024; 49:443-455. [PMID: 38073177 DOI: 10.1097/brs.0000000000004892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/23/2023] [Indexed: 03/13/2024]
Abstract
STUDY DESIGN Asymptomatic cohort: prospective, cross-sectional, multicenter. Symptomatic: retrospective, multisurgeon, single-center. OBJECTIVE To assess the association between cranial coronal alignment and adult spinal deformity (ASD) surgical risk and outcomes. SUMMARY OF BACKGROUND DATA ASD leads to decreased quality of life. Studies have shown that coronal malignment (CM) is associated with worse surgical outcomes. MATERIALS AND METHODS A total of 468 adult participants were prospectively enrolled in the asymptomatic cohort. Totally, 172 symptomatic ASD patients with 2-year follow-ups were retrospectively enrolled in the symptomatic cohort. Three cranial plumb line parameters: the positions of the plumb lines from the midpoint between the medial orbital rims (ORB-L5), the odontoid (OD-L5), and the C7 centroid (C7-L5) relative to the L5 pedicle, were measured. Each subject had plumb line medial (M), touching (T), or lateral (L) to either pedicle. The association between each group of patients and radiographic parameters, intraoperative variables, patient-reported outcomes, and clinical outcomes were analyzed. RESULTS In the asymptomatic cohort, OD-L5 was medial to or touching the L5 pedicle in 98.3% of volunteers. In the symptomatic patients, preoperative OD-L5-L exhibited higher mean age (56.2±14.0), odontoid-coronal vertical axis (OD-CVA) (5.5±3.3 cm), Oswestry disability index (ODI) score (40.6±18.4), pelvic fixation rate (56/62, 90.3%), OR time (528.4±144.6 min), median estimated blood loss (1300 ml), and durotomy rate (24/62, 38.7%). A similar pattern of higher CVA, preoperative ODI, intraoperative pelvic fixation rate, OR time, estimated blood loss, and durotomy rate was observed in ORB-L5-L and C7-L5-L patients. Final follow-up postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis (13.0%) and pseudarthrosis (17.4%). CONCLUSION Preoperative OD-L5, ORB-L5, and C7-L5 lateral to pedicles were associated with worse preoperative ODI and higher intraoperative complexity. Postoperative OD-L5-L was associated with higher rates of proximal junctional kyphosis and pseudarthrosis. Postoperative CM, approximated by the cranial plumb line lateral to the L5 pedicles, was associated with sagittal plane complications.
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Affiliation(s)
- Yong Shen
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Zeeshan M Sardar
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Gabriella Greisberg
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Prerana Katiyar
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Matan Malka
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Fthimnir Hassan
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Justin Reyes
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Gerard Marciano
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Joseph M Lombardi
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
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Cummins DD, Clark AJ, Gupta MC, Theologis AA. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100299. [PMID: 38193108 PMCID: PMC10772279 DOI: 10.1016/j.xnsj.2023.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Background Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined. Purpose To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis. Methods A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared. Results Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment. Conclusions Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.
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Affiliation(s)
- Daniel D. Cummins
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
| | - Aaron J. Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, Eighth Floor, San Francisco, CA 94143, United States
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 Euclid Avenue, Saint Louis, MO 63110, United States
| | - Alekos A. Theologis
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
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Shimizu T, Yagi M, Suzuki S, Takahashi Y, Ozaki M, Tsuji O, Nagoshi N, Yato Y, Matsumoto M, Nakamura M, Watanabe K. How coronal malalignment affects the surgical outcome in corrective spine surgery for adult symptomatic lumbar deformity. Spine Deform 2024; 12:451-462. [PMID: 37979129 DOI: 10.1007/s43390-023-00780-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/14/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The importance of coronal alignment is unclear, while the importance of sagittal alignment in the treatment of adult patients with spinal deformities is well described. This study sought to elucidate the impact of global coronal malalignment (GCMA) in surgically treated adult symptomatic lumbar deformity (ASLD) patients. METHODS A multicentre retrospective analysis of a prospective ASD database. GCMA was defined as GCA (C7PL-CSVL) ≥ 3 cm. GCMA is categorized based on the Obeid-Coronal Malalignment Classification (O-CM). Demographic, surgical, radiographic, HRQOL, and complication data were analysed. The risk for postoperative GCMA was analysed by univariate and multivariate analyses. RESULTS Of 230 surgically treated ASLD patients, 96 patients showed GCMA preoperatively and baseline GCA was correlated with the baseline SRS-22 pain domain score (r = - 30). Postoperatively, 62 patients (27%, O-CM type 1: 41[18%], type 2: 21[9%]) developed GCMA. The multivariate risk analysis indicated dementia (OR 20.1[1.2-304.4]), diabetes (OR 5.9[1.3-27.3]), and baseline O-CM type 2 (OR 2.1[1.3-3.4]) as independent risk factors for postoperative GCMA. The 2-year SRS-22 score was not different between the 2 groups, while 4 GCMA patients required revision surgery within 1 year after surgery due to coronal decompensation (GCMA+ vs. GCMA- function: 3.6 ± 0.6 vs. 3.7 ± 0.7, pain: 3.7 ± 0.8 vs. 3.8 ± 0.8, self-image: 3.6 ± 0.8 vs. 3.6 ± 0.8, mental health: 3.7 ± 0.8 vs. 3.8 ± 0.9, satisfaction: 3.9 ± 0.9 vs. 3.9 ± 0.8, total: 3.7 ± 0.7 vs. 3.7 ± 0.7). Additionally, the comparisons of 2-yr SRS-22 between GCMA ± showed no difference in any UIV and LIV level or O-CM type. CONCLUSIONS In ASLD patients with corrective spine surgery, GCMA at 2 years did not affect HRQOL or major complications at any spinal fusion extent or O-CM type of malalignment, whereas GCA correlated with pain intensity before surgery. These findings may warrant further study of the impact of GCMA on HRQOL in the surgical treatment of ASLD patients.
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Affiliation(s)
- Toshiyuki Shimizu
- National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- School of Medicine, Department of Orthopedic Surgery, International University of Health and Welfare, 852 Hatakeda Narita, Chiba Prefecture, 286-0124, Japan.
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Takahashi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Ozaki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Yato
- National Hospital Organization Murayama Medical Center, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Boissiere L, Bourghli A, Kieser D, Larrieu D, Alanay A, Pellisé F, Kleinstück F, Loibl M, Pizones J, Obeid I. Fixed coronal malalignment (CM) in the lumbar spine independently impacts disability in adult spinal deformity (ASD) patients when considering the obeid-CM (O-CM) classification. Spine J 2023; 23:1900-1907. [PMID: 37633521 DOI: 10.1016/j.spinee.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/20/2023] [Accepted: 08/13/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Postoperative flatback has been described in detail for sagittal plane considerations over the past 2 decades, and its correlations with disability are now accepted. Fixed Coronal Malalignment (CM) has been less described, and some authors report no significant association with the clinical outcome. The O-CM classification analyses CM and incorporates specific modifiers for each curve type. PURPOSE This study evaluates the O-CM classification modifiers according to age, sagittal alignment, and patient-reported outcome measures (PROMs). Our hypothesis is that fixed CM correlates with PROMs independently from sagittal alignment and age. STUDY DESIGN Retrospective analysis of a large adult spinal deformity (ASD) database prospectively collected. PATIENT SAMPLE We included 747 patients from the database with long lumbar fusion (more than 3 levels), with at least two years of follow-up. Three categories of patients met the inclusion criteria (prior surgery at baseline and no revision surgery afterward, prior surgery at baseline and revision afterward, no prior surgery at baseline but fusion>3 levels and 2 years follow-up). OUTCOME MEASURES All patients completed the Oswestry Disability Index (ODI), Short Form 36 (SF36), and Scoliosis Research Society 22 scores. METHODS The patients were classified according to the six modifiers of the O-CM classification. Central Sacral Vertical Line (CSVL) above 2, 3, and 4 cm's impact on PROMs was analyzed. Multivariate analysis was performed on the relationship between PROMS and age, global tilt (GT), and CM modifiers. RESULTS After multivariate analysis using age and GT as confounding factors, we found that CM independently affects PROMs starting at 2 cm offset. Disability increases linearly with CSVL. Patients classified with 2B modifiers have the worst SRS-22 total score, social life, and self-image. CONCLUSION In a fused spine, CM independently affects disability in ASD patients. Disability increases linearly with CSVL. Despite previous reports that failed to find correlations of CM with PROMs, our study showed that fixed postoperative CM, according to O-CM classification, correlates independently from sagittal malalignment with worse PROMs. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Louis Boissiere
- ELSAN, Polyclinique Jean Villar, 53 Avenue Maryse Bastié, Bruges, France.
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Hospital, Al Mathar Ash Shamali, Riyadh 11564, Saudi Arabia
| | - David Kieser
- School of Medicine, University of Otago, PO Box 4345, Christchurch 8140, New Zealand
| | - Daniel Larrieu
- ELSAN, Polyclinique Jean Villar, 53 Avenue Maryse Bastié, Bruges, France
| | - Ahmet Alanay
- Department of Orthopaedics and Traumatology, Acibadem University School of Medicine, Kayışdağı Cd., 34750 Ataşehir/ Istanbul, Turkey
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Val Hebron 119, 08035 Barcelona, Spain
| | - Frank Kleinstück
- Research and Development, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland
| | - Markus Loibl
- Research and Development, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, P.º de la Castellana, 261, Madrid, Spain
| | - Ibrahim Obeid
- ELSAN, Polyclinique Jean Villar, 53 Avenue Maryse Bastié, Bruges, France
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Scheer JK, Clark AJ, Mitsunaga K, Tan LA, Theologis AA. Lumbar Pedicle Subtraction Osteotomy (PSO): A Novel Surgical Technique for Correction of Sagittal and Coronal Imbalance Using Laterally Based Satellite Rods. Clin Spine Surg 2023; 36:317-322. [PMID: 37482632 DOI: 10.1097/bsd.0000000000001486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
STUDY DESIGN Operative video and supplemental manuscript. OBJECTIVE To present a novel step-by-step approach to performing a lumbar pedicle subtraction osteotomy (PSO) using laterally based satellite rods. SUMMARY OF BACKGROUND DATA Multi-rod constructs have demonstrated paramount for decreasing rates of pseudarthrosis after PSOs. Multi-rods constructs can be achieved using either "satellite" rods (rods not connected to the primary rods) and/or "accessory rods" (rods connected to the primary rods). METHODS A step-by-step approach to performing a lumbar PSO using a laterally based satellite rod configuration is provided through a case example and surgical technique video. RESULTS Lateral satellite rods can be particularly useful from a surgical perspective, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site (symmetric and/or asymmetric), and serve as the final fixation rods across the PSO without needing to be exchanged. CONCLUSIONS Use of laterally based satellite rods is a useful technique for lumbar PSOs, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site, and serve as the final fixation rods across the PSO without needing to be exchanged.
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Affiliation(s)
- Justin K Scheer
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Kyle Mitsunaga
- The Queen's Medical Center Orthopedic Spine Center, Honolulu, HI
| | - Lee A Tan
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
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Zuckerman SL, Chanbour H, Hassan FM, Lai CS, Shen Y, Kerolus MG, Ha A, Buchanan I, Lee NJ, Leung E, Cerpa M, Lehman RA, Lenke LG. The Lumbosacral Fractional Curve vs Maximum Coronal Cobb Angle in Adult Spinal Deformity Patients with Coronal Malalignment: Which Matters More? Global Spine J 2023:21925682231161564. [PMID: 36987946 DOI: 10.1177/21925682231161564] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
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.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fthimnir M Hassan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Christopher S Lai
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yong Shen
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Alex Ha
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ian Buchanan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Eric Leung
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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Hiyama A, Sakai D, Katoh H, Sato M, Watanabe M. Postoperative Radiological Improvement after Staged Surgery Using Lateral Lumbar Interbody Fusion for Preoperative Coronal Malalignment in Patients with Adult Spinal Deformity. J Clin Med 2023; 12:jcm12062389. [PMID: 36983389 PMCID: PMC10052673 DOI: 10.3390/jcm12062389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
This retrospective observational study evaluated improvement in coronal malalignment (CM) after anteroposterior staged surgery using lateral lumbar interbody fusion (LLIF) in patients with coronal lumbar curve adult spinal deformity (ASD). Sixty patients with ASD underwent surgery; 34 had SRS-Schwab type L lumbar curve. Patients with a coronal balance distance (CBD) ≥20 mm were diagnosed with CM. Using the Obeid CM classification, we classified the preoperative coronal pattern as concave CM (type 1) or convex CM (type 2). Demographic, surgical, and radiological parameters were compared. Whole-spine standing radiographs were assessed preoperatively and postoperatively. Twenty-three patients had type 1A, six had type 2A, five had no CM, and none had type 1B or 2B according to the Obeid CM classification. Compared with patients with Obeid type 1A, those with Obeid type 2A had significantly higher preoperative and postoperative coronal L4 tilts and a smaller change in corrected CBD (Δ|CBD|) (76.6 mm vs. 24.1 mm, p < 0.001). At the final follow-up, 58.6% (17/29 patients) of patients with SRS-Schwab type L CM showed improvement after corrective fusion using LLIF. Although the difference was not statistically significant, CM improved in 69.6% (16/23 patients) of patients with Obeid type 1A type but only 16.7% (1/6 patients) of those with Obeid type 2A type (p = 0.056). CM was more likely to remain after anteroposterior staged surgery using LLIF in patients with preoperative Obeid type 2A ASD.
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Affiliation(s)
- Akihiko Hiyama
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Daisuke Sakai
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Hiroyuki Katoh
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Masato Sato
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
| | - Masahiko Watanabe
- Department Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara 259-1193, Japan
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Bourghli A, Boissière L, Obeid I. The Obeid-coronal malalignment classification is reliable and helps guiding decision-making and surgical management of adult spinal deformities: letter to the editor of BMC Musculoskeletal Disorders. BMC Musculoskelet Disord 2023; 24:145. [PMID: 36823582 PMCID: PMC9948463 DOI: 10.1186/s12891-023-06257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
A recently published article by Zhang et al. in BMC Musculoskeletal Disorders reported that the classification of coronal deformity based on preoperative global coronal malalignment for adult spinal deformity is questionable. The aim of the paper was to specifically discredit the Obeid-Coronal Malalignment (O-CM) classification. In this correspondence, we thought it judicious to clarify misunderstood concepts by the authors. We highlight several limitations of their study, and explain the deep interest of the classification from our perspective in order to avoid misleading the readers. Overarching, we aim to help the colleagues through a constructive rather than destructive approach to better understand the foundations of a coronal malalignment classification.
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Affiliation(s)
- Anouar Bourghli
- Spine surgery department, King Faisal Special Hospital and Research Center, P.O.Box 3354, 11211, Riyadh, Saudi Arabia.
| | - Louis Boissière
- Clinique du Dos, Elsan Jean Villar Private hospital, Bordeaux, France
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private hospital, Bordeaux, France
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Zuckerman SL, Chanbour H, Hassan FM, Lai CS, Shen Y, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Leung E, Cerpa M, Lehman RA, Lenke LG. Evaluation of coronal alignment from the skull using the novel orbital-coronal vertical axis line. J Neurosurg Spine 2022; 37:410-419. [PMID: 35364571 DOI: 10.3171/2022.1.spine211527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Scott L Zuckerman
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- 2Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Hani Chanbour
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fthimnir M Hassan
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Christopher S Lai
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Yong Shen
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Nathan J Lee
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Mena G Kerolus
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Alex S Ha
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Ian A Buchanan
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Eric Leung
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Meghan Cerpa
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Ronald A Lehman
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Lawrence G Lenke
- 3Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
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Zuckerman SL, Lai CS, Shen Y, Cerpa M, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Leung E, Lehman RA, Lenke LG. Understanding the role of pelvic obliquity and leg length discrepancy in adult spinal deformity patients with coronal malalignment: unlocking the black box. J Neurosurg Spine 2022; 37:64-72. [PMID: 35171835 DOI: 10.3171/2021.10.spine21800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study had 3 objectives: 1) to describe pelvic obliquity (PO) and leg-length discrepancy (LLD) and their relationship with coronal malalignment (CM); 2) to report rates of isolated PO and PO secondary to LLD; and 3) to assess the importance of preoperative PO and LLD in postoperative complications, readmission, reoperation, and patient-reported outcomes. METHODS Patients undergoing surgery (≥ 6-level fusions) for adult spinal deformity at a single institution were reviewed. Variables evaluated were as follows: 1) PO, angle between the horizontal plane and a line touching bilateral iliac crests; and 2) LLD, distance from the head to the tibial plafond. Coronal vertical axis (CVA) and sagittal vertical axis measurements were collected, both from C7. The cutoff for CM was CVA > 3 cm. The Oswestry Disability Index (ODI) was collected preoperatively and at 2 years. RESULTS Of 242 patients undergoing surgery for adult spinal deformity, 90 (37.0%) had preoperative CM. Patients with preoperative CM had a higher PO (2.8° ± 3.2° vs 2.0° ± 1.7°, p = 0.013), a higher percentage of patients with PO > 3° (35.6% vs 23.5%, p = 0.044), and higher a percentage of patients with LLD > 1 cm (21.1% vs 9.8%, p = 0.014). Whereas preoperative PO was significantly positively correlated with CVA (r = 0.26, p < 0.001) and maximum Cobb angle (r = 0.30, p < 0.001), preoperative LLD was only significantly correlated with CVA (r = 0.14, p = 0.035). A total of 12.2% of patients with CM had significant PO and LLD, defined as follows: PO ≥ 3°; LLD ≥ 1 cm. Postoperatively, preoperative PO was significantly associated with both postoperative CM (OR 1.22, 95% CI 1.05-1.40, p = 0.008) and postoperative CVA (β = 0.14, 95% CI 0.06-0.22, p < 0.001). A higher preoperative PO was independently associated with postoperative complications after multivariate logistic regression (OR 1.24, 95% CI 1.05-1.45, p = 0.010); however, 2-year ODI scores were not. Preoperative LLD had no significant relationship with postoperative CM, CVA, ODI, or complications. CONCLUSIONS A PO ≥ 3° or LLD ≥ 1 cm was seen in 44.1% of patients with preoperative CM and in 23.5% of patients with normal coronal alignment. Preoperative PO was significantly associated with preoperative CVA and maximum Cobb angle, whereas preoperative LLD was only associated with preoperative CVA. The direction of PO and LLD showed no consistent pattern with CVA. Preoperative PO was independently associated with complications but not with 2-year ODI scores.
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Affiliation(s)
- Scott L Zuckerman
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
- 2The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Christopher S Lai
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Yong Shen
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Meghan Cerpa
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Nathan J Lee
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Mena G Kerolus
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Alex S Ha
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Ian A Buchanan
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Eric Leung
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Ronald A Lehman
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
| | - Lawrence G Lenke
- 1Department of Orthopedic Surgery, Columbia University Medical Center; and
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11
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Zuckerman SL, Cerpa M, Lai CS, Lenke LG. Coronal Alignment in Adult Spinal Deformity Surgery: Definitions, Measurements, Treatment Algorithms, and Impact on Clinical Outcomes. Clin Spine Surg 2022; 35:196-203. [PMID: 33843764 DOI: 10.1097/bsd.0000000000001175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
The major focus of realignment in adult spinal deformity (ASD) surgery has been on the sagittal plane, and less emphasis has been given to the coronal plane. In light of this overlooked area within ASD surgery, we aimed to refocus the narrative on coronal alignment in ASD surgery. The objectives of the current narrative review were to (1) define coronal alignment and discuss existing measurements; (2) report the incidence and prevalence of coronal malalignment (CM); (3) discuss the impact of CM on clinical outcomes; and (4) describe our preferred treatment algorithm of surgical correction of CM in ASD.
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Affiliation(s)
- Scott L Zuckerman
- Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY
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12
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Zuckerman SL, Lai CS, Shen Y, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Leung E, Cerpa M, Lehman RA, Lenke LG. Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience. J Neurosurg Spine 2022; 36:585-594. [PMID: 34678769 DOI: 10.3171/2021.6.spine21575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent). METHODS A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis. RESULTS In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar. CONCLUSIONS Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.
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Affiliation(s)
- Scott L Zuckerman
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher S Lai
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Yong Shen
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Nathan J Lee
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Mena G Kerolus
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Alex S Ha
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Ian A Buchanan
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Eric Leung
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Meghan Cerpa
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Ronald A Lehman
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Lawrence G Lenke
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
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Kieser DC, Boissiere L, Bourghli A, Hayashi K, Cawley D, Yilgor C, Alanay A, Acaroglu E, Kleinstueck F, Pizones J, Pellise F, Perez-Grueso FJS, Obeid I. Obeid-Coronal Malalignment Classification Is Age Related and Independently Associated to Personal Reported Outcome Measurement Scores in the Nonfused Spine. Neurospine 2021; 18:475-480. [PMID: 34610677 PMCID: PMC8497236 DOI: 10.14245/ns.2142458.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/03/2021] [Indexed: 02/03/2023] Open
Abstract
Objective To evaluate Obeid-coronal malalignment (O-CM) modifiers according to age, sagittal alignment, and patient-reported outcome measures (PROMs), in the mobile spine.
Methods Retrospective review of a prospective multicenter adult spinal deformity (ASD) database with 1,243 (402 nonoperative, 841 operative) patients with no prior fusion surgery. Patients were included if they were aged over 18 years and were affected by spinal deformity defined by one of: Cobb angle ≥ 20°, pelvic tilt ≥ 25°, sagittal vertical axis ≥ 5 cm, thoracic kyphosis ≥ 60°. Patients were classified according to the O-CM classification and compared to coronally aligned patients. Multivariate analysis was performed on the relationship between PROMs and age, global tilt (GT) and coronal malalignment (CM).
Results Four hundred forty-three patients had CM of more than 2 cm compared to 800 who did not. The distribution of these modifiers was correlated to age. After multivariate analysis, using age and GT as confounding factors, we found that before the age of 50 years, 2A1 patients had worse sex life and greater satisfaction than patients without CM. After 50 years of age, patients with CM (1A1, 1A2) had worse self-image and those with 2A2, 2B had worse self-image, satisfaction, and 36-item Short Form Health Survey physical function. Self-image was the consistent determinant of patients opting for surgery for all ages.
Conclusion CM distribution according to O-CM modifiers is age dependent. A clear correlation between the coronal malalignment and PROMs exists when using the O-CM classification and in the mobile spine, this typically affects self-image and satisfaction. Thus, CM classified according to O-CM modifiers is correlated to PROMs and should be considered in ASD.
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Affiliation(s)
- David Christopher Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch School of Medicine, Christchurch, New Zealand
| | - Louis Boissiere
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, Bordeaux, France
| | - Anouar Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, Riyadh, Saudi Arabia
| | - Kazunori Hayashi
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, Bordeaux, France
| | - Derek Cawley
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, Bordeaux, France
| | - Caglar Yilgor
- Acibadem University School of Medicine, Istanbul, Turkey
| | - Ahmet Alanay
- Acibadem University School of Medicine, Istanbul, Turkey
| | - Emre Acaroglu
- Spine Surgery Unit, Ankara Acibadem ARTES Spine Center, Ankara, Turkey
| | | | | | - Ferran Pellise
- Spine Surgery Unit, Hospital Universitario Val Hebron, Barcelona, Spain
| | | | - Ibrahim Obeid
- L'Institut de la Colonne Vertébrale, CHU Pellegrin, Bordeaux, France
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Zuckerman SL, Lai CS, Shen Y, Kerolus MG, Ha AS, Buchanan IA, Lee NJ, Leung E, Cerpa M, Lehman RA, Lenke LG. Be Prepared: Preoperative Coronal Malalignment Often Leads to More Extensive Surgery Than Sagittal Malalignment During Adult Spinal Deformity Surgery. Neurospine 2021; 18:570-579. [PMID: 34610688 PMCID: PMC8497231 DOI: 10.14245/ns.2142384.192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/25/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the effect of coronal alignment on: (1) surgical invasiveness and operative complexity and (2) postoperative complications.
Methods A retrospective, cohort study of adult spinal deformity patients was conducted. Alignment groups were: (1) neutral alignment (NA): coronal vertical axis (CVA) ≤ 3 cm and sagittal vertical axis (SVA) ≤ 5 cm; (2) coronal malalignment (CM) only: CVA > 3 cm; (3) Sagittal malalignment (SM) only: SVA > 5 cm; and (4) coronal and sagittal malalignment (CCSM): CVA > 3 cm and SVA > 5 cm.
Results Of 243 patients, alignment groups were: NA 115 (47.3%), CM 48 (19.8%), SM 38 (15.6%), and CCSM 42 (17.3%). Total instrumented levels (TILs) were highest in CM (14.5±3.7) and CCSM groups (14±4.0) (p<0.001). More 3-column osteotomies (3COs) were performed in SM (21.1%) and CCSM (28.9%) groups than CM (10.4%) (p=0.003). CM patients had more levels instrumented (p=0.029), posterior column osteotomies (PCOs) (p<0.001), and TLIFs (p=0.002) than SM patients. CCSM patients had more TLIFs (p=0.012) and higher estimated blood loss (EBL) (p=0.003) than SM patients. CVA displayed a stronger relationship with TIL (p=0.002), EBL (p<0.001), and operative time (p<0.001) than SVA, which had only one significant association with EBL (p=0.010). Both SM/CCSM patients had higher readmissions (p=0.003) and reoperations (p<0.001) than CM patients.
Conclusion Amount of preoperative CM was a better predictor of surgical invasiveness than the amount of SM, despite 3COs more commonly performed in SM patients. CM patients had more instrumented levels, PCOs, and TLIFs than SM patients.
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Affiliation(s)
- Scott L Zuckerman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Christopher S Lai
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Yong Shen
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Alex S Ha
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
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Buell TJ, Smith JS. Adult Spinal Deformity and Novel Classifications: Is Coronal Malalignment Making a Comeback?: Commentary on "Obeid-Coronal Malalignment Classification Is Age Related and Independently Associated to Personal Reported Outcome Measurement Scores in the Nonfused Spine". Neurospine 2021; 18:481-483. [PMID: 34610678 PMCID: PMC8497249 DOI: 10.14245/ns.2142648.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Thomas J Buell
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Buell TJ, Shaffrey CI, Kim HJ, Klineberg EO, Lafage V, Lafage R, Protopsaltis TS, Passias PG, Mundis GM, Eastlack RK, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Hamilton DK, Gupta MC, Burton DC, Hostin RA, Kebaish KM, Hart RA, Schwab FJ, Bess S, Ames CP, Smith JS. Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions. J Neurosurg Spine 2021; 35:761-773. [PMID: 34450577 DOI: 10.3171/2021.2.spine201938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm. METHODS This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up. RESULTS Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810). CONCLUSIONS In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher I Shaffrey
- 1Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Han Jo Kim
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O Klineberg
- 3Department of Orthopaedic Surgery, University of California, Davis, California
| | - Virginie Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter G Passias
- 4Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Gregory M Mundis
- 5Department of Orthopaedic Surgery, Scripps Clinic and San Diego Spine Foundation, La Jolla, California
| | - Robert K Eastlack
- 5Department of Orthopaedic Surgery, Scripps Clinic and San Diego Spine Foundation, La Jolla, California
| | - Vedat Deviren
- 6Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Michael P Kelly
- 7Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Alan H Daniels
- 8Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 9Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Alex Soroceanu
- 10Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 11Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Douglas C Burton
- 12Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard A Hostin
- 13Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Baylor Scott and White Medical Center, Plano, Texas
| | - Khaled M Kebaish
- 14Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Hart
- 15Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Frank J Schwab
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 16Denver International Spine Center, Presbyterian/St. Luke's Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher P Ames
- 17Department of Neurological Surgery, University of California, San Francisco, California
| | - Justin S Smith
- 18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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17
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Buell TJ, Shaffrey CI, Bess S, Kim HJ, Klineberg EO, Lafage V, Lafage R, Protopsaltis TS, Passias PG, Mundis GM, Eastlack RK, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Hamilton DK, Gupta MC, Burton DC, Hostin RA, Kebaish KM, Hart RA, Schwab FJ, Ames CP, Smith JS. Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction. J Neurosurg Spine 2021; 35:729-742. [PMID: 34416723 DOI: 10.3171/2020.11.spine201915] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS. METHODS The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1. RESULTS Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045). CONCLUSIONS Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.
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Affiliation(s)
- Thomas J Buell
- 1Department of Orthopaedic & Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher I Shaffrey
- 1Department of Orthopaedic & Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Shay Bess
- 2Denver International Spine Center, Presbyterian/St. Luke's Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O Klineberg
- 4Department of Orthopaedic Surgery, University of California, Davis, California
| | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter G Passias
- 5Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Gregory M Mundis
- 6Scripps Clinic and San Diego Center for Spinal Disorders, La Jolla, California
| | - Robert K Eastlack
- 6Scripps Clinic and San Diego Center for Spinal Disorders, La Jolla, California
| | | | - Michael P Kelly
- 8Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Alan H Daniels
- 9Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 10Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Alex Soroceanu
- 11Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 12Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 8Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Douglas C Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard A Hostin
- 14Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Baylor Scott and White Medical Center, Plano, Texas
| | - Khaled M Kebaish
- 15Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington; and
| | - Frank J Schwab
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Christopher P Ames
- 17Neurological Surgery, University of California, San Francisco, California
| | - Justin S Smith
- 18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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18
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Zuckerman SL, Lai CS, Shen Y, Cerpa M, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Devin CJ, Lehman RA, Lenke LG. Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative? Global Spine J 2021; 13:1080-1088. [PMID: 34036834 DOI: 10.1177/21925682211019352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Scott L Zuckerman
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA.,Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher S Lai
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Yong Shen
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Alex S Ha
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Clinton J Devin
- Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
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19
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The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3639-3646. [PMID: 34009398 DOI: 10.1007/s00586-021-06873-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 02/22/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. METHODS A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05. RESULTS 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005). CONCLUSION Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.
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20
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Buell TJ, Smith JS, Shaffrey CI, Kim HJ, Klineberg EO, Lafage V, Lafage R, Protopsaltis TS, Passias PG, Mundis GM, Eastlack RK, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Hamilton DK, Gupta MC, Burton DC, Hostin RA, Kebaish KM, Hart RA, Schwab FJ, Bess S, Ames CP. Multicenter assessment of surgical outcomes in adult spinal deformity patients with severe global coronal malalignment: determination of target coronal realignment threshold. J Neurosurg Spine 2020:1-14. [PMID: 33276327 DOI: 10.3171/2020.7.spine20606] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The impact of global coronal malalignment (GCM; C7 plumb line-midsacral offset) on adult spinal deformity (ASD) treatment outcomes is unclear. Here, the authors' primary objective was to assess surgical outcomes and complications in patients with severe GCM, with a secondary aim of investigating potential surgical target coronal thresholds for optimal outcomes. METHODS This is a retrospective analysis of a prospective multicenter database. Operative patients with severe GCM (≥ 1 SD above the mean) and a minimum 2-year follow-up were identified. Demographic, surgical, radiographic, health-related quality of life (HRQOL), and complications data were analyzed. RESULTS Of 691 potentially eligible operative patients (mean GCM 4 ± 3 cm), 80 met the criteria for severe GCM ≥ 7 cm. Of these, 62 (78%; mean age 63.7 ± 10.7 years, 81% women) had a minimum 2-year follow-up (mean follow-up 3.3 ± 1.1 years). The mean ASD-Frailty Index was 3.9 ± 1.5 (frail), 50% had undergone prior fusion, and 81% had concurrent severe sagittal spinopelvic deformity with GCM and C7-S1 sagittal vertical axis (SVA) positively correlated (r = 0.313, p = 0.015). Surgical characteristics included posterior-only (58%) versus anterior-posterior (42%) approach, mean fusion of 13.2 ± 3.8 levels, iliac fixation (90%), 3-column osteotomy (36%), operative duration of 8.3 ± 3.0 hours, and estimated blood loss of 2.3 ± 1.7 L. Final alignment and HRQOL significantly improved (p < 0.01): GCM, 11 to 4 cm; maximum coronal Cobb angle, 43° to 20°; SVA, 13 to 4 cm; pelvic tilt, 29° to 23°; pelvic incidence-lumbar lordosis mismatch, 31° to 5°; Oswestry Disability Index, 51 to 37; physical component summary of SF-36 (PCS), 29 to 37; 22-Item Scoliosis Research Society Patient Questionnaire (SRS-22r) Total, 2.6 to 3.5; and numeric rating scale score for back and leg pain, 7 to 4 and 5 to 3, respectively. Residual GCM ≥ 3 cm was associated with worse SRS-22r Appearance (p = 0.04) and SRS-22r Satisfaction (p = 0.02). The minimal clinically important difference and/or substantial clinical benefit (MCID/SCB) was met in 43%-83% (highest for SRS-22r Appearance [MCID 83%] and PCS [SCB 53%]). The severity of baseline GCM (≥ 2 SD above the mean) significantly impacted postoperative SRS-22r Satisfaction and MCID/SCB improvement for PCS. No significant partial correlations were demonstrated between GCM or SVA correction and HRQOL improvement. There were 89 total complications (34 minor and 55 major), 45 (73%) patients with ≥ 1 complication (most commonly rod fracture [19%] and proximal junctional kyphosis [PJK; 18%]), and 34 reoperations in 22 (35%) patients (most commonly for rod fracture and PJK). CONCLUSIONS Study results demonstrated that ASD surgery in patients with substantial GCM was associated with significant radiographic and HRQOL improvement despite high complication rates. MCID improvement was highest for SRS-22r Appearance/Self-Image. A residual GCM ≥ 3 cm was associated with a worse outcome, suggesting a potential coronal realignment target threshold to assist surgical planning.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Justin S Smith
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 2Departments of Neurological Surgery and Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O Klineberg
- 4Department of Orthopaedic Surgery, University of California, Davis, California
| | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter G Passias
- 5Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Gregory M Mundis
- 6Department of Orthopaedic Surgery, Scripps Clinic and San Diego Spine Foundation, La Jolla, California
| | - Robert K Eastlack
- 6Department of Orthopaedic Surgery, Scripps Clinic and San Diego Spine Foundation, La Jolla, California
| | - Vedat Deviren
- 7Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Michael P Kelly
- 8Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Alan H Daniels
- 9Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 10Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Alex Soroceanu
- 11Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 12Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 8Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Douglas C Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard A Hostin
- 14Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Baylor Scott and White Medical Center, Plano, Texas
| | - Khaled M Kebaish
- 15Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 17Denver International Spine Center, Presbyterian/St. Luke's Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado; and
| | - Christopher P Ames
- 18Department of Neurological Surgery, University of California, San Francisco, California
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21
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Ruiz Santiago F, Láinez Ramos-Bossini AJ, Wáng YXJ, López Zúñiga D. The role of radiography in the study of spinal disorders. Quant Imaging Med Surg 2020; 10:2322-2355. [PMID: 33269230 DOI: 10.21037/qims-20-1014] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite the growing use of computed tomography (CT) and magnetic resonance imaging (MRI) in the study of spinal disorders, radiography still plays an important role in many conditions affecting the spine. However, the study and interpretation of spine radiograph is receiving less attention and radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine. The aim of this article is to review the radiologic indications of radiograph in different pathologic conditions that affect the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumour disorders, as well as their main radiographic manifestations.
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Affiliation(s)
- Fernando Ruiz Santiago
- Department of Radiology, Neuro-traumatology Hospital, Hospital Virgen de las Nieves, University of Granada, Granada, Spain
| | | | - Yì Xiáng J Wáng
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
| | - Daniel López Zúñiga
- Department of Radiology, Neuro-traumatology Hospital, Hospital Virgen de las Nieves, University of Granada, Granada, Spain
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22
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Wang H, Wang L, Sun Z, Jiang S, Li W. Posterior column osteotomy plus unilateral cage strutting for correction of lumbosacral fractional curve in degenerative lumbar scoliosis. J Orthop Surg Res 2020; 15:482. [PMID: 33081812 PMCID: PMC7574557 DOI: 10.1186/s13018-020-02011-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Inadequate release of the posterior spinal bone elements may hinder the correction of the lumbosacral fractional curve in degenerative lumbar scoliosis, since the lumbosacral junction tends to be particularly rigid and may already be fused into an abnormal position. The purpose of this study was to evaluate the surgical outcome and complications of posterior column osteotomy plus unilateral cage strutting technique on lumbosacral concavity for correction of fractional curve in degenerative lumbar scoliosis patients. Methods Thirty-two degenerative lumbar scoliosis patients with lumbosacral fractional curve more than 15° that were surgically treated by posterior column osteotomy plus unilateral cage strutting technique were retrospectively reviewed. The patients’ medical records were reviewed to identify demographic and surgical data, including age, sex, body mass index, back pain, leg pain, Oswestry Disability Index, operation time, blood loss, and instrumentation levels. Radiological data including coronal balance distance, Cobb angle, lumbosacral coronal angle, sagittal vertical axis, lumbar lordosis, and lumbosacral lordotic angle were evaluated before and after surgery. Cage subsidence and bone fusion were evaluated at 2-year follow-up. Results All patients underwent the operation successfully; lumbosacral coronal angle changed from preoperative 20.1 ± 5.3° to postoperative 5.8 ± 5.7°, with mean correction of 14.3 ± 4.4°, and the correction was maintained at 2-year follow-up. Cobb’s angle and coronal balance distance decreased from preoperative to postoperative; the correction was maintained at 2-year follow-up. Sagittal vertical axis decreased, and lumbar lordosis increased from preoperative to postoperative; the correction was also maintained at 2-year follow-up. Lumbosacral lordotic angle presented no change from preoperative to postoperative and from postoperative to 2-year follow-up. Postoperatively, there were 8 patients with lumbosacral coronal angle more than 10°, they got the similar lumbosacral coronal angle correction, but presented larger preoperative Cobb and lumbosacral coronal angle than the other 24 patients. No cage subsidence was detected; all patients achieved intervertebral bone fusion and inter-transverse bone graft fusion at the lumbosacral region at 2-year follow-up. Conclusion Posterior column osteotomy plus unilateral cage strutting technique on the lumbosacral concavity facilitate effective correction of the fractional curve in degenerative lumbar scoliosis patients through complete release of dural sac as well as the asymmetrical intervertebral reconstruction by cage.
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Affiliation(s)
- Hui Wang
- Orthopaedic Department, Peking University Third Hospital, No 49. North Garden Street, HaiDian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Longjie Wang
- Orthopaedic Department, Peking University Third Hospital, No 49. North Garden Street, HaiDian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Zhuoran Sun
- Orthopaedic Department, Peking University Third Hospital, No 49. North Garden Street, HaiDian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Shuai Jiang
- Orthopaedic Department, Peking University Third Hospital, No 49. North Garden Street, HaiDian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, No 49. North Garden Street, HaiDian District, Beijing, 100191, China. .,Beijing Key Laboratory of Spinal Disease Research, Beijing, China. .,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China.
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