Surgical correction of severe adult lumbar scoliosis (major curves ≥ 75°): retrospective analysis with minimum 2-year follow-up

OBJECTIVE

Prior reports have demonstrated the efficacy of surgical correction for adult lumbar scoliosis. Many of these reports focused on mild to moderate scoliosis. The authors' objective was to report their experience and to assess outcomes and complications after deformity correction for severe adult scoliosis.

METHODS

The authors retrospectively analyzed consecutive adult scoliosis patients with major thoracolumbar/lumbar (TL/L) curves ≥ 75° who underwent deformity correction at their institution. Those eligible with a minimum 2 years of follow-up were included. Demographic, surgical, coronal and sagittal plane radiographic measurements, and health-related quality of life (HRQL) scores were analyzed.

RESULTS

Among 26 potentially eligible patients, 22 (85%) had a minimum 2 years of follow-up (range 24-89 months) and were included in the study (mean age 57 ± 11 years; 91% women). The cohort comprised 16 (73%), 4 (18%), and 2 (9%) patients with adult idiopathic scoliosis, de novo degenerative scoliosis, and iatrogenic scoliosis, respectively. The surgical approach was posterior-only and multistage anterior-posterior in 18 (82%) and 4 (18%) patients, respectively. Three-column osteotomy was performed in 5 (23%) patients. Transforaminal and anterior lumbar interbody fusion were performed in 14 (64%) and 4 (18%) patients, respectively. All patients had sacropelvic fixation with uppermost instrumented vertebra in the lower thoracic spine (46% [10/22]) versus upper thoracic spine (55% [12/22]). The mean fusion length was 14 ± 3 levels. Preoperative major TL/L and lumbosacral fractional (L4-S1) curves were corrected from 83° ± 8° to 28° ± 13° (p < 0.001) and 34° ± 8° to 13° ± 6° (p < 0.001), respectively. Global coronal and sagittal balance significantly improved from 5 ± 4 cm to 1 ± 1 cm (p = 0.001) and 9 ± 8 cm to 2 ± 3 cm (p < 0.001), respectively. Pelvic tilt significantly improved from 33° ± 9° to 23° ± 10° (p < 0.001). Significant improvement in HRQL measures included the following: Scoliosis Research Society (SRS) pain score (p = 0.009), SRS appearance score (p = 0.004), and SF-12/SF-36 physical component summary (PCS) score (p = 0.026). Transient and persistent neurological deficits occurred in 8 (36%) and 2 (9%) patients, respectively. Rod fracture/pseudarthrosis occurred in 6 (27%) patients (supplemental rods were utilized more recently in 23%). Revisions were performed in 7 (32%) patients.

CONCLUSIONS

In this single-center surgical series for severe adult scoliosis (major curves ≥ 75°), a posterior-only or multistage anterior-posterior approach provided major curve correction of 66% and significant improvements in global coronal and sagittal spinopelvic alignment. Significant improvements were also demonstrated in HRQL measures (SRS pain, SRS appearance, and SF-12/SF-36 PCS). Complications and revisions were comparable to those of other reports involving less severe scoliosis. The results of this study warrant future prospective multicenter studies to further delineate outcomes and complication risks for severe adult scoliosis correction.

Toward a comprehensive assessment of functional outcomes in pediatric patients with brain arteriovenous malformations: the Pediatric Quality of Life Inventory

OBJECTIVE Brain arteriovenous malformations (bAVMs) are rare in pediatric patients but represent the most common cause of hemorrhagic stroke in this population. Pediatric patients demonstrate superior outcomes in comparison with adult patients with similar lesions and presentations. Most studies of clinical outcomes of pediatric bAVMs use the modified Rankin Scale (mRS), despite a lack of validation in pediatric patients. METHODS The authors interviewed the parents of 26 pediatric patients who underwent multimodality bAVM treatment and administered the Pediatric Quality of Life Inventory (PedsQL)-a well-validated tool for pediatric outcomes that quantifies performance in a physical, emotional, social, and school domains. They also reviewed clinical information from the patients' medical charts. Statistical analysis was performed using a log-transformed t-test, the Mann-Whitney exact test, the Kruskal-Wallis test, and Spearman correlation. In addition, the literature was reviewed for prior reports of clinical outcome of pediatric cases of bAVM. RESULTS The average PedsQL health-related quality of life score was 71 ± 24, with an average age at diagnosis of 12.5 years and an average follow-up period of 6.8 years. Seventeen patients (65%) presented with hemorrhage and 4 (15%) with seizures. PedsQL scores correlated strongly and at a statistically significant level (p < 0.001) with mRS, Pediatric Overall Performance Category (POPC), Pediatric Cerebral Performance Category (PCPC), and Glasgow Outcome Scale scores. Multivariate modeling validated special education, corrective devices, and cure status as significant predictors of PedsQL scores. Statistically significant risk factors for undergoing placement of a ventriculoperitoneal shunt included lower Glasgow Coma Scale motor scores on admission (p = 0.042), cerebellar location (p = 0.046), and nidus volume (p = 0.017). Neither treatment modality nor location statistically affected clinical outcomes at follow-up. CONCLUSIONS There have been few studies of long-term clinical outcomes of bAVM in pediatric patients, and previously published studies have used conventional metrics that have been validated in the adult population, such as the mRS. Although these metrics can serve as reasonable surrogates, an accurate understanding of overall health-related quality of life is contingent on utilizing validated toolsets, such as the PedsQL.

Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes

OBJECT

Lenke 1C curves are challenging to manage surgically due to the structural thoracic deformity and nonstructural lumbar curve. Selective thoracic fusion (STF) is considered the standard of care because it preserves motion of the lumbar segment, yet nonselective STF (NSTF) remains prevalent. This study aims to identify baseline patient characteristics that drive treatment and to compare postoperative outcomes for both procedures.

METHODS

Studies that compared baseline and postoperative demographic data, health-related quality of life (HRQL) questionnaires, and radiographic parameters of patients with Lenke 1C curves undergoing STF or NSTF were identified for meta-analysis. The effect measure is expressed as a mean difference (MD) with 95% CI. A positive MD signifies a greater STF value, or a mean increase within the group.

RESULTS

One prospective and 6 retrospective case-control studies with sample size of 488 patients (344 STF and 144 NSTF) were identified. Baseline age, sex, and HRQLs were equivalent, except for better scores in the STF group for the Scoliosis Appearance Questionnaire (SAQ): Unrelated to Deformity item (3.47 vs 3.88, p = 0.01) and the Spine Research Society questionnaire, Item 22: Pain (4.13 vs 3.92, p = 0.04). Radiographic findings were significantly worse in NSTF, as measured by the thoracolumbar/lumbar (TL/L) Cobb angle (MD: -4.29°, p < 0.01) and TL/L apical vertebral translation (AVT) (MD: -6.08, p < 0.01). Radiographic findings significantly improved in STF, as measured in the main thoracic (MT) Cobb angle (MD: -27.78°, p < 0.01), TL/L Cobb angle (MD: -16.24°, p < 0.01), MT:TL/L Cobb ratio (MD: -0.21, p < 0.01), coronal balance (MD: 0.47, p = 0.02), and thoracic kyphosis (MD: 7.87°, p < 0.01); and in NSTF in proximal thoracic (PT) Cobb angle (24° vs 14.1°, p < 0.01), MT Cobb angle (53.5° vs 20.5°, p < 0.01), and TL/L Cobb angle (41.6° vs 16.6°, p < 0.01). Postoperative TL/L Cobb angle (23.1° vs 16.6°, p < 0.01) was significantly higher in STF; but PT Cobb angle, MT Cobb angle, and MT:TL/L Cobb ratio are equivalent.

CONCLUSIONS

Patients with larger lumbar compensatory curves displaying a larger degree of coronal translation, as measured by the TL/L AVT, are more likely to undergo an NSTF. Contrary to established guidelines, larger MT curve magnitudes and MT:TL/L Cobb angle ratios have not been found to influence the decision to pursue a selective thoracic fusion. Although overall both STF and NSTF groups are found to have effective postoperative coronal balance, the STF group has only modest improvements in the lumbar curve position as determined by a relatively unchanged TL/L AVT. Furthermore, surgeons may prefer NSTF in patients who may have a worse overall perception of their spinal deformity as measured by HRQL measures of pain and desire for appearance change.