Degenerative Lumbar Scoliosis Patients Research Articles

The clinical effectiveness and complications of lumbar selective fenestration and concave-side fusion (LSFCF) in degenerative lumbar scoliosis (DLS) combined with lumbar spinal stenosis (LSS)

PurposeThis retrospective study was performed to analyze the clinical effects and complications of LSFCF in the surgical treatment of DLS combined with lumbar spinal stenosis (LSS).MethodsA total of 26 eligible patients (mean age, 64.73 y; 17 men, 9 women) with DLS combined with LSS were included and LSFCF surgery was performed. An independent spine surgeon retrospectively reviewed the medical records and radiographs of all patients to evaluate surgical data and surgery-related complications. Preoperative, postoperative, and follow-up questionnaires were obtained to assess clinical outcomes.ResultsThe average follow-up period of this study was 20.14 ± 5.21 months. The operation time and blood loss of patients underwent LSFCF were 129.33 ± 15.74 min and 356.13 ± 21.28 ml. The clinical effects of all patients in terms of visual analogue scale (VAS) and Oswestry disability index (ODI) have been significantly improved at the final follow-up postoperatively (P < 0.05). Complications such as infection, cerebrospinal fluid leakage, nerve injury, and internal fixation failure, etc. were not observed during the follow-up period.ConclusionThe LSFCF surgery is a safe and effective treatment for DLS patients combined with LSS.

A comparative study of supine traction, supine side-bending radiographs, and supine MRI to determine coronal flexibility in degenerative lumbar scoliosis patients.

The purpose of this study was to compare curve correction in degenerative lumbar scoliosis using supine traction radiographs, supine side-bending radiographs, and supine MRI. A prospective analysis of Cobb angles from patients diagnosed with degenerative lumbar scoliosis who underwent supine traction radiography (TR), side-bending radiography (SB), and supine MRI. The Cobb angles at thoracic (T), thoracolumbar/lumbar (TL/L), and lumbosacral (LS) levels were measured, and the curvecorrection in percentages compared with standing AP radiography was calculated as corrective flexibility. Differences in curve correction were analyzed. In total, 33 patients with an age range of 50-80years were eligible for inclusion. Traction radiography provided the greatest accuracy in curve correction, with a significant difference from side-bending radiography and supine MRI in T, TL/L, and LS levels (P < 0.001). The difference between side-bending radiography and supine MRI in TL/L and LS levels wasnot significant (P = 0.721, P = 0.654, respectively). A moderate correlation was found between the corrective flexibility of TR and SB at the T level (0.563, P = 0.001), a strong correlation was observed between the corrective flexibility of TR and SB at the TL/L level (0.709, P < 0.001), and at the TL/L level, a moderate correlation was identified between TR and supine MRI corrective flexibility (0.425, P = 0.014). Traction radiographs significantly outperformed side-bending radiographs and supine MRI in terms of access curve flexibility in degenerative lumbar scoliosis.

Surface electromyography study on asymmetry in paravertebral muscle degeneration in patients with degenerative lumbar scoliosis

The asymmetry of paravertebral muscle (PVM) degeneration in degenerative lumbar scoliosis (DLS) patients has been extensively studied by imaging and histological examination and has not yet been verified by surface electromyography (sEMG) techniques. To study the relationship between the surface electromyography (sEMG) and degenerative characteristics of paravertebral muscles (PVMs) in patients with degenerative lumbar scoliosis (DLS). In twenty DLS patients and fifteen healthy subjects, sEMG activity of the PVMs at the level of the upper end vertebra (UEV), apical vertebra (AV) and lower end vertebra (LEV) was measured during static standing and dynamic standing forward flexion and backward extension tasks. Action segmentation was achieved according to inertial measurement unit (IMU) data. The sEMG characteristics of the PVMs on the convex and concave sides were compared, and the relationship of these data with the Cobb angle and lumbar lordotic angle (LL) was analyzed. In the DLS group, there was no difference in sEMG activity between the convex and concave sides at the UEV or AV level, but in the motion and return phases of the standing forward flexion task (P = 0.000, P = 0.015) and the maintenance and return phases of the standing backward extension task (P = 0.001, P = 0.01), there was a significant difference in sEMG activity between the convex and concave sides at the LEV level. Asymmetrical sEMG activity at the LEV level was negatively correlated with the Cobb angle (F = 93.791, P < 0.001) and LL angle (F = 65.564, P < 0.001). In the DLS group, asymmetrical sEMG activity of the PVMs appeared at the LEV level, with the concave side being more active than the convex side. This sEMG characteristics were consistent with their imaging and histological degenerative features and correlated with bone structural parameters.

Motion of Lumbar Endplate in Degenerative Lumbar Scoliosis Patients with Different Cobb Angle In Vivo: Reflecting the Biomechanics of the Lumbar Disc.

Objective To evaluate the influence of degenerative lumbar scoliosis (DLS) with different Cobb angles and degenerative discs on the range of motion (ROM) of the lumbar endplates during functional weight-bearing activities in vivo. Summary of Background. DLS data might influence spinal stability and range of motion of the spine. Altered lumbar segment motion is thought to be related to disc degeneration. However, to date, no data have been reported on the motion patterns of the lumbar endplates in patients with DLS in vivo. Methods We recorded 42 DLS patients with the apical disc at L2-L3 and L3-L4. Patients were divided into A group with a coronal Cobb angle >20° (number: 13; 62.00 ± 8.57 years old) and group B with a coronal Cobb angle <20° (number: 28; 65.79 ± 6.66 years old). Patients' discs were divided into a degenerated disc group (III-V) and a nondegenerated disc group (I-II) according to the Pfirrmann classification. Computed tomography (CT) was performed on every subject to build 3-dimensional (3D) models of the lumbar vertebrae (L1–S1), and then the vertebras were matched according to the dual fluoroscopic imaging system. The kinematics of the endplate was compared between the different Cobb angle groups and the healthy group reported in a previous study and between the degenerative disc group and nondegenerative disc group by multiway analysis of variance. Results Coupled translation at L5-S1 was higher than other levels during the three movements. During the flexion-extension of the trunk, around the anteroposterior axis, rotation in group A was higher than that in the control group at L2-L3 and L3-L4 (6.62 ± 3.61 mm vs 4.36 ± 2.55 mm, 5.01 ± 3.19 mm; P < 0.05, P < 0.05). During the left-right bending of the trunk, around the mediolateral axis, rotations in groups A and B were higher than those in the control group at L5-S1 (17.52 ± 11.43°, 17.25 ± 9.22° vs 10.08 ± 5.42°; P < 0.05, P < 0.05). During the left-right torsion, around the anteroposterior axis, rotation in group A was higher than that in group B and the control group at L2-3 (9.69 ± 5.94° vs 5.77 ± 4.02°, 4.47 ± 2.00°; P < 0.05, P < 0.05). In patients with Cobb angle <20°, coupled translation was higher in the degenerated disc group than in the nondegenerated disc group, especially along the anteroposterior axis. Conclusion An increase in the coupled rotation of the endplate at the scoliotic apical level in patients with DLS was related to a larger Cobb angle. Moreover, segments with degenerative discs had higher coupled translations in the anteroposterior direction than segments with nondegenerative discs in DLS patients with Cobb angle <20°. These data might provide clues regarding the etiology of DLS and the basis for operative planning.

P51. Which subscales of Oswestry Disability Index and Short Form 36 are related with sagittal and coronal parameters in degenerative lumbar scoliosis patients: a prospective study

<h3>BACKGROUND CONTEXT</h3> Degenerative lumbar scoliosis (DLS) patients had various degrees of disability. Previous studies have been inconclusive as to the correlation between radiographic and clinical parameters in DLS. <h3>PURPOSE</h3> The aim of this study was to identify the relationship between Oswestry Disability Index (ODI) and Short Form 36 (SF-36) total and subscale scores and global spinal parameters in DLS patients. <h3>STUDY DESIGN/SETTING</h3> A prospective study. <h3>PATIENT SAMPLE</h3> We enrolled 126 consecutive patients with degenerative de novo lumbar or thoracolumbar scoliosis patients who were referred to a tertiary hospital between August 2018 and December 2019. <h3>OUTCOME MEASURES</h3> ODI and SF-36 total and subscale scores. <h3>METHODS</h3> Sagittal (sagittal vertical axis; thoracic kyphosis; lumbar lordosis [LL]; pelvic tilt; pelvic incidence [PI]; PI-LL) and coronal (Cobb angle [CA]; coronal C7 plumb line; pelvic obliquity) parameters were measured on whole spinal radiographs. Pearson's correlation analysis was performed to reveal the relationship between parameters. <h3>RESULTS</h3> There were 76 female and 15 male patients with an average age of 70.2±8.4 years. The CA averaged 18.9±8.0°. ODI total score and SF-36 PCS had correlations with only coronal spinal parameters. ODI walking, standing, social life, and traveling domains were correlated with both coronal and sagittal parameters. Pain intensity, personal care, lifting, sitting and sex life domains were correlated with only coronal parameters. SF-36 physical function (PF) domain had correlations with both coronal and sagittal parameters. Bodily pain and vitality domains had correlations with only coronal parameters. <h3>CONCLUSIONS</h3> Only coronal parameters were correlated with ODI total score and SF-36 PCS in DLS patients. Coronal parameters were also correlated with most ODI subscales and SF-36 PF, BP and VT subscales. Although sagittal parameters were not correlated with ODI total score and SF-36 PCS, those were correlated with some subscale scores of ODI (walking, standing, social life and traveling) and SF-36 PF subscale. Analysis using subscale scores of ODI and SF-36 is helpful to understand and treat various degree of disability in DLS patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Factors Related to Preoperative Coronal Malalignment in Degenerative Lumbar Scoliosis: An Analysis on Coronal Parameters.

ObjectivesRecently the effects of coronal malalignment (CM) in degenerative lumbar scoliosis (DLS) have been reported, however, there was few studies on the correlated parameters of coronal alignments at pre‐operation. The aims of this current study were to investigate the associations of coronal parameters with scoliosis and coronal alignment, and to explore the relationships between the coronal pelvic tilt and coronal alignment in DLS.MethodsOne hundred and sixty‐one DLS patients in our hospital from May 2016 to December 2020 were reviewed and documented. The coronal balance distance (CBD, the offset between the center of C7 and the plumb line drawn from the center of S1), major Cobb (MC), fractional Cobb (FC), L4 coronal tilt, L5 coronal tilt, coronal pelvic tilt, apical rotation, and the vertebras in major curve were measured and documented. CM was considered if the CBD ≥ 30mm. All of those participants were assigned into group A (CBD ≥ 30 mm) and group B (CBD < 30 mm). Comparisons of demographic and radiographic data were performed between groups A and B. Pearson correlation and further multiple regression with stepwise method analysis were used to investigate those coronal parameters correlated to MC and CBD, respectively.ResultsThirty‐one patients suffering from CM were assigned into group A, and the rest of 130 patients were assigned to group B accordingly. Then the incidence of CM was about 19.3% (31/161). Patients in group A had less vertebras in the main curve (P = 0.009), however, the apical rotation (P < 0.001) and the L4 coronal tilt (P = 0.007) were much larger. Although the MC (P = 0.426) and FC (P = 0.06) had no difference between the two groups, the match between MC and FC was much smaller (p = 0.021) in group A. The coronal pelvic tilt correlated significantly with FC (r = 0.552, p < 0.001), but mildly with MC (r = −0.366, p < 0.001), L4 coronal tilt (r = 0.348, p < 0.001), and L5 coronal tilt (r = 0.351, p < 0.001), respectively. The CBD correlated strongly with L4 coronal tilt (r = −0.471, p < 0.001) and L5 coronal tilt (r = −0.468, p < 0.001), respectively, but mildly with FC (r = −0.255, p = 0.016). Further multiple regression analysis revealed that only L4 coronal tilt was the independent factor for MC (r 2 = 0.549, p < 0.001) and CBD (r 2 = 0.221, p < 0.001), respectively.ConclusionsThe prevalence of CM in DLS patients is about 19% at pre‐operation. With similar major Cobb, the less the vertebras in the major curve, the larger the CBD. L4 coronal tilt may correlate significantly to scoliosis and CBD. Coronal pelvic tilt may be just one of the compensations for the scoliosis deformity but effects CBD directly.

Association between serum β-oestradiol and health-related quality of life in postmenopausal women with degenerative lumbar scoliosis.

Degenerative lumbar scoliosis (DLS) is an age-related spinal disease. It is an important cause of low back pain, lower limb painand intermittent claudication, which seriously affects the quality of life of middle-aged and elderly people. This article aims to study the changes in serum oestrogen levels in postmenopausal women with DLS and its relationship. One hundred and sixty-eightpostmenopausal women diagnosed with DLS (DLS group) and 140 healthy postmenopausal women (control group) were recruited. Lumbar spinal bone mineral density (LSBMD) was measured by dual-energy X-ray absorptiometryand a chemiluminescence immunoassay analyser was used to detect serum β-oestradiol (E2) levels. The severity of lower back painwas assessed by the visual analogue scalescore and dysfunction was evaluated by Oswestry Disability Index (ODI). The quality of life was evaluated by Medical Outcomes Study 36-item Short Form Health Survey (SF-36). Diagnostic efficiency was evaluated by the receiver-operating characteristics curve (ROC). LSBMD and the level of E2 in the serum in DLS patients were significantly reduced when compared with the control group. The levels of E2 in the serum of postmenopausal women are reliable for predicting DLS revealed by ROC (p < .001). Serum E2 levels were negatively correlated with Cobb angle, VASand ODIand were positively correlated with LSBMD and SF-36 scores. In postmenopausal women, serum E2 levels in DLS patients are significantly reduced and low levels of E2 are associated with lower bone density and poorer quality of life.

The classification of coronal deformity based on preoperative global coronal malalignment for adult spinal deformity is questionable

Study designRetrospective case–control radiographic study.ObjectiveTo identify main effects of preoperative pattern and global coronal malalignment (GCM) on postoperative coronal imbalance in degenerative lumbar scoliosis (DLS) patients and evaluate the rationality of the classification of coronal deformity based on preoperative GCM.Summary of background dataA classification of coronal deformity based on preoperative GCM (20 mm set as the threshold of coronal imbalance) has been proposed recently, but whether it is practical is unclear.MethodsOne hundred twelve DLS patients treated with posterior instrumented fusion were reviewed. Coronal measurements included GCM and major Cobb angle. Based on relationship between C7 PL and major curve, preoperative patterns were classified into: Pattern 1(concave pattern), C7 PL shifted to the concave side of major curve; Pattern 2(convex pattern), C7 PL shifted to the convex side of major curve. Patients were separated into 4 groups (3 types): Type 0–1: GCM < 20 mm plus Pattern 1; Type 0–2: GCM < 20 mm plus Pattern 2; Type 1: GCM > 20 mm plus Pattern 1; Type 2: GCM > 20 mm plus Pattern 2. After comparison within patterns or among 4 groups, further factorial analysis was performed.ResultsSignificant differences regarding postoperative GCM or coronal imbalance/balance ratio existed among 4 groups (F = 6.219, p = 0.001; x2 = 22.506, p < 0.001, respectively), despite no significant difference in intra-pattern 1(concave pattern) or intra-pattern 2(convex pattern) groups. Two-way analysis of variance showed preoperative pattern exhibited significant effect on postoperative GCM or imbalance/balance ratio (F(1,108) = 14.286, p < 0.001; F(1,108) = 30.514, p < 0.001, respectively) while neither preoperative GCM alone nor interaction of preoperative GCM with pattern did.ConclusionIn DLS patients, it’s the preoperative pattern other than GCM that had main effects on postoperative coronal imbalance. Classification of coronal deformity based on preoperative GCM is questionable.Level of evidence3

Lateral interbody release for fused vertebrae via transpsoas approach in adult spinal deformity surgery: a preliminary report of radiographic and clinical outcomes

BackgroundLateral interbody release (LIR) via a transpsoas lateral approach is a surgical strategy to address degenerative lumbar scoliosis (DLS) patients with anterior autofusion of vertebral segments. This study aimed to characterize the clinical and radiographic outcomes of this lumbar reconstruction strategy using LIR to achieve anterior column correction.MethodsData for 21 fused vertebrae in 17 consecutive patients who underwent LIR between January 2014 and March 2020 were reviewed. Demographic and intraoperative data were recorded. Radiographic parameters were assessed preoperatively and at final follow-up, including segmental lordotic angle (SLA), segmental coronal angle (SCA), bone union rate, pelvic incidence (PI), lumbar lordosis (LL), pelvic tilt, sacral slope, PI-LL mismatch, sagittal vertical axis, Cobb angle, and deviation of the C7 plumb line from the central sacral vertical line. Clinical outcomes were evaluated using Oswestry Disability Index (ODI), visual analog scale (VAS) scores for low back and leg pain, and the short form 36 health survey questionnaire (SF-36) postoperatively and at final follow-up. Complications were also assessed.ResultsMean patient age was 70.3 ± 4.8 years and all patients were female. Average follow-up period was 28.4 ± 15.3 months. Average procedural time to perform LIR was 21.3 ± 9.7 min and was not significantly different from traditional lateral interbody fusion at other levels. Blood loss per single segment during LIR was 38.7 ± 53.2 mL. Fusion rate was 100.0% in this cohort. SLA improved significantly from − 7.6 ± 9.2 degrees preoperatively to 7.0 ± 8.8 degrees at final observation and SCA improved significantly from 19.1 ± 7.8 degrees preoperatively to 8.7 ± 5.9 degrees at final observation (P < 0.0001, and < 0.0001, respectively). All spinopelvic and coronal parameters, as well as ODI and VAS, improved significantly. Incidence of peri- and postoperative complications such as iliopsoas muscle weakness and leg numbness in patients who underwent LIR was as much as XLIF. Incidence of postoperative mechanical failure following LIR was also similar to XLIF. Reoperation rate was 11.8%. However, there were no reoperations associated with LIR segments.ConclusionsThe LIR technique for anterior column realignment of fused vertebrae in the context of severe ASD may be an option of a safe and effective surgical strategy.

A 2-year longitudinal study of skeletal muscle mass in women over 40years of age with degenerative lumbar scoliosis.

We investigated changes in skeletal muscle mass and bone mineral density in degenerative lumbar scoliosis (DLS) patients during a 2-year follow-up following diagnosis. This study included 418 Japanese women, identifying 50 patients for the DLS group (mean age 76.4years) and 368 patients for the control group (mean age 73.4years). Whole-body skeletal muscle mass was measured using a Bioelectrical Impedance Analyzer. Bone mineral density (BMD) was measured using DXA. Skin autofluorescence (SAF), a marker of advanced glycation end products in the skin, was measured using a spectroscope. Spinal alignment, skeletal muscle mass, BMD, grip strength, and SAF were examined and the amount of change 1 and 2years from the initial examination for each item was compared between groups. Height, body fat mass, grip strength, upper limb muscle mass, and trunk muscle mass in the DLS group were significantly lower, and lumbar spine BMD was significantly greater compared to controls at the first visit (p < 0.05). There was no significant difference in spinal alignment in the DLS group after 2years compared with baseline. Trunk muscle mass also decreased significantly more in the DLS group (-2.7%) than in the control group (-1.1%) over the 2-year follow-up (p < 0.05). In this study, trunk muscle mass in the DLS group decreased about 2.4 times more in 2years compared with the control group (p < 0.05). It may be possible to clarify the mechanism of kyphoscoliosis progression in the future with large-scale longitudinal studies.

Paraspinal Muscle Degeneration as an Independent Risk for Loss of Local Alignment in Degenerative Lumbar Scoliosis Patients After Corrective Surgery.

Retrospective study. To investigate the effect of paraspinal muscle degeneration on the maintenance of local and global alignment among degenerative lumbar scoliosis (DLS) patients after corrective surgery. 98 DLS patients with a mean follow-up period of 38.3 months after corrective surgery were included. The T1 pelvic angle (TPA), lumbar lordosis (LL), pelvic incidence were measured preoperatively, immediate postoperatively and at last follow-up. All patients were divided into LL maintenance group (n = 21) and LL loss group (n = 77). For patients with well-aligned correction (immediate postoperative TPA ≤ 20°, n = 73), they were divided into TPA maintenance group (last follow-up TPA ≤ 20°) and TPA loss group (last follow-up TPA > 20°). The relative gross cross-sectional area (rGCSA) and fat infiltration (FI) of multifidus (MF) and erector spinae (ES), and the relative functional CSA (rFCSA) of psoas major (PS) were measured at L3, L4 and L5 on preoperative magnetic resonance imaging. MF rGCSA were significantly smaller in LL loss group than in LL maintenance group. Both MF rGCSA and PS rFCSA were significantly smaller and MF FI was significantly higher in TPA loss group than in TPA maintenance group. Binary logistic regression revealed that the MF rGCSA was an independent factor of LL loss; Large immediate postoperative TPA was an independent risk factor of TPA loss, but not the parameters of paraspinal muscles. The effect of paraspinal muscles in lower lumbar segments might be mainly focused on the maintenance of local alignment rather than the global alignment.

Evaluation of lumbar stiffness after long-level fusion for degenerative lumbar scoliosis via a Chinese version of the lumbar stiffness disability index

BACKGROUND CONTEXTLong-level spinal fusion for degenerative lumbar scoliosis (DLS)seeks to eliminate spinal motion in an attempt to alleviate pain, improve deformity, and reduce disability. However, this surgery considerably impairs the performance of activities of daily living (ADL) due to the resulting stiffness. The lumbar stiffness disability index (LSDI) is a validated measure of the effect of lumbar stiffness on functional activity, but this index might not be fully applicable to the elderly Chinese population given several specific lifestyle characteristics. PURPOSETo evaluate lumbar stiffness in patients with DLS after long-level fusion by Chinese-LSDI (C-LSDI). STUDY DESIGNA retrospective study. PATIENT SAMPLEA total of 129 DLS patients who underwent long-level (≧4 levels) fusion surgery with at least one-year follow-up from June 2009 to September 2017 were retrospectively included. OUTCOME MEASURESThe C-LSDI was designed by modifying LSDI and Korean-LSDI (K-LSDI) based on elderly Chinese lifestyles and the internal consistency and retest repeatability of the patient-reported outcome questionnaire in the measurement of the impact of lumbar stiffness on functional abilities was assessed. METHODSThe radiographic parameters including Cobb angle, apical vertebral translation (AVT), coronal vertical axis (CVA), sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), and PI-LL, and clinical symptoms including visual analogue scale (VAS) for back and low extremity pain; Oswestry disability index (ODI), Japanese Orthopedic Association-29 (JOA–29), Scoliosis Research Society⁃22 (SRS–22), 36⁃Item short form survey (SF–36), physical component scores (PCS) and mental component scores (MCS) were measured preoperatively and at the last follow-up. RESULTSCompared with LSDI and K-LSDI, the C-LSDI demonstrated higher internal consistency (Cronbach's alpha=0.902) and retest reliability (Internal consistency coefficients, ICC=0.904) in the elderly Chinese population. All patients showed increased lumbar stiffness and significant improvement in pain and deformity postoperatively. Regarding items, such as performing personal hygiene after toileting and getting out of a car, people reported more inconvenience with increasingly fixed levels. CONCLUSIONSThis study demonstrated that the C-LSDI questionnaire was a reliable and valid instrument for assessing functional limitations due to lumbar stiffness among elderly Chinese patients with DLS after long-level fusion. Although the effects of stiffness did trend toward greater impacts among patients who underwent longer fusions, most patients were satisfied with trade-offs of function and pain relief in exchange for perceived increases in lumbar stiffness.

Incidence, Risk, and Outcome of Pedicle Screw Loosening in Degenerative Lumbar Scoliosis Patients Undergoing Long-Segment Fusion.

Retrospective study. To investigate the incidence, risk factors, and outcomes of pedicle screw loosening in degenerative lumbar scoliosis (DLS) undergoing long-segment spinal fusion surgery. One hundred and thirty DLS patients who underwent long-segment fusion surgery with at least a 12-month follow-up were studied. The incidence and risk factors of screw loosening were investigated. VAS, SRS-22, and ODI scores were obtained preoperatively and at follow-up. One hundred and sixty-eight of 1784 (9.4%) screws showed evidence of loosening in 71 (54.6%) patients. Three patients required revision surgery. Screw loosening rates according to vertebral insertion level were lowest instrumented vertebra (LIV): 45.4%; uppermost instrumented vertebra (UIV):17.7%; one vertebra above the LIV: 0.5%; 2 vertebrae above the LIV: 0.4%. Multiple logistic regression analysis of possible risk factors indicated that preoperative lateral subluxation ≥8 mm (odds ratio [OR]: 2.68, 95% confidence interval [CI]: 1.16-6.20), osteopenia (OR: 5.52, 95% CI: 1.64-18.56), osteoporosis (OR: 8.19, 95% CI: 2.40-27.97), fusion to sacrum (OR: 2.55, 95% CI: 1.12-5.83), postoperative TLK greater than 10° (OR: 2.63, 95% CI: 1.14-6.04) and SVA imbalance (OR: 3.44, 95% CI: 1.17-10.14) were statistically significant. No difference was noted in preoperative, follow-up, and change of VAS, ODI, and SRS-22 scores. Screw loosening in DLS underwent long-segment surgery is common and tends to occur in the LIV or UIV. Lateral subluxation ≥8 mm, osteopenia, osteoporosis, fusion to the sacrum, postoperative TLK greater than 10°, and SVA imbalance were the independent influencing factors. Screw loosening can be asymptomatic, while longer-term follow-up is required.

Long-term outcome of targeted therapy for low back pain in elderly degenerative lumbar scoliosis.

Treatment of low back pain (LBP) associated with elderly degenerative lumbar scoliosis (DLS) remains controversial. We have developed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) targeting to the intervertebral vacuum as a minimally invasive surgery. The present study compared the long-term clinical outcomes of PIPI to that of nonoperative treatment. Patients with de novo DLS, aged ≥ 65years, who had LBP with visual analog scale (VAS) of ≥ 50 for ≥ 6months with intervertebral vacuum on computed tomography and bone marrow edema (BME) on magnetic resonance imaging were included. The clinical outcomes were evaluated using VAS and the Oswestry Disability Index (ODI) at baseline, 1, 6, 12, 24months, and at the final follow-up. The course of BME was also evaluated. One hundred and one patients underwent PIPI and 61 received nonoperative treatment. The mean follow-up duration after PIPI and nonoperative treatment was 63.7 ± 32.4 and 43.9 ± 20.9months, respectively. VAS and ODI after PIPI were significantly improved compared to post-nonoperative treatment. BME decreased substantially in the PIPI group and it was significantly correlated with VAS and ODI improvement. Following PIPI, LBP recurred in 28 patients (35%). LBP recurrence was identified at the same level of PIPI in 10 patients, at the adjacent level of PIPI in 11 patients, and at the non-adjacent level of PIPI in seven patients. Eighteen patients underwent additional PIPIs, and both VAS and ODI were significantly improved after additional PIPIs. Bone marrow lesions of the endplate are strongly associated with the presence of LBP. PIPI can be considered as an effective, safe and repeatable treatment for LBP in elderly DLS patients.

Proximal Fusion Level Above First Coronal Reverse Vertebrae: An Essential Factor Decreasing the Risk of Adjacent Segment Degeneration in Degenerative Lumbar Scoliosis.

Retrospective radiological analysis. To explore whether proximal fusion level above first coronal reverse vertebrae (FCRV) could decrease risk of adjacent segment degeneration (ASD) in degenerative lumbar scoliosis (DLS). One hundred and 16 DLS patients were divided into 2 groups according to occurrence of ASD: study group (ASD positive group) and control group (ASD negative group). FCRV was defined as the first vertebrae that presents opposite orientation of asymmetric Hounsfield unit (HU) ratio from the other vertebrae within major curve. Incidence of ASD was evaluated in subgroups according to location between FCRV and upper instrumented vertebrae (UIV). The fusion level was shorter in study group than that in control group. There were 12 patients presented FCRV 2-level proximal than SV, 32 patients presented FCRV 1-level proximal than SV, 35 patients presented the same vertebra of FCRV with SV, 23 patients presented FCRV 1-level distal than SV, 14 patients presented FCRV 2-level distal than SV. When UIV located above FCRV, no patient presented ASD, while 15.4% patients presented ASD when UIV located on FCRV. In study group, proximal scoliosis progression was detected in 1 patient (3.9%) when UIV located on FCRV, and 17 patients (29.8%) when UIV located below FCRV. Proximal fusion level above FCRV could decrease the risk of ASD in DLS, especially for the proximal scoliosis progression. FCRV represent the transitional point of the mechanical load on coronal plane, and may be within a more stable condition than stable vertebrae measured from radiographs.

Supine Traction Versus Prone Bending Radiographs for Assessing the Curve Flexibility in Spinal Deformity

Study Design:Retrospective cohort study.Objectives:No consensus exists among surgeons on which radiologic method to prefer for the assessment of curve flexibility in spinal deformity. The objective of this study was to evaluate the difference in curve correction on supine traction radiographs versus prone side bending radiographs.Methods:A retrospective analysis of idiopathic scoliosis (IS), degenerative idiopathic scoliosis (DIS) and de novo degenerative lumbar scoliosis (DNDLS) patients was performed on supine traction as well as prone bending films (when available). Age, weight, traction force, diagnosis and Cobb angles of the primary and secondary curves were extracted. Differences in curve correction (percentages) on traction versus prone bending radiographs were analyzed for the primary and secondary curve. Subgroup analyses were performed for the 3 different diagnoses.Results:In total, 170 patients were eligible for inclusion. 43 were diagnosed with IS, 58 with DIS and 69 with DNDLS. For the primary curve, greater curve correction was obtained with bending in the DNDLS group (P < 0.001). In the DIS group, there was a trend toward more correction on bending (P = 0.054). In de IS group no difference was found. For the secondary curve, bending showed more curve correction in the IS and DIS group (P = 0.002 and P <0.001). No difference was found in the DNDLS group.Conclusion:Compared to traction radiographs, bending radiographs better serve the purpose of curve flexibility assessment of IS, DIS and DNDLS spinal deformity, despite the fact that patients are exposed to more radiation.

Degenerative lumbar scoliosis patients with proximal junctional kyphosis have lower muscularity, fatty degeneration at the lumbar area.

To assess the lumbar muscle conditions on the incidence of proximal junctional kyphosis (PJK) after long-level correction and instrumentation surgery for degenerative lumbar scoliosis (DLS) patients with a minimum 2-year follow-up. Eighty-four DLS patients undergoing long instrumented fusion surgery (≥ 5 vertebrae) were retrospectively studied. According to the occurrence of PJK at the final follow-up, patients were divided into the PJK group and the Non-PJK group. Patient characteristics, surgical variables and radiographic parameters were analyzed statistically. The lumbar muscularity (cross-sectional area of muscle-disc ratio × 100) and fatty degeneration (signal intensity of muscle-subcutaneous fat ratio × 100) were evaluated on magnetic resonance imaging . The prevalence of PJK was 20.24%. Gender, age at surgery, body mass index, uppermost instrumented vertebrae level, fusions extending to the sacrum, and levels fused were not significantly different between the groups. Lower bone mineral density, smaller functional cross-sectional area (FCSA) of paraspinal extensor muscles (PSE), higher lean muscle-fat index and total muscle-fat index of PSE, greater preoperative thoracolumbar kyphosis (TLK), smaller preoperative sacral slope (SS), larger preoperative sagittal vertical axis were identified in PJK group. Logistic regression analysis showed that osteoporosis, preoperative TLK > 15°, SS > 24°, FCSA of PSE > 138.75, and total muscle-fat index of PSE > 4.08 were independently associated with PJK. The final follow-up VAS score for back pain was higher, and SRS-22 subcategories of pain, function, self-image, and total score were significantly lower in the PJK group. Osteoporosis, lower lumbar muscularity and higher fatty degeneration, preoperative greater TLK and smaller SS were found to be strongly associated with the presence of PJK in DLS.

Directionality of Lumbosacral Fractional Curve Relative to C7 Plumb Line, A Novel Index Associated with Postoperative Coronal Imbalance in Patients with Degenerative Lumbar Scoliosis.

Retrospective case-control radiographic study. The aim of this study was to explore whether directionality of lumbosacral fractional curve relative to C7 plumb line (PL) affected postoperative coronal imbalance in patients with degenerative lumbar scoliosis (DLS). The spatial relationship between lumbar main curve and C7 PL was reported to have impact on postoperative coronal imbalance in DLS. Although fractional curve played more important role than lumbar main curve in DLS, the spatial relationship between fractional curve and C7 PL and their impact on the postoperative coronal balance are still unknown. One hundred one DLS patients treated with posterior instrumented fusion were reviewed. Coronal measurements included C7 migration, fractional curve, L4/L5 coronal tilt, major Cobb angle. Based on directionality of fractional curve (orientation of L4 coronal tilt was used to represent it) relative to C7 PL preoperatively, coronal patterns was separated into: consistency pattern, L4 coronally tilts toward C7 PL; opposition pattern, L4 coronally tilts opposite C7 PL; the distributions of these two patterns and Type A, B,C were analyzed. According to postoperative C7 migration, patients were divided into imbalanced group and balanced group. Compared to balanced group, the imbalanced group had higher percentage of preoperative consistency pattern (80.6% vs. 33.8%, P < 0.001) and Type C (36.1% vs. 7.7%, P < 0.001); larger fractional curve or L4 coronal tilt pre- and postoperatively, larger L5 coronal tilt postoperatively. Logistic regression analysis showed predictors for postoperative coronal imbalance were consistency pattern (odds ratio [OR] 5.103, 95% confidence interval [CI]: 1.660-15.687, P = 0.004) and type C (OR 4.061; 95% CI: 1.056-15.618; P = 0.041). Directionality of fractional curve relative to C7 PL was associated with postoperative coronal imbalance in DLS patients. In addition to type C, consistency pattern might be an independent risk factor for postoperative coronal imbalance.Level of Evidence: 3.

Risk Factors Associated With Failure to Reach Minimal Clinically Important Difference After Correction Surgery in Patients With Degenerative Lumbar Scoliosis.

A retrospective study. The aim of this study was to evaluate the factors affecting health-related quality of life (HRQOL) after surgery in patients with degenerative lumbar scoliosis (DLS) by minimum clinically important difference (MCID). MCID has been introduced in the adult spinal deformity to quantify the absolute minimum change that can be considered a success. There are limited data available to identify factors affecting reaching MCID after DLS surgery. This study reviewed a cohort of 123 DLS patients after correction surgery and with a minimum 2-year follow-up (FU). Inclusion criteria included age ≥40 and minimum five vertebrae fused and the availability of Scoliosis Research Society (SRS)-22 scores and radiographic data at baseline (BL) and FU. Using a multivariate analysis, two groups were compared to identify possible risk factors: those who reached MCID in the all four SRS domains (N = 65) at the last FU and those who missed MCID (N = 58). At baseline, patients differed significantly from matched normative data in all SRS-22 domains. The baseline HRQOL was comparable in reached MCID and missed MCID group patients (P > 0.05). The HRQOL scores at FU were significantly higher than those at baseline. Of 123 included patients, 77.2% (N = 95), 72.4% (N = 89), 76.4% (N = 94), and 89.4% (N = 110) reached MCID in SRS pain, activity, appearance, and mental domain, respectively. Pelvic incidence (PI) >55°, lumbar lordosis (LL) loss >4.65°, coronal imbalance at FU, sagittal vertical axis (SVA) at FU >80 mm, and presence of proximal junctional kyphosis (PJK) and distal junctional problem (DJP) had negative effects on the recovery process. Factors affecting reaching MCID after surgery for DLS were higher PI, LL loss, coronal imbalance, severe sagittal imbalance, and the occurrence of PJK and DJP. 4.

Orientation of L4 coronal tilt relative to C7 plumb line as a predictor for postoperative coronal imbalance in patients with degenerative lumbar scoliosis

The study design is case–control. To evaluate the impact of preoperative coronal patterns based on the relationship between orientation of L4 coronal tilt and C7 plumb line on immediate postoperative coronal imbalance in degenerative lumbar scoliosis (DLS) patients. Although lumbosacral fractional curve has been long stressed in correction surgery of DLS, there is paucity of literature focusing on preoperative coronal pattern based on the relationship between orientation of L4 coronal tilt and C7 plumb line and its impact on immediate postoperative coronal imbalance in DLS patients. A consecutive series of DLS patients who underwent deformity correction surgery via posterior-only approach were reviewed. According to the relationship between orientation of L4 coronal tilt and C7 plumb line preoperatively, a total of 77 DLS patients who underwent posterior spinal corrective surgery were classified into: 1. Coronal consistency pattern, L4 coronally tilts toward C7 plumb line; 2. Coronal opposition pattern, L4 coronally tilts opposite C7 plumb line. Coronal imbalance was defined as global coronal malalignment (GCM) on either side more than or equal to 20 mm. Whole-spine standing radiographs of both pattern groups were assessed preoperatively and postoperatively. There were 37 patients with coronal consistency pattern and 40 patients with coronal opposition pattern. Compared to patients with coronal opposition pattern, patients with coronal consistency pattern had significantly higher postoperative GCM (P = 0.028), lower amount of GCM correction (P = 0.013) and higher incidence of postoperative coronal imbalance (P = 0.001); further logistic regression analysis revealed coronal consistency pattern was associated with increased odds of postoperative coronal imbalance (odds ratio: 5.981; 95% confidence interval 2.029–17.633; P = 0.001). DLS patients with preoperative coronal consistency pattern carried greater risk for immediate postoperative coronal imbalance following posterior long correction surgery.Level of evidence 3