Degenerative Lumbar Scoliosis Research Articles

Quantitative analysis of paravertebral muscle asymmetry and its correlation with spinal deformity in patients with degenerative lumbar scoliosis: a retrospective case-control study.

The degeneration and functional decline of paravertebral muscles (PVMs) are reported to be closely linked to the incidence of degenerative lumbar scoliosis (DLS), a spinal deformity of the mature skeleton. However, the functional role and degeneration of PVMs and their relationship to the development of spinal deformities remain controversial. Therefore, the present study analyzed the morphological changes in the PVMs of patients with DLS, and explored the relationship between PVM degeneration and spinal osseous parameters. In this retrospective case-control study, we evaluated the PVM parameters of patients with DLS (n=120) and compared them with patients free of DLS (control group, n=120). The cross-sectional area (CSA) and computed tomography (CT) values of the PVM at the lumbar vertebra 1-5 levels were measured. Further, the lumbar scoliosis Cobb, lumbar lordotic, and apical vertebral rotation angles were measured on CT and radiographs in the DLS group, and the relationship between PVM changes and these factors was analyzed. In the control group, the PVM CSA and CT values differed insignificantly between the bilateral sides at all levels (P>0.05). In the DLS group, the CSAs of the multifidus (MF) and erector spinae (ES) were larger on the convex side than the concave side (P>0.05), whereas that of the psoas major (PM) was smaller on the convex side than the concave side (P<0.05). The CT value of the PVM was lower on the convex side at all levels (P<0.05). The CSA and CT values on both sides of the patients were lower in the DLS group than the control group at all levels (P<0.05). Further, the degree of PVM asymmetry at the apical vertebral level was positively correlated with the lumbar scoliosis (P<0.01) and apical vertebral rotation angles (P<0.05), but negatively correlated with the lumbar lordotic angle (P<0.05). Asymmetric degeneration of the PVM was observed bilaterally in DLS patients, and the degeneration was more pronounced on the concave side than the convex side. This asymmetrical degeneration was closely associated with the severity of lumbar scoliosis, vertebral rotation, and loss of lumbar lordosis, and a stronger correlation was observed with the MF and ES than with the PM.

The Influence of Radiographic Parameter on the S2 Alar-Iliac Screw Virtual Trajectory in Degenerative Lumbar Scoliosis Patients: A Computed Tomography Study.

S2 alar-iliac (S2AI) screw had been widely used in the pelvic fusion for degenerative lumbar scoliosis (DLS) patients. However, whether S2AI screw trajectory was influenced by sagittal profile in DLS patients had not been comprehensively investigated. The objective of this study was to evaluate the associations between the optimal S2 alar-iliac (S2AI) screw trajectory and sagittal spinopelvic parameters in DLS patients. Computed tomography (CT) scans of pelvis were performed in 47 DLS patients for three-dimensional reconstruction of S2AI screw trajectory from September 2019 to November 2021. Five S2AI screw trajectory parameters were measured in CT reconstruction images, including: 1) angle in the transverse plane (Tsv angle); 2) angle in the sagittal plane (Sag angle); 3) maximal screw length; 4) screw width; and 5) skin distance. The lumbar Cobb angle, lumbar apical vertebral translation (AVT); global kyphosis (GK); thoracic kyphosis (TK); lumbar lordosis (LL); sagittal vertical axis (SVA); sacral slope (SS); pelvic tilt (PT); and pelvic incidence (PI) were measured in standing X-ray films of the whole spine and pelvis. Both Tsv angle and Sag angle had significant positive associations with SS (p < 0.05) but negative associations with both PT (p < 0.05) and LL (p < 0.05) in all cases. Patients with SS less than 15° had both smaller Tsv angle and Sag angle than those with SS equal to or more than 15° (p < 0.05). The decreased LL would lead to the backward rotation of the pelvis, resulting in a more cephalic and less divergent trajectory of S2AI screw in DLS patients. For DLS patients with lumbar kyphosis, spine surgeons should avoid both excessive Tsv and Sag angles for S2AI screw insertion, especially when using free-hand technique.

Simplified S1 vertebral bone quality score independently predicts proximal junctional kyphosis after surgery for degenerative lumbar scoliosis

ObjectiveOur study aimed to assess the effectiveness of the simplified S1 vertebral bone quality (VBQ) score in predicting the incidence of proximal junctional kyphosis (PJK) after surgery for degenerative lumbar scoliosis (DLS).MethodsWe reviewed 122 patients with DLS who underwent posterior lumbar decompression and long-segment fusion surgery in our hospital from January 2016 to December 2020. The patients were classified into PJK group and non-PJK group. S1 VBQ scores are determined by signal intensity measurements taken from the mid-sagittal plane of T1-weighted non-contrast MRI. Logistic regression analysis was used to identify factors associated with PJK. Receiver-operating characteristic curve (ROC) analysis was used to evaluate the value of S1 VBQ score in predicting pedicle PJK after DLS.Results122 DLS patients (90 females and 32 males) met the inclusion criteria. In addition, 27 patients (22.13%) had PJK at the time of last follow-up. VBQ was higher in PJK patients than non-PJK patients (3.58 ± 0.67 vs. 3.08 ± 0.54, p < 0.001). Preoperatively, patients in the PJK group had a greater TLK than those in the non-PJK group (20.00 ± 6.22 vs. 16.86 ± 5.38, p = 0.011). After surgery, patients in the PJK group had greater TLK (p < 0.001) and PJA (p < 0.001) compared with the non-PJK group. At final FU, patients in the PJK group had greater TK (p = 0.002), TLK (p < 0.001), SVA (p < 0.001), and PJA (p < 0.001) than patients in the non-PJK group (Table 4). In multivariate logistic regression analysis, higher VBQ score (OR 4.565, 95% CI 1.43–14.568, p = 0.010), advanced age (OR 1.119, 95% CI 1.021–1.227, p = 0.016), and larger TLK (OR 1.191, 95% CI 1.041–1.362, p = 0.011) were significant predictors of postoperative PJK in patients with DLS (Table 6). A statistically significant positive correlation existed between VBQ score and PJA change (r = 0.370, p < 0.001). We created ROC curves for VBQ scores as predictors of PJK with a diagnostic accuracy of 72.1% (95% CI 60.15–82.9%.The ideal limit for the VBQ score was 3.205 (sensitivity: 77.8%, specificity: 81.4%).ConclusionTo the best of our knowledge, this is the first study to evaluate the effectiveness of the S1 VBQ score in predicting postoperative PJK in DLS. Our study included major risk factors and found that S1 VBQ score was a significant predictor of PJK in patients undergoing DLS surgery. The higher the S1 VBQ score, the higher the probability of PJK.

Clinical efficacy and imaging analysis of oblique lateral lumbar interbody fusion in the treatment of different types of lumbar intervertebral foramen stenosis

PurposeTo analyze and study the clinical efficacy and imaging indexes of oblique lateral lumbar interbody fusion (OLIF) in the treatment of lumbar intervertebral foramen stenosis(LFS) caused by different causes.Method33 patients with LFS treated with OLIF from January 2018 to May 2022 were reviewed. Oswestry Dysfunction Index (ODI) and visual analogue scale (VAS) were calculated before and after operation. Segmental lordotic angle (SLA), lumbar lordotic angle (LLA) and segmental scoliosis angle (SSA), disc height (DH), posterior disc height (PDH), lateral disc height (LDH), foraminal height (FH), foramen width (FW) and foraminal cross-sectional area (FSCA) were measured before and after operation.ResultThe VAS and ODI after operation were significantly improved as compared with those before operation. Compared with pre-operation, the DH, PHD increased by 67.6%, 94.6%, LDH increased by 107.4% (left), 101.7% (right), and FH increased by 30.2% (left), 34.5% (right). The FSCA increased by 93.1% (left), 89.0% (right), and the FW increased by 137.0% (left), 149.6% (right). The postoperative SSA was corrected by 74.5%, the postoperative SLA, LLA were corrected by 70.2%, 38.1%, respectively. All the imaging indexes were significantly improved (p < 0.01).ConclusionThe clinical efficacy and imaging data of OLIF in the treatment of LFS caused by low and moderate lumbar spondylolisthesis, intervertebral disc bulge and reduced intervertebral space height, degenerative lumbar scoliosis, articular process hyperplasia or dislocation have been well improved. OLIF may be one of the better surgical treatments for LFS caused by the above conditions.

Importance of the accurate diagnosis and treatment of patients with lumbar degenerative scoliosis

Under the background of aging population, the incidence of degenerative lumbar scoliosis is increasing year by year. How to conduct reasonable clinical diagnosis and treatment has gradually become a hot topic in the field of spinal surgery. This article discusses the key issues in the diagnosis and treatment of degenerative spinal deformities, including symptom differentiation, spinal alignment reconstruction, fusion level selection, and clinical efficacy evaluation. The aim is to further promote the accurate diagnosis and treatment of degenerative spinal deformities.

Limited Improvement with Minimally Invasive Lumbar Decompression Alone for Degenerative Scoliosis with Cobb Angle over 20 Degrees: The Impact of Decompression Location.

Retrospective review of a prospectively collected multi-surgeon registry. To evaluate the outcomes of minimally invasive (MI) decompression in patients with severe degenerative scoliosis (DS) and identify factors associated with poorer outcomes. MI decompression has gained widespread acceptance as a treatment option for patients with lumbar canal stenosis and DS. However, there is a lack of research regarding the clinical outcomes and the impact of MI decompression location in patients with severe DS exhibiting a Cobb angle exceeding 20 degrees. Patients who underwent MI decompression alone were included and categorized into the DS or control groups based on Cobb angle (>20 degrees). Decompression location was labeled as "scoliosis-related" when the decompression levels were across or between end vertebrae, and "outside" when the operative levels did not include the end vertebrae. The outcomes including Oswestry Disability Index (ODI) were compared between the propensity score-matched groups for improvement and minimal clinical importance difference (MCID) achievement at ≥1 year postoperatively. Multivariable regression analysis was conducted to identify factors contributing to the non-achievement of MCID in ODI of the DS group at the ≥1 year timepoint. A total of 253 patients (41 DS) were included in the study. Following matching for age, gender, osteoporosis status, psoas muscle area, and preoperative ODI, the DS groups exhibited a significantly lower rate of MCID achievement in ODI (DS: 45.5% vs. control 69.0%, P=0.047). The "scoliosis-related" decompression (Odds ratio: 9.9, P=0.028) was an independent factor of non-achievement of MCID in ODI within the DS group. In patients with a Cobb angle>20 degrees, lumbar decompression surgery, even in the MI approach, may result in limited improvement of disability and physical function. Caution should be exercised when determining a surgical plan, especially when decompression involves the level between or across the end vertebrae. 3.

Hip-sacroiliac joint-spine syndrome in total hip arthroplasty patients

This study is designed to compare the extent of sacroiliac joint (SIJ) degeneration at total hip arthroplasty (THA) for two pathologies: osteoarthritis of the hip (OA) and osteonecrosis of the femoral head (ON). We also assessed the prevalence of SIJ degeneration in patients with lumbar spondylolisthesis or degenerative scoliosis. A total of 138 hips from 138 patients (69 OA and 69 ON) were assessed in this study, including 66 hips affected by OA secondary to developmental dysplasia of the hip. The degenerative changes in the SIJ and lumbar spine were evaluated prior to THA using radiographs and computed tomography (CT) scans, showing 9 instances of spondylolisthesis and 38 of degenerative scoliosis. The OA group exhibited longer duration from onset to surgery than the ON group. The OA group also included more cases with significant pelvic obliquity (3 degrees or more) and with significant increases in SIJ sclerosis and irregularities. Patients with lumbar spondylolisthesis or degenerative scoliosis were significantly more likely to have SIJ irregularities. The prevalence of SIJ degeneration was higher in cases of THA for OA than for ON. This study also suggests the possibility of Hip-SIJ-Spine syndrome in THA patients with OA.

Application of a Magnetic Resonance Imaging–Based Lumbar Vertebral Bone Quality Scoring System in Patients with Degenerative Lumbar Scoliosis

Although dual-energy X-ray absorptiometry (DXA) is still the gold standard for diagnosing osteoporosis, it can lead to inaccurate bone mineral density (BMD) measurements due to lumbar degeneration and scoliosis. Many researchers have investigated diagnostic methods for osteoporosis in patients with degenerative lumbar scoliosis (DLS). This study aimed to investigate the differences between conventional vertebral bone quality (VBQ) scores and modified VBQ scores in patients with DLS and the influence of lumbar scoliosis on VBQ scores. We retrospectively collected the clinical and radiological data of 68 patients with DLS admitted to Sun Yat-sen Memorial Hospital from July 2018 to April 2023. The patients were classified into one of two groups based on the T score of the left femoral neck. VBQ scores relative to cerebrospinal fluid (CSF) at different levels, VBQ scores on different planes and single-level VBQ scores were compared. Receiver operating characteristic (ROC) analysis was also performed. Different modified VBQ scores were compared between the moderate scoliosis group (10°≤Cobb angle<20°) and the severe scoliosis group (Cobb angle≥20°). There were no significant differences in VBQ scores relative to CSF at different levels (p=0.983), on different planes (p=0.832) or at single-level (p=0.996). All the VBQ scores were negatively correlated with the T score of the left femoral neck. There were no significant differences in the modified VBQ scores between the moderate and severe scoliosis groups. Different modified VBQ scores can be used as supplementary methods for diagnosing osteoporosis in patients with DLS. Lumbar scoliosis may not significantly affect the VBQ score.

Risk factors of adjacent-segment disease after short-segment fusion in patients with de novo degenerative lumbar scoliosis.

Short-segment fusion (SSF) is an effective surgical option for appropriately selected patients with de novo degenerative lumbar scoliosis (DNDLS). Considering that DNDLS is frequently accompanied by multisegment degeneration and potential instability across the entire lumbar segments, it is inevitable that unhealthy segments remain after SSF, thereby increasing the potential risk of adjacent-segment disease (ASD) occurrence. Therefore, the authors aimed to identify the risk factors for ASD in patients with DNDLS who underwent SSF. This retrospective study included 80 patients with DNDLS (Cobb angle > 10°) who underwent SSF (1 or 2 levels) between December 2010 and July 2018 with a minimum follow-up duration of 5 years. The participants were divided into two groups: ASD and non-ASD. ASD was defined as clinical ASD rather than radiographic ASD. Various patient and operative variables were compared between the groups. Global and regional radiographic parameters (preoperatively and postoperatively) were also compared between the two groups using plain radiography and MRI. Consequently, univariate and multivariate analyses were conducted to identify the risk factors for ASD occurrence. The receiver operating characteristic (ROC) curve was used to calculate the cutoff values. The mean ± SD age was 67.7 ± 7.2 years at the time of SSF, and there were 62 women (77.5%) enrolled in the study. Thirty patients (37.5%) were in the ASD group and 50 patients (62.5%) were in the non-ASD group. The mean time from the surgery to ASD diagnosis was 34.9 ± 28.2 months in ASD group. Thirteen patients required revision surgery at a mean time of 8.8 ± 7.0 months after ASD occurrence. Multivariate logistic regression analysis demonstrated that preoperative disc wedging angle (OR 1.806, 95% CI 1.255-2.598, p = 0.001), presence of facet tropism (defined as ≥ 10° difference between the facet joint angles of the right and left sides) (OR 5.534, 95% CI 1.528-20.040, p = 0.009), and foraminal stenosis ≥ grade 2 (OR 5.935, 95% CI 1.253-28.117, p = 0.025) were significant risk factors for ASD development. The cutoff value of the preoperative disc wedging angle was calculated to be 2.5° using the ROC curve. Preoperative disc wedging angle ≥ 2.5°, presence of facet tropism, and foraminal stenosis ≥ grade 2 were identified as significant risk factors for ASD development after SSF in patients with DNDLS.

Analysis of the causes of cage subsidence after oblique lateral lumbar interbody fusion

To observe the cage subsidence after oblique lateral interbody fusion (OLIF) for lumbar spondylosis, summarize the characteristics of the cage subsidence, analyze causes, and propose preventive measures. The data of 144 patients of lumbar spine lesions admitted to our hospital from October 2015 to December 2018 were retrospectively analyzed. There were 43 males and 101 females, and the age ranged from 20 to 81 years old, with an average of (60.90±10.06) years old. Disease types:17 patients of lumbar intervertebral disc degenerative disease, 12 patients of giant lumbar disc herniation, 5 patients of discogenic low back pain, 33 patients of lumbar spinal stenosis, 26 patients of lumbar degenerative spondylolisthesis, 28 patients of lumbar spondylolisthesis with spondylolisthesis, 11 patients of adjacent vertebral disease after lumbar internal fixation, 7 patients of primary spondylitis in the inflammatory outcome stage, and 5 patients of lumbar degenerative scoliosis. Preoperative dual-energy X-ray bone mineral density examination showed 57 patients of osteopenia or osteoporosis, and 87 patients of normal bone density. The number of fusion segments:124 patients of single-segment, 11 patients of two-segment, 8 patients of three-segment, four-segment 1 patient. There were 40 patients treated by stand-alone OLIF, and 104 patients by OLIF combined with posterior pedicle screw. Observed the occurrence of fusion cage settlement after operation, conducted monofactor analysis on possible risk factors, and observed the influence of fusion cage settlement on clinical results. All operations were successfully completed, the median operation time was 99 min, and the median intraoperative blood loss was 106 ml. Intraoperative endplate injury occurred in 30 patients and vertebral fracture occurred in 5 patients. The mean follow-up was (14.57±7.14) months from 6 to 30 months. During the follow-up, except for the patients of primary lumbar interstitial inflammation and some patients of lumbar spondylolisthesis with spondylolisthesis, the others all had different degrees of cage subsidence. Cage subsidence classification:119 patients were normal subsidence, and 25 patients were abnormal subsidence (23 patients were gradeⅠ, and 2 patients were gradeⅡ). There was no loosening or rupture of the pedicle screw system. The height of the intervertebral space recovered from the preoperative average (9.48±1.84) mm to the postoperative average (12.65±2.03) mm, and the average (10.51±1.81) mm at the last follow-up. There were statistical differences between postoperative and preoperative, and between the last follow-up and postoperative. The interbody fusion rate was 94.4%. The low back pain VAS decreased from the preoperative average (6.55±2.2 9) to the last follow-up (1.40±0.82), and there was statistically significant different. The leg pain VAS decreased from the preoperative average (4.72±1.49) to the final follow-up (0.60±0.03), and the difference was statistically significant (t=9.13, P<0.000 1). The ODI index recovered from the preoperative average (38.50±6.98)% to the latest follow-up (11.30±3.27)%, and there was statistically significant different. The complication rate was 31.3%(45/144), and the reoperation rate was 9.72%(14/144). Among them, 8 patients were reoperated due to fusion cage subsidence or displacement, accounting for 57.14%(8/14) of reoperation. The fusion cage subsidence in this group had obvious characteristics. The monofactor analysis showed that the number of abnormal subsidence patients in the osteopenia or osteoporosis group, Stand-alone OLIF group, 2 or more segments fusion group, and endplate injury group was higher than that in the normal bone mass group, OLIF combined with pedicle screw fixation group, single segment fusion group, and no endplate injury group, and the comparison had statistical differences. Cage subsidence is a common phenomenon after OLIF surgery. Preoperative osteopenia or osteoporosis, Stand-alone OLIF, 2 or more segments of fusion and intraoperative endplate injury may be important factors for postoperative fusion cage subsidence. Although there is no significant correlation between the degree of cage subsidence and clinical symptoms, there is a risk of cage migration, and prevention needs to be strengthened to reduce serious complications caused by fusion of cage subsidence, including reoperation.

Oblique lateral interbody fusion for lumbosacral fractional curve correction in degenerative lumbar scoliosis.

In combined anterior-posterior adult spinal deformity surgery, the optimal combination of anterior and posterior procedures remains unclear. We aimed to demonstrate the radiological outcomes and relevant factors in oblique lateral interbody fusion (OLIF) for lumbosacral fractional curve (FC) correction combined with open posterior surgery in degenerative lumbar scoliosis (DLS). This study involved 42 consecutive patients with DLS who had a major curve (MC) ≥ 20° and an FC (L4 to S1) ≥ 10°, and underwent a combined anterior-posterior surgery Changes in the MC, FC, coronal balance distance, type of coronal imbalance, coronal/sagittal disc angle at L4-5 and L5-S1, L4 and L5 tilt, and sagittal parameters were examined. The associations between FC correction and demographic, surgical, and radiological factors were analysed. The FC decreased from 16.9 ± 7.3° preoperatively to 6.6 ± 4.4° at the last follow-up (P < 0.001). The coronal disc angle at L4-5 and L5-S1 were, respectively, 6.8 ± 2.2° and 6.0 ± 4.1° preoperatively and decreased to 2.2 ± 2.1 and 1.2 ± 1.3° at the last follow-up (both P < 0.001). The changes in FC were greater in uppermost instrumented level > T10 (P < 0.001), and associated with the preoperative FC (r = 0.820, P < 0.001), L4 tilt (r = 0.434, P = 0.007), and L5 tilt (r = 0.462, P = 0.003). OLIF at the FC combined with open posterior surgery is an effective combined anterior-posterior correction strategy in DLS.

Impact of preoperative clinical state on 2-year clinical outcomes following degenerative lumbar scoliosis surgery.

To assess the preoperative clinical state's impact on clinical outcomes after surgery for degenerative lumbar scoliosis (DLS) based on the minimal clinically important difference (MCID). Preoperative and follow-up (FU) scores in eachScoliosis Research Society-22(SRS-22)domain were compared with age- and sex-matched normative references. At baseline, patients were classified by differences from normative values in four groups: Worst, Severe, Poor, and Moderate. At 2 years postoperative FU, patients were divided into four groups (WorstSevere Poor Asymptomatic) based on the difference in MCID between postoperative and normal values. The changes in MCID were considered as the criterion for surgical efficacy. In addition, we calculated the classification of preoperative and FU clinical symptom severity in each domain in same patient. The distinction among curve types was also performed based on the SRS-Schwab classification. A total of 123 patients were included. During FU, patients with more severe preoperative clinical symptoms were more likely to achieve clinical changes (>1 MCID, p < 0.05), but the rate of reaching "asymptomatic" was lower (p < 0.05). Kendall's tau-b correlation analysis found that preoperative clinical severity was correlated with clinical changes category in Activity (Tau-b = 0.252; p = 0.002), Pain (Tau-b = 0.230; p = 0.005), Appearance (Tau-b = 0.307; p < 0.001), and Mental (Tau-b = 0.199; p = 0.016), and it also was correlated with FU clinical severity in Activity (Tau-b = 0.173; p = 0.023), Pain (Tau-b = 0.280; p < 0.001), and Mental (Tau-b = 0.349; p < 0.001). There was a correlation between preoperative clinical severity and FUSRS-22 score outcomes. Patients with severe preoperative clinical symptoms can experience better treatment outcomes during FU, but it is also more difficult to recover to the normal reference.

Correlation analysis of surgical outcomes and spino-pelvic parameters in patients with degenerative lumbar scoliosis.

The study aims to analyze factors that affect the postoperative health-related quality of life (HRQOL) of degenerative lumbar scoliosis (DLS) patients and explore the appropriate pelvic incidence minus lumbar lordosis (PI-LL) value for Chinese DLS patients. DLS patients who met the inclusion and exclusion criteria were included in this study. General information, spino-pelvic parameters, and HRQOL were collected. Correlation analysis was used to explore the spino-pelvic parameters that affect the postoperative HRQOL. Thresholds of each parameter were obtained using the receiver operating characteristic (ROC) curve. Regardless of the effect of age, DLS patients were classified into three groups according to the SRS-Schwab classification: group 0 means PI-LL < 10°, group+means PI-LL = 10-20°, and group ++ means PI-LL > 20°. Postoperative HRQOL was analyzed using variance methods. The ROC curve was used to measure the appropriate PI-LL threshold. When considering the effect of age, the patients with Oswestry Disability Index (ODI) < 75% percentile were considered to have a satisfactory clinical outcome, which was drawn to an equation between PI-LL, age, and PI by multiple linear regression equation. A total of 71 patients were included. Compared with the control group, there were significant differences in both postoperative ODI and Scoliosis Research Society 22 (SRS-22) scores when the postoperative Cobb angle ≤11°, postoperative lumbar lordosis index (LLI) > 0.8, postoperative sagittal vertical axis (SVA) ≤ 5 cm, postoperative T1 pelvic angle (TPA) ≤ 16° and postoperative global tilt (GT) ≤ 22°, respectively. Regardless of the effect of age, there was a statistical difference in postoperative HRQOL between group 0 and group ++. The PI-LL threshold derived from the ROC curve was 14.4°. Compared with the PI-LL > 14° group, the PI-LL ≤ 14° group achieved a lower postoperative ODI score and a higher postoperative SRS-22 score. Considering the influence of age, the equation for ideal PI-LL was PI-LL = 0.52age + 0.38PI-39.4 (R = 0.509, p = 0.001). PI-LL was an important parameter that affects the postoperative HRQOL of DLS patients. Sufficient LL should be restored during the operation (LL ≥ PI-14°). The appropriate PI-LL value was affected by age. Smaller LL needed to be restored as the age increased.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons.

Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Sex-based differences in clinical and radiological presentation of patients with degenerative lumbar scoliosis: a cross-sectional study

BackgroundTo evaluate the sex-based differences in clinical and radiological presentation of patients with degenerative lumbar scoliosis (DLS) and to explore whether the difference is helpful in investigating the etiology and progression of DLS.MethodA retrospective review of 199 patients (41 males, 158 females) with DLS was included. Patient demographics including age, gender, bone mineral density were collected. Back and leg pain was assessed by visual analog scale, and general physical condition was assessed by Oswestry Disability Index. Cobb’s angle was measured, and direction of scoliosis, position of the superior, inferior and apex vertebrae, number of vertebrae included in the scoliosis, rotation of apex vertebrae (Nash-Mo index), translation of apex vertebrae were recorded. Sagittal longitudinal axis, thoracolumbar kyphosis, lumbar lordosis (LL), pelvic incidence angle (PI), sacral slope, apex of lumbar lordosis and coronal balance distance were measured by whole spine lateral radiographs, and type of coronal imbalance was evaluated in all patients. Fat infiltration rate (FIR) of the paraspinal muscles at the vertebral apex was measured by MRI.ResultCompared to female patients, male patients showed more back and leg pain on clinical presentation and smaller Cobb angle, less parietal rotation, larger LL, smaller PI-LL and lower paravertebral muscle FIR on radiologic features.ConclusionGender differences do exist in DLS patients with regard to clinical and radiological presentation, low back pain was more pronounced in male patients, and scoliosis was more severe in female patients based on this cross-sectional study.

Lasso Analysis of Gait Characteristics and Correlation with Spinopelvic Parameters in Patients with Degenerative Lumbar Scoliosis.

This study quantifies the gait characteristics of patients with degenerative lumbar scoliosis (DLS) and patients with simple lumbar spinal stenosis (LSS) by means of a three-dimensional gait analysis system, aiming to determine the image of spinal deformity on gait and the correlation between spinal-pelvic parameters and gait characteristics in patients with DLS to assist clinical work. From June 2020 to December 2021, a total of 50 subjects were enrolled in this study, of whom 20 patients with DLS served as the case group and 30 middle-aged and elderly patients with LSS were selected as the control group according to the general conditions (sex, age, and BMI) of the case group. Spinal-pelvic parameters were measured by full-length frontal and lateral spine films one week before surgery, and kinematics were recorded on the same day using a gait analysis system. Compared to the control group, DLS patients exhibited significantly reduced velocity and cadence; gait variability and symmetry of both lower limbs were notably better in the LSS group than in the DLS group; joint ROM (range of motion) across multiple dimensions was also lower in the DLS group; and correlation analysis revealed that patients with a larger Cobb angle, T1PA, and higher CSVA tended to walk more slowly, and those with a larger PI, PT, and LL usually had smaller stride lengths. The greater the PI-SS mismatch, the longer the patient stayed in the support phase. Furthermore, a larger Cobb angle correlated with worse coronal hip mobility. DLS patients demonstrate distinctive gait abnormalities and reduced hip mobility compared to LSS patients. Significant correlations between crucial spinopelvic parameters and these gait changes underline their potential influence on gait disturbances in DLS. Our study identifies a Cobb angle cut-off of 16.1 as a key predictor for gait abnormalities. These insights can guide personalized treatment and intervention strategies, ultimately improving the quality of life for DLS patients.

Upper instrumented vertebrae selection criteria for degenerative lumbar scoliosis based on the hounsfield unit asymmetry of the first coronal reverse vertebrae: an observational study

BackgroundSelection of the upper instrumented vertebra (UIV) is crucial for surgical treatment of degenerative lumbar scoliosis (DLS), given the relevance of UIV in postoperative proximal adjacent segment degeneration (pASD). Our previous research found that selection of UIV not lower than (≤) the first coronal reverse vertebra (FCRV), which marks the turning point of Hounsfield unit (HU) asymmetry, could significantly reduce pASD. However, the degree of HU asymmetry can vary among patients, suggesting a demand for more individualized UIV selection criteria, which we aimed to develop using quantitative HU measurement in the current study.MethodsWe included 153 consecutive patients with DLS. Quantitative measurement of HU of both sides of the vertebrae of these patients was performed on three planes of CT reconstruction for average values and determination of FCRV. Pre- and postoperative X-ray plain films were examined for radiological measurements and determination of pASD. Further, 35 patients with lumbar disc herniation and without significant scoliosis were also included as the reference group, and their bilateral HU was measured.ResultsIn all 153 patients, those with UIV ≤ FCRV had a significantly lower rate of pASD (9.4% vs. 24.6%, P = 0.011). The difference between HU of the left and right sides of the FCRV (dF) could range from close to 0–59.4. The difference between HU of the left and right sides of the vertebrae in the reference group had an average value of 5.21. In 101 dF ≥ 5 DLS patients, those with UIV ≤ FCRV had a significantly lower rate of pASD (7.6% vs. 28.6%, P = 0.005), while this rate was insignificant in the other 52 dF < 5 patients (13.3% vs. 18.2%, P = 0.708). No other general, radiological, or operative parameter was found to have significant influence on the occurrence of pASD.ConclusionsSelection of UIV ≤ FCRV can significantly reduce the risk of pASD for patients with DLS with dF ≥ 5.Trial Registration Not applicable, since this is an observational study.

Radiological Assessment of Morphological Changes of Lumbar Spine: From First to 9th Decade of Life.

Analysis of lumbar spine radiograms of 1,496 Jeju islanders of Korea. To look into the age- and gender-matched incidences of morphological changes and their severities. There have been several prior research on the prevalence and severity of age-related diseases, both related and unrelated. Those offer some fundamental clinical data for clinicians. Radiograms of 1,496 patients (555 males and 941 females) from the first to 9th decade were examined for this study. Sagittal and coronal alignment, disc space narrowing, spur formation including diffuse idiopathic spinal hyperostosis (DISH), spondylolisthesis, and ballooned discs associated with biconcave bodies due to osteoporosis were among the parameters of lumbar spine morphologies examined on high-quality radiographs by both human observers and computers. The alignment of the lumbar spine altered after birth and set at growth maturity, and then the curve was maintained till the end of the 5th decade afterward and the curve gradually hypolordotic. There were three types of coronal alignment abnormalities can be seen: idiopathic, osteopathic, and discogenic (degenerative lumbar scoliosis [DLS]). DLS developed after 6th decade. There was no scoliosis associated with spondylolysis or the post-laminofacetectomy period. Disc space narrowing and corporal spur formation were not seen till the end of 3rd decade comparatively speaking, the corporal spurs generated in the non-scoliotic spine were smaller than those in the scoliotic spine. DISH began to appear in the 5th-decade patients and its incidences increased gradually afterward. Porosis-related vertebral body collapse started to happen after 6th decade. There are three different types of spondylolisthesis: anterior, posterior, and lateral. The lateral slip occurred only in the scoliotic spine. All types were related to degenerative discs. It has been shown that the morphology of the lumbar spine changes throughout time.

In vivo segmental vertebral kinematics in patients with degenerative lumbar scoliosis.

This study aimed to find a standard of the vertebra kinematics during functional weight-bearing activities in degenerative lumbar scoliosis (DLS) patients. Fifty-four patients were involved into this study with forty-two in DLS group and twelve in the control group. The three-dimensional (3D) vertebral models from L1 to S1 of each participant were reconstructed by computed tomography (CT). Dual-orthogonal fluoroscopic imaging, along with FluoMotion and Rhinoceros software, was used to record segmental vertebral kinematics during functional weight-bearing activities. The primary and coupled motions of each vertebra were analyzed in patients with DLS. During flexion-extension of the trunk, anteroposterior (AP) translation and craniocaudal (CC) translation at L5-S1 were higher than those at L2-3 (9.3 ± 5.1mm vs. 6.4 ± 3.5mm; P < 0.05). The coupled mediolateral (ML) translation at L5-S1 in patients with DLS was approximately three times greater than that in the control group. During left-right bending of the trunk, the coupled ML rotation at L5-S1 was higher in patients with DLS than that in the control group (17.7 ± 10.3° vs. 8.4 ± 4.4°; P < 0.05). The AP and CC translations at L5-S1 were higher than those at L1-2, L2-3, and L3-4. During left-right torsion of the trunk, the AP translation at L5-S1 was higher as compared to other levels. The greatest coupled translation was observed at L5-S1 in patients with DLS. Coupled AP and ML translations at L5-S1 were higher than those in healthy participants. These data improved the understanding of DLS motion characteristics.