Scoliosis Research Society Questionnaire Scores Research Articles

Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population

Study DesignRetrospective review of a prospectively collected multicenter database. ObjectivesTo evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients. Summary of Background DataASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks. MethodsAdult patients undergoing ASD surgery from 2009 to 2016 were analyzed (n = 905). Preoperative and surgical parameters were compared across years. Subgroup analysis of 436 patients with minimum two-year follow-up was also performed. ResultsFrom 2009 to 2016, there was a significant increase in the mean preoperative age (52 to 63.1, p < .001), body mass index (26.3 to 32.2, p = .003), Charlson Comorbidity index (1.4 to 2.2, p < .001), rate of previous spine surgery (39.8% to 53.1%, p = .01), and baseline disability (visual analog scale [VAS] back and leg pain) scores (p < .01), Oswestry Disability Index, and 22-item Scoliosis Research Society Questionnaire scores (p < .001). Preoperative Schwab sagittal alignment modifiers and overall surgical invasiveness index were similar across time. Three-column osteotomy utilization decreased from 36% in 2011 to 16.7% in 2016. Lateral lumbar interbody fusion increased from 6.4% to 24.1% (p = .004), anterior lumbar interbody fusion decreased from 22.9% to 16.7% (p = .043), and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion utilization remained similar (p = .448). Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2012 was 84.6%, declined to 58% in 2013, and rebounded to 76.3% in 2016 (p = .006). Tranexamic acid use increased rapidly from 2009 to 2016 (13.3% to 48.6%, p < .001). Two-year follow-up sagittal vertical axis, pelvic tilt, pelvic incidence–lumbar lordosis, and maximum Cobb angles were similar across years. Intraoperative complications decreased from 33% in 2010 to 9.3% in 2016 (p < .001). Perioperative (<30 days, <90 days) complications peaked in 2010 (42.7%, 46%) and decreased by 2016 (24.1%, p < .001; 29.6%, p = .007). The overall complication rate decreased from 73.2% in 2008–2014 patients to 62.6% in 2015–2016 patients (p = .03). Two-year health-related quality of life outcomes did not significantly differ across the years (p > .05). ConclusionsFrom 2009 to 2016, despite an increasingly elderly, medically compromised, and obese patient population, complication rates decreased. Evolving strategies may result in improved treatment of ASD patients. Level of EvidenceLevel IV.

Transforaminal Anterior Release for the Treatment of Fixed Sagittal Imbalance and Segmental Kyphosis, Minimum 2-Year Follow-Up Study

Study DesignRetrospective review of prospectively accrued patient cohort. ObjectiveTo report minimum 2 years' follow-up after a single-surgeon series of 47 consecutive patients in whom fixed sagittal imbalance or segmental kyphosis was treated with a novel unilateral transforaminal annular release. Summary of Background DataFixed sagittal imbalance has been treated most recently with pedicle subtraction osteotomy with great success but is associated with significant blood loss and neurologic risk. MethodForty-seven consecutive patients with fixed sagittal imbalance (n = 29) or segmental kyphosis (n = 18) were treated by a single surgeon with a single-level transforaminal anterior release (TFAR) to effect an opening wedge correction. Sagittal and coronal correction was performed with in situ rod contouring. An interbody cage was captured in the disc space with rod compression. Radiographic and clinical outcome analysis was performed with a minimum 2-year follow-up (range 2–7.8 years). ResultsThe average increase in lordosis was 36° (range 24°–56°) in the fixed sagittal deformity group. Coronal corrections averaged 34° (range 18°–48°). The average improvement in plumb line was 13.6 cm. There were four pseudarthroses, one at the TFAR. Average blood loss was 578 mL (range 200–1,200). One patient had a transient grade 4/5 anterior tibialis weakness. There were no vascular injuries or permanent neurologic deficits. There were significant improvements in the Oswestry Disability Index (p < .001) and Scoliosis Research Society Questionnaire scores (p = .003). Eighty-four percent of patients reported improvement in pain, self-image, and satisfaction with the procedure. ConclusionTFAR is a useful procedure for correcting segmental kyphosis and fixed sagittal imbalance with relatively low blood loss and was found to be neurologically safe in this single-surgeon series. Level of EvidenceTherapeutic study, Level IV (case series, no control group).

Should Shoulder Balance Determine Proximal Fusion Levels in Patients With Lenke 5 Curves?

Study DesignMulticenter review of prospectively collected data. ObjectivesTo identify the frequency of an opposite high shoulder in Lenke 5 patients and evaluate factors that influence preoperative and postoperative shoulder balance. Summary of Background DataA high left shoulder is an indication to extend the fusion proximally in a right thoracic curve. Some apply a similar rule to high right shoulders in patients with left thoracolumbar/lumbar curves. MethodsA prospective multicenter adolescent idiopathic scoliosis database was queried for patients with Lenke 5 curves and minimum 2-year follow-up. Preoperative and postoperative shoulder height differences were recorded and categorized by the opposite shoulder (right shoulder in a left thoracolumbar curve) as high (greater than 1 cm), level (0–1 cm), and low (less than 1 cm). Preoperative and postoperative radiographic variables and Scoliosis Research Society questionnaire scores were evaluated. ResultsOf the 104 patients identified, 37% had level shoulders and 53% had a high opposite shoulder. A high shoulder was associated with a greater mean thoracic Cobb (31°) than a level (24°) or low shoulder (26°) (p = .008). Postoperatively, 64% of patients had level shoulders (less than 1 cm); 93% had a shoulder difference less than 2 cm. Preoperative lumbar Cobb was a significant predictor of postoperative shoulder height (p = .051). A slightly greater proportion of preoperative high shoulders (36%) had a nonselective fusion than those with level (27%) or low (9%) shoulders. Among the 29 patients with a preoperative moderate or significant high shoulder (greater than 2 cm), 3 continued to have a high shoulder greater than 2 cm that was not influenced by fusing the thoracic spine. There were no significant differences in preoperative or postoperative Scoliosis Research Society scores based on shoulder height (p > .05). ConclusionsHalf of all Lenke 5 curves have a high opposite shoulder that is influenced by the size of the compensatory thoracic curve. Postoperatively, most patients had level shoulders. Inclusion of the thoracic spine did not influence postoperative shoulder balance.

Surgical Treatment of Lenke 1 Main Thoracic Idiopathic Scoliosis

Prospective, consecutive, nonrandomized, multicenter study. The purpose of this study was to compare the outcomes of idiopathic scoliosis treatment for Lenke 1 curves with 3 treatment approaches. Surgical treatment options for Lenke 1 or primary main thoracic curve pattern in adolescent idiopathic scoliosis include thoracoscopic anterior spinal fusion, open anterior spinal fusion, and posterior spinal fusion (PSF) and instrumentation procedures. This was a prospective, consecutive, nonrandomized, multicenter study of surgical correction in adolescent idiopathic scoliosis. Patients with Lenke type 1 curve patterns from 7 sites were enrolled in this minimum 2-year follow-up study. Changes in pre- to postoperative radiographs, pulmonary function tests, Scoliosis Research Society questionnaire scores, and trunk rotation measures were compared. A total of 149 patients (age: 14.5 ± 2 yr) were included (91% follow-up at 2 yr). The 3 groups were similar preoperatively in thoracic and lumbar curve size. There were 55 patients with thoracoscopic anterior spinal fusion, 17 patients with open anterior spinal fusion, and 64 patients with PSF. The fusion included on average 3 to 4 more levels in PSF than the 2 anterior approaches (P ≤ 0.001). Surgical time tended to be greater in the anterior groups by approximately 2 to 3 hours; however, blood loss was greatest with PSF. At 2 years, all 3 approaches showed similar improvements in the thoracic Cobb angle, coronal balance, the lumbar Cobb angle, Scoliosis Research Society questionnaire scores, and trunk rotation measures. The PSF approach resulted in overall reduction in kyphosis compared with the anterior approaches. Postoperative hyperkyphosis was an issue only in the 2 anterior groups. Major complication rates were similar. All 3 approaches resulted in similarly satisfactory outcomes for the majority of patients with specific advantages to each technique. The patients with PSF had more levels fused, yet with the shortest operative time. The thoracoscopic anterior spinal fusion group had the smallest incisions and the lowest requirement for transfusion. The open anterior spinal fusion group had a modest loss of pulmonary function without any clear advantages compared with the other 2 groups. 2.