SRS-22 Scores Research Articles

Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study.

Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis OBJECTIVE.: Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis. There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population. A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ± 2.9, range: 7.9-23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05. HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients. This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis. 2.

Feasibility and Acceptability of Technology-Based Exercise and Posture Training in Older Adults With Age-Related Hyperkyphosis: Pre-Post Study.

BackgroundHyperkyphosis is common among older adults and is associated with multiple adverse health outcomes. Kyphosis-specific exercise and posture training programs improve hyperkyphosis, but in-person programs are expensive to implement and maintain over long periods. It is unclear if a technology-based posture training program disseminated through a mobile phone is a feasible or acceptable alternative to in-person training among older adults with hyperkyphosis.ObjectiveThe primary purpose was to assess the feasibility of subject recruitment, short-term retention and adherence, and acceptability of a technology-based exercise and posture training program disseminated as video clip links and text messaging prompts via a mobile phone. The secondary purpose was to explore the potential efficacy of this program for kyphosis, physical function, and health-related quality of life in older adults with hyperkyphosis.MethodsIn this 6-week pre-post design pilot trial, we recruited community-dwelling adults aged ≥65 years with hyperkyphosis ≥40° (±5°) and access to a mobile phone. The intervention had two parts: (1) exercise and posture training via video clips sent to participants daily via text messaging, including 6 weekly video clip links to be viewed on the participant’s mobile phone, and (2) text messaging prompts to practice good posture. We analyzed the subject recruitment, adherence, retention, and acceptability of the intervention. Outcomes included change in kyphometer-measured kyphosis, occiput-to-wall (OTW) distance, Short Physical Performance Battery score, Scoliosis Research Society (SRS-30) score, Center for Epidemiological Studies Depression score, and Physical Activity Scale for the Elderly (PASE) score.ResultsA total of 64 potential participants were recruited, 17 were enrolled, and 12 completed postintervention testing at 6 weeks. The average age was 71.6 (SD 4.9) years, and 50% were women. The median adherence to daily video viewing was 100% (range, 14%-100%) and to practicing good posture at least three times per day was 71% (range, 0%-100%). Qualitative evaluation of intervention acceptability revealed that the mobile phone screen was too small for participants to view the videos well and daily prompts to practice posture were too frequent. Kyphosis, OTW distance, and physical activity significantly improved after the 6-week intervention. Kyphosis decreased by 8° (95% CI –12 to –5; P<.001), OTW decreased by 1.9 cm (95% CI –3.3 to –0.7; P=.007), and physical activity measured by PASE increased by 29 points (95% CI 3 to 54; P=.03). The health-related quality of life SRS-30 score increased by 0.11 point (SD 0.19), but this increase was not statistically significant (P=.09).ConclusionsTechnology-based exercise and posture training using video clip viewing and text messaging reminders is feasible and acceptable for a small cohort of older adults with hyperkyphosis. Technology-based exercise and posture training warrants further study as a potential self-management program for age-related hyperkyphosis, which may be more easily disseminated than in-person training.

The Effect of Kyphosis Correction for Ankylosing Spondylitis by Hilus Pulmonis Approach

The efficacy of application of Hilus pulmonic in guiding of kyphosis correction was explored by radiographic parameters and the quality of life scores of AS kyphosis patients. A retrospective analysis was performed with patients that were diagnosed as ankylosing spondylitis with kyphosis and using the hilus pulmonic to guide kyphosis correction. A total of 16 cases, 15 males and 1 female, were enrolled. The spine-pelvic imaging parameter, the SRS-22 score and ODI dysfunction score were recorded and analyzed at pre-operation and post-operation. The post-operation spine-pelvic parameters PT, SS, GK, TLK, LL, SVA and TPA were all improved compared with preoperative parameters (P < 0.05). SRS-22 score and ODI score were significantly improved after osteotomy (P < 0.05). After using the Hilus pulmonic to guide kyphosis correction, patients with AS kyphosis can obtain good radiographic parameters and physical activity ability score, and can meet the functions of head-up, standing, sitting and lying in patients after orthopedic surgery. PT、SVA、GK and TPA have significant influences on the quality of life of patients with AS kyphosis. Correcting spine-pelvic imaging parameters is important guarantees of higher quality of life after surgery.

COMPARISON OF IMPLANT DENSITY IN THE MANAGEMENT OF LENKE 1B AND 1C ADOLESCENT IDIOPATHIC SCOLIOSIS.

ABSTRACTObjective:To compare radiographic and surgical outcomes of Lenke 1B and 1C patterns.Methods:One hundred twenty patients with Lenke 1B and 1C scoliosis were grouped according to implant density as follows: low density (LD) of ≤1.4 and high density (HD) of >1.4. Matched subgroups (30 patients each) based on age, curve magnitude, and body mass index (BMI) were analyzed. Radiographic parameters were evaluated before operation, immediately after operation (ipo), and at 2 years’ follow-up. SRS-30 was administered before operation and at 2 years’ follow-up.Results:The major curves of the LD (n = 82) and HD groups (n=38) were respectively 59.1° and 65.6° before operation (p <.001), 26.3° and 22.9° ipo (p =.05), and 29.9° and 19.8° at 2 years’ follow-up (p <.001). No significant differences in postoperative trunk shift and coronal balance were found (p =.69 and p =.74, respectively). The HD group had higher blood loss (p =.02), number of implants (p <.001), levels fused (p =.002), and surgical time (p <.001). The HD group had a higher prevalence of hypokyphosis from before operation to follow-up (p <.001). No significant differences were observed in the SRS-30 scores before operation and at 2 years’ follow-up. The matched groups had similar preoperative major curves (p =.56), ages (p =.75), and BMIs (p =.61). Significantly longer surgical time (p =.009), higher density (p <.001), and better correction (p =.0001) were found in the HD group at 2 years’ follow-up. No significant differences were found in the SRS-30 scores before operation and at 2 years’ follow-up.Conclusion:LD constructs included fewer segments fused, lower intraoperative estimated surgical blood loss, and shorter operation time, and potentially decreasing complication risks due to fewer implants. Level of evidence III, Retrospective Cohort Study.

Evaluation of Efficacy and Safety of All Pedicle Screw Posterior-Only Surgery in Patients with Dystrophic Neurofibromatosis Scoliosis

Background Data: Neurofibromatosis type 1 (NF-1) patients with dystrophic changes of the spine develop severe spinal deformity and/or instability and always need early surgical treatment. Combined anterior-posterior fusion was the treatment of choice of such curves because of the risk of progression and pseudoarthrosis even in the presence of solid posterior fusion mass. Recent 3rd-generation posterior stabilization systems using pedicle screw fixation allow better 3-column purchase and 3D control and correction of deformity and stable posterior fixation of the spine preventing progression of the curves. Posterior-only surgery has been recently used in dystrophic NF-1 scoliosis due to use of pedicle screws fixation and development of different types of posterior release/osteotomies which lead to successful and sustained correction of these curves.Study Design: A retrospective clinical cohort study.Purpose: To study the results of posterior stabilization alone using all pedicle screws fixation in NF-1 patients with dystrophic scoliosis.Patients and Methods: 16 patients with NF-1 having dystrophic scoliosis were treated by posterior instrumentation using all pedicle screws. There were 5 female and 11 male patients and the average age was 13 years (range, 9–16 years). The study was done in the period between 2009 and 2016. Preoperative clinical examination included examination for neurofibromatosis, assessment of curve flexibility, and thorough neurological examination. Radiological examination included standard plain X-rays, anterior-posterior (A-P) and lateral and flexibility views, and MRI. Screw density of the whole construct and of the apical region (two vertebrae above and below the apex) was calculated. Functional outcomes were assessed by the ODI and SRS-30 scores at the last follow-up.Results: The mean follow-up was 5.15±1.78 years (range, 3–8). The mean Cobb angle improved in the coronal plane from 67.13±11.88 (range, 45–90◦) to 20±8.9 (range, 6–30◦) showing 70.1±11.2%. The mean preoperative sagittal plane deformity significantly improved from 61.82±20.28 (range, 35–90◦) to 25.91±7.68 (range, 10–35◦) postoperatively yielding 53.15±21.43 (range, 25–83.33%) mean correction with insignificant loss of correction at last follow-up. Loss of correction was 2±1.8% and 1.8±2.1% in the coronal and sagittal planes, respectively. At last follow-up the average SRS-30 score was 121±17.7 and the

Selection of the Distal Fusion Level in Posterior-Only Surgery of Scheuermann Kyphosis: The Concept of the FLV-1

Background Data: Lumber spine mobility is very important clinically and functionally especially in younger patients. Fusion in Scheuermann kyphosis is a long fusion surgery that usually extends into the lumber spine leaving less mobile segments. Debate has focused on the selection of the LIV. Some recommend fusing into the SSV to decrease the incidence of DJK while others use the FLV which is just caudal to the first lordotic disc as the LIV to save more motion segments. Few studies recommend fusion into the vertebra just cephalic to the first lordotic disc (FLV-1).Study Design: A prospective clinical case study.Purpose: To evaluate the outcomes of fusing into the FLV-1 in surgical treatment of SK and whether it is associated with increased incidence of distal junctional failure and DJK or not.Patients and Methods: The study included 25 patients with SK treated by posterior-only surgery using all pedicular screw instrumentation with or without posterior release/Ponte osteotomies using the FLV-1 as the LIV. The study was done in the period between February 2011 and February 2015. Patients were evaluated radiologically by full length standing biplanar X-rays and hyperextension flexibility X-ray. Parameters assessed included KA, TK, LL, and SVA for assessments of sagittal balance together with three pelvic parameters including the PI, PT, and SS angles. Clinical outcome was measured by the ODI and SRS-30 scores. Any complication encountered was documented, especially DJK, PJK, or implant failure.Results: Mean follow-up period of the patients was 40±14.88 months. The average KA improved from 82.2±9.2◦ preoperatively to 38.2±5.47◦ yielding 53.54% correction rate with minimal change at final follow-up of 39.9±5.47◦ and 2% loss of correction. SVA improved from 6.35 mm (range, 60–40) to 12.25 mm (range, 25–10) at final follow-up. The difference between the FLV and FLV-1 was 1 segment whereas the difference between the SSV and FLV-1 was 1.7±0.47 segments (range, 1-2) and the difference between the SSV and the FLV was 0.7±0.47 segments (range, 0-1). PJK occurred in 2 patients without symptoms and another 2 patients suffered mild radiological DJK and all required no treatment. Only one patient had screw pull-out and required revision. Final SRS-30 score was 125.4±15.71 (range, 95–140) and the average ODI was 7.3±2.56 (range, 4–12) without any disability.

Major Complications at Two Years After Surgery Impact SRS Scores for Adolescent Idiopathic Scoliosis Patients

Study DesignRetrospective review of prospectively collected data. ObjectiveTo determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores. Summary of Background DataThere is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients. MethodsSurgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated. Results1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p < .05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p < .05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p < .001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10). ConclusionsWhen timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score. Level of EvidenceLevel III.

Radiographic and Clinical Outcomes of Surgical Correction of Poliomyelitis-Related Spinal Deformities: A Comparison Among Three Types of Pelvic Instrumentations

We compared the clinical and radiographic outcomes of corrective surgery in patients with poliomyelitis-related spinal deformity (PSD) using 3 types of pelvic fixation and investigated the incidence and risk factors for complications. We reviewed the data from 42 patients with PSD who had undergone spinopelvic reconstruction at a single institution from 2000 to 2016. Of the 42 patients, 15 had been treated with the Galveston technique, 13 with iliac screw fixation, and 14 with S2-alar-iliac (S2AI) screw fixation. Demographic data, radiographic parameters, and complications were analyzed. Health-related quality of life was determined using Scoliosis Research Society (SRS) 22-item questionnaires and the Oswestry Disability Index scores. After surgery, the correction rate of the main curve was 51.7%, 57.8%, and 52.1% in the 3 groups, with significant improvement in regional kyphosis, coronal balance, and pelvic obliquity (PO) (P < 0.05). The correction of PO was similar among the 3 types of pelvic fixation; however, the patients treated with S2AI fixation required significantly less operative time (P < 0.05) and blood loss (P< 0.006). The overall complication rate was 40.5%, with a major complication rate of 23.8%. Age at surgery (P=0.006) and grade >2 SRS-Schwab osteotomy (P=0.036) were significant risk factors for complications. Significant improvement was found in the SRS-22 and Oswestry Disability Index scores at the final follow-up examination in the 3 groups. The present study showed satisfactory correction of spinopelvic deformity for 42 patients with PSD. Compared with the Galveston technique and iliac screw fixation, the use of S2AI significantly decrease the operative time and estimated blood loss and obtained similar correction of PO. Patient age at surgery and grade >2 SRS-Schwab osteotomy were significant risk factors for complications.

Disc Degeneration in Unfused Caudal Motion Segments Ten Years Following Surgery for Adolescent Idiopathic Scoliosis

HypothesisThe frequency of disc degeneration (DD) in the distal mobile segments will increase over time following surgery for adolescent idiopathic scoliosis (AIS). DesignRetrospective review of a prospective AIS registry. IntroductionDurability of surgical outcomes is essential for maintenance of quality of life as well as for family decision making and for assessment of the value of a healthcare intervention. We assessed DD, its risk factors, and association with health-related quality of life 10 years after AIS surgery. MethodsFive radiographic indicators of DD, previously validated, were evaluated preoperatively and 1 month, 2, 5, and 10 years postoperatively by a radiologist in operative AIS patients. A composite radiographic score (CRS; range 0-10) was calculated using the sum of each of the DD indicators. The severity of CRS in relation to the time point after surgery and various risk factors were assessed using linear regression or Pearson χ2 test. CRS ≥3 was chosen to indicate significant DD. Association of CRS with SRS-22 outcome was evaluated by linear regression. Results193 consecutive patients (mean age at surgery 14.4 years; 86% female) were assessed. Surgical approach included 102 posterior and 91 anterior fusions. Contributors to maximum CRS at 10 years were Schmorl’s nodes (7.3% of patients), osteophytes (40.4%), sclerosis (29%), and irregular endplate (8.3%). CRS ≥3 occurred in 1.6%, 0.54%, 3.7%, 6.8%, and 7.3% of patients at the various time points (r2=0.83, p=.0313), respectively. More than 50% of DD occurred at the second (35.5%) and third (20%) disc caudal to the LIV. LIV of L4 compared with more cephalad LIV had the highest risk of developing significant DD (27.3%; p=.0267). It was found that disc wedging subjacent to the LIV (≥5°) and LIV translation (≥2 cm) lead to a sixfold increase in significant DD (odds ratio=6.71 and 6.13, respectively). Severity of DD was not associated with the number of levels fused (p=.2131), the surgical approach (p=.8245), or the construct type (p=.2922). No significant association was established between 10-year CRS and SRS-22 scores. ConclusionIn the first study of its kind, we found that only 7.3% of patients had significant DD 10 years after surgical correction of AIS. Rates of DD increased over time. Our data provide evidence to support recommendations to save as many caudal motion segments as possible, to avoid fusing to L4, and maintain the LIV tilt angle below 5° and LIV translation less than 2 cm.

Quality of Life Improvement Following Surgery in Adolescent Spinal Deformity Patients: A Comparison Between Scheuermann Kyphosis and Adolescent Idiopathic Scoliosis*

Study DesignPreoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society–22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population. ObjectivesThis study assessed changes in HRQOL prospectively and compared them to those occurring in AIS. Summary of Background DataThere has been limited evaluation of patient-reported HRQOL changes with operative management of SK. MethodsMedian SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison. ResultsKyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8–4.4) in self-image (p < .001). Changes in SRS Pain, Activity, and Self-Image domains met the minimal clinically important difference. Baseline SK and AIS scores differed significantly in the Self-Image, Mental Health and Total Score domains, with SK having worse scores (p < .001). At two years postoperatively, the greatest improvements were made in Self-Image, along with Mental Health and Total Score, and the SK group achieved greater gains (p < .001). At two years postoperatively, the SK scores improved to reach equivalent values to the AIS scores. VAS scores improved from 3.69 to 1.51, and these changes were correlated with change in the Pain, Mental Health, and Total Score SRS domains (p < .001). ConclusionsSurgery for SK in the adolescent population results in significant improvements in HRQOL, which outpace those of the AIS population. Level of EvidenceLevel II.

Effectiveness of basic body awareness therapy in adolescents with idiopathic scoliosis: A randomized controlled study1.

In scoliosis, curve progresses due to muscle imbalance and poor posture. Basic body awareness therapy (BBAT) aims to improve posture, coordination, and balance by increasing body awareness, which may help decrease deformities. This study aimed to investigate effects of Basic body awareness therapy (BBAT) on curve magnitude, trunk asymmetry, cosmetic deformity, and quality of life in adolescent idiopathic scoliosis (AIS) patients. Twenty female AIS patients were randomly assigned to BBAT and traditional exercises (TEs) groups. The BBAT group received BBAT and traditional exercises (TEs), while the TEs group received only TEs. The following assessments were included: Cobb angles using X-ray, angle of trunk rotation (ATR) using scoliometer, trunk asymmetry using the Posterior Trunk Symmetry Index (POTSI), cosmetic deformity using the Walter Reed Visual Assessment Scale (WRVAS), and quality of life using the SRS-22 test. Measurements were conducted at baseline examination and ten weeks later. Patients were instructed to wear their brace 23 h daily. Results were analyzed using the Wilcoxon rank-sum test to compare repeated measurements and Mann-Whitney U test to compare the groups. The BBAT group had greater improvement in the thoracic Cobb angle than the TEs group. Cosmetic deformity improved in both groups, whereas body asymmetry improved in only the BBAT group. SRS-22 scores were unchanged in both groups. BBAT as an additive to bracing and TEs improve curve magnitude, body symmetry and trunk deformity.

Scoliose idiopathique de l’adolescent Lenke 1 : influence du niveau de la vertèbre supérieure instrumentée sur l’équilibre sagittal du rachis cervical

BackgroundThis study aimed to evaluate the relationship between upper instrumented vertebra (UIV) level and cervical sagittal alignment (CSA) in Lenke 1 adolescent idiopathic scoliosis (AIS) patients, treated with posterior instrumentation. The hypothesis was that higher level of UIV would cause decreased cervical lordosis. MethodsSixty-three Lenke 1 AIS patients that underwent posterior fusion with pedicle screw instrumentation were retrospectively evaluated. Patients were divided into three groups according to UIV level (T2, T3, T4). Twenty patients without spinal deformity made up the control group. Patients were compared at two years follow-up according to radiographic changes in coronal and sagittal planes. Main sagittal parameters were C2-C7 cervical lordosis (CL), T1 slope, T1-T5 and T5-T12 kyphosis. Clinical outcomes were assessed using scoliosis research society (SRS)-22, short form (SF)-36 and neck disability index (NDI) questionnaires. ResultsPreoperative sagittal plane values of AIS patients were similar to the control group. C2-C7 CL, T1-T5 kyphosis and T1 slope significantly decreased postoperatively in T2 and T3 groups (p<0.05). These parameters were not changed significantly in T4 group after the surgery. T5-T12 kyphosis did not change significantly in all groups. SRS-22 and SF-36 scores significantly improved (p<0.05), while NDI scores were not changed significantly after the surgery. ConclusionsIn Lenke 1 AIS, treated with segmental all pedicle screw instrumentation using precontoured rods and rod rotation maneuver, postoperative decreased CL is more likely to occur if the UIV is selected as T2 or T3. Decreased CL seems to be caused by reduced T1-T5 kyphosis and T1 slope. However, the decrease in CL did not affect clinical outcome scores, including NDI, adversely. Hence, extending the fusion to appropriate level for shoulder balance seems reasonable. Level of evidenceIV.

Asymmetric osteotomy via posterior adjacent vertebrae in treating traumatic thoracolumbar kyphotic scoliotic deformity

Objective To investigate the clinical efficacy of asymmetric osteotomy via posterior adjacent vertebrae in the treatment of traumatic thoracolumbar kyphotic scoliotic deformity. Methods A retrospective case series study was conducted on the clinical data of 16 patients with traumatic thoracolumbar kyphotic scoliotic deformity admitted to our department from January 2012 to January 2017. There were 10 males and six females, aged (42.5±7.6) years (range, 20-62 years). According to the location of injured vertebrae, there were two patients with T11, five with T12, six with L1, and three with L2, all of which had scoliosis deformity and obvious low back pain. All patients underwent asymmetric osteotomy via posterior adjacent vertebrae. The operation time and intraoperative bleeding were recorded. The imaging parameters such as kyphosis Cobb angle, scoliosis Cobb angle, distance between C7 plumbline and central sacral vertebral line (C7-CSVL), and distance between C7 plumbline and sagittal vertical axis (SVA) were measured before and after operation. At the same time, the visual analogue scale (VAS), Oswestry dysfunction index (ODI), and SRS-22 scale were used to evaluate the clinical efficacy. The AISA score was used to evaluate the neurological function recovery before and after operation. Results All patients were followed up for (26.3±16.8) months (range, 15-65 months). The operation time was (6.0±1.4)hours (range, 4.5-9.0 hours), and the intraoperative bleeding was (900.5±360.8)ml (range, 800-1600 ml). The kyphosis Cobb angle was improved from (70.3±9.8)° before operation to (12.2±2.9)° after operation (P<0.01). The scoliosis Cobb angle was improved from (47.6±11.6)° before operation to (4.0±0.9)°after operation (P<0.01). The C7-CSVL decreased from preoperative (3.1±0.8)cm to postoperative (1.2±0.4)cm (P<0.01), and the SVA decreased from preoperative (5.0±0.9)cm to postoperative (2.9±0.5)cm (P<0.01). No severe complications such as spinal cord and nerve injury occurred. The VAS decreased from preoperative (6.8±1.0) to (1.9±0.9) points at the last follow up. The ODI decreased from (54.6±4.2)% before operation to (8.1±2.5)% at the last follow up. The SRS-22 score was increased from (64.6±7.5) points before operation to (87.4±3.2)points at the last follow-up. In terms of the ASIA classification, two patients were improved from grade C to grade D after operation, and six patients were improved from grade D to grade E. Conclusion Asymmetric osteotomy via posterior adjacent vertebrae is safe and effective in the treatment of traumatic thoracolumbar scoliosis, with high correction rate of scoliosis and kyphosis at the same time. Key words: Thoracic vertebrae; Lumbar vertebrae; Spinal fractures; Old fracture

Modic changes and disc degeneration in adolescent idiopathic scoliosis patients who reach middle age without surgery: Can residual deformity cause lumbar spine degeneration?

BackgroundWe have yet to determine what types of lumbar degenerative changes can be observed on MRI in middle-aged adolescent idiopathic scoliosis (AIS) patients without undergoing surgery. The aims of this study were to investigate AIS patients who have reached middle age without undergoing surgery and to clarify if residual spinal deformities may have affected health-related quality of life (HRQOL) and lumbar spine degeneration. MethodsSubjects comprised AIS patients who reached middle age without surgery and who underwent whole-spine X-rays, lumbar MRI, and SRS-22 surveys. Of the 60 cases collected from five scoliosis centers, 25 patients who met the inclusion criteria were enrolled into the residual deformity (RD) group and analyzed. Controls (CTR) group comprised 25 individuals matched for age, sex, and BMI with the patient group. ResultsMRI revealed no significant differences in the percentage of individuals with Pfirrmann grade 4 or 5 disc degeneration in 1 or more segments (RD group: 84%, CTR group: 60%, p = 0.059). Significantly more patients with Modic changes in 1 or more segments were observed in the RD group (RD group: 56%, CTR group: 8%, p < 0.001). All SRS-22 scores were significantly lower in the RD group. The lumbar curve cutoff point based on whether or not Modic change could be observed using ROC analysis was 39.5°. ConclusionsCompared to healthy individuals, AIS patients with residual deformity who have never had surgery showed similar prevalence of disc degeneration, but they had more Modic changes and poor HRQOL. The cutoff point for lumbar curves of patients with and without Modic changes in middle age was 39.5°.

Back pain in adolescents with spinal deformities

Back pain prevalence ranges from 7 to 58% of subjects aged between 13 and 15, equally distributed in males and females. Back pain is thought to be associated with spinal deformities but no studies investigated the prevalence of back pain in different spinal deformities like, spondylolisthesis, Scheuermann disease, hyperkyphosis, scoliosis. To document the prevalence of back pain, in all its forms in a large population of adolescents with spine deformities and to investigate the association of back pain and different spine pathologies. All the patients visited in 2010–2015 were asked for pain at first clinical evaluation by a single expert physician. PAINGroup and NOPAINGroup were formed. Pain description was then classified into 4 subtypes (localized or generalized, limiting or occasional). Inclusion criteria: age between 10 and 18, spine deformity diagnosis, Exclusion criteria: secondary deformities and other associated pathologies. Descriptive statistics. t -test to check the difference in the two groups considered for SRS-22 score, age and BMI. Chi 2 test to check the association between the presence of pain and diagnosis and pain subtypes; sports activities and previous treatment with brace. In total, 702 patients were included (males n = 468), mean age 13.3 ± 1.92. Subjects’ diagnosis: adolescent idiopathic scoliosis ( n = 387; 55.1%), sagittal unbalance (idiopathic) ( n = 134; 19.1%) Scheuermann deformities ( n = 67; 9.55%); all other diagnosis ( n = 114; 16.2%). In AIS 32% referred pain, 55% in sagittal unbalanced patients and 52% in Scheuermann disease. Only Scheuermann disease predispose to pain (Chi 2 = 10.2, Fisher exact test = 0.002), Sagittal unbalance is slightly associated to pain with Chi 2 = 3.65, Fisher exact test = 0.05. BMI, age, sports and brace were not associated with SRS-22. This is the first study investigating the epidemiology of different type of back pain in a large adolescents population with spinal deformities, Scheuermann deformity resulted associated to pain.

Proximal junctional kyphosis following correction surgery in the Lenke 5 adolescent idiopathic scoliosis patient

BackgroundTo investigate the risk factors of proximal junctional kyphosis (PJK) in Lenke 5 AIS patients after all-pedicle instrumentation and correction, and to compare the difference of radiographic and clinical outcome between PJK and Non-PJK populations. MethodMedical records of Lenke 5 AIS patients were reviewed from January 2008 to January 2013, included posteroanterior and lateral full spine X-ray films preoperatively, postoperatively (4–7 days after surgery), and at final follow-up. Demographic data and radiologic parameters were evaluated. Based on the proximal junctional angle (PJA) at final follow-up, those patients were divided into 2 groups: PJK group (n = 35, PJA≧10°), and Non-PJK group (n = 52, PJA<10°). Comparisons analyses between PJK and Non-PJK groups were carried out. Binary logistic Regression analysis was performed to detect the risk factors of PJK at follow-up. ResultsThe current study recruited 87 Lenke 5 AIS patients with average follow-up of 4.67 ± 1.17 years. Significant differences between PJK and Non-PJK groups were observed as follows: UIV(P = 0.010), the disruption of junctional ligaments (P < 0.001); preoperative variables [MTC (P = 0.001), TK(P < 0.001), LL (P = 0.017), SVA (P = 0.036), and PJA (P = 0.014)], postoperative variables [TLK(P = 0.004), and PJA (P < 0.001)], and follow-up [SVA (P = 0.014), C-SVA (P < 0.001), and PJA (P0.001). Binary logistic regression showed that the disruption of junctional ligaments, postoperative PJA and UIV (upper instrumented vertebra) at proximal or lower thoracic levels were the main risk factors of PJK [Odds Ratio (OR) = 5.114, 2.345, and 6.212, respectively]. However, the SRS-22 scores did not change significantly in PJK and Non-PJK groups. ConclusionGreater postoperative PJA, disruption of junctional ligaments, UIV at lower thoracic levels were the main risk factors for PJK in Lenke 5 AIS patients. Recommedation: Preserve junctional ligaments in those individuals with UIV located in the lower thoracic region.

The effect of upper instrumented vertebra level on cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis

This study aimed to evaluate the relationship between upper instrumented vertebra (UIV) level and cervical sagittal alignment (CSA) in Lenke 1 adolescent idiopathic scoliosis (AIS) patients, treated with posterior instrumentation. The hypothesis was that higher level of UIV would cause decreased cervical lordosis. Sixty-three Lenke 1AIS patients that underwent posterior fusion with pedicle screw instrumentation were retrospectively evaluated. Patients were divided into three groups according to UIV level (T2, T3, T4). Twenty patients without spinal deformity made up the control group. Patients were compared at two years follow-up according to radiographic changes in coronal and sagittal planes. Main sagittal parameters were C2-C7 cervical lordosis (CL), T1 slope, T1-T5 and T5-T12 kyphosis. Clinical outcomes were assessed using scoliosis research society (SRS)-22, short form (SF)-36 and neck disability index (NDI) questionnaires. Preoperative sagittal plane values of AIS patients were similar to the control group. C2-C7 CL, T1-T5 kyphosis and T1 slope significantly decreased postoperatively in T2 and T3 groups (p<0.05). These parameters were not changed significantly in T4 group after the surgery. T5-T12 kyphosis did not change significantly in all groups. SRS-22 and SF-36 scores significantly improved (p<0.05), while NDI scores were not changed significantly after the surgery. In Lenke 1 AIS, treated with segmental all pedicle screw instrumentation using precontoured rods and rod rotation maneuver, postoperative decreased CL is more likely to occur if the UIV is selected as T2 or T3. Decreased CL seems to be caused by reduced T1-T5 kyphosis and T1 slope. However the decrease in CL did not effect clinical outcome scores, including NDI, adversely. Hence, extending the fusion to appropriate level for shoulder balance seems reasonable. IV.

COMPARISON OF THE USE OF PEDICLE SUBTRACTION OSTEOTOMY (PSO) IN PRIMARY AND REVISION OPERATIONS

Purpose of study: to evaluate clinical and roentgenologic results of the use of pedicle subtraction osteotomy (PSO) in primary and revision operations to determine the feasibility of radical spinal sagittal imbalance correction at primary surgical intervention.Patients and methods. Retrospective review of 42 patients (30 men and 12 women, mean age 58.5 years) with rigid spinal deformities who underwent PSO was performed. Revision interventions (group R) were performed in 23 cases, primary (group P) in 19 cases. The comparative analysis of spino-pelvic parameters and global spine balance, demographic indices, volume of intraoperative blood loss, duration of surgical intervention, complications in the late postoperative period and quality-of-life indices by SRS-22 and ODI scores was performed. Results. Minimum follow up period was 12 months. Osteotomy was more often performed at L3 level. No differences in the extent of fixation, duration of surgical intervention and degree of segmental correction were detected. The average blood loss was significantly lower in group P (p0.05). Analysis of the late postoperative period changes in roentgenologic parameters showed statistically significant differences for the lumbar lordosis index as well as inconsistency between the lumbar lordosis and pelvic index that were better in group P. Quality of life increased significantly in both groups with the only statistically significant difference in ODI that was better in group P. Serious complications were observed in 47.8 and 38.6% of cases in group R and group P, respectively (p0.05). Revision interventions were required in 26.1% of cases in group R and in 15.8% in group P. Conclusion. In primary surgical interventions use of PSO technique enables to correct global spinal sagittal balance more effectively. Its use in primary interventions ensures lower volume of intraoperative blood loss as well as lower risk of pseudarthrosis formation and neurologic disorders development.

Ethnic Variations in Radiographic Parameters and SRS-22 Scores in Adult Spinal Deformity: A Comparison Between North American and Japanese Patients Above 50 Years of Age With Minimum 2-Year Follow-up.

Retrospective review of North American and Japanese adult spinal deformity (ASD) database. To investigate the ethnical differences in radiographic parameters and Scoliosis Research Society (SRS)-22 between North American and Japanese ASD. Previous comparison study between North American and Japanese ASD patients has revealed Japanese patients had marked pelvic tilt deformity and had lower Oswestry Disability Index scores corresponding to established thresholds of radiographic deformity. However, the subjects of the previous study included relatively younger ASD patients (above 18 y) of idiopathic origin. Total 282 ASD patients older than 50 years, 211 patients from North America (United States) and 71 patients from Japan (JP), with minimum 2-year follow-up postoperatively were included in the study. Radiologic parameters were compared at the baseline and at 2-year follow-up. SRS-22 score was used for the comparison of clinical outcome. At baseline, Japan showed significantly worse sagittal alignment such as smaller lumbar lordosis (LL), larger pelvic incidence (PI), and larger sagittal vertical axis than United States. However, Japan had significantly fewer levels fused than United States (US, 12.66±4.6; JP, 8.49±2.7). At 2 years after the surgery, Japan still had significantly worse residual sagittal deformity. Comparison of SRS-22 scores revealed Japan had better pain but worse functional domain scores at baseline which improved to comparable levels to the United States at 2 years. Self-image and mental health scores in Japan were significantly worse both at baseline and at 2 years. Analysis of factors affecting SRS-22 satisfaction score at 2 years revealed that previous spinal fusion surgery in the United States and LL, PI-LL, and sagittal vertical axis at 2 years in Japan had significant correlation. These similarities and discrepancies may be influenced by the cultural or lifestyle differences between both nations and should be considered when interpreting the results of ASD studies among different ethnicities.

The Lumbar Gap Measurement in Lenke 1–4C Curves

Study DesignRetrospective review. ObjectivesTo assess whether the lumbar gap (LG) measurement, which is the distance between the center sacral vertical line and the concave edge of the apical vertebra of the lumbar curve, would be a useful tool to predict the need for lumbar curve fusion in the Lenke 1–4C curves. Summary of Background DataThe current treatment guidelines of selective thoracic fusion in the Lenke 1–4C curves are not routinely accepted. MethodsOne hundred three adolescent idiopathic scoliosis (AIS) patients had undergone either selective thoracic fusion (STF) or both thoracic and lumbar curves fusion (TLF) for Lenke 1–4C curves. The correlations between the fusion decision making and preoperative LG, coronal balance, thoracic and lumbar Cobb, apical vertebra translation, and rotation were analyzed. The radiographic outcomes and SRS-30 of a minimum 2-year follow-up were reviewed in each group. ResultsA total of 51 patients (49.5%) underwent an STF, and 52 patients (50.5%) underwent a TLF. The mean LG was 22.0 ± 8.8 mm in the TLF, which was 2.3 times greater than the STF (9.6 ± 3.9 mm) (p < .0001). Only 5% of the lumbar curves were fused when the LG was 10 mm or less. Ninety percent of the lumbar curves were fused when the LG was 16 mm or greater, and 100% lumbar curves were fused with an LG of 21 mm or greater. The preoperative coronal imbalance to the left in the TLF was significantly greater than the STF. A mean 47% thoracic correction corresponded to a mean 39% spontaneous correction of the lumbar curve obtained in the SFT, which was significantly different from the TLF (56% and 65%). There were no differences in the SRS-30 scores at 2 years postoperatively between the STF and the TLF. ConclusionThe lumbar curve should not be fused when the LG was 10 mm or less, and very likely should be fused when the LG exceeds 20 mm in the Lenke 1–4C AIS patients. Level of EvidenceLevel III