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The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1342 - 1347
1 Nov 2024
Onafowokan OO Jankowski PP Das A Lafage R Smith JS Shaffrey CI Lafage V Passias PG

Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347


Bone & Joint 360
Vol. 12, Issue 4 | Pages 30 - 32
1 Aug 2023

The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.


The Bone & Joint Journal
Vol. 105-B, Issue 2 | Pages 172 - 179
1 Feb 2023
Shimizu T Kato S Demura S Shinmura K Yokogawa N Kurokawa Y Yoshioka K Murakami H Kawahara N Tsuchiya H

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Methods

The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model.


The Bone & Joint Journal
Vol. 104-B, Issue 2 | Pages 265 - 273
1 Feb 2022
Mens RH Bisseling P de Kleuver M van Hooff ML

Aims

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Methods

AIS patients were systematically enrolled in an institutional registry. In all, 144 AIS patients aged ≤ 25 years undergoing primary surgery (median age 15 years (interquartile range 14 to 17) were included. Patient-reported (condition-specific and health-related quality of life (QoL); functional status; back and leg pain intensity) and clinician-reported outcomes (complications, revision surgery) were recorded. Changes in patient-reported outcome measures (PROMs) were analyzed using Friedman’s analysis of variance. Clinical relevancy was determined using minimally important changes (Scoliosis Research Society (SRS)-22r), cut-off values for relevant effect on functioning (pain scores) and a patient-acceptable symptom state (PASS; Oswestry Disability Index).


Bone & Joint 360
Vol. 10, Issue 5 | Pages 32 - 35
1 Oct 2021


Bone & Joint 360
Vol. 10, Issue 2 | Pages 40 - 43
1 Apr 2021


Bone & Joint Open
Vol. 2, Issue 3 | Pages 163 - 173
1 Mar 2021
Schlösser TPC Garrido E Tsirikos AI McMaster MJ

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Methods

SRS-22r and full-spine lateral radiographs were collected for the 28 young patients (age 13.4 years (SD 2.6) who underwent surgery for high-grade dysplastic spondylolisthesis in our centre (Scottish National Spinal Deformity Service) between 1995 and 2018. The mean follow-up was nine years (2 to 25), and one patient was lost to follow-up. The standard surgical technique was an all-posterior, partial reduction, and S1 to L5 transfixation screw technique without direct decompression. Parameters for segmental (slip percentage, Dubousset’s lumbosacral angle) and regional alignment (pelvic tilt, sacral slope, L5 incidence, lumbar lordosis, and thoracic kyphosis) and global balance (T1 spino-pelvic inclination) were measured. SRS-22r scores were compared between patients with a balanced and unbalanced pelvis at final follow-up.


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 148 - 156
1 Jan 2021
Tsirikos AI Carter TH

Aims

To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

Methods

We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire.


The Bone & Joint Journal
Vol. 102-B, Issue 4 | Pages 513 - 518
1 Apr 2020
Hershkovich O D’Souza A Rushton PRP Onosi IS Yoon WW Grevitt MP

Aims. Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis. Methods. A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression. Results. Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex. Conclusion. Our study supports the ‘essential lordosis’ hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513–518


The Bone & Joint Journal
Vol. 102-B, Issue 2 | Pages 261 - 267
1 Feb 2020
Tøndevold N Lastikka M Andersen T Gehrchen M Helenius I

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Methods

In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications.


The Bone & Joint Journal
Vol. 98-B, Issue 9 | Pages 1240 - 1247
1 Sep 2016
Thompson W Thakar C Rolton DJ Wilson-MacDonald J Nnadi C

Aims

We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis.

Patients and Methods

Between January 2011 and January 2015, 19 children were treated with magnetically-controlled growing rods (MCGRs) and underwent distraction at three-monthly intervals. The mean age of our cohort was 9.1 years (4 to 14) and the mean follow-up 22.4 months (5.1 to 35.2). Of the 19 children, eight underwent conversion from traditional growing rods. Whole spine radiographs were carried out pre- and post-operatively: image intensification was used during each lengthening in the outpatient department. The measurements evaluated were Cobb angle, thoracic kyphosis, proximal junctional kyphosis and spinal growth from T1 to S1.


The Bone & Joint Journal
Vol. 98-B, Issue 3 | Pages 402 - 409
1 Mar 2016
Sudo H Kaneda K Shono Y Iwasaki N

Aims

A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed.

Patients and Methods

Radiographic parameters and clinical outcomes were compared among patients with lowest instrumented vertebra (LIV) at the lower end vertebra (LEV; EV group) (n = 13) and those treated by short fusion (S group), with LIV one level proximal to EV (n = 17 patients).


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 10 | Pages 1393 - 1398
1 Oct 2012
Mattila M Jalanko T Puisto V Pajulo O Helenius IJ

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (sd 29, 25° to 141°) and 81° (sd 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (sd 20; 2° to 87°) and 20° (sd 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (sd 2.18) and 6.04 hours (sd 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (sd 2790) and 1785 ml (sd 1110), respectively (p = 0.001).

Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_II | Pages 110 - 110
1 Feb 2012
Hussain N Freeman B Watkins R He S Webb J
Full Access

Our prospective observational study of patients treated for Thoracolumbar Adolescent Idiopathic Scoliosis (AIS) by anterior instrumentation aimed at investigating the correlation between the radiographic outcome and the recently-developed scoliosis research society self-reported outcomes instrument (SRS-22) which has been validated as a tool for self-assessment in scoliosis patients. Previous patient based questionnaires demonstrated poor correlation with the radiological parameters. Materials and Methods. Pre-operative, post-operative and two years follow-up radiographs of 30 patients were assessed. Thirteen radiographic parameters including Cobb angles and balance were recorded. The percentage improvements for each were noted. The SRS-22 questionnaire was completed by all patients at final follow-up. Correlation was sought between each radiographic parameter, total SRS score and each of the five domains by quantifying Pearson's Correlation Coefficient (r). Results. Percentage improvement in primary Cobb angle (r = 0.052), secondary Cobb angle (r = 0.165), apical vertebra translation of the primary curve (r = -0.353), thoracic kyphosis (r = 0.043) and lumbar lordosis (r = 0.147) showed little or no correlation with the SRS-22 total score and its five individual domains. Significant inverse correlation was found between the upper instrumented vertebra angle and at follow-up and SRS-22 (r = -0.516). The same was true for Sagittal plumb line shift at final follow up (r = -0.447). Conclusion. SRS-22 is a validated tool for the self-assessment of health status in spinal deformity patients; however, it does not seem to correlate with most of the radiographic parameters commonly used by clinicians to assess patient outcome with the exception of upper instrumented vertebra angle and sagittal plumb line which do correlate significantly with the SRS-22 outcomes instrument. A comprehensive system of assessing the success of surgery both from the patient and clinicians perspective is required in the spinal deformity patient


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 564 - 564
1 Oct 2010
Grabmeier G Engel A Eyb R Kroener A
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Background: Although the clinical relevance still remains unclear there is an increased interest in the incidence of proximal junctional kyphosis (PJK) following posterior spinal scoliosis surgery. Several authors suppose patients with hybrid instrumentation (cranial laminar hooks, caudal pedicle screws and sublaminar wires) to be at greater risk for developing PJK. The aim of our study was to evaluate the incidence of PJK and to determine risk factors in our series of AIS patients with hybrid instrumentation after a minimum follow up of 5 years. Methods: 60 consecutive AIS patients (56 female, 4 male, average age 16 years, range 14 to 18 years) underwent scoliosis surgery using pedicle screws caudal and laminar hooks cranial at our institution. Pre - and postoperative Cobb angle, junctional kyphosis angle, number of fused levels and upper instrumented vertebra were assessed on lateral and anteriorposterior standing long cassette radiographs after an average follow up of 8 years (range 5 to 12 years). As published by Glattes et al. proximal junction was defined as the caudal end-plate of the upper instrumented vertebra to the cranial endplate two vertebrae proximal. A Cobb angle of the proximal junction greater than 10° and at least 10° greater than preoperative was defined abnormal. Results: Average number of fused levels was 10.2 (range 8.1 to 12.3). Average Cobb angle decreased from pre-operative 65° (range 50° to 80°) to 32° (range 22° to 40°). T 4 was the upper instrumented vertebra in 30 patients, T 5 in 18 and below T 6 in 12 patients. Average Preoperative saggital PJK Cobb was 7° (range 4° to 13°). 5 patients (12%) showed abnormal proximal junctional kyphosis angel at latest follow up (average 18°, range 14 to 28°). There was no positive correlation found between upper instrumented vertebra and abnormal PJK (r. 2. = 0.01). A greater preoperative PJK angle however showed positive correlation (r. 2. = 0.8). Conclusion: Compared to literature our data show a low rate (12%) of PJK after an average follow up of 8 years. We could not find any positive correlation between upper instrumented vertebra and incidence of PJK, a preoperative increased proximal kyphosis however seems to be a risk factor for developing PJK


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 437 - 437
1 Aug 2008
Freeman B Hussain N Watkins R Webb J
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Introduction: Patient questionnaires permit a direct measure of the value of care as perceived by the recipient. The Scoliosis Research Society outcomes questionnaire (SRS-22) has been validated as a tool for self-assessment. We investigated the correlation between SRS-22 and a detailed radiological outcome two years following anterior correction of Thoraco-Lumbar Adolescent Idiopathic Scoliosis (TL-AIS). Methods: The SRS-22 questionnaire was completed by 30 patients two years following anterior correction of TL-AIS. Pre-operative, post-operative and two year follow-up radiographs of all 30 patients were assessed. The following parameters were measured at each time point:. Primary Cobb angle,. Secondary Cobb angle,. Coronal C7-midsacral plumb line,. Apical Vertebra Translation (AVT) of primary curve,. AVT of the secondary curve,. Upper instrumented vertebra (UIV) translation,. UIV tilt angle,. Lower instrumented vertebra (LIV), 8) LIV tilt angle. Apical Vertebra Rotation (AVR) of the primary curve,. Sagittal C7-posterior corner of sacrum plumb line. T5-T12 angle,. T12-S1 angle,. shoulder height difference. The percentage improvements for each were noted. Correlation was sought between Total SRS score, each of the five individual domains and various radiographic parameters listed above by quantifying Pearson’s Correlation Coefficient (r). Results: Percentage improvement in primary Cobb angle (r = 0.052), secondary Cobb angle (r = 0.165) and AVT of the primary curve (r = −0.353) showed little or no correlation with the SRS-22 total score or any of its five domains. Significant inverse correlation was found between the UIV tilt angle at two years and the SRS-22 (r = −0.516). Lateral radiographs however showed little or no correlation between thoracic kyphosis (r = 0.043) and SRS-22. Conclusion: The SRS-22 outcomes questionnaire does not correlate with most of the radiographic parameters commonly used by clinicians to assess patient outcome


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 451 - 451
1 Aug 2008
Hussain N Freeman BJC Watkins R Webb JK
Full Access

Introduction: Patient questionnaires permit a direct measure of the value of care as perceived by the recipient. The Scoliosis Research Society outcomes questionnaire (SRS-22) has been validated as a tool for self-assessment. We investigated the correlation between SRS-22 and a detailed radiological outcome two-years following anterior correction of ThoracoLumbar Adolescent Idiopathic Scoliosis (TL-AIS). Methods: The SRS-22 questionnaire was completed by 30 patients two-years following anterior correction of TL-AIS. Pre-operative, post-operative and two-year follow-up radiographs of all 30 patients were assessed. The following parameters were measured at each time point: 1) Primary Cobb angle, 2) Secondary Cobb angle, 3) Coronal C7-midsacral plumb line, 4) Apical Vertebra Translation (AVT) of primary curve, 5) AVT of the secondary curve, 6) Upper instrumented vertebra (UIV) translation, 7) UIV tilt angle, 8) Lower instrumented vertebra (LIV), 8) LIV tilt angle 9) Apical Vertebra Rotation (AVR) of the primary curve, 10) Sagittal C7-posterior corner of sacrum plumb line 11) T5–T12 angle, 12) T12-S1 angle, 13) shoulder height difference. The percentage improvements for each were noted. Correlation was sought between Total SRS score, each of the five individual domains and various radiographic parameters listed above by quantifying Pearson’s Correlation Coefficient (r). Results: Percentage improvement in primary Cobb angle (r = 0.052), secondary Cobb angle (r = 0.165) and AVT of the primary curve (r = −0.353) showed little or no correlation with the SRS-22 total score or any of its five domains. Significant inverse correlation was found between the UIV tilt angle at two years and the SRS-22 (r = −0.516). Lateral radiographs however showed little or no correlation between thoracic kyphosis (r = 0.043) and SRS-22. Conclusion: The SRS-22 outcomes questionnaire does not correlate with most of the radiographic parameters commonly used by clinicians to assess patient outcome