Aims. There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes. Patients and Methods. A total of 284 DLS patients were recruited into this study, among whom 69 patients were treated surgically and the remaining 215 patients conservatively Patients were classified based on the coronal balance distance (CBD): Type A, CBD < 3 cm; Type B, CBD > 3 cm and C7 Plumb Line (C7PL) shifted to the concave side of the curve; Type C, CBD > 3 cm and C7PL shifted to the convex side. Results. A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. Conclusion. This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227–33

Aim. To investigate anterior instrumented corrective fusion for thoracolumbar or lumbar scoliosis. Methods. A retrospective review of medical records and radiographs of 38 consecutively managed patients who underwent anterior spine surgery for thoracolumbar curves by a single surgeon between 2001 and 2011. The cohort consisted of 28 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up x-rays. Results. Thoracolumbar/lumbar curves were corrected from 70 to 27 degrees. The thoracic compensatory curve spontaneously corrected from 34 to 19 degrees. Sagittal imbalance of greater than 4 centimeters was found in 40 percent of patients preoperatively and in 16 percent post operatively (85 percent negative sagittal imbalance, 15 percent positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.13 of a grade. Average operative time was 194 minutes and estimated blood loss was 450 ml. The diaphragm was taken down in 36 of the 38 patients but no post-op ventilation was required. The average high care stay was 1.2 days. Average follow-up was 18 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 29 degrees, and the mean compensatory thoracic curve measuring 21 degrees. There were no significant neurological or respiratory complications. Conclusion. Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. NO DISCLOSURES

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.

Aims

This study compared the long-term results following Salter osteotomy and Pemberton acetabuloplasty in children with developmental dysplasia of the hip (DDH). We assessed if there was a greater increase in pelvic height following the Salter osteotomy, and if this had a continued effect on pelvic tilt, lumbar curvature or functional outcomes.

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients. We reviewed all abdominal radiographs performed in our hospital over ten months. 2276 radiographs were analysed for degenerative lumbar scoliosis and lateral vertebral slips in patients who are over 20 years. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work). 2233 (98%) radiographs were included. 48% of patients were female. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age. Degenerative scoliosis was present in 1.6% of 30–39 year olds increasing every decade to 29.7% of patients 90 years or older. In all age groups curves were more frequent and had greater average Cobb angles in female patients. Degenerative lumbar scoliosis starts to appear in the third decade of life increasing in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery

Aims. We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique. Patients and Methods. We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15). Results. The mean post-operative follow-up was 5.8 years (2.5 to 9.5). There were no neurological complications, deep wound infection, obvious nonunion or need for revision surgery. Upper thoracic scoliosis was corrected by a mean 68.2% (38% to 48%, p < 0.001). Main thoracic scoliosis was corrected by a mean 71% (43.5% to 8.9%, p < 0.001). Lumbar scoliosis was corrected by a mean 72.3% (41% to 90%, p < 0.001). No patient lost more than 3° of correction at follow-up. The thoracic kyphosis improved by 13.1° (-21° to 49°, p < 0.001); the lumbar lordosis remained unchanged (p = 0.58). Coronal imbalance was corrected by a mean 98% (0% to 100%, p < 0.001). Sagittal imbalance was corrected by a mean 96% (20% to 100%, p < 0.001). The Scoliosis Research Society Outcomes Questionnaire score improved from a mean 3.6 to 4.6 (2.4 to 4, p < 0.001); patient satisfaction was a mean 4.9 (4.8 to 5). . Conclusions. This technique carries low neurological and vascular risks because the screws are placed in the pedicles of the convex side of the curve, away from the spinal cord, cauda equina and the aorta. A low implant density (pedicle screw density 1.2, when a density of 2 represents placement of pedicle screws bilaterally at every instrumented segment) achieved satisfactory correction of the scoliosis, an improved thoracic kyphosis and normal global sagittal balance. Both patient satisfaction and functional outcomes were excellent. Cite this article: Bone Joint J 2017;99-B:1080–7

The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients. We reviewed all abdominal radiographs performed in our hospital over ten months. 2276 radiographs were analysed for degenerative lumbar scoliosis and lateral vertebral slips in patients who are ≥ 20 years old. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work). 2233 (98%) radiographs were analysed. 48% of patients were female. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age. Degenerative scoliosis was present in 1.6% of 30–39 year olds increasing every decade to 29.7% of patients 90 years or older. In all age groups curves were more frequent and had greater average Cobb angles in female patients except in the 30–39 year olds - where males equalled females. Degenerative lumbar scoliosis starts to appear in the third decade of life increasing in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery

The October 2012 Spine Roundup. 360. looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture

Introduction: The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter and is often the only investigation used pre-operatively in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients requiring abdominal and KUB radiographs at our institution. Method: We reviewed all abdominal and KUB radiographs performed in our hospital in the first ten months from the introduction of our digital PACS system. 2276 radiographs were analysed for the incidence of degenerative lumbar scoliosis and lateral vertebral slips in patients who are ≥ 20 years old, in ten-year age ranges. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work/laminectomy). Results: 2233 (98%) radiographs were analysed. 48% of patients were female. The youngest patient was 20 and the oldest 101 years. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age. In all age groups curves were more frequent and had greater average Cobb angles in female patients except in the 30–39 year olds–where the males equalled females in frequency and had the greatest Cobb angles. Conclusions: Degenerative lumbar scoliosis starts to appear in the third decade of life and increases in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery

Objective: An anatomical study to describe the radiographic pattern of canal, foraminal and lateral recess stenosis in degenerative lumbar stenosis associated with open and closed subluxations of the lumbar spine. Introduction: Degenerative lumbar scoliosis is a three-dimensional deformity frequently associated with facet joint subluxation. It is suggested that the causative mechanism of open subluxation is vertebral rotation, whereas closed subluxation is driven by erosion of the convex facet joint. Patients with degenerative lumbar scoliosis are predominantly symptomatic on standing. However, standing MRI scans are not currently feasible to investigate this dynamic problem, therefore an accurate interpretation of the standing and lateral radiographs is essential to effectively treat this condition. We have undertaken a study to compare standing radiographs with supine MRI to determine the pattern of nerve root entrapment with open and closed facet joint dislocations in DLS. Methods: Plain radiographs and MRI scans of 35 consecutive patients with de novo degenerative lumbar scoliosis (average age 72 years) were evaluated. Radiographic measurements included the angle of the dislocation, degree of translation, position of osteophytes, vertebral rotation and the degree and location of any stenosis present on the axial MRI images. Results: Open dislocations were associated with a pre-dominant contralateral lateral recess and/or foraminal stenosis in 74% of cases. Closed dislocations were associated with ipsilateral lateral recess and/or foraminal stenosis in 82% of cases. Both open and closed dislocations had a similar degree of vertebral rotation. 67% of open subluxations occurred at L3/4. In closed subluxations the most frequent level involved was LI/2 (53% of cases). Open dislocations are located closest to the apex of the curve, with closed dislocations being more peripheral. The curve was noted to rotate towards the apex. Conclusion: Open and closed subluxations of the lumbar spine result in different, but predictable, patterns of stenosis. The findings are important in the diagnosis and planning of treatment in patients with lumbar spinal stenosis, when associated with degenerative scoliosis and lateral spondylolisthesis

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting thoracolumbar/lumbar idiopathic scoliosis in adolescent patients. Summary of Background Data. Thoracolumbar/lumbar scoliosis has been traditionally treated through an anterior approach and instrumented arthrodesis with the aim to include in the fusion the Cobb-to-Cobb levels and preserve distal mobile spinal segments. Posterior instrumentation has been extensively used for thoracic or thoracic and lumbar scoliosis. In the advent of all-pedicle screw constructs there is debate on whether thoracolumbar/lumbar scoliosis is best treated through an anterior or a posterior instrumented arthrodesis. Methods. We reviewed the medical notes and radiographs of 19 consecutive adolescent patients with Lenke 5C idiopathic scoliosis (17 female-2 male, prospectively collected single surgeon's series). We measured the scoliosis, thoracic kyphosis and lumbar lordosis angles, apical vertebral rotation (AVR) and translation (AVT), trunk shift (TS), as well as the lower instrumented vertebra angle (LIVA) both pre-and post-operatively and at minimum 2-year follow-up. SRS 22 data was available for all patients. Results. All patients underwent posterior spinal arthrodesis of the primary thoracolumbar/lumbar curve using all-pedicle screw constructs. Mean age at surgery was 15.1 years. We identified 3 separate groups: Group 1 (9 patients) had a fusion to include the preoperative Cobb-to-Cobb levels of the curve; in Group 2 (8 patients) the fusion extended 1-2 levels distal (all patients) +/− proximal (4 patients) to the end Cobb vertebrae; in Group 3 (2 patients) the fusion extended to one level proximal to the lower end Cobb vertebra. Eight patients had compensatory thoracic curves. Mean Cobb angle before surgery was 60.3° (range: 43-91°). This was corrected by 79% to mean 13° (p<0.001) with no patient losing >2° correction at follow-up. Mean preoperative Cobb levels of the thoracolumbar/lumbar curve were 6.3; mean levels of instrumented fusion were 7 (mean extent of fusion: preoperative Cobb angle + 0.7 levels). Mean preoperative thoracic kyphosis was 34.7° and lumbar lordosis 45.3°. Mean postoperative thoracic kyphosis was 36.6° and lumbar lordosis 43°. Mean theatre time was 3.8 hours, hospital stay 7.5 days and intraoperative blood loss 0.26 blood volumes. There were no neurological complications other than one temporary brachial plexus neuropraxia (recovered before patient discharge from hospital), no wound infections or detected non-union at follow-up. Mean preoperative SRS 22 score was 3.7; this was improved to 4.5 at 2-year follow-up (p=0.01). Pain and self-image demonstrated significant improvement (p=0.02, p=0.001 respectively) with mean satisfaction rate 4.8. Comparison between Groups 1 and 2 showed similar age at surgery but higher preoperative scoliosis in Group 2 (Group 1: 54°/Group 2: 65°, p=0.05). Preoperative AVR, TS and LIVA were similar between the 2 groups (p>0.05). Preoperative AVT was significantly higher in Group 2 (Group 1: 3.3 cm/Group 2: 5 cm, p=0.01). Conclusion. Pedicle screw instrumentation can achieve excellent correction of Lenke 5C idiopathic scoliosis which is maintained at follow-up. This is associated with high patient satisfaction and low complication rates. Greater preoperative AVT and scoliosis angle predicted the need for longer fusion both distally and proximally beyond the end vertebra of the preoperative Cobb angle

Objective: An anatomical study to describe the radiographic pattern of canal, foraminal and lateral recess stenosis in degenerative lumbar stenosis associated with open and closed subluxations of the lumbar spine. Introduction: Degenerative lumbar scoliosis is a three-dimensional deformity frequently associated with facet joint subluxation. It is suggested that the causative mechanism of open subluxation is vertebral rotation, whereas closed subluxation is driven by erosion of the convex facet joint. Methods: Plain radiographs and MRI scans of 40 consecutive patients with de novo degenerative lumbar scoliosis (average age 72 years) were evaluated. Radiographic measurements included the angle of the dislocation, degree of translation, position of osteophytes, vertebral rotation and the degree and location of any stenosis present on the axial MRI images. Results: Open dislocations were associated with a contralateral lateral recess and/or foraminal stenosis in 85.7% of cases. Closed dislocations were associated with ipsilateral lateral recess and/or foraminal stenosis in 83.3% of cases. Open dislocations had a greater degree of vertebral rotation than closed (10.9° v 7.8°). 56% of open subluxations occurred at L3/4. In closed subluxations the most frequent level involved was LI/2 (36% of cases). Where both subluxations coexisted, the open subluxation was more proximal. Conclusion: Open and closed subluxations of the lumbar spine result in different, but predictable, patterns of stenosis. The findings are important in the diagnosis and planning of treatment in patients with lumbar spinal stenosis, when associated with degenerative scoliosis and lateral spondylolisthesis

Degenerative lumbar scoliosis with lateral deviation of the spine is frequently seen in elderly. Clinical presentation varies. The deformity is often associated with loss of lordosis, axial rotation and spinal stenosis. The operative treatment is a challenge to achieve the greatest benefit with least amount of intervention. Therefore the potential benefit to be obtainened by means of spinal fusion must be measured against the operative risks. A retrospective study was performed to investigate patient outcomes after fusion for degenerative lumbar scoliosis using XIA-Instrumentation. Functional outcome was assessed 2 to 9 years later using the Roland Morris score, a visual analogue scale and the Short Form 36 Health survey. The aim was to determine the effectiveness of the surgical procedure in terms of patient satisfaction, outcome scores and radiological aspects. There is an accepted deficiency of this form of outcomes assessment in the literature. Methods: Final evaluation was possible in 28 patients at a mean period of observation of 48 months. Inclusion criteria were: age ≥60 years, Cobb angle preop. greater than 15degrees, degenerative deformity, no prior surgery (spine), and complete records. Each patient completed the standard Short Form-36 (SF-36) questionnaire. Radiographic and clinical data were evaluated. The measures of outcomes assessment included patient satisfaction, pain scores, low back outcome, medication use and social status. Results: Questionnaire data indicated good satisfactory and bad surgical results in 9 (32%), 12 (43%) and 7 (25%) patient. Scoliosis was converted from a mean preoperative Cobb angle of 17 degrees to 10 degrees. On an average of 5 spinal segments were instrumented and fused. In the first two years after spinal fusion the patient satisfaction was about 90%. In the following years until final evaluation the satisfaction rate decrease continuously by all patients often caused by adjacent instability of neighbouring unfixed motion segments. No pseudarthrosis were seen in final evaluation. Conclusion: Proper preoperative planning, a sufficient fusion length and a good biomechanical properties of the used implants, such as XIA, are prior to prevent adjacent instability and can achieve satisfactory results with less operative risks

Précis: A recently developed Classification of adult scoliosis was utilised to study surgical treatment in 339 patients. At 12 month follow up after surgery for thoracolumbar/lumbar scoliosis greatest improvement in outcome scores were noted in the following patients: lost lumbar lordosis, treatment with osteotomies, fusion to the sacrum for marked sagittal imbalance. Complication rates were greatest for: fusion to the sacrum, sagittal imbalance greater than 4cm. Introduction: A recently proposed radiographic Classification of adult scoliosis offers a useful system with high clinical impact and reliability. Continued work is required to apply this system in the development of treatment guidelines. The purpose of this study was to anal surgical treatment outcomes, and complications, by Classification subtype at 12 months post-operative follow up. Material and Method: This study included 339 patients: Type IV (thoracolumbar major) and Type V (lumbar major) adult scoliosis (Spinal Deformity Study Group). All patients had complete full-length spine radiographs and outcomes questionnaires (SRS, ODI and SF-12). An analysis of classification subtypes (modifiers) included outcome scores by surgical treatment. The latter included approach (anterior, posterior, both), use of osteotomies, and extension to the sacrum (or not). Results: Lordosis modifier was strongly correlated with baseline disability and post-operative improvement. Type C (loss of lordosis) patients had the lowest baseline outcome but also greatest improvement with surgery (p< 0.05). Subluxation modifier had impact on preoperative but not on postoperative outcomes measures. Marked sagittal balance had the worst outcomes of all groups if fusion fell short of the sacrum. Patients with osteotomies saw greater improvement than those without (p< 0.05). Anterior, posterior or combined procedures showed no significant difference in outcomes. Peri- and post-operative complications did not vary by lordosis modifier, subluxation modifier but were elevated for fusion to the sacrum (p< 0.05). Conclusion: At 12 month follow up for surgical treatment of adult thoracolumbar/lumbar scoliosis greatest improvement in outcome scores were noted in the following patients: lost lumbar lordosis, treatment with osteotomies, fusion to the sacrum for marked sagittal imbalance. Complication rates were greatest for: fusion to the sacrum, sagittal imbalance greater than 4cm. Further longitudinal follow up will permit validation of optimal treatment by Classification type of adult spinal deformity and refine patient and surgeon expectations of operative care

During the last 2 decades it has been recognized that scoliosis may start de novo during adult life as a result of advanced degenerative disc disease, osteoporosis or both. In some the degenerative process is superimposed on a previous adolescent curve. Aside from the disfigurement caused by the spinal deformity, pain and disability are usually the major clinical problem. The prevalence of adult scoliosis rises with age: from 4% before age 45, 6% at age 59 to 15% in-patients older than 60 years. More than two thirds of the patients are females and the prevalence of right lumber curves is higher than in comparable series of patients with adolescent scoliosis. Adult scoliosis is characterized by vertebral structural changes with translatory shifts i.e. lateral olisthesis accompanied by degenerative disc and facet joint arthrosis. Although the magnitude of these curves is usually mild (20–30 degrees) lateral spondylolisthesis is observed frequently. It is also common to observe degenerative spondylolisthesis in patients with degenerative lumbar scoliosis. The annual rate of curve progression ranges from 0.3 to 3%. Patients present with a history of a spinal deformity accompanied by loss of lumbar lordosis, trunk imbalance and significant mechanical back pain. Pain may arise not only from degenerative disc disease and facet arthritis leading to symptoms of spinal stenosis, but also from muscle fatigue due to the altered biomechanics secondary to a deformity in the coronal and sagittal planes. Root entrapment is common and occurs more often on the concavity of the curve. Symptoms of neurogenic claudication are also common in adults with lumbar scoliosis. Non-operative care includes exercises, swimming, NSAIDs, and occasional epidural injections. Brace treatment can be tried as well. Curve progression as well as axial or radicular pain not responding to non-operative care are indications for surgical intervention. Surgery may include decompression alone or in conjunction with curve correction and stabilization. Posterior instrumentation may be supplemented with interbody cages. Fusion is usually carried down to L5 but occasional instrumentation to the sacropelvis is mandatory. Problems with a high pseudoarthrosis rate are common with sacral fixation. Even in the best of hands a long recovery period (6–12 month) and moderate pain relief should be expected. As summarized by Dr. Bradford “despite recent advancements evaluation and successful management of patients with adult spinal deformity remains a significant challenge”

Background: In lumbar scoliosis curves of school screening referrals were evaluated (1) for the possible relation of pathomechanisms to standard and non-standard vertebral rotation (NSVR) [. 1. ], and (. 2. ) the relation between apical lumbar axial vertebral rotation and the frontal plane spinal offset angle (FPTA) [. 2. ]. Methods: Consecutive patients referred to hospital during routine school screening using the Scoliometer were examined in 1996–9. None had surgery for their scoliosis. There are 40 subjects with either pelvic tilt scoliosis (11), idiopathic lumbar scoliosis (19), or double curves (10)(girls 31, postmenarcheal 25, boys 9, mean age 15.3 years). One observer (RGB) measured: 1) in AP spinal radiographs Cobb angles (CAs), apical vertebral rotations (Perdriolle AVRs), and trigonometrically sacral alar tilt angle (SATA), and FPTA as the tilt of the T1–S1 line to the vertical; and 2) total leg lengths (tape). Results: Excluding the double curves there are 16 left and 14 right lumbar curves mean CA 11 degrees (range 4–24 degrees), mean AVR 9 degrees (concordant to CA in 18/30, discordant in 7/30), SATA 2.8 degrees (range 0.2–7.7 degrees associated with CA side and severity, p=0.0003), and leg-length inequality 0.7 cm (significantly shorter on left, p< 0.0001 and associated with SATA (p=0.02) but not CA). Neither CA nor AVR in each of the laterality concordant and discordant lumbar or thoracic curves is significantly different. Twenty-six subjects have thoracic curves (16 right) 22 with AVR (mean CA 11 degrees, range 4–17 degrees, AVR 9 degrees, n=22) the CA being associated with each of lumbar CA and SATA (respectively p< 0.0001, p=0.003, n=26). Thoracic curve laterality of CA and AVR is concordant in 12/26 curves and discordant in 10/26 and for concordance/discordance neither is significantly different; thoracic AVR sides with laterality of lumbar curve AVR shown by thoracic AVR (but not CA) being greater in lumbar discordant than in lumbar concordant curves (14 & 7 degrees respectively, p=0.03, n=18 & 7). Both for lumbar curves alone and for lumbar with double curves, AVR by side is significantly associated with FPTA by side (r= −0.568, p=0.001, n=30; r=−0.560, p=0.0002, n=40). Conclusion: (1) It is hypothesized that different pathomechanisms may separately affect the frontal (CA) and transverse (AVR) planes: in discordant curves these mechanisms may neutralize each other and limit curve progression; concordant curves require these biplanar mechanisms to summate and facilitate curve progression. (2) The association of frontal plane spinal tilt angle and lumbar AVR may result from balance mechanisms affecting trunk muscles – mechanisms that may underlie the complication of post-operative frontal plane spinal imbalance or decompensation [. 2. ]

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making

Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for decision making, the merit of predictable outcome with THA first, leg weakness as an indication for spine surgery, the concern of THA position with spinal deformity, and the urgency of myelopathy. Conclusion. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial in certain clinical scenarios, even for experienced hip and spine surgeons. Additional outcome studies of these patients are necessary for appropriate decision making

To present the results of surgical correction in patients with double or triple thoracic/lumbar AIS (Lenke types 2,3,4) with the use of a novel convex/convex unilateral segmental screw correction technique in a single surgeon's prospective series. We reviewed the medical records and spinal radiographs of 92 consecutive patients (72 female-20 male). We measured scoliosis, thoracic kyphosis, lumbar lordosis, scoliosis flexibility and correction index, coronal and sagittal balance before and after surgery, as well as at minimum 2-year follow-up. SRS-22 data was available preoperatively, 6-month, 12-month and 2-year postoperatively for all patients. Surgical technique. All patients underwent posterior spinal fusion using pedicle screw constructs. Unilateral screws were placed across the convexity of each individual thoracic or lumbar curve to allow for segmental correction. ‘Corrective rod’ was the one attached to the convexity of each curve with the correction performed across the main thoracic scoliosis always before the lumbar. Maximum correction of main thoracic curves was always performed, whereas the lumbar scoliosis was corrected to the degree required to achieve a balanced effect across the thoracic and lumbar segments and adequate global coronal spinal balance. Concave screws were not placed across any deformity levels. Bilateral screws across 2 levels caudally and 1–2 levels cephalad provided proximal/distal stability of the construct. Mean age at surgery was 14.9 years with mean Risser grade 2.8. The distribution of scoliosis was: Lenke type 2–26 patients; type 3–43 patients; type 4–23 patients. Mean preoperative Cobb angle for upper thoracic curves was 45°. This was corrected by 62% to mean 17° (p<0.001). Mean preoperative Cobb angle for main thoracic curves was 70°. This was corrected by 69% to mean 22° (p<0.001). Mean preoperative Cobb angle for lumbar curves was 56°. This was corrected by 68% to mean 18° (p<0.001). No patient lost >2° correction at follow-up. Mean preoperative thoracic kyphosis was 34° and lumbar lordosis 46°. Mean postoperative thoracic kyphosis was 45° (p<0.001) and lumbar lordosis 46.5° (p=0.69). Mean preoperative coronal imbalance was 1.2 cm. This corrected to mean 0.02 cm at follow-up (p<0.001). Mean preoperative sagittal imbalance was −2 cm. This corrected to mean −0.1 cm at follow-up (p<0.001). Mean theatre time was 187 minutes, hospital stay 6.8 days and intraoperative blood loss 0.29 blood volumes (1100 ml). Intraoperative spinal cord monitoring was performed recording cortical and cervical SSEPs and transcranial upper/lower limb MEPs and there were no problems. None of the patients developed neurological complications, infection or detected non-union and none required revision surgery to address residual or recurrent deformity. Mean preoperative SRS-22 score was 3.6; this improved to 4.6 at follow-up (p<0.001). All individual parameters also demonstrated significant improvement (p<0.001) with mean satisfaction rate at 2-year follow-up 4.9. The convex-convex unilateral pedicle screw technique can reduce the risk of neurological injury during major deformity surgery as it does not require placement of screws across the deformed apical concave pedicles which are in close proximity to the spinal cord. Despite the use of a lesser number of pedicle fixation points compared to the bilateral segmental screw techniques, in our series it has achieved satisfactory scoliosis correction and restoration of global coronal and sagittal balance with improved thoracic kyphosis and preserved lumbar lordosis. These results have been associated with excellent patient satisfaction and functional outcomes as demonstrated through the SRS-22 scores