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STUDY DESIGN Prospective, multi-centric, cross-sectional study. OBJECTIVE To analyze the construct validity of the Tampa Scale of Kinesiophobia (TSK) in a cohort of patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF THE BACKGROUND DATA Back pain is not uncommon in AIS. The fear of movement (kinesiophobia) in response to pain is related to back pain. TSK psychometric properties in AIS patients have not been properly analyzed. METHODS Patients with AIS and no prior spine surgery were prospectively included. They fulfilled the Spanish version of the TSK-11 questionnaire, a pain intensity numerical rating scale (NRS), refined SRS-22 (SRS-22r), the Hospital Anxiety and Depression Scale (HADS), and item 7 of the Core Outcome Measurement Index (COMI). The sample was split into two groups for the statistical analysis: adolescents and young adults. Cronbach alpha was used to assess internal consistency. Discriminant and concurrent validity were obtained by computing Pearson correlation coefficients between the TSK score and several criterion measures. RESULTS A total of 275 patients were included-198 adolescents (mean age of 14.6 yrs) and 77 young adults (mean age of 26.9 yrs). The Cobb of largest curve means were 44.9° and 48.9°, respectively. In the adolescent group, the TSK mean (±SD) was 21.5 (±5.93), with a floor effect of 2.5%. In the adult group, the TSK mean was 24.2 (±6.63), with a floor effect of 3.9%. The ceiling effect was 0% in both groups. Cronbach alphas for the adolescent and adult groups were 0.76 and 0.79, respectively. No correlation was found in any group between the TSK score and the curve magnitude or pattern (Lenke classification). The TSK was significantly correlated with HAD depression and SRS-22r in both groups. However, these correlations were weaker in adolescents. In adults, the TSK also significantly correlates with NRS and work/school absenteeism. CONCLUSION The Spanish version of TSK-11 is a reliable and valid instrument to analyze kinesiophobia in AIS. However, the weak correlation between kinesiophobia and pain intensity, disability, and emotional condition in adolescents requires further study.Level of Evidence: 4.

STUDY DESIGN Sagittal pelvic parameters (SPPs) of a representative patient sample drawn from a consecutive adult spinal deformity database were measured using Surgimap Spine. Estimated coefficient of reliability intraclass coefficient (95% confidence interval), standard error of measurement, and mean absolute deviation were used for the analysis. OBJECTIVE The primary objective of this study was to assess the reliability of SPP measurements using Surgimap Spine. The secondary objective was to evaluate the impact of pelvic instrumentation as well as the impact of user expertise. SUMMARY OF BACKGROUND DATA The radiographical measurement of SPP is increasingly recognized as playing a critical role in establishing the surgical goals and surgical strategy of many spinal disorders. Although instrumented flatback is a common cause of sagittal malalignment, to our knowledge, SPP measurement reliability has never been assessed in instrumented spines. METHODS Sixty-three adult full-spine standing lateral radiographs (31 with lumbosacral instrumentation) were measured twice by 13 observers using Surgimap Spine. Observers were stratified into 3 levels of experience: high (research coordinators, 4), mid (senior surgeons, 5), and low (junior surgeons, 4). Research coordinators trained all surgeons for less than 30 minutes. Parameters measured were pelvic incidence, pelvic tilt, and sacral slope. RESULTS Thirteen observers and 63 radiographs generated 817 observations (2 misses). Overall inter- and intraobserver reliability of SPP measurement was excellent (intraclass coefficient > 0.85). Lumbosacral instrumentation did not modify intraobserver reliability but reduced significantly interobserver reliability of pelvic tilt (P = 0.006) and sacral slope (P = 0.007). Experience did not affect intraobserver reliability but interobserver reliability of highly experienced observers was significantly lower (P < 0.05) than among less experienced observers. CONCLUSION Measurement of SPP using Surgimap Spine equals or improves previously reported reliability data. Lumbosacral instrumentation reduces interobserver reliability taking it from excellent to moderate in the sacral slope measurement. Inexperienced observers can measure SPP reliably after a short tutorial. LEVEL OF EVIDENCE 4.

Study Design. A cross-sectional multicenter study was performed to validate the Spanish version of the Scoliosis Research Society-22 (SRS-22) Patient Questionnaire. Objectives. To determine the construct validity and convergent validity of the instrument. Methods. The Spanish version of the SRS-22 was given to 175 patients with scoliosis (mean age, 19 years old and 86% women). A subgroup of 31 patients also received the Quality of Life for Spine Deformities Profile (QLSDP). Construct validity was studied by factor analysis. Discriminant validity was assessed analyzing the relation between SRS-22 scores and the variables of deformity severity. Convergent validity as related to the QLSDP was studied with a multitrait-multimethod matrix analysis. Results. Factor analysis offered a solution of four factors coherent with the dimensions of the original instrument. SRS-22 scores were worse in older patients (r = -0.34); patients using analgesics demonstrated lower scores (P < 0.001). Patients treated with a brace had a poorer self-image and were less satisfied with their treatment (P < 0.001) than the other treatment groups. Angular improvement of the curves was associated with better self-image scores (r = 0.34). The SRS-22 and QLSDP demonstrated high correlation coefficients in the convergent validity tests (r = 0.84). Conclusion. The Spanish version of the SRS-22 is valid. It has a factorial structure similar to that of the original questionnaire. Moreover, it relates to known severity characteristics of the disease, distinguishes among scoliosis patient groups, and shows concordant values with another valid instrument for measuring self-perceived health.

STUDY DESIGN Prospective study of a cohort of patients who underwent L5-S1 laparoscopic anterior lumbar interbody fusion. OBJECTIVES To assess the fusion rate and the clinical outcome more than 2 years after L5-S1 laparoscopic anterior lumbar interbody fusion using twin stand-alone carbon-fiber cages. SUMMARY OF BACKGROUND DATA The first reports on laparoscopic anterior lumbar interbody fusion using stand-alone cages appeared in 1995. Since then several articles have reported contradictory data regarding fusion rate. There are no publications describing the fusion rate of stand-alone lumbar carbon-fiber cages. METHODS The authors evaluated 12 patients (mean age 36.5 years) in whom endoscopic L5-S1 anterior lumbar interbody fusion was performed using twin stand-alone laparoscopic carbon-fiber cages. Clinical evaluation was carried out prospectively by the use of three self-evaluation scales. Radiologic evaluation was performed by an independent radiologist using dynamic flexion-extension films and CT scans at 6 and 12 months after surgery and subsequently every year until fusion was demonstrated. RESULTS After a mean follow-up of 36.6 months (range 24-63 months) the clinical condition of the patients was significantly better than their preoperative status: visual analog scale (P < 0.01), Prolo score (P < 0.05), and Waddell Disability Index (P < 0.01). L5-S1 mobility did not exceed 5 degrees in any dynamic study. However, the overall CT scan fusion rate at 2 years of follow-up was 16.6%. Three years after surgery, CT demonstrated fusion in one of five patients. CONCLUSION Two years after endoscopic L5-S1 anterior lumbar interbody fusion using twin stand-alone laparoscopic carbon-fiber cages, the fusion rate was unacceptably low. However, the clinical outcomes of these patients were significantly improved compared with their preoperative status.

Study design A case report. Objectives To document a fracture of the 11th thoracic vertebra after spine fusion for adult idiopathic scoliosis. Summary of background data Three cases of vertebral fractures associated with spine fusion for scoliosis were found in the literature. Methods Medical and radiologic records and related literature were reviewed. Results A 30-year-old woman had undergone anterior and posterior fusion with Cotrel-Dubousset instrumentation for progressive idiopathic scoliosis. Two years after surgery, she was in a car accident. A radiographic study and computer tomographic scanning depicted a fracture of T11 and bending of the rods. Observation was instituted and symptoms resolved. Conclusions Fracture of a vertebra within an extensive spine fusion for scoliosis is rare. The 360 degrees solid fusion together with strong posterior instrumentation may have had some protective effect in this patient.

Study Design. Prospective observational case series. Objectives. To improve the Scoliosis Research Society-22 (SRS-22) Health-Related Quality of Life (HRQL) questionnaire Function domain internal consistency for patients younger than 18 years. of Background Data. During English validation as well as Spanish and Turkish transcultural adaptation studies, low internal consistency of the Function domain was discovered for patients younger than 18 years. The problem was traced to questions 15 (relating to financial considerations) and 18 (relating to going out with friends). Otherwise, the SRS-22 HRQL questionnaire has been shown to be valid and has been successfully translated into Spanish and Turkish. Methods. Based on existing data, question 18's stem and responses were revised without changing its content and added to the SRS-22 questionnaire. Question 15 remained unchanged, and the effect of inclusion or exclusion on domain score was determined. During a 3-month period, the questionnaire was completed by 111 outpatients, including four groups: idiopathic scoliosis age

Study design Patients in whom a posterior spinal fusion instrumentation had been performed to treat low back pain were asked to recall their preoperative clinical status by retrospectively filling out the same 3 self-evaluation scales they had completed before surgery in a prospective fashion. Objectives To evaluate the impact of recollection error and compare outcomes using retrospective versus prospective methodologies among a cohort of patients treated with posterior spinal fusion instrumentation. Summary of background data Literature on spine surgery from 1990 to 2000 shows a greater increase in retrospective studies as compared to randomized controlled trials and other prospective studies. Cross-sectional studies evaluate therapeutic effectiveness by comparing the current condition with the recalled (retrospectively recorded) pretreatment condition. There are no studies analyzing the characteristics of recalled data in a cohort of patients with chronic low back pain treated with posterior spinal fusion instrumentation. Methods The preoperative clinical status of 58 patients, 33 women and 25 men, with a mean age of 48.3 years (22-84 years) was assessed prospectively with 3 self evaluation questionnaires and retrospectively at a mean of 37.5 months (2-58 months) after surgery using the same questionnaires. The Wilcoxon test was used to compare prospective and retrospective preoperative data and to compare prospective outcomes with outcomes determined from cross-sectional data. Agreement between prospective and retrospective measures was estimated with intraclass correlation coefficients for absolute agreement and consistency. Results Comparisons between prospective and recalled data showed significant differences, demonstrating a worse preoperative situation when using retrospective data. Assessment of treatment effectiveness showed that cross-sectional evaluation significantly improved the real surgical outcome. Both absolute agreement and consistency intraclass correlation coefficients showed poor agreement between prospective and cross-sectional data, revealing no systematic bias. Follow-up, age, and gender did not modify agreement and cross-sectional overestimation. Conclusions Relying on a patient's recall of preoperative clinical status is not an accurate method to evaluate surgical outcome after posterior spinal fusion instrumentation. Cross-sectional studies may overestimate the effectiveness of surgery.