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Study design Prospective, cross-sectional study. Objective To determine Scoliosis Research Society (SRS)-30 health-related quality of life (HRQOL) reference values by age and gender in an adult population unaffected by scoliosis thereby allowing clinicians and investigators to compare individual and/or groups of spinal deformity patients to their generational peers. Summary of background data Normative data are collected to establish means and standard deviations of health-related quality of life outcomes representative of a population. The SRS HRQOL questionnaire has become the standard for determining and comparing treatment outcomes in spinal deformity practices. With the establishment of adult SRS-30 HRQOL population values, clinicians, and investigators now have a reference for interpretation of individual scores and/or the scores of subgroups of adult patients with spinal deformities. Methods The SRS-30 HRQOL was issued prospectively to 1346 adult volunteers recruited from across the United States. Volunteers self-reported no history of scoliosis or prior spine surgery. Domain medians, means, confidence intervals, percentiles, and minimum/maximum values were calculated for six generational age-gender groups: male/female; 20-39, 40-59, and 60-80 years of age. Results Median and mean domain values ranged from 4.1 to 4.6 for all age-gender groups. The older the age-gender group, the lower (worse) the reported domain median and mean scores. The only exception was the mental health domain scores in the female groups which improved slightly. Males reported higher (better) scores than females but only the younger males were significantly higher in all domains than their female counterparts. In addition, all male groups reported higher Mental Health domain scores than their female counterparts (P=0.003). Conclusion This study reports population medians, means, standard deviations, percentiles, and confidence intervals for the domains of the SRS-30 HRQOL instrument. Clinicians must be mindful of age-gender differences when assessing deformity populations. Generational decreases noted in the older adult volunteer scores may provide a basis for future investigators to interpret observed score decreases in patient cohorts at long-term follow-up.

Study Design. Retrospective review of a prospective, multicenter database. Objective. The purpose of this study was to assess whether elderly patients undergoing scoliosis surgery had an incidence of complications and improvement in outcome measures comparable with younger patients. Summary of Background Data. Complications increase with age for adults undergoing scoliosis surgery, but whether this impacts the outcomes of older patients is largely unknown. Methods. This is a retrospective review of a prospective, multicenter spinal deformity database. Patients complete the Oswestry Disability Index (ODI), SF-12, Scoliosis Research Society-22 (SRS-22), and numerical rating scale (NRS; 0―10) for back and leg pain. Inclusion criteria included age 25 to 85 years, scoliosis (Cobb ≥ 30°), plan for scoliosis surgery, and 2-year follow-up. Results. Two hundred six of 453 patients (45%) completed 2-year follow-up, which is distributed among age groups as follows: 25 to 44 (n = 47), 45 to 64 (n = 121), and 65 to 85 (n = 38) years. The percentages of patients with 2-year follow-up by age group were as follows: 25 to 44 (45%), 45 to 64 (48%), and 65 to 85 (40%) years. These groups had perioperative complication rates of 17%, 42%, and 71%, respectively (P < 0.001). At baseline, elderly patients (65-85 years) had greater disability (ODI, P = 0.001), worse health status (SF-12 physical component score (PCS), P < 0.001 and more severe back and leg pain (NRS, P = 0.04 and P = 0.01, respectively) than younger patients. Mean SRS-22 did not differ significantly at baseline. Within each age group, at 2-year follow-up there were significant improvements in ODI (P ≤ 0.004), SRS-22 (P ≤ 0.001), back pain (P < 0.001), and leg pain (P ≤ 0.04). SF-12 PCS did not improve significantly for patients aged 25 to 44 years but did among those aged 45 to 64 (P < 0.001) and 65 to 85 years (P = 0.001). Improvement in ODI and leg pain NRS were significantly greater among elderly patients (P = 0.003, P = 0.02, respectively), and there were trends for greater improvements in SF-12 PCS (P = 0.07), SRS-22 (P = 0.048), and back pain NRS (P = 0.06) among elderly patients, when compared with younger patients. Conclusion. Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery.

STUDY DESIGN Prospective observational cohort study with matched and unmatched comparisons. Level II evidence. OBJECTIVE The purpose of this study is to compare results of adult symptomatic lumbar scoliosis (ASLS) patients treated nonoperatively and operatively. This is an evidence-based prospective multicenter study to answer the question of whether nonoperative and operative treatment improves the quality of life (QOL) in these patients at 2-year follow-up. SUMMARY OF BACKGROUND DATA Only 1 paper in the peer-reviewed published data directly addresses this question. That paper suggested that operative treatment was more beneficial than nonoperative care, but the limitations relate to historical context (all patients treated with Harrington implants) and the absence of validated patient-reported QOL (QOL) data. METHODS This study assesses 160 consecutively enrolled patients (ages 40-80 years) with baseline and 2-year follow-up data from 5 centers. Lumbar scoliosis without prior surgical treatment was defined as a minimum Cobb angle of 30 degrees (mean: 54 degrees for patients in this study). All patients had either an Oswestry Disability Index (ODI) score of 20 or more (mean: 33) or Scoliosis Research Society (SRS) domain scores of 4 or less in pain, function, and self-image (mean: 3.2) at baseline. Pretreatment and 2-year follow-up data collected prospectively included basic radiographic parameters, complications and SRS QOL, ODI, and Numerical Rating Scale back and leg pain scores. RESULTS At 2 years, follow-up on the operative patients was 95% and for the nonoperative patients it was 45%. The demographics for the nonoperative patients who were followed up for 2 years versus those who were lost to follow-up were identical. The operative cohort significantly improved in all QOL measures. The nonoperative cohort did not improve and nonsignificant decline in QOL scores was common. At minimum 2-year follow-up, operative patients outperformed nonoperative patients by all measures. CONCLUSION It would appear from this study that common nonoperative treatments do not change the QOL in patients with ASLS at 2-year follow-up. However, operative treatment does significantly improve the QOL for this group of patients. Our conclusions are limited by the fact that we were only able to follow-up 45% of the nonoperative group to 2-year follow-up, in spite of extensive efforts on our part to accomplish such.

Study Design. Retrospective review of a prospective, multicenter study. Objective. The purpose of this study was to assess the prevalence and severity of leg pain in adults with scoliosis and to assess whether surgery significantly improved leg pain compared with nonoperative management. Summary of Background Data. Patients with adult scoliosis characteristically present with pain. The presence of leg pain is an independent predictor of a patient's choice for operative over nonoperative care. Methods. Data were extracted from a prospective, multicenter database for adult spinal deformity. At enrollment and follow-up, patients complete the Oswestry Disability Index (ODI) and assessment of leg pain using the numerical rating scale (NRS) score, with 0 and 10 representing no pain and unbearable pain, respectively. Plan for operative or nonoperative treatment was made at enrollment. The vast majority of adult scoliosis patients seen in our surgical clinics have received nonoperative therapies and are being seen for a surgical evaluation. Patients are counseled regarding operative and nonoperative management options and are in general encouraged to maximize nonoperative treatments. Results. Two hundred eight (64%) of 326 adults with scoliosis had leg pain at presentation (mean NRS score = 4.7). Ninety-six patients with leg pain (46%) were managed operatively and 112 were treated nonoperatively. The operative group had higher baseline mean NRS score for leg pain (5.4 vs. 4.1, P < 0.001) and higher mean ODI (41 vs. 30, P < 0.001). At 2-year follow-up, nonoperative patients had no significant change in ODI or NRS score for leg pain (P= 0.2). In contrast, at 2-year follow-up surgically treated patients had significant improvement in mean NRS score for leg pain (5.4 vs. 2.2, P < 0.001) and ODI (41 vs. 24, P < 0.001). Compared with nonsurgically treated patients, at 2-year follow-up operative patients had lower mean NRS score for leg pain (2.2 vs. 3.8, P < 0.001) and mean ODI (24 vs. 31, P = 0.005). Conclusion. Despite having started with significantly greater leg pain and disability, surgically treated patients at 2-year follow-up had significantly less leg pain and disability than nonoperatively treated patients. Surgical treatment has the potential to provide significant improvement of leg pain in adults with scoliosis.

STUDY DESIGN The enrollment data were retrospectively reviewed for 1,061 patients entered into a prospective multicenter study of adult spinal deformity between January 2002 and June 2004. OBJECTIVE The purpose of this study is to quantify and analyze the use of nonsurgical resources in patients with adult spinal deformity. SUMMARY OF BACKGROUND DATA Limited data exist regarding the utilization of nonsurgical treatment methods for adult spinal deformity. METHODS Demographic data, surgical history, symptom assessment, and nonsurgical treatment regimen were reviewed. Health status measures were the SF-12, SRS-29, and ODI. Nonsurgical patients were divided into low- and high-symptom subgroups based on age adjusted ODI score. Resource utilization was analyzed based on both patient and physician questionnaire responses. RESULTS High- and low-symptom nonsurgical subgroups differed significantly on all reported health status measures (P < 0.0001). High-symptom patients used greater resources in terms of narcotics, epidural blocks, and physical agent methods (P < 0.001), analgesics (P < 0.01), pain management referral and bed rest (P < 0.02), strength training, nerve root blocks, and stabilization exercises (P < 0.05). CONCLUSIONS The results of this study demonstrate that, within the population of adult deformity patients, distinct high- and low-symptom groups exist and can be clearly identified. While high-symptom patients used significantly greater resources, most low-symptom patients used nonsurgical resources as well.

This study is a retrospective review of 752 patients with adult spinal deformity enrolled in a multicenter prospective database in 2002 and 2003. Patients with positive sagittal balance (N = 352) were further evaluated regarding radiographic parameters and health status measures, including the Scoliosis Research Society patient questionnaire, MOS short form-12, and Oswestry Disability Index.To examine patients with adult deformity with positive sagittal balance to define parameters within that group that might differentially predict clinical impact.In a multicenter study of 298 adults with spinal deformity, positive sagittal balance was identified as the radiographic parameter most highly correlated with adverse health status outcomes.Radiographic evaluation was performed according to a standardized protocol for 36-inch standing radiographs. Magnitude of positive sagittal balance and regional sagittal Cobb angle measures were recorded. Statistical correlation between radiographic parameters and health status measures were performed. Potentially confounding variables were assessed.Positive sagittal balance was identified in 352 patients. The C7 plumb line deviation ranged from 1 to 271 mm. All measures of health status showed significantly poorer scores as C7 plumb line deviation increased. Patients with relative kyphosis in the lumbar region had significantly more disability than patients with normal or lordotic lumbar sagittal Cobb measures.This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance. The results also show that kyphosis is more favorable in the upper thoracic region but very poorly tolerated in the lumbar spine.

Eighteen human torsos were used in three experiments (A, B, and C) to determine the changes in sagittal motion due to three different sequences of three surgical releases.To investigate the relative effects of releasing the intervertebral disc, the costosternal joint, the sternum, and the facet joints on sagittal thoracic motion and the consequences of altering the sequence of the releases.The biomechanics of the thoracic spine are different from the cervical and lumbar spine particularly due to the ribs and sternum, which contribute to stability and control motion. The role of the sternum and costosternal articulation in the biomechanics of thoracic sagittal motion has not been well studied. The effects of releasing each of these structures, whether alone or with discectomy and/or facetectomy, is potentially relevant in the surgical correction of thoracic deformities, such as severe kyphosis, and in the biomechanics of thoracic fracture.In Experiment A, the release sequence was back to front: total facetectomy (T4-T8), then radical discectomy (T4-T8), then costosternal release, then sternal osteotomy. In Experiment B, the release sequence was front to back: sternal osteotomy, then costosternal release, then radical discectomy, and finally total facetectomy. In Experiment C, the release sequence was: radical discectomy, then sternal osteotomy, then costosternal release, then total facetectomy. The different sequences allowed separate analysis of each component and the synergistic patterns. In each of the three experiments, the torso was flexed then extended each time by an applied force (25 N) before and after each release. The extent of flexion and the extent of extension were measured each time and compared with the intact condition, after each release.The results obtained for sternal osteotomy were combined with the results obtained for costosternal release to give "sternal release." Radical discectomy provided the greatest increase (P0.05) in range of motion (ROM) compared with the other two single releases, no matter what the sequence. For paired release combinations, the radical discectomy and sternal release (as in Experiments B and C) provided a significant (P0.05) increase in total sagittal ROM compared with the combination of radical discectomy and total facetectomy (Experiment A). In Experiment A, sternal release accounted for 42% of the total sagittal ROM compared with only 26% related to the total facetectomy (Experiment B). In general, all of the releases allowed more extension than flexion.Sagittal plane motion in the thoracic spine is influenced by all three structures tested in this experiment. Overall, the radical discectomy provides the greatest increase in total ROM and in extension compared with the other two releases. The second most influential release is the combination of sternal osteotomy plus costosternal release (i.e., sternal release), particularly in extension (correction of kyphosis). When two releases are done in sequence, radical discectomy plus sternal release provides the greatest increase in total ROM and in extension. Overall, total facetectomy is the least effective release. These data have relevance for surgical strategies in the correction of thoracic kyphosis or lordosis and suggest a potential role for sternal osteotomy and costosternal release in severe and rigid upper thoracic kyphosis.

Study Design. An anatomic and radiographic study of archeological skeletal remains from two genetically and geographically distinct groups with high occurrence rates of spondylolytic spondylolisthesis was done. Specimens were Aleut (27% known occurrence rate, n = 48) and Arikara Plains Indians (9% occurrence, n = 250+ of 1,062). Objective. To evaluate three radiographic parameters highly correlated with spondylolisthesis (pelvic incidence [PI], sacral table angle [STA], and lumbar index [LI]) in genetically homogeneous populations to determine which may be etiologic or most predictive for lysis. Summary of Background Data. LI has been known to vary with the percentage of slip in lytic spondylolisthesis. Recent clinical studies have shown that PI is also significantly higher in high-grade slips, and a possible etiologic effect has been ascribed to this association. STA has also been shown to vary between normals, those with only lysis, and those with lysis and slip. The etiologic significance of STA is unknown. Methods. Radiographic and direct morphologic measurement of PI, LI, and STA was done on L5 and reassembled sacra and ilia. Statistical analysis of these three parameters among all groups was done. Results. 1) There is a genetically determined difference in the upper sacral tilt (STA) that may be etiologic. 2) Genetically homogeneous groups with a lower STA in normal specimens have an increased occurrence rate of spondylolysis. 3) When there has been pars lysis, changes in the STA occur as well as deformity more caudal in the sacrum. 4) These changes are likely related to remodeling with epiphyseal growth related to changed axial stresses secondary to pars lysis. 5) PI is not a primary etiologic factor in the process. Conclusions. The STA in the normal population for each genetic group varies and relates significantly to the occurrence rate and is thus probably etiologic. STA is more highly associated with the occurrence of pars defect than is PI. Upper sacral deformities appear due to the growth plate response to the changed pressure gradients across the epiphyseal plate rather than interosseous remodeling of the ilium and acetabular area. Thus, changes in PI would be secondary.

Study design This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. Objectives The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. Summary of background data Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. Methods The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. Results The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. Conclusions This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

STUDY DESIGN Scoliosis patients were prospectively x-rayed in three positions with independent analysis. OBJECTIVES To determine if one positioning technique provides superior visualization of critical landmarks (C7, T2, T12, L5-S1) and to determine any position dependent variations in regional measures or sagittal balance. SUMMARY OF BACKGROUND DATA Different techniques for positioning patient's arms are used for 36" lateral radiograph with no data on relative effects. METHODS A total of 25 scoliosis patients were prospectively studied with 36" lateral radiographs in three positions varying arm location (straight out, partially flexed, and the "clavicle" position). Films were analyzed independently by three surgeons. Vertebral landmarks were scored for clarity; and lordosis, kyphosis, and global balance were analyzed. Statistical analysis was done with a General Estimating Equations model. RESULTS The overall visualization score for the clavicle position was superior to either the 60 degrees or 90 degrees positions (clavicle vs. 60 degrees, P < 0.0001; clavicle vs. 90 degrees, P < 0.0003). Analysis of vertebral landmarks showed significantly better visualization of T2 with clavicle versus 90 degrees (P < 0.047), better visualization of T12 with clavicle versus either 60 degrees (P < 0.006) or 90 degrees (P < 0.049), and better visualization of L5-S1 with clavicle versus 90 degrees (P < 0.02). Regional measures showed no differences, but sagittal balance was significantly more positive in the 60 degrees position than either clavicle (P < 0.04) or 90 degrees (P < 0.015). CONCLUSIONS The clavicle position for obtaining lateral 36" radiographs produces significantly better overall visualization of critical vertebral landmarks. Regional measures do not differ between the three positions, but global balance is more positive with the 60 degrees position. Clinically, the clavicle position may result in more accurate radiographic measures and may minimize repeated radiograph exposures.

Study design Retrospective analysis of data entered prospectively into a multicenter database-clinical and radiographic outcomes assessment. Objective Our hypothesis is that between the 2-year and the 3- to 5-year points surgically treated adult spinal deformity patients will show significant reduction in outcomes by Scoliosis Research Society (SRS), Oswestry Disability Index (ODI), and numerical rating scale back and leg pain scores and will show increasing thoracic kyphosis, loss of lumbar lordosis, and loss of coronal and sagittal balance. Summary of background data Most analyses of primary presentation adult spinal deformity surgery assess 2-year follow-up. However, it is established that in some patients unfavorable events occur between the 2-year and 5-year points. Methods The cohort of 113 patients entered into a multicenter database with complete preoperative, 2-year, and 3- to 5-year data. All patients who had adult spinal deformity and surgical treatment represented their first reconstruction. Diagnoses were scoliosis (82.5%), kyphosis (10%), and scoliosis and kyphosis combined (7.5%). Outcome measures and basic radiographic parameters (curve size, thoracic and lumbar sagittal plane, coronal and sagittal balance) were assessed at those 3 time intervals. Complications (pseudarthrosis/implant failure, infection, and junctional deformities) were assessed at the 2-year and the 3- to 5-year (mean, 3.76 years) points. RESULTS.: The mean major curve Cobb angle (preoperative, 57°; 2-year, 29°; 3-5 year, 26°); thoracic kyphosis T5 to T12 (30°, 31°, 32°) and lumbar lordosis T12 to sacrum (48°, 49°, 51°) did not change from the 2-year to ultimate follow-up. Likewise, coronal and sagittal balance parameters were the same at 2-year and ultimate follow-up. SRS total scores and modified ODI were similar at the 2 year and final follow-up (SRS: 3.89-3.88; ODI: 19-18). Preoperative SRS total score was 3.17. Six patients demonstrated complications at the 2-year point and additional 9 patients demonstrated complications at the 3- to 5-year point. Those 9 patients with complications at ultimate follow-up demonstrated significant deterioration in their ODI and SRS scores when compared with the patients who did not have complications at ultimate follow-up. Conclusion Contrary to our hypothesis, we could not establish deterioration in mean radiographic or clinical outcomes between the 2-year and 3- to 5-year follow-up points when analyzing the group as a whole. However, for the 9 patients who experienced complications between 3- and 5-year follow-up, their outcomes were significantly worse than for the other 104 patients.One should not anticipate an overall radiographic and clinical deterioration of the outcomes of surgically treated primary presentation adult spinal deformity patients in this studied time interval. However, close to 10% of patients will experience a new complication at the 3- to 5-year point, most commonly implant failure/nonunion and/or junctional kyphosis, which will negatively effect the patient-reported outcome.

Sixty-three discs in 25 consecutive patients with nonradicular discogenic pain were studied with magnetic resonance imaging and lumbar discography. Sagittal T2 magnetic resonance imaging sequences were blindly classified according to the nuclear signal intensity and to the status of the posterior anulus. A positive discogram had to include abnormal morphology and a provocative pain response of significant intensity and familiar quality. Specific magnetic resonance imaging patterns with a high probability for positive and negative discograms are identified. Also identified are magnetic resonance imaging patterns with intermediate probability, ie, ones that should not be presumed either asymptomatic or symptomatic. In many cases, magnetic resonance imaging could not reliably predict or replace discography.

Study design Prospective, observational study. Objective To further validate the Scoliosis Research Society (SRS) instrument by comparing scores of adult deformity patients with no prior history of spine surgery to the scores of normal adult volunteers in age-gender matched groups. Summary of background data Efforts have been made to validate the SRS questionnaire in adolescent and adult deformity patients. An important psychometric attribute of any quality of life tool is its ability to discriminate between subjects with and without the condition of interest. Discriminate validity of the SRS questionnaire has not been established in the primary (no prior surgical treatment) adult deformity population. Methods The SRS questionnaire was issued prospectively to 935 primary adult deformity patients with a diagnosis of idiopathic or de novo scoliosis and minimum Cobb angle of 30 degrees (average Cobb angle: 54 degrees; range: 30 degrees-132 degrees). Five hundred forty-three patients were treated nonsurgically while 392 patients underwent surgical intervention. Baseline SRS scores of the deformity population were compared to 1222 volunteers with no history of spine disease randomly sampled from the US population. Analysis between the 2 populations was broken down into 6 age-gender groups: male/female; 20-40, 41-60, 61-80 years of age. Results SRS domain scores of the deformity subgroups demonstrated significant statistical differences from their corresponding age-gender matched normative group. The only exceptions were the mental health domain in the older males, 61-80 years of age. The average SRS subscore for each age-gender subgroup was less than the tenth percentile in the corresponding normative population, indicating substantial limitations in these patients. Conclusion Our findings confirm the SRS instrument has excellent discriminate validity in the adult population. It appears to be disease-specific in the domains of pain, appearance and activity in adult spinal deformity patients who have not had prior surgery.

STUDY DESIGN Multicenter study. OBJECTIVE The purpose of this study is to prospectively analyze responsiveness of the SRS-22 to change at 1 and 2 years following primary surgery. SUMMARY OF BACKGROUND DATA A number of efforts have been directed at validation of the SRS-22 instrument in the setting of adolescent and adult spinal deformity. However, few have extensively analyzed the ability of the instrument to detect change (brought on by surgical treatment) in adult scoliosis patients. METHODS A multicenter prospective series of consecutive adult scoliosis patients (all primary/no revisions) were administered SRS-22, Oswestry Disability Index (ODI)and Short Form-12 (SF-12) questionnaires preoperation and 1 and 2 years postoperation. Fifty-six patients had preoperative, 1-year postoperative, and 2-year postoperative data. RESULTS The greatest changes from preoperation to 2-year postoperation were the SRS self-image domain followed by SRS total, SRS pain, and ODI scores. SRS pain and function scores significantly (P < 0.05) improved from 1-year to 2-year postoperation. There were not substantial differences in the outcome measures according to age or curve type. All outcome measures except SF-12 mental health showed statistically significant (P < 0.05) improvement from baseline to 2-year follow-up. CONCLUSION Based on these 3 outcome tools, the greatest responsiveness to change was demonstrated by the SRS self-image domain followed by SRS total, then SRS pain, then ODI. This suggests that the SRS tool is more responsive than ODI, which is more responsive than SF-12 to change brought on by primary surgical treatment of adult scoliosis patients. Surgical treatment in adult scoliosis significantly improved pain, self-image, and function based on the health-related quality of life measures used in this study.

STUDY DESIGN Multicenter, prospective, consecutive clinical series. OBJECTIVES To establish and validate classification of scoliosis in the adult. SUMMARY OF BACKGROUND DATA Studies of adult scoliosis reveal the impact of radiographic parameters on self-assessed function: lumbar lordosis and frontal plane obliquity of lumbar vertebrae, not Cobb angle, correlate with pain scores. Deformity apex and intervertebral subluxations correlate with disability. METHODS A total of 947 adults with spinal deformity had radiographic analysis: frontal Cobb angle, deformity apex, lumbar lordosis, and intervertebral subluxation. Health assessment included Oswestry Disability Index and Scoliosis Research Society instrument. Deformity apex, lordosis (T12-S1), and intervertebral subluxation were used to classify patients. Outcomes measures and surgical rates were evaluated. RESULTS Mean maximal coronal Cobb was 46 degrees and lumbar lordosis 46 degrees . Mean maximal intervertebral subluxation (frontal plane) was 4.2 mm (sagittal plane, 1.2 mm). In thoracolumbar/lumbar deformities, the loss of lordosis/higher subluxation was associated with lower Scoliosis Research Society pain/function and higher Oswestry Disability Index scores. Across the study group, lower apex combined with lower lordosis led to higher disability. Higher surgical rates with decreasing lumbar lordosis and higher intervertebral subluxation were detected. CONCLUSIONS A clinical impact classification has been established based on radiographic markers of disability. The classification has shown correlation with self-reported disability as well as rates of operative treatment.

Study design Prospective analysis of a consecutive cohort of adult spinal deformity patients queried over a 12-month period. Objectives To assess the SRS-22 instrument compared with the SF-12 and Oswestry. Summary of background data Very few reports in the literature have applied the SRS-22 to adult spinal deformity patients. Methods Consecutive adult spinal deformity patients were applied the SRS-22, SF-12, and Oswestry. Four analyses were done: 1) floor/ceiling effect; 2) Pearson's correlation coefficients between the SRS-22, SF-12, and Oswestry; 3) Cronbach's alpha analysis for internal consistency within the SRS-22; and 4) test/retest. Results Floor/ceiling range for the SRS-22 compared favorably with the SF-12 and Oswestry. The Pearson's coefficients correlating the two questionnaires relative to the SRS-22 were > 0.7. The Cronbach's alpha within each domain for the SRS-22 were > 0.7, except for pain (0.67). Test/retest correlation coefficients ranged from 0.84 to 0.95 for the subscales. Conclusions The SRS-22 is a disease-specific instrument with the capacity to demonstrate change in health status more effectively than the SF-12 and in more domains than the Oswestry. The SRS-22 showed high criterion validity with the SF-12 and Oswestry based on Pearson's coefficients. High Cronbach's alpha scores suggested a high internal consistency within each domain of the SRS-22, except for pain (0.67). Test/retest reliability was excellent.

Study Design. A prospective analysis of the clinical outcome of a consecutive series of patients treated with posterior lumbar arthrodesis. Preoperative data were collected retrospectively by chart review. Objectives. To measure by independent review the clinical outcome of posterolateral intertransverse fusion as a treatment for discogenic low back pain in a highly selected group of patients. Summary of Background Data. Although numerous studies have reported on the surgical management of degenerative disc disease, they have been difficult to interpret because they lack patient-oriented outcome assessment and objective pain measurement criteria, independent review, and include patients with diagnoses other than degenerative disc disease. Methods. Between 1991 and February 1993 all patients seen by a single surgeon, evaluated with magnetic resonance imaging and discography, and treated with posterolateral lumbar fusion were reviewed by independent investigation. Outcome was assessed in the areas of radiographic fusion, pain, function, and patient satisfaction. Results. Twenty-three patients (12 women, 11 men; 100% follow-up an average of 47 months after surgery [range, 24-84 months]) met the inclusion criteria. Overall, 39%, had a good or excellent result, 13% fair, and 48% poor. Nine of 10 patients receiving worker's compensation had a poor result; four of five patients with radiographic pseudarthrosis had a poor result. Statistically significant improvement in the visual analogue scale was noted in the good and excellent group (P=0.0001) and the fair group (P=0.002) with no change in the poor group. Patients out of work more than 3 months before surgery tended to have poor results. Overall, 56% of patients were extremely satisfied with the result of their surgery. Conclusion. Posterolateral intertransverse fusion can be used to successfully manage chronic discogenic back pain. However, patient selection remains a challenge, and successful outcome appears to be limited in the subset of patients receiving worker's compensation and those chronically disabled. Prospective and randomized study with objective pain criteria, independent review, and patient-oriented outcome is recommended.

Study Design. The technique of hole preparation and the placement or orientation of anterior transvertebral screws in relation to the endplates were the subjects of two experiments. Objectives. Experiment 1-to determine if anterior transvertebral body screws have higher pull-out strengths after unicortical predrilling compared with a bicortical predrilling ; Experiment 2-to determine the effect of the screw's orientation in the vertebral body on its resistance to loosening. Summary of Background Data. There are a variety of surgical techniques for using anterior transvertebral screws in the vertebral body without any clear guidelines as to which techniques optimize the strength of fixation. Methods. In Experiment 1, 31 cadaveric vertebral bodies were tested for pull-out strength of transvertebral body screws placed after unicortical predrilling compared with bicortical predrilling. In Experiment 2, 48 cadaveric vertebral bodies were tested with transvertebral screws inserted using four different screw orientations. Results. There is no statistically significant difference in pull-out strength of anterior transvertebral body screws inserted after unicortical compared with bicortical predrilling (Experiment 1). The resistance to loosening is greatest when transvertebral screws are oriented in the superior oblique position (Experiment 2). Conclusions. Experiment 1-preparation of the far cortex by predrilling is not necessary. Experiment 2-transvertebral screws should be obliquely oriented so that the forces applied to the screws are resisted by both of the endplates.

Study Design. Two separate experiments (A and B), each involving six human cadaveric torsos with intact rib cages and sternums, were done to determine the effect of two different sequences of surgical releases (at T8-T9) on thoracic spinal motion. Objectives. Experiment A was designed to test the effects of three releases in sequence from anterior to posterior, analogous to a two-stage operative treatment with anterior and posterior releases. Experiment B, which involved three releases, was desgined to determine 1) if unilateral posterior total facetectomy alone allowed a significant increase in motion and 2) if rib head resection without discectomy allowed a significant increase in motion. Summary of Background Data. In the surgical treatment of thoracic spinal deformity, surgical release is often done to impart additional flexibility to the spine. Available releases include discectomy, rib head resection, and facetectomy. There is little work to date on the relative importance of the disc, rib head, and facet joint in the stability of the thoracic spine. Methods. In experiment A and experiment B, the cadaveric torsos were mounted on a custom-made loading frame. Mechanical testing (using weights, pulleys, and digital goniometers) was done after each surgical release to measure the extent of angular rotation in the coronal plane (right lateral bending and left lateral bending) and in the sagittal plane (flexion and extension). Results. The combination of rib head resection and radical discectomy provided the greatest increase in thoracic spinal motion. Standard discectomy alone did not allow a significant increase in motion. Rib head resection without discectomy did not allow a significant increase in motion. Unilateral posterior total facet excision did not allow a significant increase in motion. Conclusions. These experiments indicate that the combination of rib head resection and radical discectomy may be the optimal thoracic spinal release

Sixty-eight patients with idiopathic scoliosis treated with Zielke instrumentation are reviewed. Comparison of Groups A and B demonstrates a statistically significant reduction in the incidence of rod fracture by modifying preoperative selection criteria and operative technique as described. Only one-half of the cases with broken implants had an unfavorable clinical course, and those rod fractures with curve progression were associated with significant pain. Average kyphosis was 9.7 degrees, and did not correlate with the subjective result. Analysis of Group A showed that thoracic progression was rare, and tended to occur in patients who were out of balance. Seventy-two percent of patients operated on for severe pain report significant relief at 4.2 years average follow-up, many reporting continued improvement between 1 and 3 years after surgery.