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Purpose: Different methods of sagittal alignment assessment compete for predicting adverse events after adult spinal deformity (ASD) surgery. We wanted to study which method provides greater benefit. Methods: Retrospective study of 391 patients operated for ASD, with > 6 instrumented levels, fused to the pelvis, and 2 years of follow-up. Three alignment methods were analyzed 6-week postoperatively: (1) Roussouly mismatch; (2) GAP score/GAP categories; (3) T4-L1-Hip axis. Binary logistic regression generated models that best predict the following adverse events: mechanical complications (MC): in general and isolated (PJK, PJF, rod breakage); reinterventions (in general and after MC); and readmissions. ROC/AUC analysis was also implemented. In a second regression round, we added different variables that were selected on univariate analysis—demographic, surgical, and radiographic—to complete the models. Results: The best predictor parameters in most models were T4-L1PA mismatch and GAP score; we could not prove a predictive ability of the Roussouly mismatch. The T4-L1PA mismatch best predicted general MC, PJK, PJK + PJF, and readmission, while the GAP score best predicted PJF and reinterventions (for MC and for any complication). However, the variance explained by these models was limited (Nagelkerke's R2 = 0.031–0.113), with odds ratios ranging from 1.070 to 1.456. ROC curves plotted an AUC between 0.57 and 0.70. Introducing additional variables (demographic, surgical, and radiographic) improved prediction in all the models (Nagelkerke's R2 = 0.082–0.329) and allowed predicting rod breakage. Conclusion: The T4-L1-Hip axis and GAP score show potential in predicting adverse events, surpassing the Roussouly method. Despite partial efficacy in complication anticipation, recognizing postoperative sagittal alignment as a key modifiable risk factor, the crucial need arises to integrate diverse variables, both modifiable and non-modifiable, for enhanced predictive accuracy. Level of evidence: Level IV.

Introduction: Poor restoration of pelvic version after adult spinal deformity (ASD) surgery is associated with an increased risk of mechanical complications and worse quality of life. We studied the factors linked to the improvement of postoperative pelvic version. Materials and methods: This is a retrospective analysis of a prospective multicenter ASD database. Selection criteria were: operated patients having preoperative severe pelvic retroversion as per GAP score (Relative Pelvic Version-RPV < − 15°); panlumbar fusions to the pelvis; 2-year follow-up. Group A comprised patients with any postoperative improvement of RPV score, and group B had no improvement. Groups were compared regarding baseline characteristics, surgical factors, and postoperative sagittal parameters. Parametric and non-parametric analyses were employed. Results: 177 patients were studied, median age 67 years (61; 72.5), 83.6% female. Groups were homogeneous in baseline demographics, comorbidities, and preoperative sagittal parameters (p> 0.05). The difference in RPV improvement was 11.56º. Group A (137 patients) underwent a higher percentage of ALIF procedures (OR = 6.66; p= 0.049), and posterior osteotomies (OR = 4.96; p< 0.001) especially tricolumnar (OR = 2.31; p= 0.041). It also showed a lower percentage of TLIF procedures (OR = 0.45; p= 0.028), and posterior decompression (OR = 0.44; p= 0.024). Group A displayed better postoperative L4–S1 angle and relative lumbar lordosis (RLL), leading to improved sacral slope (and RPV), and global alignment (RSA). Group A patients had longer instrumentations (11.45 vs 10; p= 0.047) and hospitalization time (13 vs 11; p= 0.045). All postoperative sagittal parameters remained significantly better in group A through follow-up. However, differences between the groups narrowed over time. Conclusions: ALIF procedures and posterior column osteotomies improved pelvic version postoperatively, and associated better L4–S1 and lumbar lordosis restoration, indirectly improving all other sagittal parameters. However, these improvements seemed to fade during the 2-year follow-up.

Study design: Retrospective analysis of prospectively collected data. Objective: To determine the influence of postoperative ideal lordosis distribution and ideal sagittal harmony on mechanical complications in patients undergoing one-level lumbar pedicle subtraction osteotomy (L-PSO). Summary of background data: Many variables have been associated with mechanical complications after L-PSO. However, the impact of restoring the ideal inflexion point, lumbar apex, and sagittal shape is still underexplored. Methods: Analyzed risk factors were: age and patient-related variables, PSO level, interbody cages, rod material/diameter, number of rods, upper instrumented vertebra, lower instrumented vertebra, PI-LL mismatch, global tilt (GT), postoperative level of lumbar apex (LApex), postoperative level of inflexion point (InfxP), and postoperative type of Roussouly sagittal profile (R-type). These last variables were compared to ideal (based on pelvic incidence). Univariate and multivariate analyses were performed to identify risks for mechanical complications with a minimum 2-year follow-up. Results: A total of 87 patients were included. Mean follow-up was 4.5?±?1.7 years. 40.2% of the patients suffered postoperative mechanical complications (7 PJK, 4 PJF, 18 pseudoarthrosis/rod breakage, 6 screw pullout). Mean time for complications was 584?±?416 days from surgery. Univariate analysis showed that age (63 vs 57 years; P?=?0.04), BMI (28.1 vs 25.9; P?=?0.024), preoperative-GT (50.7° vs 38.7°; P?<?0.001), postoperative-GT (28.9° vs 23.4°; P?=?0.018), postoperative LApex location mismatched from ideal (77.8% vs 22.2%; P?=?0.036), and postoperative R-type mismatched from ideal (67.6% vs 22.6%; P?<?0.001) were significantly related to mechanical complications. The independent factors selected by multivariate analysis were: postoperative R-type mismatched from ideal OR 11.3 (95% CI? ?3.9–32.6; P?<?0.001), age OR 1.05 (95% CI 1–1.1; P?=?0.03), and LApex matching OR 0.5 (95% CI 0.27–0.97; P?=?0.04). The further the LApex was from its ideal position, the higher the risk of mechanical complications (P?=?0.036). Conclusions: Over other multiple suspected risk factors, proper lumbar apex position and ideal sagittal shape restoration played an important role in postoperative mechanical complications after L-PSO. Level of evidence: III.

Study Design: Prospective cohort.Objective: To prospectively evaluate PROs up to 5-years after complex ASD surgery.Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures.Results: Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, P< 0.001), SF36-PCS (31.5 vs. 38.8, P< 0.001), SF36-MCS (44.9 vs. 49.1, P= 0.009), SRS-22-total (2.78 vs. 3.61, P< 0.001), NRS-back pain (5.70 vs. 2.95, P< 0.001) and NRS leg pain (3.64 vs. 2.62, P= 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values (P> 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without.Conclusions: After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.

Purpose: A normal sagittal vertical axis (SVA) after spinal deformity correction can yield mechanical complications of up to 30%. Post-operative compensatory pelvic orientation can produce a normal SVA. We assess relative pelvic version (RPV), an individualised measure, for persistent post-operative compensatory measures. Methods: Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA (&lt; ± 50 mm) at 6-week follow-up were included, who were then followed-up after 2 years. These only included patients with fusion of > 4 vertebrae extending to L5 or below. Six-week subgroups were made regarding pelvis orientation, relative pelvic version (RPV: anteversion, aligned, moderate or severe retroversion) with analysis of patient-related outcome measures (PROMs), complications and spino-pelvic sagittal parameters. Results: At 6 weeks, 140 patients met the inclusion criteria, 5 (3.6%) patients had anteversion, 59 (42.1%) were aligned, 60 (42.9%) had moderate retroversion and 16 (11.4%) patients had severe retroversion. Follow-up after 2 years demonstrated increased RPV in all groups except the severe RPV group who were more likely to develop SVA > 50 mm. Complications occurred in all groups. Significant 2-year differences were observed between moderate and severe RPV for back pain and PROMs but not between other RPV groups. Conclusion: Adult spinal deformity patients with a normal SVA after spino-pelvic instrumentation carry a significant risk of retroversion progression post-operatively, followed by increased positive sagittal balance. Relative pelvic version (RPV) measurements when categorised into anteversion, aligned, moderate retroversion and severe retroversion at 6 weeks were predictive of PROMs at 2 years.

Study Design/Setting Retrospective cohort study.Objective Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.Methods ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.Results By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2= .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2= .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2= .408, P< .001).Conclusions The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions. Level of evidence:III

Study Design Prospective multicenter database post-hoc analysis.Objectives Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity.Methods Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up.Result Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P= .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P= .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P= .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P= .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P= .632) were observed.Conclusions In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.

Retrospective study of prospectively collected data.

Study Design: Retrospective study of prospectively collected data. Objectives: The purpose of this study was to evaluate the relationship between apical vertebral axial rotation and pretreatment patient-reported health-related quality of life (HRQOL), disability, and pain in patients with adult degenerative scoliosis (ADS) using a novel radiographic software tool. Summary of Background Data: Recent studies have demonstrated that in ADS, sagittal and coronal plane deformity are weakly to moderately associated with HRQOL, disability, and pain. However, as ADS is a three-dimensional spinal deformity, the impact of axial malalignment on HRQOL is yet to be determined. Methods: A total of 74 ADS patients were enrolled. HRQOL measures included the Short Form-36v2 (SF-36v2) and Scoliosis Research Society questionnaire (SRS-22r). Disability and pain measures included the Oswestry Disability Index (ODI) and numeric rating scale back and leg pain. Radiographic measures included Cobb angle (CA), sagittal spinopelvic parameters, lateral and anteroposterior (AP) translation of the apical vertebra. The amount of apical vertebral axial rotation was measured on digital AP radiograph images using a novel software technology. Subjects were stratified into four clinical groups based on the degree of apical vertebral axial rotation. Results: Apical vertebral axial rotation showed no association with lateral (r = 0.21; p = .15) and AP (r = 0.08, p = .80) translation of the apical vertebra. A significant moderate association was found between apical vertebral axial rotation and Cobb angle (r = 0.57; p &lt; .05). Patients in the group with the highest degree of apical vertebral axial rotation reported significantly worse ODI and SRS-22r Subtotal and Pain scores (p &lt; .05), irrespective of sagittal spinopelvic parameters. Conclusions: This is the first study that reports on the association between apical vertebral axial rotation and pretreatment HRQOL, disability, and pain in ADS. This study suggests that increased apical vertebral axial rotation is associated with suboptimal pretreatment health status scores. Level of Evidence: Level III.

Longitudinal cohort.

Retrospective two-cohort comparative analysis of data collected prospectively.

Retrospective review.

Study Design: Retrospective review. Objectives: To determine whether routine periodic radiographic examination is worthwhile in adolescent idiopathic scoliosis (AIS) patients undergoing instrumented fusion with third-generation implants. Summary of Background Data: In common practice, patients who have undergone surgery for idiopathic scoliosis are followed up for a minimum of 2 years by clinical assessment and routine radiographic study at 3, 6, 12, and 24 months. The radiation related to these examinations is not negligible. To our knowledge, the use of routine radiographic follow-up after posterior spinal fusion for adolescent idiopathic scoliosis has not been evaluated. Methods: We retrospectively analyzed full-spine X-rays and clinical records from the first 2 postoperative years of 43 patients. We sought any clinical feature (eg, pain, deformity progression, material protrusion) justifying X-ray, and any relevant radiologic finding (eg, loss of correction, instrumentation loosening, junctional kyphosis). Results: Excluding the immediate postoperative films, 14.8% of X-rays were clinically justified, 8.3% were associated with a relevant finding, and 4.3% led to a therapy change. All patients with clinical deformity progression had a relevant X-ray finding. Pain was associated with a relevant finding in 23.5% of cases (positive predictive value, 0.1); 7.4% of films with no clinical justification showed a relevant finding (negative predictive value, 0.86). Lower Risser sign increased the risk of having a relevant radiographic finding (p &lt;.05). Conclusions: With the current use of third-generation implants, routine biplanar postoperative X-rays at 3, 6, 12, and 24 months do not seem to be justified in AIS and should be avoided in mature, asymptomatic patients.

Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11–12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.

OBJECTIVES To assess the prevalence of low back pain (LBP) in adolescents and the clinical features of LBP in 2 European countries and to evaluate the effect of LBP on health-related quality of life (HRQOL) using standardized validated generic and disease-specific instruments. DESIGN Cross-sectional study. SETTING Secondary schools of Barcelona, Spain, and Fribourg, Switzerland. PARTICIPANTS Representative sample of adolescents from the 2 cities. INTERVENTION Selected adolescents completed a questionnaire including a generic HRQOL (KIDSCREEN-52) and 2 LBP-specific instruments. MAIN OUTCOME MEASURES Results of KIDSCREEN-52, the Roland-Morris Disability Questionnaire, and the Hanover Functional Ability Questionnaire. RESULTS A total of 1470 adolescents (52.6% male) with a mean (SD) age of 15.05 (1.17) years completed the questionnaires (response rate, 85.1%). Low back pain was reported by 587 adolescents (39.8%): isolated LBP in 250 (42.6%), LBP plus other pain in 271(46.2%), LBP plus whole-body pain in 50 (8.5%, and unclassifiable LBP in 16 (2.7%). Five hundred adolescents (34.7%) reported no pain, and 369 (25.6%) reported other pain without LBP. In those with isolated LBP, the percentage of adolescent boys was higher (54.6%; P &lt; .001) and the LBP was mildest. In those with LBP plus whole-body pain, the percentage of adolescent girls was higher (62%; P &lt; .001) and LBP was most severe. All KIDSCREEN scores in the group with LBP plus whole-body pain were significantly lower than in the other groups (effect size, 0.52-1.24). No differences were found between the groups who reported isolated pain, no pain, or other pain with no LBP. On the LBP-specific instruments, adolescents who reported LBP plus other pain had significantly poorer scores (P &lt; .001) compared with those with isolated LBP but better scores (P &lt; .001) than those with LBP plus whole-body pain. CONCLUSIONS Low back pain in adolescents is a prevalent symptom with overall low associated disability and little effect on health-related quality of life. A subset of adolescents in whom LBP is associated with whole-body pain report significant impairment and deserve more attention.Arch Pediatr Adolesc Med. 2009;163(1):65-71--

Pain is a multidimensional experience that is a prominent feature of many musculoskeletal disorders. Despite its subjective nature, pain is a highly relevant complaint; hence, nothing should deter physicians from attempting to formally assess it. This Review summarizes the main aspects of pain measurement from a practical standpoint, with a specific focus on low back pain. On balance, for the assessment of pain intensity, categorical scales with verbal descriptors or numerical rating scales seem to be preferable to traditional visual analogue scales, although no single best measure can be recommended. Pain per se should be assessed, rather than surrogate measures such as analgesic use. Back and leg pain should be evaluated separately in patients in whom these conditions coexist. For assessing change, prospective measurements are preferable to retrospective reports. Pain is not synonymous with function or quality of life, and other tools covering these important outcome dimensions should complement the assessment of pain, especially in patients with chronic symptoms. Clinicians should be aware of the psychometric properties of the tool to be used, including its level of imprecision (random measurement error) and its minimum clinically important difference (score difference indicating meaningful change in clinical status).

Thrombosis of the external jugular vein (EJV) is an infrequent clinical condition that has been associated with central venous catheterization, head and neck infections, intravenous drug abuse, and compression at the affected site. The authors report a case of thrombotic obstruction of the EJV in the late postoperative period after laparoscopic anterior lumbar interbody fusion. A 40-year-old morbidly obese woman with a depressive syndrome was diagnosed with L5–S1 discopathy and was submitted to laparoscopic anterior isthmic fusion. The operation lasted approximately 6 hours, during which the patient remained in a supine decubitus and Trendelenburg position. The left radial artery, peripheral veins, and right internal jugular vein were canalized. The internal jugular vein catheter was electively withdrawn 24 hours after the intervention. The postoperative period was satisfactory, and the patient was started on prophylaxis with low-molecular-weight heparin. She sat up and began walking at 24 hours and was discharged to her home 4 days after the procedure. Eight days after discharge she returned, experiencing right cervical pain. Palpation revealed a painful induration and erythematous area under the anterior edge of the sternocleidomastoid muscle. Results of otoscopy and laryngoscopy were normal. Cervical echo-Doppler disclosed an image consistent with EJV thrombosis. The most frequent causes of jugular vein thrombosis are mentioned above. A higher incidence has been described after upper abdomen and pelvic surgery; other contributing factors are age, obesity, and associated illness. There are few references in the literature to position-induced EJV thrombosis in the late postoperative period. The authors' patient presented signs and symptoms of EJV thrombosis (probably because of various factors), which was confirmed by echo-Doppler study and treated with 10 days of calcic heparin.

Les réadmissions hospitalières après chirurgie représentent un réel surcoût de santé. Cependant, les facteurs de risque sont mal connus, en particulier après arthrodèse thoracolombaire. Notre hypothèse était que des facteurs liés au patient et à la chirurgie pouvaient être identifiés dans une revue de littérature. Notre objectif était d’identifier ces facteurs de risque de réadmission dans les 30jours suivant une arthrodèse thoracolombaire par la réalisation d’une méta-analyse.

Le déséquilibre sagittal est un facteur prédictif du résultat postopératoire pour les patients atteints de DRA. L’influence de l’âge sur ces paramètres a été décrite dans la population asymptomatique. L’objectif de cette étude est d’identifier la relation entre les paramètres radiologiques de l’équilibre sagittal et l’âge ; et la corrélation entre les scores de qualité de vie pour les patients opérés (O) et non opérés (NO). L’hypothèse est que les paramètres radiologiques de l’équilibre sagittal influencent en partie l’indication chirurgicale dans les DRA.

L’indication chirurgicale dans les déformations de l’adulte est difficile à poser, car elle concerne une population très hétérogène. L’âge est un paramètre reconnu, mais aucune étude exhaustive incluant l’ensemble des paramètres radioclinique n’est décrite. L’objectif est d’évaluer l’impact des paramètres radio-clinique sur l’indication chirurgicale.

La prise de morphiniques avant une chirurgie rachidienne augmente le risque de dépendance aux morphiniques en postopératoire. L’évaluation postopératoire de prise d’antalgiques après une chirurgie de déformation rachidienne de l’adulte n’est pas bien évaluée. L’objectif de cette étude est d’évaluer cette prise d’antalgique avant et après chirurgie de déformation rachidienne. Notre hypothèse est que la prise de morphinique en préopératoire peut avoir un impact négatif sur le résultat postopératoire.

La classification SRS-Schwab est une classification validée mais complexe, offrant 27 catégories pour l’analyse de l’équilibre sagittal. Une simplification de cette classification a été proposée en additionnant le nombre de « + » obtenu après mesure de la version pelvienne (VP), de la SVA et de la soustraction de l’incidence pelvienne à la lordose lombaire (IP-LL). 3 catégories ont été identifiées : rachis aligné (0+), déséquilibre modéré (1 à 3+) et déséquilibre sévère (4 à 6+). En dépit d’une bonne corrélation avec l’indication chirurgicale, la mesure de trois paramètres sagittaux est nécessaire. Le alignement spinopelvien relatif (RSA) est un paramètre récemment décrit permettant d’évaluer l’alignement global en ajustant le global tilt(GT) à l’IP (RSA=GT− GT idéal avec GT idéal=0,48×PI–15). Quatre catégories sont rapportées : alignement négatif<−7°, rachis aligné −7°–10°, déséquilibre modéré 10,1°–18°, déséquilibre sévère>18°. L’objectif de cette étude est d’évaluer la capacité du RSA et de la classification simplifiée SRS-Schwab (CSS) à identifier les patients pour lequel une indication chirurgicale a été retenue.