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Study Design Prospective, multicenter, international, observational studyObjective Identify independent prognostic factors associated with achieving the minimal clinically important difference (MCID) in patient reported outcome measures (PROMs) among adult spinal deformity (ASD) patients ≥60 years of age undergoing primary reconstructive surgery.Methods Patients ≥60 years undergoing primary spinal deformity surgery having ≥5 levels fused were recruited for this study. Three approaches were used to assess MCID: (1) absolute change:0.5 point increase in the SRS-22r sub-total score/0.18 point increase in the EQ-5D index; (2) relative change: 15% increase in the SRS-22r sub-total/EQ-5D index; (3) relative change with a cut-off in the outcome at baseline: similar to the relative change with an imposed baseline score of ≤3.2/0.7 for the SRS-22r/EQ-5D, respectively.Results 171 patients completed the SRS-22r and 170 patients completed the EQ-5D at baseline and at 2 years postoperative. Patients who reached MCID in the SRS-22r self-reported more pain and worse health at baseline in both approaches (1) and (2). Lower baseline PROMs ((1) – OR: .01 [.00-.12]; (2)- OR: .00 [.00-.07]) and number of severe adverse events (AEs) ((1) – OR: .48 [.28-.82]; (2)- OR: .39 [.23-.69]) were the only identified risk factors. Patients who reached MCID in the EQ-5D demonstrated similar characteristics regarding pain and health at baseline as the SRS-22r using approaches (1) and (2). Higher baseline ODI ((1) – OR: 1.05 [1.02-1.07]) and number of severe AEs (OR: .58 [.38-.89]) were identified as predictive variables. Patients who reached MCID in the SRS22r experienced worse health at baseline using approach (3). The number of AEs (OR: .44 [.25-.77]) and baseline PROMs (OR: .01 [.00-.22] were the only identified predictive factors. Patients who reached MCID in the EQ-5D experienced less AEs and a lower number of actions taken due to the occurrence of AEs using approach (3). The number of actions taken due to AEs (OR: .50 [.35-.73]) was found to be the only predictive variable factor. No surgical, clinical, or radiographic variables were identified as risk factors using either of the aforementioned approaches.Conclusion In this large multicenter prospective cohort of elderly patients undergoing primary reconstructive surgery for ASD, baseline health status, AEs, and severity of AEs were predictive of reaching MCID. No clinical, radiological, or surgical parameters were identified as factors that can be prognostic for reaching MCID.

Study Design Multicenter, international prospective study.Objective This study investigated the clinical outcome up to 2 years after multi-level spinal deformity surgery in the elderly by reporting the minimal clinically important difference (MCID) of EuroQol 5-dimensions (EQ-5D), EQ-VAS, and residential status.Methods As an ancillary study of 219 patients ≥60 years with spinal deformity undergoing primary instrumented fusion surgery of ≥5 levels, this study focuses on EQ-5D (3-L) as the primary outcome and EQ-VAS and residential status as secondary outcomes. Data on EQ-5D were compared between pre-operatively and postoperatively at 10 weeks, 12 months, and 24 months. An anchor-based approach was used to calculate the MCID.Results The EQ-5D index and EQ-VAS, respectively, improved significantly at each time point compared to pre-operatively (from .53 (SD .21) and 55.6 (SD 23.0) pre-operatively to .64 (SD .18) and 65.8 (SD 18.7) at 10 weeks, .74 (SD .18) and 72.7 (SD 18.1) at 12 months, and .73 (SD .20) and 70.4 (SD 20.4) at 24 months). 217 (99.1%) patients lived at home pre-operatively, while 186 (88.6%), 184 (98.4%), and 172 (100%) did so at 10 weeks, 12 months, and 24 months, respectively. Our calculated MCID for the EQ-5D index at 1 year was .22 (95% CI .15-.29).Conclusions The EQ-5D index significantly increased at each time point over 24 months after ≥5 level spinal deformity surgery in elderly patients. The MCID of the EQ-5D-3 L was .22. Patients living at home pre-operatively can expect to be able to live at home 2 years postoperatively.

Purpose: The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution. Methods: Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed. Results: 572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%). Conclusions: This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.

Study Design Basic science (finite element analysis).Objectives Pedicle subtraction osteotomy (PSO) at L5 is an effective treatment for sagittal imbalance, especially in select cases of patients showing kyphosis with the apex at L4-L5 but has been scarcely investigated. The aim of this study was to simulate various “high-demand” instrumentation approaches, including varying numbers of rods and sacropelvic implants, for the stabilization of a PSO at L5.Methods A finite element model of T10-pelvis was modified to simulate posterior fixation with pedicle screws and rods from T10 to S1, alone or in combination with an L5 PSO. Five additional configurations were then created by employing rods and novel porous fusion/fixation implants across the sacroiliac joints, in varying numbers. All models were loaded using pure moments of 7.5 Nm in flexion-extension, lateral bending, and axial rotation.Results The osteotomy resulted in a general increase in motion and stresses in posterior rods and S1 pedicle screws. When the number of rods was varied, three- and four-rod configurations were effective in limiting the maximal rod stresses; values approached those of posterior fixation with no osteotomy. Maximum stresses in the accessory rods were similar to or less than those observed in the primary rods. Multiple sacropelvic implants were effective in reducing range of motion, particularly of the SIJ.Conclusions Multi-rod constructs and sacropelvic fixation generally reduced maximal implant stresses and motion in comparison with standard posterior fixation, suggesting a reduced risk of rod breakage and increased joint stability, respectively, when a high-demand construct is utilized for the correction of sagittal imbalance.

Introduction: Spinal measurements play an integral role in surgical planning for a variety of spine procedures. Full-length imaging eliminates distortions that can occur with stitched images. However, these images take radiologists significantly longer to read than conventional radiographs. Artificial intelligence (AI) image analysis software that can make such measurements quickly and reliably would be advantageous to surgeons, radiologists, and the entire health system. Materials and methods: Institutional Review Board approval was obtained for this study. Preoperative full-length standing anterior–posterior and lateral radiographs of patients that were previously measured by fellowship-trained spine surgeons at our institution were obtained. The measurements included lumbar lordosis (LL), greatest coronal Cobb angle (GCC), pelvic incidence (PI), coronal balance (CB), and T1-pelvic angle (T1PA). Inter-rater intra-class correlation (ICC) values were calculated based on an overlapping sample of 10 patients measured by surgeons. Full-length standing radiographs of an additional 100 patients were provided for AI software training. The AI algorithm then measured the radiographs and ICC values were calculated. Results: ICC values for inter-rater reliability between surgeons were excellent and calculated to 0.97 for LL (95% CI 0.88–0.99), 0.78 (0.33–0.94) for GCC, 0.86 (0.55–0.96) for PI, 0.99 for CB (0.93–0.99), and 0.95 for T1PA (0.82–0.99). The algorithm computed the five selected parameters with ICC values between 0.70 and 0.94, indicating excellent reliability. Exemplary for the comparison of AI and surgeons, the ICC for LL was 0.88 (95% CI 0.83–0.92) and 0.93 for CB (0.90–0.95). GCC, PI, and T1PA could be determined with ICC values of 0.81 (0.69–0.87), 0.70 (0.60–0.78), and 0.94 (0.91–0.96) respectively. Conclusions: The AI algorithm presented here demonstrates excellent reliability for most of the parameters and good reliability for PI, with ICC values corresponding to measurements conducted by experienced surgeons. In future, it may facilitate the analysis of large data sets and aid physicians in diagnostics, pre-operative planning, and post-operative quality control.

Purpose: To evaluate the sagittal alignment of the lumbar spine in patients with degenerative spondylolisthesis at the L4-5 level. Methods: Patients with untreated degenerative spondylolisthesis at L4-5 were retrospectively identified from the clinical practice of spine surgeons at an academic medical center. All patients had standing X-rays that were reviewed by the senior surgeon to confirm the presence of degenerative spondylolisthesis at L4-5. Radiographs were analyzed for the following: lumbar lordosis (LL), lower lumbar lordosis (L4-S1; LLL), L5-S1 lordosis, pelvic incidence (PI), and pelvic tilt (PT). From these measurements, lumbar distribution index (LLL/LL × 100; LDI), ideal lumbar lordosis (PI × 0.62 + 29; ILL), PI-LL mismatch, and relative lumbar lordosis (LL-ILL; RLL) were calculated. These parameters were used to evaluate the sagittal alignment of the lumbar spine. Normal alignment was defined based on previous studies and clinical experience. Results: 117 participants met inclusion criteria, with an average age of 67.2 years. The majority of the cohort demonstrated hypolordotic sagittal alignment of the L5-S1 segment when assessed in relation to ILL, PI, and LL (73.5%, 61.5%, and 50.4% respectively). Evaluation of the lower lumbar spine (L4-S1) demonstrated normal sagittal alignment when evaluated via LDI and LLL (65%, 52.1%, respectively), suggesting the presence of compensatory hyperextension at L4-5 in response to the L5-S1 hypolordosis. Consequently, normal sagittal alignment of the regional lumbar spine was maintained when evaluated using LL, PI-LL mismatch, and RLL (51.3%, 47%, and 62.4% respectively). Conclusions: This study demonstrates that there is a high incidence of relative hypolordosis at the L5-S1 level among patients who present with degenerative spondylolisthesis at L4-5. The L5-S1 hypolordosis is associated with L4-5 hyperlordosis, such that the lower lumbar lordosis (L4-S1; LLL) and regional lumbar lordosis (LL) are still within normal range. It is probable that L5-S1 hypolordosis was the initial pathologic event that incited compensatory L4-5 hyperlordosis, which in turn may have led to facet degeneration and laxity, and eventually to development of spondylolisthesis.

Purpose: Although many techniques exist, spinopelvic fixation continues to present challenges in the management of adult spinal deformity. Shear forces, complex anatomy, and bone quality are common reasons why spine surgeons continue to explore options for fixation. Methods: A retrospective chart reviewed of patients receiving pelvic fixation for adult spinal deformity over a 12-year period was conducted. Patients were divided into 3 cohorts based on date of surgery: (1) 2010 to 2013, (2) 2014 to 2017, and (3) 2018 to 2021. Pelvic fixation constructs in the study included traditional iliac screws, stacked S2-alar-iliac (S2AI screws), and triangular titanium implants. Results: Of the 494 patients with multiple implant constructs who met the inclusion criteria for this study, patients undergoing pelvic fixation surgery who received at least 2 implants increased by approximately 5% every 4 years (90.2%, 94.6%, 99.1% respectively). Over the 12-year span, the implementation of the S2AI screw grew 120%. Conclusion: At our institution, there is a trend toward using multiple bilateral implant constructs for pelvic fixation, with nearly a tenfold percentage increase between the most recent cohorts. These include iliac screws with S2AI screws, multiple stacked S2AI screws, and S2AI screws used in conjunction with triangular titanium implants in hopes to decrease implant failure.

Purpose: Our institution employs a multimodal approach to manage postoperative pain after spine surgery. It involves continuous intravenous (IV) lidocaine until the morning of postoperative day two. This study aimed to determine the rate and reasons for early discontinuation of IV lidocaine in our spine patients. Methods: We conducted a retrospective chart review and included pediatric patients who underwent ≥ 3-level spine surgery and received postoperative IV lidocaine from November 2019 to September 2022. For each case, we recorded the side effects of IV lidocaine, adverse events, time to discontinuation, and discontinuation rate. Subsequently, we used the same methodology to generate an adult cohort for comparison. Results: We included 52 pediatric (18M:34F) and 50 (21M:29F) adult patients. The pediatric cohort’s mean age was 14 years (8–18), and BMI 23.9 kg/m2(13.0–42.8). The adult cohort’s mean age was 61 years (29–82), and BMI 28.8 kg/m2(17.2–44.1). IV lidocaine was discontinued prematurely in 21/52 (40.4%) of the pediatric cases and 26/50 (52.0%) of the adult cases (RR = 0.78, p = 0.2428). The side effects noted in the pediatric cases vary, including numbness, visual disturbance, and obtundation, but no seizures. The most common adverse events were fever and motor dysfunction. Conclusion: The early discontinuation rate of IV lidocaine use after spine surgery for children in our institution does not differ significantly from that of adults. The nature of the side effects and the reasons for discontinuation between the groups were similar. Thus, the safety profile of IV lidocaine for pediatric spine patients is comparable to adults.

Study Design: Modified Delphi study.Objective: Adult spinal deformity (ASD) is an increasingly recognized condition, comprising a spectrum of pathologies considerably impacting patients’ health and functional status. Patients present with a combination of pain, disability, comorbidities and radiological deformity. The study aims to propose a systematic approach of gathering information on the factors that drive decision-making by developing a patient profile.Methods: The present study comprises of 3 parts. Part 1: Development of prototype of patient profile: The data from the Core Outcome Study on SCOlisis (COSSCO) by Scoliosis Research Society (SRS) was categorized into a conceptual framework. Part 2: Modified Delphi study: Items reaching >70% agreement were included in a 4 round iterative process with 51 panellists across the globe. Part 3: Pilot testing—feasibility: Content validity and usability were evaluated quantitatively.Results: The profile consisted of 4 domains. 1. General healthwith demographics and comorbidities, 2.Spine-specific healthwith spine related health and neurological status, 3. Imagingwith radiographic and MRI parameters and 4. Deformity type. Each domain consisted of 1 or 2 components with various factorsand their measuring instruments. Profile was found to have an excellent content validity (I-CVIr0.78-1.00; Ave-CVI 0.92) appropriateness, relevance and usefulness.Conclusions: The present study, is first to provide a universally applicable multimodal ASD patient profile to methodically describe patients. Physicians are encouraged to assess ASD patients holistically using this profile and not just based on radiographic findings.

Study Design: Retrospective study.Objective: Proximal junctional failure (PJF) commonly occurs as a recognized potential outcome of fusion surgery. Here we describe a unique series of patients with multilevel spine fusion including the cervical spine, who developed PJF as an odontoid fracture.Methods: We performed a single site retrospective review of patients with prior fusion that included a cervical component, who presented with an odontoid fracture between 2012 and 2019. Radiographic measurements included C2-C7 SVA, C2-C7 lordosis, T1 slope, Occiput-C2 angle, proximal junctional kyphosis, and cervical mismatch. Associated fractures, medical comorbidities, and treatments were determined via chart review after IRB approval.Results: Nine patients met inclusion criteria. 5 reported trauma with subsequent onset of pain. All patients sustained a Type II odontoid fracture. 5 with associated C1/Jefferson fractures. In all patients, pre-injury Occiput-C2 angle was outside normative range; C2-C7 SVA was greater than 4 cm in 6 patients; T1-slope minus cervical lordosis was greater than 18.5 degrees in 6 patients. 7 patients were treated operatively with extension of fusion to C1 and 2 patients declined operative treatment.Conclusion: In this series of 9 patients with multilevel fusion with type II odontoid fractures, all patients demonstrated abnormal pre-fracture sagittal alignment parameters and a greater than normal association of C1 fractures was noted. Further study is needed to establish the role of poor sagittal alignment with compensatory occiput-C2 angulation as a predisposing factor for odontoid fracture as a proximal junctional failure mechanism.

Purpose: To develop a modeling framework to predict the secondary consequences on spinal alignment following correction and to demonstrate the impact of pedicle subtraction osteotomy (PSO) location on sagittal alignment. Methods: Six patients were included, and pelvic incidence (PI) was measured. Full-length standing radiographs were uploaded into PowerPoint and manipulated to model S1–S2 joint line sacral fractures at 15°, 20°, 25°, and 30°. PSO corrections with hinge points at the anterior superior corner and vertical midpoint of the L3-5 vertebral bodies were modeled. Anterior translation (AT) and vertical shortening (VS) were calculated for the six PSO locations in the four fracture angle (FA) models. Results: PI had a strong effect in the mixed AT and VS models (P< 0.001). Both AT and VS were significantly different from zero at all FA (p< 0.001), and pairwise comparisons revealed all FA were different from each other with respect to both AT and VS after adjusting for PSO location (p< 0.001), increasing as FA increased. Varying PSO location resulted in significant differences in AT when comparing all locations (p< 0.001). AT was greatest for all FA in all patients when the PSO correction was performed at the L3-AS (p< 0.001). There were significant differences in VS when comparing the L5-Mid PSO location to the L3-AS, L3-Mid, L4-AS, and L4-Mid PSO locations (p< 0.034). Conclusion: PSO correction superior to a sacral fracture resulted in AT and VS of the spine. It is crucial that these changes in spinal measures be predicted and accounted for to optimize patient sagittal alignment and outcomes.

Study design: Assessment of sagittal lordosis distribution on mechanical proximal junctional failure-related risks through computer-based biomechanical models. Objective: To biomechanically assess how lordosis distribution influences radiographical and biomechanical indices related to Proximal Junctional Failure (PJF). Summary of background data: The “optimal” patient-specific targets to restore the sagittal balance in posterior spinal fusion are still not known. Among these, the effect of the lumbar lordosis correction strategy on complications such as PJF remain uncertain. Methods: In this computational biomechanical study, five adult spinal deformity patients who underwent posterior spinal fixation were retrospectively reviewed. Their surgery, first erect posture and flexion movement were simulated with a patient-specific multibody model. Three pedicle subtraction osteotomy (PSO) levels (L3, L4, and L5) were simulated, with consistent global lordosis for a given patient and pelvic tilt adjusted accordingly to the actual surgery. Computed loads on the anterior spine and instrumentation were analyzed and compared using Kruskal–Wallis statistical tests and Spearman correlations. Results: In these models, no significant correlations were found between the lordosis distribution index (LDI), PSO level and biomechanical PJF-related indices. However, increasing the sagittal vertical axis (SVA) and thoracolumbar junction angle (TLJ) and decreasing the sacral slope (SS) increased the bending moment sustained by the rods at the proximal instrumented level (r= 0.52, 0.57, − 0.56, respectively, p< 0.05). There was a negative correlation between SS and the bending moment held by the adjacent proximal segment (r= − 0.71, p< 0.05). Conclusion: Based on these biomechanical simulations, there was no correlation between the lordosis distribution and PJF-associated biomechanical factors. However, increasing SS and flattening the TLJ, as postural adjustment strategies required by a more distal PSO, did decrease such PJF-related factors. Sagittal restoration and PJF risks remain multifactorial, and the use of patient-specific biomechanical models may help to better understand the complex interrelated mechanisms.

Purpose: To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits. Methods: Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. Results: Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines. Conclusion: A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients. Level of evidence: Level V.

Purpose: To expand on previously described intraoperative aids by developing consensus-based best practice guidelines to optimize the approach to intraoperative neuromonitoring (IONM) events associated with “high-risk” spinal deformity surgery. Methods: Consensus was established among a group of experienced spinal deformity surgeons by way of the Delphi method. Through a series of iterative surveys and a final virtual consensus meeting, participants expressed their agreement (strongly agree, agree, disagree, and strongly disagree) with various items. Consensus was defined as ≥ 80% agreement (“strongly agree” or “agree”). Near-consensus was defined as ≥ 60% but < 80%. Equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%. Results: 15 out of 15 (100%) invited surgeons agreed to participate. Final consensus supported inclusion of 105 items (53 in Response Algorithm, 13 in Ongoing Consideration of Etiology, 31 in Real-Time Data Scenarios, 8 in Patterns of IONM Loss), which were organized into a final set of best practice guidelines. Conclusion: Detailed consensus-based best practice guidelines and aids were successfully created with the intention to help organize and direct the surgical team in exploring and responding to neurological complications during high-risk spinal deformity surgery. Level of evidence: Level V.

Purpose: Symptomatic adult spinal deformity (ASD) with an extremely variable presentation with pain, with and without neurogenic leg pain, and/or disturbed sagittal and coronal balance, causes a significant societal burden of disease. It is an important consequence of the aging adult population, generating a plethora of spine-related interventions with variable treatment efficacy and consistently high costs. Recent years have witnessed more than a threefold increase in the prevalence and treatment of ASD, and further increases over the coming decades are expected with the growing elderly population worldwide. The ability to monitor and assess clinical outcomes has not kept pace with these developments. This paper addresses the pressing need to provide a set of common outcome metrics for this growing group of patients with back pain and other disabilities due to an adult spinal deformity. Methods: The standard outcome set was created by a panel with global representation, using a thorough modified Delphi procedure. The three-tiered outcome hierarchy (Porter) was used as a framework to capture full cycle of care. The standardized language of the International Classification of Functioning, Disability and Health (WHO-ICF) was used. Results: Consensus was reached on a core set of 25 WHO-ICF outcome domains (‘What to measure’); on the accompanying globally available clinician and patient reported measurement instruments and definitions (‘How to measure’), and on the timing of the measurements (‘When to measure’). The current work has brought to light domains not routinely reported in the spinal literature (such as pulmonary function, return to work, social participation), and domains for which no adequate instruments have yet been identified (such as how to clinically quantify in routine practice lumbar spinal stenosis, neurogenic claudication, radicular pain, and loss of lower extremity motor function). Conclusion: A standard outcome set was developed for patients undergoing treatment for adult spinal deformity using globally available outcome metrics. The current framework can be considered a reference for further work, and may provide a starting point for routine methodical and systematic monitoring of outcomes. Post-COVID e-health may accelerate the routine capture of these types of data.

Existing adult spinal deformity (ASD) classification systems are based on radiological parameters but management of ASD patients requires a holistic approach. A comprehensive clinically oriented patient profile and classification of ASD that can guide decision-making and correlate with patient outcomes is lacking.

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.

Surgery for degenerative lumbar spondylolisthesis is significantly more cost-effective than nonsurgical management in patients who have failed to improve with a 6-week trial of nonsurgical management. Decompression plus fusion becomes more cost-effective compared with decompression alone at 2 years following surgery. Further study is needed to evaluate the most cost-effective fusion approach and augmentation strategy.

Longitudinal cohort.

Study Design: Longitudinal cohort. Objectives: To determine the patient-reported functional outcomes and need for related surgical procedures in a US cohort of adolescent idiopathic scoliosis (AIS) patients with minimum 20-year follow-up. Summary of Background Data: There is limited information regarding the long-term outcomes of scoliosis treatment in the US population. Methods: A novel population of patients who underwent pediatric treatment for AIS with minimum 20-year follow-up was identified. Search of a single-center diagnostic registry generated 337 patients who fulfilled the inclusion criteria (AIS, curve magnitude >35°, and childhood treatment with bracing, surgery, or observation from 1975 to 1992). Any additional spine surgery as well as EQ5D, ODI, SRS 22, SAQ were determined. A total of 180 patients were included (mean of 30-year follow-up, range 20–37). Childhood treatment entailed bracing (41 patients), surgery (103 patients), and observation (36 patients). Results: During the study period, only 1 of the 41 bracing patients underwent additional scoliosis-related spine surgery, whereas 5 of the 36 patients in the observation cohort underwent scoliosis surgery as adults. Seven of 103 childhood surgical patients required additional revision surgery as adults. Fifteen patients (4 braced, 7 fusion, and 4 observed) underwent chest wall surgery as adults. SRS scores were around 10% worse compared to population-based controls, with the exception of SRS mental health scores, which were similar to controls. Overall, 5.6% of patients were on disability, with no difference between operative and nonoperative groups. Conclusion: We found a low rate of adult scoliosis surgery in the braced population, and a low rate of revision surgery at the 30-year follow-up in patients undergoing spine fusion for AIS between 1975 and 1992. No detected differences in patient-reported outcomes were found between the braced, surgical, and observed populations at a mean of 30 years’ follow-up. Level of Evidence: Level III, therapeutic.

Study Design: Retrospective case study on prospectively collected data.Objectives: The purpose of this explorative study was: 1) to determine if patterns of spinal cord injury could be detected through intra-operative neuromonitoring (IONM) changes in pediatric patients undergoing spinal deformity corrections, 2) to identify if perfusion based or direct trauma causes of IONM changes could be distinguished, 3) to observe the effects of the interventions performed in response to these events, and 4) to attempt to identify different treatment algorithms for the different causes of IONM alerts.Methods: Prospectively collected neuromonitoring data in pre-established forms on consecutive pediatric patients undergoing coronal spinal deformity surgery at a single center was reviewed. Real-time data was collected on IONM alerts with >50% loss in signal. Patients with alerts were divided into 2 groups: unilateral changes (direct cord trauma), and bilateral MEP changes (cord perfusion deficits).Results: A total of 97 pediatric patients involving 71 females and 26 males with a mean age of 14.9 (11-18) years were included in this study. There were 39 alerts in 27 patients (27.8% overall incidence). All bilateral changes responded to a combination of transfusion, increasing blood pressure, and rod removal. Unilateral changes as a result of direct trauma, mainly during laminotomies for osteotomies, improved with removal of the causative agent. Following corrective actions in response to the alerts, all cases were completed as planned. Signal returned to near baseline in 20/27 patients at closure, with no new neurological deficits in this series.Conclusion: A high incidence of alerts occurred in this series of cases. Dividing IONM changes into perfusion-based vs direct trauma directed treatment to the offending cause, allowing for safe corrections of the deformities. Patients did not need to recover IONM signal to baseline to have a normal neurological examination.

Scoliosis in patients with neurofibromatosis type I (NF1) can manifest as dystrophic or nondystrophic curves. Dystrophic scoliosis is rapidly progressive, rendering treatment challenging. Radiographic characteristics have been reported to predict dystrophic scoliosis, but their reliability and predictive value have not been well described. The purpose of this study is to assess the interobserver reliability for eight radiographic characteristics of dystrophic scoliosis and to evaluate the sensitivity and specificity of these characteristics relative to the gold standard of a definitive clinical diagnosis.

Background: Scoliosis in patients with neurofibromatosis type I (NF1) can manifest as dystrophic or nondystrophic curves. Dystrophic scoliosis is rapidly progressive, rendering treatment challenging. Radiographic characteristics have been reported to predict dystrophic scoliosis, but their reliability and predictive value have not been well described. The purpose of this study is to assess the interobserver reliability for eight radiographic characteristics of dystrophic scoliosis and to evaluate the sensitivity and specificity of these characteristics relative to the gold standard of a definitive clinical diagnosis. Methods: Spine radiographs of 122 NF1 patients from multiple institutions were graded by five spine surgeons as dystrophic or nondystrophic, based on eight radiographic characteristics of dystrophic modulation: rib penciling, vertebral rotation, scalloping, wedging, spindling of transverse processes, short sharp angular curve, widened interpedicular distance, and atypical location. The curves were classified by each submitting institution as dystrophic or nondystrophic based on clinical outcome. Interobserver reliability analysis was performed using Fleiss kappa. Results: For the 122 cases, the interrater agreement among the five readers for the diagnosis of dystrophic scoliosis was good at 0.61. The agreement for individual radiographic characteristic ranged from 0.62 for wedging to 0.14 (poor) for scalloping. Surgeons underestimated the number of dystrophic curves, rating from 45% to 67% of the curve patterns as dystrophic, compared to the gold standard, which revealed 68% of the curves to be dystrophic. On multivariate analysis, rib penciling, vertebral rotation, vertebral wedging, and atypical location were significantly associated with true dystrophic status (odds ratios of 2.4, 3.0, 2.4, and 3.0, respectively). Conclusion: Overall dystrophic diagnosis can be assessed by radiographic characteristics. Better understanding of the predictive value of specific radiographic features may assist in early diagnosis of patients with dystrophic NF and assist surgeons in identifying dystrophic curve patterns and instituting prompt, appropriate treatment. Level of Evidence: Level III.

High-grade dysplastic spondylolisthesis (HGDS) is a subset of L5-S1 spondylolisthesis that occurs due to dysmorphic anatomy at the lumbosacral junction, often resulting in sagittal imbalance. Enhanced understanding of global sagittal alignment has led many to preferentially treat HGDS with reduction and fusion to restore sagittal balance. The purpose of this article is to review published surgical techniques for obtaining sagittal correction in HGDS and to evaluate the current evidence regarding the associated surgical complications.

Retrospective cohort.

The sacroiliac joint moves 2.5°. It is innervated with nociceptive fibers. It is a common cause of low back pain (15%–30%). Degenerative changes occur, especially after lumbosacral fusion. When performed in series, physical examination maneuvers are diagnostic. Confirmatory image-guided injections can aid the diagnosis. In randomized clinical trials, surgical treatment in appropriately selected patients has been demonstrated to be statistically and clinically superior to nonsurgical management.

Lumbar degenerative scoliosis is a relatively common problem, and is being treated more frequently due to the confluence of an aging population and an increased capacity and willingness to manage difficult problems in older patients. Lumbar degenerative scoliosis is a complex pathology as it often involves the intersection of degenerative spinal stenosis and spinal deformity. While previous studies provide an indication that these patients may benefit from surgical treatment, the substantial variability in treatment underscores the opportunity for improvement. Optimizing treatment for lumbar degenerative scoliosis is critical as surgical intervention, while potentially providing substantial clinical benefit also entails measurable risk and significant expense. In light of these issues, evidence-based guidance generated through Appropriate Use Criteria (AUC) development offers the potential to improve both the quality and cost effectiveness of care.The lumbar degenerative scoliosis AUC represents a significant step toward evidence-based treatment in spinal surgery. This is the first time that spine societies and industry partners have collaborated to support evidence development. The willingness of all involved to support a completely independent process underlines a commitment to trust the evidence. Subsequent studies may validate and/or refine the AUC recommendations, but the most important result is that the standard for evidence quality has been raised.

Spondylolysis is common among the pediatric population, yet no formal systematic literature review regarding diagnostic imaging has been performed. The Scoliosis Research Society (SRS) requested an assessment of the current state of peer reviewed evidence regarding pediatric spondylolysis.

The Meyerding classification grades the degree of slippage in the sagittal plane on lateral standing neutral imaging: 0-25% Grade I, 25-50% Grade II, 50-75% Grade III, 75-100% Grade IV, and >100% Grade V (Spondyloptosis). Grades I and II are considered low-grade and Grades III-V are considered high-grade. There are several etiologies of spondylolisthesis. A classification system of the most common causes: Type I – Dysplastic, Type II – Isthmic (including subtypes: A – Lytic, B – Elongation, and C – Acute fracture), Type III – Degenerative, Type IV – Traumatic, Type V – Pathological, and Type VI – Iatrogenic. Dysplastic spondylolisthesis is a type of spondylolisthesis that occurs at L5-S1 when dysplastic lumbosacral anatomy is present, and is associated with high-grade slip and spina bifida occulta.

Study Design Prospective cohort study.Objective The sacroiliac joint (SIJ) is an important cause of lower back pain. The degree to which minimally invasive surgical fusion of the SIJ improves health state utility has not been previously documented.Methods Health state utility values were calculated using the EuroQOL-5D (EQ-5D) and Short Form-36 (SF-36) at baseline and 6 and 12 months after SIJ fusion surgery in subjects participating in a prospective, multicenter clinical trial (n?=?172). Values were compared with individuals who participated in a nationally representative cross-sectional survey (National Health Measurement Study [NHMS], n?=?3,844). Health utility values in the SIJ cohort were compared with those of the NMHS participants using both weighted linear regression and calculation of “health quantile” (i.e., percentile of health normalized to the NHMS cohort adjusted for age and gender).Results Baseline health state utility was significantly depressed in SIJ patients compared with normal subjects (SF-6D 0.509 versus 0.789, SF-36 physical component summary 31.7 versus 49.2, SF-36 mental component summary 8.5 versus 53.8, EQ-5D 0.433 versus 0.868; all p?

Structured literature review.

Structured literature review.

Study Design: Structured literature review. Objectives: The Scoliosis Research Society requested an assessment of the current state of peer-reviewed evidence regarding pediatric spondylolysis with the goal of identifying both what is really known and what research remains essential to further understanding. Summary of Background Data: Spondylolysis is common among children and adolescents and no formal synthesis of the published literature regarding treatment has been previously performed. Methods: A comprehensive literature search was performed. The researchers reviewed abstracts and analyzed by committee data from included studies. From 947 initial citations with abstract, 383 articles underwent full text review. The best available evidence for clinical questions regarding surgical and nonsurgical treatment was provided by 58 included studies. None of the studies were graded as level I or level II evidence. Two of the studies were graded as level III evidence. Fifty-six of the studies were graded as level IVevidence. No level V (expert opinion) studies were included in the final list. Results: Although natural history studies suggest a benign, relatively asymptomatic course for spondylolysis in most patients, both nonsurgical and surgical treatment series suggest that a substantial number of patients present with pain and activity limitations attributed to spondylolysis. Pain resolution and return to activity are commonwith both nonsurgical and surgical treatment (80% to85%, respectively).Although it is implied thatmost surgically treated patients have failed nonsurgical treatment, the specific treatmentmodalities and duration required before failure is declared are not well defined. There is insufficient evidence to know which patients will benefit from specific treatment modalities (both nonsurgical and surgical). Conclusions: Because of the preponderance of uncontrolled case series and the lack of comparative studies, only low-quality evidence is available to guide the treatment of pediatric spondylolysis.

Study Design: Structured literature review. Objectives: To assess the current state of evidence as a first step in the development of practice guidelines for pediatric spondylolysis. Summary of Background Data: Progress in published medical knowledge, changes in societal expectations, and developments in health care economics have led medical organizations to develop evidence-based documents and products. Methods: A comprehensive literature search for pediatric spondylolysis was performed with the assistance of a medical librarian. The authors reviewed citations and abstracts. Abstracts were reviewed for exclusions and data from included studies were analyzed by committee. A total of 44 articles provided the best available evidence for the questions of etiology, prevalence, natural history, and prognosis: 9 were graded as level I evidence, 23 were level II, 3 were level III, and 9 were level IV. No level V studies were included in the final list. Results: There is good evidence that pediatric lumbar spondylolysis is an acquired fracture of the pars interarticularis that can occur unilaterally or bilaterally. Evidence shows that when chronic, bilateral pars defects develop, 43% to 74% of patients will progress to grade 1 or 2 spondylolisthesis. In addition, unilateral, incomplete, and early lesions can obtain bony union. With or without bony union or spondylolisthesis, shortterm symptom resolution is the norm. Long-term prognosis is less clear, but there is fair evidence that most patients will have lumbar symptoms compared with the general population. There is also fair evidence that some patientswill develop significant symptoms as adults and will undergo surgical treatment. There is insufficient knowledge to predict which patients will continue to do well in the long term with conservative or no treatment and which patients will develop symptoms significant enough to warrant early intervention. Conclusions: The current medical literature provides fair to good evidence for clinically relevant questions regarding the etiology, prevalence, natural history, and prognosis of pediatric spondylolysis.

Retrospective comparative radiographic review.

Study Design: Retrospective comparative study. Objective: To evaluate changes in sagittal plane alignment in patients with Scheuermann’s kyphosis after spinal fusion. Summary of Background Data: Although surgery is commonly undertaken in patients with severe Scheuermann’s kyphosis for deformity correction, there are limited data regarding the response of spinopelvic parameters and sagittal plane alignment of the spine to surgical treatment. Methods: Eighteen consecutive surgical Scheuermann’s kyphosis patients were retrospectively reviewed (mean preoperative kyphosis, 76°). Full-length spine films were evaluated for maximal sagittal Cobb angle, thoracic kyphosis, cervical and lumbar lordosis, pelvic parameters, and sagittal plane alignment. Findings were compared with reported literature values in normal patients. Results: After surgery, thoracic kyphosis improved significantly, with mean maximum kyphosis improving from 76° to 56° (p =.001). Preoperative cervical lordosis was increased compared with reported normal adolescent values (−35° vs. −5°) and did not significantly change after surgery. Lumbar lordosis decreased significantly after surgery, from −77° to −57° (p =.023). No change was noted in pelvic tilt, sacral slope, or pelvic incidence. Furthermore, there was little improvement in sagittal plane alignment. Preoperatively, 12 of the 18 patients had deviation in sagittal plane alignment greater than 2 cm (5 positive and 7 negative); postoperatively, 11 patients had persistent sagittal imbalance (6 positive and 5 negative). Five patients were noted to have proximal junctional kyphosis and 3 underwent revision surgery for malpositioned screw (1) and loss of distal fixation (2). Conclusions: Surgical management of Scheuermann’s kyphosis resulted in normalization of thoracic kyphosis and lumbar lordosis. Compared with reported values in unaffected adolescents, cervical lordosis remained increased and most patients had residual sagittal plane imbalance greater than 2 cm on imaging.

Retrospective comparative study.

Background: Relatively few patients have dual-energy x-ray absorptiometry to quantify the magnitude of bone loss as they age. Recent work correlates mean computed tomography (CT) attenuation in the level I (L1) vertebra with bone mineral density (BMD), making it possible to objectively evaluate the magnitude of bone loss in osteoporosis by this method. The aims of this study were to evaluate the utility of using CT scans in patients with acute thoracic and lumbar spine fractures to diagnose osteoporosis and using CT attenuation to evaluate the association between age and BMD.Methods: We performed a retrospective study of patients with acute fractures of the thoracic or lumbar spine who had also undergone an abdominal (or L1) CT scan and compared mean CT attenuation in L1 against threshold values. We also compared differences in CT attenuation between younger (<65 years) and older (≥65 years) and older patients.Results: A total of 124 patients were evaluated (74 thoracic and 50 lumbar fractures). Overall, there was a strong correlation between age and bone density as measured by CT attenuation (r= −.76). Among those with thoracic fractures (<65 years), mean CT attenuation was 196.51 HU. Forty-one patients were ≥65 years and had mean CT attenuation of 105.90 HU (P< .001). In patients with lumbar fractures, 27 patients were <65 years and had a mean CT attenuation of 192.26 HU and 23 patients were ≥65 years and had mean CT attenuation of 114.31 HU (P< .001). At the threshold of 110 HU, set for specificity, the magnitude of difference between the age-stratified cohorts was greater in the thoracic spine (P< .0001 vs P= .003).Discussion: Using opportunistic CT, we demonstrate the relative frequency of osteoporosis in patients with acute fractures of the thoracic and lumbar spine and confirm that the association increases with age. The CT attenuation may provide a cheap and convenient method to help confirm a clinical diagnosis of osteoporosis in patients with fractures.

Study Design: Longitudinal cohort. Objectives: To determine the responsiveness of the Spinal Appearance Questionnaire (SAQ) in patients with adolescent idiopathic scoliosis (AIS) undergoing surgical correction of the deformity. Summary of Background Data: The SAQ has been found to be a valid and reliable measure in patients with AIS. A recently published factor analysis and scoring system has been shown to be applicable to all Lenke types and had greater correlation to the curve magnitude than the Scoliosis Research Society (SRS) Appearance and Total score. Methods: From a prospective multicenter database, 126 AIS patients who underwent correction of the spinal deformity with complete SAQ and SRS-22 Revised data at baseline and 2-year follow-up were identified. Discriminative properties of the SAQ domains (Expectations, Appearance, and Total) and SRS domains (Appearance, Activity, Pain, Mental, Satisfaction, and Total) were compared by computing the effect size (ES) and the standardized response mean (SRM). Results: The SAQ Total had the largest ES (1.8) and SRM (1.5). This was followed by the SAQ Appearance, with an ES of 1.7 and SRM of 1.4; and the SAQ Expectations, with an ES of 1.5 and SRM of 1.2. Among the different SRS domains, only the Appearance (ES = 1.2, SRM = 1.1), Satisfaction (ES = 0.8, SRM = 0.6), and Total scores (ES = 0.8, SRM = 0.9) had effect sizes that were considered large. The SRS Mental domain had a moderate effect size (ES = 0.3, SRM = 0.3), whereas the Activity (ES = 0.0, SRM = 0.0) and Pain (ES = 0.2, SRM = 0.2) domains had small effect sizes. Conclusions: The SAQ is sensitive and responsive to change, as evidenced by the large effect size for both domain and the Total score. The effect sizes are larger than those for any of the SRS domains, including Appearance and Total scores.

Longitudinal cohort.

There is increasing awareness of adult degenerative or de novo scoliosis, and its surgical treatment when indicated can be challenging and resource intense. Surgical randomized controlled trials are rare, and observational studies pose limitations because of the heterogeneity of surgical practices, techniques, and patient populations. Pooled analysis of current literature may identify effective treatment strategies and guide future efforts at prospective clinical research. This study aimed to synthesize existing data on the outcomes of surgical intervention for adult degenerative scoliosis.

Systematic review of clinical studies.

Introduction: There is increasing awareness of adult degenerative or de novo scoliosis, and its surgical treatment when indicated can be challenging and resource intense. Surgical randomized controlled trials are rare, and observational studies pose limitations because of the heterogeneity of surgical practices, techniques, and patient populations. Pooled analysis of current literature may identify effective treatment strategies and guide future efforts at prospective clinical research. This study aimed to synthesize existing data on the outcomes of surgical intervention for adult degenerative scoliosis. Methods: PubMed, Medline, Cochrane, and Web of Science databases were searched using key words and were limited to the English language. Spine surgeons reviewed abstracts and evaluated whether they contained surgically treated cohorts of adults (more than 18 years of age) with degenerative scoliosis. Full-text articles were reviewed in detail and data were abstracted. All meta-analyses were conducted using random effects models and heterogeneity was estimated with I2. Random-effects meta-regression models were used to investigate the association of treatment effects with baseline levels of each outcome. Results: Of 482 articles, 24 (n = 805) met inclusion criteria Available outcomes included Cobb angle correction, coronal and sagittal balance, visual analog scale for pain (VAS), and Oswestry Disability Index. Despite significant heterogeneity among studies, random-effects meta-analysis showed significant improvements in Cobb angle (—11.1°; 95% confidence interval [CI], —13.86° to —8.40°), coronal balance (7.674 mm; 95% CI, -10.5 to -4.9), VAS (-3.24; 95% CI, -4.5 to -1.98), and Oswestry Disability Index (-27.18%; 95% CI, -34.22 to - 20.15) postoperative treatment (p &lt;.001). Meta-regression models showed that preoperative values for Cobb angle, coronal balance, and VAS were significantly associated with surgical treatment effect (p !.05). Changes in sagittal balance did not reach statistical significance although only 6 articles were included. Conclusions: Exhaustive literature review yielded 24 studies reporting preoperative and postoperative data regarding the surgical treatment of adult degenerative scoliosis. No randomized clinical trials (RCTs) were identified. Despite heterogeneity, a limited meta-analysis showed significant improvement in Cobb angle, coronal balance, and VAS after surgical treatment of adult degenerative scoliosis.

Study Design: Systematic review of clinical studies. Objectives: To critically evaluate existing literature to determine whether increased anchor or implant density (screws, wires, and hooks per level fused) results in improved curve correction for adolescent idiopathic scoliosis (AIS) surgery. Summary of Background Data: Wide variability exists in the number of screws used for AIS surgery. High numbers of pedicle screws are increasingly used, but there is limited evidence to support this as best practice. Methods: Online English-language databases were searched to identify articles addressing anchor density. Articles were reviewed for anchor type/number, radiographic measures, and patient-reported outcomes. Results: Of 196 references identified, 10 studies totaling 929 patients met the inclusion criteria. Reported mean anchor density varied from 1.06 to 2.0 implants per level fused. Mean percent coronal curve correction varied from 64% to 70%. Two studies (463 patients) analyzed hook, hybrid (combined hooks and screws), and screw constructs as a single cohort. Both found increased correction with high-density constructs (p =.01, p &lt;.001), perhaps as a result of the hooks and hybrid constructs. Eight retrospective studies and 1 prospective randomized, controlled trial had predominantly screw constructs (466 patients). Increased anchor density was not associated with improved curve correction. The studies evaluating screw density are significantly underpowered to detect a difference in curve correction. Conclusions: Wide heterogeneity in anchor density exists in the surgical treatment of AIS. Reports evaluating the effects of increased anchor density are mostly retrospective and significantly underpowered to detect a difference in curve correction and patient outcomes. At this time, there is insufficient evidence to show that anchor density affects clinical outcomes in AIS.