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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.Adult spinal deformity (ASD) patients who were treated operatively, with a normal SVA ( ± 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.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.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.

Purpose To evaluate the pain and functional effect of the COVID-19 pandemic on patients with ASD reflected by their response to SRS-22, ODI, and SF-36 questionnaires. Methods Patients who had stable pain and functional outcome scores over the preceding 2 years were enrolled in a local prospectively collected adult spinal deformity (ASD) database. A reanalysis of their SRS22, ODI and SF-36 data 14 days into confinement were compared to their last pre-confinement scores. Results 89 patients were included in this study (average age 60.7 years, 91% female) with an average time from last FU until confinement of 9.6 months. The ODI total score worsened by 5 points post-confinement with no difference seen in personal care, walking and social life. In contrast, the SRS-22 score showed small improvements in function/activity and satisfaction, but no significant differences for the other domains. Similarly, the SF-36 showed small improvements in physical function, physical and emotional role, vitality and PCS. Conclusion The global COVID-19 pandemic and ensuing confinement had variable overall effects on ASD patients, without the expected marked worsening. In addition, this study illustrates that the SRS-22 questionnaire is less influenced by environmental and psychological factors than the ODI supporting its objectivity and accuracy in the evaluation of the QoL of ASD patients.

Achieving an adequate level of patient’s satisfaction with results is one of the goals of adult spinal deformity (ASD) surgery. However, it is unclear whether the same factors affect satisfaction in all patient populations. Patients’ age influences the postoperative course and prevalence of complications after ASD surgery. The purpose of this study was to determine the factors predicting satisfaction 2 years after ASD surgery in younger and older patients. A total of 119 patients under 40 years old, 155 patients 40 to 65 years old, and 148 patients over 65 years old at surgery who were followed for a minimum of 2 years after surgery were included. Multivariate analysis was used to determine independent related factors with maximum AUC for satisfaction 2 years after surgery in each group. A propensity-matched cohort under equivalent demographic and clinical characteristics was used to confirm the results. Logistic regression analyses revealed satisfaction among the under-40 group corresponded to prior spine surgery, complications, and self-image. That among the 40-to-65 group corresponded to neurologic complication, revision surgery, pain, and sagittal vertical axis restoration. Among the over-65 group satisfaction correlated with revision surgery, standing ability, and lumbar lordosis index restoration. Propensity score matching confirmed that sagittal alignment correction led to substantial satisfaction. In younger patients, avoiding complications and improving patients’ self-image were essential for substantial satisfaction levels. In older patients, revision, standing ability, as well as sagittal spinopelvic alignment restoration, were the key factors. Surgeons should consider the differences in goals of each patient.

Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

To compare the radiological outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either a domino connector was applied for osteotomy correction or not.Retrospective review of a prospective, multicenter adult spinal deformity database (5 sites). Inclusion criteria were adult patients who underwent PSO between L3 and L5 with a minimum follow-up of 2 years. Among 1243 patients in the database, 79 met the inclusion criteria, 41 in the no-domino (ND) group and 38 in the domino (D) group. The domino technique consisted of using 2 parallel rods connected by a domino on one side of the PSO in order to achieve gradual and controlled compression at the osteotomy site. Demographic data, operative parameters, spinopelvic parameters and complications were collected.Demographic data and operative parameters were globally similar between both groups, and they showed a comparable preoperative sagittal malalignment. Segmental lordosis improved by 22° and 31° (p 0.05) and L1S1 lordosis improved by 23° and 32° (p 0.05) in the ND and D group, respectively. The use of multiple rods was similar between the groups (58% vs. 57%). Also, mechanical complications rate was globally similar between both groups with no statistically significant difference (22% vs. 28.9%).Domino connector is a safe, powerful and efficient tool for pedicle subtraction osteotomy site closure. It improved the lumbar lordosis correction angle with an acceptable rate of complications.

Despite the evidence in appendicular skeletal surgery, the effect of infection on spinal fusion remains unclear, particularly after Adult Spinal Deformity (ASD) surgery.The purpose of this study was to determine the impact of surgical site infection (SSI) in ASD surgery fusion rates and its association with other risks factors of pseudarthrosis.We conducted an international multicenter retrospective study on a prospective cohort of patients operated for spinal deformity.A total of 956 patients were included (762 females and 194 males).Patient's preoperative characteristics, pre and postoperative spinopelvic parameters, surgical variables, postoperative complications and were recorded. Surgical site infections were asserted in case of clinical signs associated with positive surgical samples. Each case was treated with surgical reintervention for debridement and irrigation. Presence of pseudarthrosis was defined by the association of clinical symptoms and radiological signs of nonfusion (either direct evidence on CT-scan or indirect radiographic clues such as screw loosening, rod breakage, screw pull out or loss of correction). Each iterative surgical intervention was collected.Univariate and multivariate analysis with logistic regression models were performed to evaluate the role of risk factors of pseudarthrosis.Nine hundred fifty-six surgical ASD patients with more than two years of follow-up were included in the study. 65 of these patients were treated for SSI (6.8%), 138 for pseudarthrosis (14.4%), and 28 patients for both SSI and pseudarthrosis. On multivariate analysis, SSI was found to be a major risk factor of pseudarthrosis (OR=4.4; 95% CI=2.4,7.9) as well as other known risks factors: BMI (OR=1.1; 95% CI=1.0,1.1), smoking (OR=1.6; 95% CI=1.1,2.9), performance of Smith-Petersen osteotomy (OR = 1.6; 95% CI 1.0,2.6), number of vertebrae instrumented (OR=1.1; 95% CI=1.1,1.2) and the caudal level of fusion, with a distal exponential increment of the risk (OR max for S1=6, 95% CI=1.9,18.6).SSI significantly increases the risk of pseudarthrosis with an OR of 4.4.

To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period. In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed. Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P

OBJECTIVEAchieving high patient satisfaction with management is often one of the goals after adult spinal deformity (ASD) surgery. However, literature on associated factors and their correlations with patient satisfaction is limited. The aim of this study was to determine the clinical and radiographic factors independently correlated with patient satisfaction in terms of management at 2 years after surgery.METHODSA multicenter prospective database of ASD surgery was retrospectively reviewed. The demographics, complications, health-related quality of life (HRQOL) subdomains, and radiographic parameters were examined to determine their correlation coefficients with the Scoliosis Research Society-22 questionnaire (SRS-22R) satisfaction scores at 2 years (Sat-2y score). Subsequently, factors determined to be independently associated with low satisfaction (Sat-2y score ≤ 4.0) were used to construct 2 types of multivariate models: one with 2-year data and the other with improvement (score at 2 years − score at baseline) data.RESULTSA total of 422 patients who underwent ASD surgery (mean age 53.1 years) were enrolled. All HRQOL subdomains and several coronal and sagittal radiographic parameters had significantly improved 2 years after surgery. The Sat-2y score was strongly correlated with the SRS-22R self-image (SI)/appearance subdomain (r = 0.64), followed by moderate correlation with subdomains related to standing (r = 0.53), body pain (r = 0.49–0.55), and function (r = 0.41–0.55) at 2 years. Conversely, the correlation between radiographic or demographic parameters with Sat-2y score was weak (r < 0.4). Multivariate analysis to eliminate confounding factors revealed that a worse Oswestry Disability Index (ODI) score for standing (≥ 2 points; OR 4.48) and pain intensity (≥ 2 points; OR 2.07), SRS-22R SI/appearance subdomain (< 3 points; OR 2.70) at 2 years, and a greater sagittal vertical axis (SVA) (> 5 cm; OR 2.68) at 2 years were independent related factors for low satisfaction. According to the other model, a lower improvement in ODI for standing (< 30%; OR 2.68), SRS-22R pain (< 50%; OR 3.25) and SI/appearance (< 50%; OR 2.18) subdomains, and an inadequate restoration of the SVA from baseline (< 2 cm; OR 3.16) were associated with low satisfaction.CONCLUSIONSSelf-image, pain, standing difficulty, and sagittal alignment restoration may be useful goals in improving patient satisfaction with management at 2 years after ASD surgery. Surgeons and other medical providers have to take care of these factors to prevent low satisfaction.

Study Design Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. Objective To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. Summary of Background Data The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence–lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. Methods Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability Results Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. Conclusions Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. Level of Evidence Level II.

Objective: To compare the radiological and functional outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either 2-rod or multiple-rod construct is applied.Methods: Sixty-seven patients met the inclusion criteria, and were categorized into 3 groups: 2 rods (2R), multiple rods around the PSO (MRP), multiple rods around the PSO and lumbosacral junction (MRL). Demographic data, operative parameters, spinopelvic parameters, functional outcomes, and complications were collected.Results: Health-related quality of life scores showed a better outcome at 6 months and last follow-up visits in the MRP and MRL groups which were noted on different domains of Scoliosis Research Society-22 questionnaire, 36-item Short Form Health Surve, and Oswestry Disability Index scores (p < 0.05). The 3 groups showed similar rates of rod-related complications with no significant difference (p = 0.95). And inside each group, distribution of complications between pseudarthrosis with revision and rod fracture without revision was also similar (p = 0.99).Conclusion: The use of multiple rods across the PSO did not show a better outcome when compared to single rods in terms of incidence and types of mechanical complications. However, better postoperative coronal alignment and health-related quality of life scores in the multiple rods group could be seen demonstrating an improved functional outcome.

Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

Sagittal lumbar apex has been demonstrated to be a key parameter in sagittal plane morphology. Our aim was to understand its behavior with postural changes, analyzing two different concepts of lumbar apex. Prospective observational study with a cohort of patients presenting sagittal malalignment identified from a monocenter database of adult spinal deformities (ASD). Inclusion criteria were age > 30 years, SVA > 40 mm, and/or PT > 20. All patients had full-spine EOS radiographs in 2 different positions: (P1: natural position) and position 2 (P2: compensated position). Sagittal alignment, spinopelvic values, and two different methods of assessing lordosis apex location were analyzed in both P1 and P2 positions. Changes between P1 and P2 were compared using a paired t test with a significance level at p

Multicenter, retrospective study.The aim of this study was to examine the performance and concurrent validity of the adult spinal deformity surgical decision-making (ASD-SDM) score compared to decision-making factors in the ASD population.The ASD-SDM score, which has been recently proposed, is a scoring system to guide the selection of treatment modality for the ASD population. To secure the justification for its clinical use, it is necessary to verify its clinical performance and concurrent validity.A multicenter prospective ASD database was retrospectively reviewed. The data were analyzed separately in younger (≤40 years) and older (≥41 years) age groups. The discriminating capacity of the ASD-SDM score in cases who selected surgical and nonsurgical management was compared using area under the receiver operator characteristic curves (AUROC). Concurrent validity was examined using Spearman correlation coefficients, comparing factors that are reported to be associated with the decision-making process for ASD, including baseline symptomatology, health-related quality of life measures, and the severity of radiographic spinal deformity.There were 338 patients (mean age: 26.6 years; 80.8% female; 129 surgical and 209 nonsurgical) in the younger age group and 750 patients (mean age: 63.5 years; 84.3% female; 410 surgical and 340 nonsurgical) in the older age group. In both younger and older patients, the ASD-SDM score showed a significantly higher performance for discriminating the surgical and nonsurgical cases (AUROC: 0.767, standard error [SE]: 0.026, P 0.001, 95% confidence interval [CI]: 0.712-0.813; AUROC: 0.781, SE: 0.017, P 0.001, 95% CI: 0.747-0.812, respectively) compared to the decision-making factors analyzed. In addition, the ASD-SDM showed significant correlations with multiple decision-making factors.The ASD-SDM score alone can effectively grade the indication for surgical management whilst considering multiple decision-making factors.3.

Study design This was a retrospective multicentric study. Objective The objective of this study was to determine the different risk factors for development of proximal junctional kyphosis (PJK) in patients with adult scoliosis. Summary of background data This study was conducted as the reasons for development of PJK in adult scoliosis are still not clear. Materials and methods In total, 314 patients met the inclusion criteria. The main outcome measure was the PJK, as described by Glattes and colleagues. Extent of the instrumentation, operative time, bleeding, and the use of an osteotomy as well as the type of proximal anchorage were collected. Radiologic variables included preoperative Cobb angles of the lumbar and the thoracic curvatures, pelvic parameters, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. All measures were performed using the KEOPS software. Results The mean follow-up of this series was 2.5 years with a female to male ratio of 6.6/1 and a mean age of 56.66 years. The incidence of PJK was 25%. Proximal fixation extended to the proximal thoracic spine (TS) in 39%, to the middle TS in 39.5% of cases, and to the thoracolumbar junction in 20.4%, with a higher incidence of PJK noted in the first group. The proximal anchors had no effect on PJK incidence. Age as well as body mass index had a positive correlation to the incidence of PJK. The association, fusion to sacrum and fusion to the upper TS, is associated with the highest incidence of PJK. Preoperative pelvic tilt had a positive correlation with PJK occurrence. Finally, revision for PJK occurred in 2.3% of all patients and accounted for 15% of revisions. Conclusions Increased age, as well as increased body mass index, is a risk factor for the development of PJK. The proximal extent of the construct is also shown to be a risk factor for PJK, but fusion to the sacrum is a risk factor only if fusion extends to the proximal TS. Moderate PJK was observed with undercorrection of the sagittal balance and severe PJKs with overcorrection of the sagittal balance. Level of evidence Level IV.

We aimed to elucidate the factors for the decision-making process in the treatment of adult spinal deformity (ASD), including sagittal parameters, that impact health-related quality of life (HRQOL). A multicenter prospective ASD database was retrospectively reviewed. The demographic data, HRQOL, and radiographic measures were analyzed using multivariate analyses in younger (≤ 50 years) and older (> 50 years) age groups. This study included 414 patients (134 surgical and 280 nonsurgical; mean age 30.7 years) in the younger age group and 575 patients (323 surgical and 252 nonsurgical; mean age 65.8 years) in the older age group. Worse HRQOL measures drove surgical treatment, both in younger and older patients. The SRS-22 self-image score was the most differentiating domain, both in the younger and older age groups, and an additional significant factor in the older age group was pain and disability. Coronal deformity drove surgical treatment for the younger age group; however, older surgical patients were less likely to have coronal malalignment. Sagittal parameters were associated with the decision-making process. Greater pelvic incidence minus lumbar lordosis mismatch in the younger age group and smaller lumbar lordosis index in the older age group were most correlated with the decision to undergo surgery. Aside from the HRQOL measures and coronal deformity, sagittal parameters were identified as significant factors for the decision-making process in the ASD population, and the lack of lumbar lordosis in relation to pelvic incidence was a strong driver to pursue surgical treatment. These slides can be retrieved under Electronic Supplementary Material.

Pedicle Subtraction Osteotomy (PSO) is an effective surgical technique for the correction of fixed sagittal malalignment of the spine. It is a demanding technique that requires a long learning curve. The aim of this study is to analyze a surgeon’s learning curve for lumbar PSO in relation to the preoperative, perioperative, and postoperative management, with assessment of the global outcome. 102 patients operated over an 8-year period were included, distributed in 3 groups over the time, and retrospectively analyzed. The following data were collected: demographic characteristics, preoperative and postoperative radiological parameters, operative technical details, and complications. Multiple regression analysis was performed, and while the number of cases was the predictor, other variables such as demographic, radiographical, and surgical variables were considered as a covariate in the final model. When comparing the first group and the last group of patients, the mean surgical time had decreased by 50 min, the estimated blood loss was decreased by 655 ml, and a significant decrease in dural tear occurrence was noticed. In addition, we found a significant decrease in the hospital stay length. Multivariate linear regression analysis showed that when the surgeon’s experience doubles, the operative time decreases by 29 min, the blood loss by 281 ml, and the odds of hospital stay ≥ 21 days decrease by 0.66 times. PSO technique has a relatively long learning curve. This study showed that accumulating the experience over the years, while performing cases on a regular basis, is definitely the key in mastering this complex and risky technique, with significant improvements in the perioperative parameters that directly impact the recovery and global outcome. These slides can be retrieved under Electronic Supplementary Material.

BACKGROUND: Thoracic hyperkyphosis can display pathological deterioration, resulting in either hyperlordotic cervical compensation or sagittal malalignment. Various techniques have been described to treat fixed malalignment. Pedicle subtraction osteotomy (PSO) is commonly used in the lumbar spine and frequently limited to the distal thoracic spine. This series focuses on the surgical specificities of proximal thoracic PSO, with clinical and radiological outcomes. OBJECTIVE: To report the surgical specificities and assess the clinical and radiological outcomes of proximal thoracic osteotomies for correction of rigid kyphotic deformities. METHODS: This is a retrospective review of 10 consecutive patients who underwent single level proximal thoracic PSO (T2-T5). Preoperative and postoperative full-body EOS(TM) radiographs, perioperative data, and complications were recorded. The surgical technique and its nuances were described in detail. RESULTS: Patients had mean age of 41.8 yr and 50% were female. The technique provided correction of segmental and global kyphosis, 26.6° and 29.5°, respectively. Patients reported reciprocal reduction in C2-C7 cervical lordosis (37.6°-18.6°, P < .001), significantly correlating with the reduction of thoracic hyperkyphosis (R = 0.840, P = .002). Mean operative time was 291 min, blood loss 1650 mL, and mean hospital stay was 13.8 d. Three patients reported complications that were resolved, including 1 patient who was revised because of a painful cross link. There were no neurological complications, pseudarthroses, instrumentation breakage, or wound infections at a minimum of 2-yr follow-up. CONCLUSION: Proximal thoracic PSO can be a safe and effective technique to treat fixed proximal thoracic hyperkyphosis leading to kyphosis reduction and craniocervical relaxation.

ASD is assessed radiologically with the spinopelvic parameters and clinically with HRQOL scores. The revision rate after ASD surgery is high and usually occurs during the first or second postoperative year. The aim of this study is to find clinical or radiological factors that could predict revision surgery in the second postoperative year. Inclusion criterion: ASD patients operated on by instrumented posterior fusion with more than 2 years follow-up were enrolled prospectively. Additional criterion was no revision surgery during the first postoperative year. From a multicenter database of 560 operated ASD patients, 164 patients met these criteria. The patients were divided into two groups depending on the need of revision surgery during the second postoperative year. Preoperative, 6-month, 1-year and 2-year data were collected and compared for both groups. A total of 22 patients needed revision surgery and 142 did not. All revisions were for mechanical complications (non-fusion and implant related). Preoperatively, there was a significant difference between the groups (no revision vs. revision) for age (48 vs. 60 years), ODI (37 vs. 53), and SVA (29 vs. 76 mm), respectively. At 6 months, a significant difference in sagittal alignment was found, though HRQOL scores were similar. At 1 year, the no revision group scores improved, whereas the revision group scores remained stable or worsened. At 2 years, the no revision group scores remained stable. Comparing 6- and 12-month data, patients with improved, stable and worsened HRQOL scores had 8, 15 and 28% revision rates, respectively. The revision rate at the second-year post-surgery (13.4%) remains high and demonstrated that a 2-year follow-up is mandatory. In addition to usual risk factors for mechanical complications in ASD surgery, stabilization or worsening of the HRQOL scores between the 6th and 12th month postop was highly predictive of revision rate. This observation is beneficial for ASD patient follow-up as clinical symptoms clearly precede mechanical failure.

BACKGROUND: Both adult spinal deformity (ASD) and obesity are growing concerns internationally. This study therefore aims to determine the effect of increasing body mass index (BMI) on the pain and function of patients with ASD. METHODS: A retrospective review of prospectively collected data from a multicentre European database was undertaken. Initially a univariate analysis was performed on the effect of BMI on the initial presentation of functional scores in patients with ASD. The functional scores included the Numerical Rating Scale (NRS) back and leg score, Core Outcome Measures Index (COMI) back score, SRS22 total score, Short Form 36 (SF-36) [general health, physical component score (PCS) and mental component score (MCS)] and Oswestry Disability Index (ODI) score (including all domains). Subsequently a multivariate analysis controlling for age, sex, comorbidities, employment status, smoking status and radiological parameters [coronal cobb, coronal balance, sagittal balance, global tilt, and pelvic incidence minus lumbar lordosis (PI − LL) mismatch] was performed. RESULTS: A total of 1,004 patients were included in this study (166 male, 838 female). On univariate analysis a statistically significant (P0.05). CONCLUSIONS: Increasing BMI has a significant adverse effect on the pain and functioning of patients with ASD. Clinicians should recognise this association and treat patients accordingly.

Preoperative patient self-image (SI) in adult spinal deformity (ASD) is the most relevant factor for surgical decision-making. Postoperative SI has an important role in a patient’s satisfaction with surgery. However, few studies are available to describe these variables. The aim was to investigate the factors that correlate with SI before and 2 years after ASD surgery. This study was a retrospective review of prospectively collected multicentric data. Patients who underwent ASD surgery with a minimum follow-up of 2 years were enrolled (n = 391). They were divided into high-SI and low-SI groups, both preoperatively and postoperatively, according to SRS-22R SI/appearance subdomain scores at baseline and at 2 years, respectively. Independently related factors for SI were determined using logistic regression analysis. Crucial factors for SI at baseline were the scores on the SRS-22R function/activity (OR: 2.61), SRS-22R mental health (OR: 2.63) subdomains, and relative spinopelvic alignment (RSA, OR: 0.95). SF-36 MCS (OR: 1.07) at baseline as well as sagittal vertical axis (SVA, OR: 0.99) at 2 years, and complications (OR: 0.44) were independent predictive factors for SI at 2 years. The patients who transitioned from the preoperative low-SI group to the postoperative high-SI group achieved larger global sagittal alignment restoration and had lesser complications than those who did not. Mental status and sagittal spinopelvic alignment are key determinants of SI. The results indicate that considering mental status, preventing complications, and global sagittal alignment, restoration is crucial for achieving substantial SI scores after ASD surgery. These slides can be retrieved under Electronic Supplementary Material.

We aimed to develop and internally validate a scoring system, the adult spinal deformity surgical decision-making (ASD-SDM) score, to guide the decision-making process for ASD patients aged above 40 years. A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation set and was internally validated in a validation set. The performance of the ASD-SDM score for predicting surgical management was assessed using the area under the receiver operating characteristic curve (AUC). A total of 702 patients were included for analysis in the present study. The scoring system developed based on 562 patients, ranging from 0 to 12 points, included five parameters: leg pain scored by the numerical rating scale; pain and self-image domains in the Scoliosis Research Society-22 score; coronal Cobb angle; and relative spinopelvic alignment. Surgical indication was graded as low (score 0 to 4), moderate (score 5 to 7), and high (score 8 to 12) groups. In the validation set of 140 patients, the AUC for predicting surgical management according to the ASD-SDM score was 0.797 (standard error = 0.037, P

Purpose Regarding the close interaction between the spinal balance and the pelvis orientation no parameter is routinely used to describe and to evaluate the global spinopelvic balance, taking into account simultaneously the spinal part and the pelvic part of the global alignment. The global tilt was described to analyze malalignment, considering spinal and pelvic imbalance together. From a geometrical point of view, the global tilt is the sum of the C7 vertical tilt and the pelvic tilt. The aim of this study is to evaluate the global tilt by analyzing its correlation with spinal malalignment. Methods A cohort of patients who underwent a lumbar pedicle subtraction osteotomy (PSO) for major sagittal malalignment was realized. All patients had preoperative and postoperative full spine EOS radiographies to measure spinopelvic parameters. The lack of lordosis was calculated after prediction of theoretical lumbar lordosis. Correlation analysis between different spinopelvic parameters, including the global tilt, was performed for preoperative and postoperative values. Results Thirty-one consecutive patients were included. All parameters were correlated with spinal malalignment but the global tilt was the most correlated parameter in preoperative (r = 0.71) and in postoperative (r = 0.78). When spinal and pelvic parameters were analyzed separately, 19% of patients presented mismatches between spine and pelvis. Conclusion This study highlights the interest of a global parameter evaluating the spinal balance and the pelvic balance together. The global tilt appeared to be the most correlated parameter in this study with spinal malalignment and could be used for the interpretation of clinical series in spine surgery.

Regarding the close interaction between the spinal alignment and the pelvis orientation, no parameter is routinely used to describe and to evaluate the global spinopelvic balance, taking into account simultaneously the spinal part and the pelvic part of the global alignment. We described the global tilt (GT) that could analyze malalignment considering the spine and the pelvis simultaneously. From a geometrical point of view, the global tilt is the sum of the pelvic tilt (PT) and the C7 vertical tilt (angular value of sagittal vertical axis). The aim of this study is to evaluate the global tilt with comparison to PT and sagittal vertical axis (SVA), with the hypothesis that GT would be the least sensitive to positional changes. A cohort of 22 patients with sagittal malalignment was identified from a multicentric database of adult spinal deformities (ASD). Inclusion criteria were age >30 years, SVA > 40 mm and/or PT > 20°. All patients had full spine EOS radiographs in positions 1 and 2 (P1 and P2), in which the patient was asked to stand and put his hands on his shoulders without any effort (P1), or to make an effort to be as straight as possible (P2). PT, SVA and GT were measured in both positions and changes between P1 and P2 were calculated and compared using Student’s t test with significance level at p

Multiple-rod constructs (Multi-Rod: extra rods for additional pillar support) are occasionally used in adult spinal deformity (ASD) surgery. We aimed to compare and analyze the general outcome of multi-rod constructs with a matched two-rod cohort, to better understand the differences and the similitudes. This is a retrospective matched cohort study including patients with ASD that underwent surgical correction with long posterior instrumentation (more than five levels), pelvic fixation and a minimum 1-year follow-up. Matching was considered with demographical data, preoperative radiographical parameters, preoperative clinical status [health-related quality-of-life (HRQoL) scores] and surgical characteristics (anterior fusion, decompression, rod material, osteotomies). Postoperative radiographical and clinical parameters, as well as complications, were obtained. Univariate and multivariate analysis was performed regarding postoperative improvement, group variables comparison and parameters correlation. Thirty-three patients with multi-rod construct and 33 matched with a two-rod construct were selected from a database with 346 ASD-operated patients. Both groups had a significant improvement with surgical management in the radiographical and HRQoL parameters (p

We aimed to develop and internally validate a simple scoring system: the adult spinal deformity (ASD) surgical decision-making (ASD-SDM) score, which is specific to the decision-making process for ASD patients aged below 40 years. A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation cohort and was internally validated in a validation cohort. The accuracy of the ASD-SDM score was assessed using the area under the receiver operating characteristic curve (AUC). A total of 316 patients were randomly divided into derivation (253 patients, 80%) and validation (63 patients, 20%) cohorts. A 10-point scoring system was created from four variables: self-image score in the Scoliosis Research Society-22 score, coronal Cobb angle, pelvic incidence minus lumbar lordosis mismatch, and relative spinopelvic alignment, and the surgical indication was graded into low (score 0–4), moderate (score 5–7), and high (score 8–10) surgical indication groups. In the validation cohort, the AUC for selecting surgical management according to the ASD-SDM score was 0.789 (SE 0.057, P

STUDY DESIGN Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE To evaluate back and leg pain as a combined score in ASD and compare their relative and cumulative correlations with health-related quality of life (HRQOL) and sagittal parameters. SUMMARY OF BACKGROUND DATA Pain and disability are commonly reported in patients with ASD. This can affect their back, their legs or both. ASD-associated pain has been correlated with numerous HRQOL scores and radiological parameters. METHODS Preoperative pain intensity was assessed with a Numerical Rating Scale (NRS) for individual back and leg pain as well as a combined score, NRS20 (0-20, back plus leg pain).This yielded a range of static measures in all patients with ASD with differing burdens of disease. Linear regression analysis was performed to calculate the correlation between pain and HRQOL scores (Scoliosis Research Society 22, 36-Item Short Form Health Survey Physical Component Summary, 36-Item Short Form Health Survey Mental Component Summary, Core Outcome Measures Index, and Oswestry Disability Index), and radiological spinopelvic parameters (sagittal and coronal planes). RESULTS A total of 1309 patients were included in this study. A combined score (NRS20) was better correlated with HRQOL (P

Introduction L’Echelle d’Evaluation Numerique (EEN) lombaire et radiculaire est effectuee en routine clinique. L’evolution des symptomes, notamment apres une chirurgie de deformation rachidienne, peut rendre difficile l’interpretation des resultats cliniques et de l’impact reel d’une chirurgie rachidienne. L’objectif de cette etude est d’evaluer l’EEN global correspondant a la somme de l’EEN lombaire et radiculaire. L’hypothese est que ce parametre simple est correle aux scores de qualites de vie et aux parametres radiologiques sagittaux. Materiel et methodes Il s’agit d’une etude retrospective de patient inclus de maniere prospective et consecutive. Au total, 1526 patients suivi pour une deformation rachidienne de l’adulte ont ete inclus. Au moment de l’inclusion, les patients ont ete stratifies en 3 categories de douleur pour l’EEN lombaire et radiculaire (douleur legere : 0–4, douleur moderee : 5–7, douleur severe : 8–10) et en 4 categories pour l’EEN global (douleur tres legere : 0–5, douleur legere : 11–15, douleur moderee : 11–15, douleur severe : 16–20). Une regression lineaire a ete realisee pour evaluer la correlation entre la douleur, les parametres radiologiques sagittaux (Global Tilt, VP, SVA) et les scores de qualite de vie (SRS-22, SF-36, COMI, ODI). Resultats L’EEN globale est plus correlee que l’EEN lombaire ou radiculaire aux parametres radiologiques et aux scores de qualite de vie. (Pearson 0,6 vs. 0,56 ou 0,46, 0,3 vs. 0,23 or 0,27 respectivement). L’EEN lombaire est plus correlee avec les scores de qualite de vie alors que l’EEN radiculaire est plus correle avec les parametres radiologiques sagittaux. Pour une valeur d’EEN Discussion L’EEN globale est plus correlee aux scores de qualites de vie et aux parametres radiologiques sagittaux que l’EEN lombaire ou que l’EEN radiculaire. Il est interessant de noter que les douleurs au niveau des membres inferieurs sont quasi nulles pour un score EEN global Conclusion L’EEN globale est un parametre interessant pour evaluer l’intensite des douleurs chez des patients atteints de deformations rachidiennes.

Lysyl oxidases (Lox), which are members of the amine oxidase family, are involved in the maturation of elastic lamellae and collagen fibers. Modifications of amine oxidases in idiopathic annulo-aortic ectasia disease (IAAED) have never been investigated. Our aim was to examine the expression of several proteins that might interfere with elastic fiber organization in control ( n = 10) and IAAED ( n = 18) aortic tissues obtained at surgery. Expression of amine oxidases and semicarbazide-sensitive amine oxidase (SSAO), and cellular phenotypic markers were examined by immunohistopathology and confocal microscopy. The expression of these proteins was assessed in relation to clinical and histomorphological features of the arterial wall. In control aorta, SSAO staining was expressed along elastic lamellae, whereas in aneurysmal areas of IAAED, SSAO was markedly decreased, in association with severe disorganization of elastic lamellae. Smooth muscle myosin heavy chain was also decreased in IAAED compared with controls, indicating smooth muscle cell dedifferentiation. Multiple regression analysis showed that elastic lamellar thickness (ELT) was correlated positively with the SSAO: elastin ratio and negatively with the Lox: elastin ratio, and that the clinical features of IAAED (aneurysm, thoracic aorta diameter, and aortic insufficiency) were positively correlated with ELT but not with SSAO. The relationship between SSAO expression and ELT suggests that this amine oxidase may be involved in elastic fiber organization. However, in advanced IAAED, the deficit in SSAO expression could be secondary to the decrease and fragmentation of elastic fibers and/or to vascular smooth muscle cell dedifferentiation.

Introduction Le desequilibre sagittal est un facteur predictif du resultat postoperatoire pour les patients atteints de DRA. L’influence de l’âge sur ces parametres a ete decrite dans la population asymptomatique. L’objectif de cette etude est d’identifier la relation entre les parametres radiologiques de l’equilibre sagittal et l’âge ; et la correlation entre les scores de qualite de vie pour les patients operes (O) et non operes (NO). L’hypothese est que les parametres radiologiques de l’equilibre sagittal influencent en partie l’indication chirurgicale dans les DRA. Patients et methodes Nous presentons une etude multicentrique, retrospective de patients presentant une deformation rachidienne de l’adulte, inclus consecutivement de maniere prospective. Cinq cent soixante-quinze patients ont ete inclus (O = 244 + NO = 331). Les patients ont ete separes en deux groupes (O et NO) et stratifie en 4 groupes d’âge 70 ans (G4). Les scores d’Oswestry (ODI), SRS-22, SF-36 PCS, ont ete realises en preoperatoire. Une regression lineaire pour apprecier l’evolution des donnees cliniques et radiologiques en fonction de l’âge a ete realisee. Un p Resultats Le groupe 0 etait significativement plus âge (51,9 vs 47,1 ans), plus invalide, et plus desequilibre dans le plan sagittal (SVA = 29,4 vs 11,6 cm) (tableau). Une forte correlation (r = 0,9) a ete retrouvee entre les parametres radiologiques et les groupes d’âge. Des scores de qualite de vie plus pejoratifs ont ete retrouves pour chaque groupe d’âge en comparant les groupes O et NO. Dans le groupe G1, les parametres radiologiques sagittaux etaient identiques mais le Cobb frontal etait plus important pour le groupe O. Pour les groupes G2 et G3, les patients O etaient plus desequilibres que les patients NO, alors que dans le groupe G4, aucune difference n’a ete retrouvee pour les parametres de l’equilibre sagittal. Conclusion L’alteration des scores de qualite de vie est un facteur determinant de la decision d’indication chirurgicale dans les DRA. Les parametres radiologiques sont fortement correles a l’âge dans les groupes O et NO. Entre 50 et 70 ans, le desequilibre sagittal etait plus important pour le groupe O et il doit etre pris en consideration. En revanche, pour les patients les plus jeunes et les plus âges, le desequilibre sagittal n’est pas un facteur predictif d’indication chirurgicale ; d’autres parametres doivent etre pris en compte tel que le Cobb frontal pour les plus jeunes et les radiculalgies pour les plus âges.

Cellular mechanisms controlling smooth muscle cells (SMCs) phenotypic modulation are largely unknown. Intracellular Ca2+ movements are essential to ensure SMC functions; one of the roles of Ca2+ is to regulate calcineurin, which in turn induces nuclear localization of the nuclear factor of activated T-cell (NFAT). In order to investigate, during phenotypic differentiation of SMCs, the effect of calcineurin inhibition on NFAT2 nuclear translocation, we used a culture model of SMC differentiation in serum-free conditions. We show that the treatment of cultured SMC with the calcineurin inhibitor cyclosporine A induced their dedifferentiation while preventing their differentiation. These findings suggest that nuclear translocation of NFAT2 is dependent of calcineurin activity during the in vitro SMC differentiation kinetic and that the nuclear presence of NFAT2 is critical in the acquisition and maintenance of SMC differentiation.