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OBJECTIVE The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS). METHODS The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017–2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen’s d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large. RESULTS A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017. CONCLUSIONS The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.

BACKGROUND: More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS: Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS: Included: 544 surgical ASD patients (mean age: 58.0 years; fusion length 11.3 levels; operative time: 378 minutes). The strongest predictor for operative time was institution/surgeon. Center/surgeons, grouped by decision tree hierarchy, a and b were, on average, 2 hours faster than center/surgeons c-f, who were 43 minutes faster than centers g-j, all P < 0.001. The next most important predictors were, in order, approach (combined vs posterior increases time by 139 minutes, P < 0.001), levels fused (

Objective Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. Methods This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. Results Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. Conclusions This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting.

Sexual function is an important factor contributing to quality of life. Adult spinal deformity (ASD) patients may have sexual limitations due to lumbar spinal stiffness that may be affected by long-segment fusion.This study utilized a multicenter, prospectively defined, consecutive cohort of ASD patients. The primary outcome in this study was the Lumbar Stiffness Disability Index (LSDI) question 10: "Choose the statement that best describes the effect of low back stiffness on your ability to engage in sexual intercourse".In total, 368 patients were included in this study, including 76 men and 292 women, of which 80.7% (n = 293) underwent 9 or more level fusion and 74.4% (n = 270) had pelvic fixation. Baseline LSDI sexual function scores averaged 1.7 (SD 1.3), which improved to 1.3 (SD 1.2) at 2-year follow-up (P = 0.0008). After adjusting for confounding factors, worse LSDI sexual function score was strongly associated with worse Oswestry Disability Index, Scoliosis Research Society-22r total, and SF-36 Physical Component Summary and Mental Component Summary scores at both baseline and 2-year follow-up (p0.05 for all comparisons). Predictors of poorer baseline sexual function included older age, increased SVA, and increased back pain (p0.05 for all comparisons). Predictors of improvement in sexual function at 2-year follow-up included sagittal vertical axis improvement (P = 0.0032) and decreased postoperative back pain (P0.0001).This study found that sexual dysfunction scores due to lumbar stiffness significantly improved after surgery for ASD. Additionally, lumbar stiffness-related sexual dysfunction is strongly related to overall outcome measured by Oswestry Disability Index and Scoliosis Research Society-22r total score, highlighting the importance of sexual health on overall outcome in ASD patients.

The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients60 years old would perceive greater lumbar stiffness-related functional limitation following fusion for adult spinal deformity.Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age60 versus ≥60. Multivariable regression analyses were used.Analysis included 267 patients. Patients60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β -9.8, P0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β -5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P0.0001); the association was stronger among patients age60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age60 (P0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients60 years old and ≥60 years old was significant (P = 0.0021).Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age60 versus ≥60. Preoperative counseling is needed for patients age60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction.

Retrospective cohort study.We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism.ASD patients experience markedly decreased health-related quality of life along many dimensions.Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP).In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P 0.0001), while no significant change was observed for the nonoperative cohort (P 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P 0.0001), while the NON-OP cohort showed no such difference (P 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type.ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.

Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients.We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life.ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population.Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized.In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P 0.05).ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.

BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20o) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (

The aim was to determine whether applying Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles for external fixation of long bone fracture to patients with a 3-column osteotomy (3CO) would be associated with reduced rod fracture (RF) rates.AO dictate principles to follow when fixating long bone fractures: (1) decrease bone-rod distance; (2) increase the number of connecting rods; (3) increase the diameter of rods; (4) increase the working length of screws; (5) use multiaxial fixation. We hypothesized that applying these principles to patients undergoing a 3CO reduces the rate of RF.Patients were categorized as having RF versus no rod fracture (non-RF). Details on location and type of instrumentation were collected. Dedicated software was used to calculate the distance between osteotomy site and adjacent pedicle screws, angle between screws and the distance between the osteotomy site and rod. Classic sagittal spinopelvic parameters were evaluated.The study included 170 patients (34=RF, 136=non-RF). There was no difference in age (P=0.224), sagittal vertical axis correction (P=0.287), or lumbar lordosis correction (P=0.36). There was no difference in number of screws cephalad (P=0.62) or caudal (P=0.31) to 3CO site. There was a lower rate of RF for patients with2 rods versus 2 rods (P0.001). Patients with multiplanar rod fixation had a lower rod fracture rate (P=0.01). For patients with only 2 rods (N=68), the non-RF cohort had adjacent screws that trended to have less angulation to each other (P=0.06) and adjacent screws that had a larger working length (P=0.03).A portion of AO principles can be applied to 3CO to reduce RF rates. Placing more rods around a 3CO site, placing rods in multiple planes, and placing adjacent screws with a larger working length around the 3CO site is associated with lower RF rates.

Retrospective review of a prospective multicenter cervical deformity database.To examine the differences in sagittal alignment correction between three positioning methods in cervical spinal deformity surgery (CD).Surgical correction for CD is technically demanding and various techniques are utilized to achieve sagittal alignment objectives. The effect of different patient positioning techniques on sagittal alignment correction following CD remains unknown.Patients with sagittal deformity who underwent a posterior approach (with and without anterior approach) with an upper instrumented vertebra of C6 or above. Patients with Grade 5, 6, or 7 osteotomies were excluded. Positioning groups were Mayfield skull clamp, bivector traction, and halo ring. Preoperative lower surgical sagittal curve (C2-C7), C2-C7 sagittal vertical axis (cSVA), cervical scoliosis, T1 slope minus cervical lordosis (TS-CL), T1 slope (T1S), chin-brow vertebral angle (CBVA), C2-T3 curve, and C2-T3 SVA was assessed and compared with postoperative radiographs. Segmental changes were analyzed using the Fergusson method.Eighty patients (58% female) with a mean age of 60.6 ± 10.5 years (range, 31-83) were included. The mean postoperative C2-C7 lordosis was 7.8° ± 14 and C2-C7 SVA was 34.1 mm ± 15. There were overall significant changes in cervical alignment across the entire cohort, with improvements in T1 slope (P 0.001), C2-C7 (P 0.001), TS-CL (P 0.001), and cSVA (P = 0.006). There were no differences postoperatively of any radiographic parameter between positioning groups (P 0.05). The majority of segmental lordotic correction was achieved at C4-5-6 (mean 6.9° ± 11). Additionally, patients who had bivector traction applied had had significantly more segmental correction at C7-T1-T2 compared with Mayfield and halo traction (4.2° vs. 0.3° vs. -1.7° respectively, P 0.027).Postoperative cervical sagittal correction or alignment was not affected by patient position. The majority of segmental correction occurred at C4-5-6 across all positioning methods, while bivector traction had the largest corrective ability at the cervicothoracic junction.Level of Evidence: 4.

AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics—this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology. This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map—a form of artificial neural network frequently employed in unsupervised classification tasks—was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared. Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not. This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

This case series examined patients undergoing caudal extension of prior fusion without alteration of the prior upper instrumented vertebra (UIV) to assess patient outcomes and rates of proximal junctional kyphosis (PJK)/proximal junctional failure (PJF).Patients eligible for 2-year minimum follow-up undergoing caudal extension of prior fusion with unchanged UIVs were identified. These patients were evaluated for PJK/PJF, and patient reported outcomes were recorded.In total, 40 patients were included. Mean follow-up duration was 2.2 ± 0.3 years. Patients in this cohort had poor preoperative sagittal alignment (pelvic incidence minus lumbar lordosis [PI-LL] 26.7°, T1 pelvic angle [TPA] 29.0°, sagittal vertical axis [SVA] 93.4 mm) and achieved substantial sagittal correction (ΔSVA -62.2 mm, ΔPI-LL -19.8°, ΔTPA -11.1°) after caudal extension surgery. At final follow-up, there was a 0% rate of PJF among patients undergoing caudal extension of previous fusion without creation of a new UIV, but 27.5% of patients experienced PJK. Patients experienced significant improvement in both the Oswestry Disability Index and Scoliosis Research Society-22r total score at 2 years postoperatively (P0.05). In total, 7.5% (n = 3) of patients underwent further revision, at an average of 1.1 ± 0.54 years after the surgery with unaltered UIV. All 3 of these patients underwent revision for rod fracture with no revisions for PJK/PJF.Patients undergoing caudal extension of previous fusions for sagittal alignment correction have high rates of clinical success, low revision surgery rates, and very low rates of PJF. Minimizing repetitive tissue trauma at the UIV may result in decreased PJF risk because the PJF rate in this cohort of patients with unaltered UIV is below historical PJF rates of patients undergoing sagittal balance correction.

BACKGROUND Surgical treatments for adult cervical spinal deformity (ACSD) are often complex and have high complication rates. OBJECTIVE To assess all-cause mortality following ACSD surgery. METHODS ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Clinical and surgical parameters and all-cause mortality were assessed. RESULTS Of 123 ACSD patients, 120 (98%) had complete baseline data (mean age, 60.6 yr). The mean number of comorbidities per patient was 1.80, and 80% had at least 1 comorbidity. Surgical approaches included anterior only (15.8%), posterior only (50.0%), and combined anterior/posterior (34.2%). The mean number of vertebral levels fused was 8.0 (standard deviation [SD] = 4.5), and 23.3% had a 3-column osteotomy. Death was reported for 11 (9.2%) patients at a mean of 1.1 yr (SD = 0.76 yr; range = 7 d to 2 yr). Mean follow-up for living patients was 1.2 yr (SD = 0.64 yr). Causes of death included myocardial infarction (n = 2), pneumonia/cardiopulmonary failure (n = 2), sepsis (n = 1), obstructive sleep apnea/narcotics (n = 1), subsequently diagnosed amyotrophic lateral sclerosis (n = 1), burn injury related to home supplemental oxygen (n = 1), and unknown (n = 3). Deceased patients did not significantly differ from alive patients based on demographic, clinical, or surgical parameters assessed, except for a higher major complication rate (excluding mortality; 63.6% vs 22.0%, P = .006). CONCLUSION All-cause mortality at a mean of 1.2 yr following surgery for ACSD was 9.2% in this prospective multicenter series. Causes of death were reflective of the overall high level of comorbidities. These findings may prove useful for treatment decision making and patient counseling in the context of the substantial impact of ACSD.

Patients with severe cervical deformity (CD) often have profound deficits in numerous activities of daily living. The association between health status and postoperative radiographic goals is difficult to quantify.We aimed to investigate the radiographic characteristics of patients who achieved optimal health related quality of life scores following surgery for CD.We performed a retrospective review of a prospectively collected database of patients with spinal deformity.One hundred and fifty-three patients with cervical deformity OUTCOME MEASURES: Common health-related quality of life scores (HRQOLs) measurements were taken for patients treated operatively for cervical deformity including neck disability index (NDI), modified Japanese Orthopaedic Association scale (mJOA) for myelopathy and numeric rating scale for neck pain (NRS-neck), METHODS: Surgical patients with severe CD were isolated based upon a previously presented discriminant analysis which outlined a combination of preoperative cervical sagittal vertical axis (cSVA), T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. Those with available preoperative and 1-year postoperative HRQL data were included. Based on a previous study, patients were grouped into three distinct sagittal morphotypes of CD: focal deformity (FD), flat neck (FN = large TS-CL and lack of compensation), or cervicothoracic (CT). Postoperative outcomes were defined as "good" if a patient had ≥2 of the three following criteria (1) NDI20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Within each distinct deformity group, patients with good outcomes were compared to those with poor outcomes (ie, not meeting the criteria for good) for differences in demographics, HRQOL scores, and alignment, via Chi-squared or student's t tests.Overall, 83 of 153 patients met the criteria of severe CD and 40 patients had complete 1-year follow-up of clinical/radiographic data. Patient breakdown by deformity pattern was: CT (N=13), FN (N=17), and FD (N=17), with 7 patients meeting criteria for both FD and FN deformities. Within the FD cohort, maximal focal kyphosis (ie, kyphosis at one level) was better corrected in patients with a "good" outcome (p=.03). In the FN cohort, patients with "good" outcomes presented preoperatively with worse horizontal gaze (McGregor Slope 21° vs. 6°, p=.061) and cSVA (72 mm vs. 60 mm, p=.030). "Good" outcome FN patients showed significantly greater postop correction of horizontal gaze (-25° vs. -5°, p=.031). In the CT cohort, patients with "good" outcomes had superior global alignment both pre- (SVA: -17 mm vs. 108 mm, p.001) and postoperatively (50 mm vs. 145 mm, p=.001). CT patients with "good" outcomes also had better postop cervical alignment (cSVA 35 mm vs. 49 mm, p=.030), and less kyphotic segments during extension (p=.011). In the FD cohort, there were no differences between "good" and "poor" outcomes patients in preoperative alignment; however, "good" outcome patients showed superior changes in postoperative focal kyphosis (-2° vs. 5°, p=.030). Within all three deformity pattern categories, there were no differences between "good" and "poor" outcome patients with respect to demographics or surgical parameters (levels fused, surgical approach, decompression, osteotomy, all p.050).The results of this study show each CD patient's unique deformity must be carefully examined in order to determine the appropriate alignment goals to achieve optimal HRQOLs. In particular, the recognition of the sagittal morphotype can help assist surgeons to aim for specific alignment goals for CT, FN and FD. Distinct deformity specific intra-operative goals include obtaining proper sagittal global/cervical alignment for cervicothoracic patients, correcting maximal focal kyphosis in focal deformity patients, and correcting horizontal gaze for flatneck patients.

Study Design: Retrospective cohort study. Objective: Factors that predict outcomes for adult cervical spine deformity (ACSD) have not been well defined. To compare ACSD patients with best versus worst outcomes. Methods: This study was based on a prospective, multicenter observational ACSD cohort. Best versus worst outcomes were compared based on Neck Disability Index (NDI), Neck Pain Numeric Rating Scale (NP-NRS), and modified Japanese Orthopaedic Association (mJOA) scores. Results: Of 111 patients, 80 (72%) had minimum 1-year follow-up. For NDI, compared with best outcome patients (n = 28), worst outcome patients (n = 32) were more likely to have had a major complication ( P = .004) and to have undergone a posterior-only procedure ( P = .039), had greater Charlson Comorbidity Index ( P = .009), and had worse postoperative C7-S1 sagittal vertical axis (SVA; P = .027). For NP-NRS, compared with best outcome patients (n = 26), worst outcome patients (n = 18) were younger ( P = .045), had worse baseline NP-NRS ( P = .034), and were more likely to have had a minor complication ( P = .030). For the mJOA, compared with best outcome patients (n = 16), worst outcome patients (n = 18) were more likely to have had a major complication ( P = .007) and to have a better baseline mJOA ( P = .030). Multivariate models for NDI included posterior-only surgery ( P = .006), major complication ( P = .002), and postoperative C7-S1 SVA ( P = .012); models for NP-NRS included baseline NP-NRS ( P = .009), age ( P = .017), and posterior-only surgery ( P = .038); and models for mJOA included major complication ( P = .008). Conclusions: Factors distinguishing best and worst ACSD surgery outcomes included patient, surgical, and radiographic factors. These findings suggest areas that may warrant greater awareness to optimize patient counseling and outcomes.

BACKGROUND High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. OBJECTIVE To compare outcomes of operative and nonoperative treatment for ASD. METHODS This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence-to-lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up. RESULTS Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications. CONCLUSION Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability. ABBREVIATIONS ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis.

Background Context Adult spinal deformity (ASD) surgery is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and more than $1.7 billion in charges for managed care population in the last decade. Given the recent move toward bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component toward the bundled payment. Purpose To examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient-reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. Study Design/Setting Retrospective analysis of prospective, multicenter database. Patient Sample Consecutive patients enrolled in an ASD database from four spinal deformity centers. Outcome Measures Total in-patient EOC costs and Short Form (SF)-6D. Methods The study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. Results A total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4±12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by $2,500, whereas recombinant human bone morphogenetic protein-2 (BMP) use and posterior-only surgical approach lowered total EOC costs by $10,500 and $9,400, respectively. No significant difference was observed in 2-year quality-adjusted life year across centers. Conclusions Total EOC costs for ASD surgery varied significantly by center. Levels fused, BMP use, and surgical approach were the primary drivers of cost variation across centers. Differences in resource utilization had no impact on 2-year quality-adjusted life year improvement across centers.

OBJECTIVEAlthough 3-column osteotomy (3CO) can provide powerful alignment correction in adult spinal deformity (ASD), these procedures are complex and associated with high complication rates. The authors' objective was to assess complications associated with ASD surgery that included 3CO based on a prospectively collected multicenter database.METHODSThis study is a retrospective review of a prospectively collected multicenter consecutive case registry. ASD patients treated with 3CO and eligible for 2-year follow-up were identified from a prospectively collected multicenter ASD database. Early (≤ 6 weeks after surgery) and delayed (> 6 weeks after surgery) complications were collected using standardized forms and on-site coordinators.RESULTSOf 106 ASD patients treated with 3CO, 82 (77%; 68 treated with pedicle subtraction osteotomy [PSO] and 14 treated with vertebral column resection [VCR]) had 2-year follow-up (76% women, mean age 60.7 years, previous spine fusion in 80%). The mean number of posterior fusion levels was 12.9, and 17% also had an anterior fusion. A total of 76 early (44 minor, 32 major) and 66 delayed (13 minor, 53 major) complications were reported, with 41 patients (50.0%) and 45 patients (54.9%) affected, respectively. Overall, 64 patients (78.0%) had at least 1 complication, and 50 (61.0%) had at least 1 major complication. The most common complications were rod breakage (31.7%), dural tear (20.7%), radiculopathy (9.8%), motor deficit (9.8%), proximal junctional kyphosis (PJK, 9.8%), pleural effusion (8.5%), and deep wound infection (7.3%). Compared with patients who did not experience early or delayed complications, those who had these complications did not differ significantly with regard to age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, smoking status, history of previous spine surgery or spine fusion, or whether the 3CO performed was a PSO or VCR (p ≥ 0.06). Twenty-seven (33%) patients had 1–11 reoperations (total of 44 reoperations). The most common indications for reoperation were rod breakage (n = 14), deep wound infection (n = 15), and PJK (n = 6). The 24 patients who did not achieve 2-year follow-up had a mean of 0.85 years of follow-up, and the types of early and delayed complications encountered in these 24 patients were comparable to those encountered in the patients that achieved 2-year follow-up.CONCLUSIONSAmong 82 ASD patients treated with 3CO, 64 (78.0%) had at least 1 early or delayed complication (57 minor, 85 major). The most common complications were instrumentation failure, dural tear, new neurological deficit, PJK, pleural effusion, and deep wound infection. None of the assessed demographic or surgical parameters were significantly associated with the occurrence of complications. These data may prove useful for surgical planning, patient counseling, and efforts to improve the safety and cost-effectiveness of these procedures.

STUDY DESIGN Retrospective cohort. OBJECTIVE To explore proximal junctional kyphosis (PJK) as a function of age-adjusted surgical correction goals. SUMMARY OF BACKGROUND DATA Recent adult spinal deformity (ASD) studies show that alignment targets are age-specific. Despite recognizing age and malalignment as PJK risk factors, no study has assessed the age-specific effects of alignment on PJK. METHODS ASD patients with fusions to the pelvis were included and stratified into three groups: young adults (YA 65 years old). Analysis of variance compared the groups with respect to 1-year postoperative alignments and 1-year offsets from age-specific alignment targets. RESULTS A total of 679 patients were enrolled (mean age = 61 years old, 77% female, body mass index = 28.1). At 1 year postoperatively, there was a significant decrease in pelvic tilt (PT; 29-23°), spinopelvic mismatch (pelvic incidence [PI]-lumbar lordosis [LL]) (28-5°), and sagittal vertical axis (SVA; 110-37 mm); overall incidence of PJK was 45.1%. Stratification by age (YA, n = 28; MA, n = 389; ED, n = 262) revealed an increase in PJK incidence with age: YA = 17.9%, MA = 43.8%, and ED = 50.2% (P

Study design Retrospective review of a prospective multicenter database. Objective To develop a method to analyze sagittal alignment, free of the influence of proximal junctional kyphosis (PJK), and then compare PJK to non-PJK patients using this method. Summary of background data PJK after adult spinal deformity (ASD) surgery remains problematic as it alters sagittal alignment. The present study proposes a novel virtual modeling technique that attempts to eliminate the confounding effects of PJK on postoperative spinal alignment. Methods A virtual spinal modeling technique was developed on a retrospective ASD cohort of patients with multilevel spinal fusions to the pelvis with at least 2-year postoperative follow-up. The virtual postoperative alignment (VIRTUAL) was created from the postoperative alignment of the instrumented segments and the preoperative alignment of the unfused segments. VIRTUAL was validated by comparisons to actual 2-year postoperative alignment (REAL) in non-PJK patients. Patients were then divided into two groups: PJK and non-PJK based on the presence/absence of PJK at 2 years postoperatively. PJK and non-PJK patients were compared using VIRTUAL and REAL. Results A total of 458 patients (78F, mean 57.9 yr) were analyzed. The validation of VIRTUAL versus REAL demonstrated correlation coefficients greater than 0.7 for all measures except sagittal vertical axis (SVA; r = 0.604). At 2 years, REAL alignment in PJK patients demonstrated a smaller pelvic incidence minus lumbar lordosis and a larger thoracic kyphosis than non-PJK patients, but similar SVA, T1 pelvic angle, and pelvic tilt. An analysis of VIRTUAL demonstrated that patients with PJK had a smaller pelvic incidence minus lumbar lordosis, pelvic tilt, SVA, and T1 pelvic angle than non-PJK patients (P Conclusion This technique demonstrated strong correlations with actual postoperative alignment. Comparisons between REAL and VIRTUAL alignments revealed that postoperative PJK may develop partially as a compensatory mechanism to the overcorrection of sagittal deformities. Future research will evaluate the appropriate thresholds for deformity correction according to age and ASD severity. Level of evidence 3.

STUDY DESIGN Multicenter, retrospective series. OBJECTIVE To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. SUMMARY OF BACKGROUND DATA Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. METHODS A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. RESULTS Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). CONCLUSION APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

Background Although adult cervical spine deformity (ACSD) is associated with pain and disability, its health impact has not been quantified in comparison to other chronic diseases. Objective To perform a comparative analysis of the health impact of symptomatic ACSD to US normative and chronic disease values using EQ-5D (EuroQuol-5 Dimensions questionnaire) scores. Methods ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Baseline demographics and EQ-5D scores were collected and compared with US normative and disease state values. Results Of 121 ACSD patients, 115 (95%) completed the EQ-5D (60% women, mean age 61 years, previous spine surgery in 44%). Diagnoses included kyphosis with mid-cervical (63.4%), cervico-thoracic (23.5%), or thoracic (8.7%) apex and primary coronal deformity (4.3%). The mean ACSD EQ-5D index was 0.511 (standard definition = 0.224), which is 34% below the bottom 25th percentile (0.780) for similar age- and gender-matched US normative populations. Mean ACSD EQ-5D index values were worse than the bottom 25th percentile for several other disease states, including chronic ischemic heart disease (0.708), malignant breast cancer (0.708), and malignant prostate cancer (0.708). ACSD mean index values were comparable to the bottom 25th percentile values for blindness/low vision (0.543), emphysema (0.508), renal failure (0.506), and stroke (0.463). EQ-5D scores did not significantly differ based on cervical deformity type ( P = .66). Conclusion The health impact of symptomatic ACSD is substantial, with negative impact across all EQ-5D domains. The mean ACSD EQ-5D index was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke.

BACKGROUND In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO. OBJECTIVE To investigate if performance of 3CO surgeries improves with years of practice. METHODS Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis. RESULTS Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001). CONCLUSION Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.

STUDY DESIGN Cross-sectional analysis. OBJECTIVE To compare Lumbar Stiffness Disability Index (LSDI) scores between asymptomatic adults and patients with spinal deformity. SUMMARY OF BACKGROUND DATA The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. Baseline disability levels of patients with adult spinal deformity (ASD) are high as measured by multiple validated outcome tools. Baseline lumbar stiffness-related disability has not been assessed in adults with and without spinal deformity. METHODS The LSDI and Scoliosis Research Society-22r (SRS-22r) were submitted to a group of asymptomatic adult volunteers. Additionally, a multicenter cross-sectional cohort analysis of patients with ASD from 10 centers was conducted. Baseline LSDI and SRS-22r were completed for both operatively and nonoperatively treated patients with deformity. RESULTS The LSDI was completed by 176 asymptomatic volunteers and 693 patients with ASD. Mean LSDI score for asymptomatic volunteers was 3.4 +/- 6.3 out of a maximum score of 100, with significant correlation between increasing age and higher (worse) LSDI score (r = 0.30, P = 0.0001). Of the patients with spinal deformity undergoing analysis, 301 subsequently underwent surgery and 392 were subsequently treated nonoperatively. Operative patients had significantly higher preoperative LSDI scores than both nonoperative patients and asymptomatic volunteers (29.9 vs. 17.3 vs. 3.4, P < 0.0001 for both). For patients with ASD, significant correlations were found between LSDI and SRS-22 Pain and Function subscales (r = -0.75 and -0.76, respectively; P < 0.0001 for both). CONCLUSION LSDI scores are low among asymptomatic volunteers, although stiffness-related disability increases with increasing age. Patients with ASD report substantial stiffness-related disability even prior to surgical fusion. Stiffness-related disability correlates with pain- and function-related disability measures among patients with spinal deformity.

STUDY DESIGN Multi-center, retrospective review. OBJECTIVE Identify age associated clinical and radiographic features correlating with AS treatment. SUMMARY OF BACKGROUND DATA Little information exists about factors determining treatment for adult scoliosis (AS). Existing studies have not evaluated age stratified differences. METHODS Multicenter, retrospective review of 290 patients treated for AS. Patients divided into operative (OP) or nonoperative (NON), and age stratified into 3 groups (G1 = 65 years). Demographic and spinopelvic radiographic parameters evaluated. Health-related quality of life (HRQL) measures included SRS-22, Oswestry Disability Index (ODI), visual analog pain scale. RESULTS Treatment groups (OP, n = 137; NON, n = 153) demonstrated similar age (OP = 52.7 years; NON = 55.5 years; P > 0.05) and comorbidities. OP had larger thoracic curves than NON (OP = 51 degrees, NON = 45 degrees; P < 0.05). OP had worse HRQL scores than NON (SRS = 2.95 vs. 3.12, P < 0.05; ODI = 33.4 vs. 28.7, P < 0.05; visual analog pain scale = 6.9 vs. 5.6, P < 0.05, respectively). Age stratification of OP demonstrated larger curves in G1 and G2 versus G3, progressively worsening sagittal imbalance in older age groups, and worse HRQL scores in G3 versus G1 and G2. Age stratification of NON demonstrated worsening sagittal imbalance with age, however, other radiographic values and HRQL scores were similar between all NON age groups. Treatment stratification of age groups demonstrated G1-OP had greater deformity than G1-NON (mean thoracic curve: G1-OP = 53 degrees, G1-NON = 43 degrees; P < 0.05) but similar HRQL values. Whereas G2 and G3-OP had similar radiographic coronal and sagittal values as G2 and G3-NON, but worse HRQL scores. CONCLUSION Counter to previous reports, age, comorbidities, and sagittal balance did not influence treatment modality for AS. Operative treatment for younger patients was driven by increased coronal plane deformity. Conversely, pain and disability mandated treatment for older patients, independent of radiographic measures. These findings suggest that AS patients do not become uniformly disabled with age, and that disability can not be solely predicted by radiographic findings. These data should be considered when considering treatment for AS.

Study Design. Prospective observational consecutive\ case series. Objectives. To determine the responsiveness to change of the Scoliosis Research Society-22 (SRS-22) patient questionnaire after surgical treatment. Summary of Background Data. The SRS-22 outcomes questionnaire is the outgrowth of of prior research that led to modifications and improvements of- the original 5(15 questionnaire. Methods. Fifty-eight patients with an average age of 16 years and an average Cobb size of 63° enrolled. They were tested preoperatively and at 3'-(within 4 months), 6(5-8 months), 12- (9-18 months), and 24-month (22-36 months) intervals postoperatively using the SRS-22 outcomes questionnaire. The paired-Student t test with multiple comparison adjustment was used to test significance of change score aver time. Only patients with data on both time points of interest were inciuded in the analysis. Results. Self-image was significantly improved at 3 months. (P < 0.0001) and maintained improvement through 24 months. Function was significantly decreased at 3 months (P < 0.0001), but returned to baserine by 6 rnonths. Pain was significantly worse at 3 months (P = 0.0099), but was significantly less at 6 (P = 0.0011), 12 (P < 0.0001), and 24 (P = 0.0037) months when compared to 3 months. Conclusion. The SRS-22 questionnaire is responsive to changes in the postsurgical period.

Multicenter, retrospective, consecutive case series.This study aims to identify demographic and radiographical characteristics that influence the decision to perform revision surgery among patients with proximal junctional failure (PJF).Revision rates after PJF remain relatively high, yet the decision criteria for performing revision surgical procedures are not uniform and vary by surgeon. A better understanding of the factors that impact the decision to perform revision surgery is important in order to improve efficiency of surgical treatment of adult spinal deformity.A cohort of 57 patients with PJF was identified retrospectively from 1218 consecutive patients with adult spinal deformity. PJF was identified on the basis of 10° postoperative increase in kyphosis between upper instrumented vertebra (UIV) and UIV +2, along with 1 or more of the following: fracture of the vertebral body of UIV or UIV +1, posterior osseoligamentous disruption, or pullout of instrumentation at the UIV. Univariate statistical analysis was performed using t tests and Fisher exact tests. Multivariate analysis was performed using logistic regression.Twenty-seven (47.4%) patients underwent revision surgery within 6 months of the index operation. Regression results revealed that patients with combined posterior/anterior approaches at index were significantly more likely to undergo revision (P = 0.001) as were patients with more extreme proximal junctional kyphosis angulation (P = 0.034). Patients sustaining trauma were also significantly more likely to undergo revision (P = 0.019). Variables approaching but not reaching significance as predictors of revision included female sex (P = 0.066) and higher sagittal vertical axis (SVA) (P = 0.090).The decision to perform revision surgery is complicated and varies by surgeon. Factors that seem to influence this decision include traumatic etiology of PJF, severity of proximal junctional kyphosis angulation, higher SVA, and female sex. Factors that were expected to influence revision but had no statistical effect included soft tissue versus bony mode of failure, age, levels fused, and upper thoracic versus thoracolumbar proximal junction.

Quantified trunk rotational strength training has shown promise as a non-operative management option for individuals with AIS. The purposes of our study are to test whether a quantified trunk rotational strength training protocol can increase trunk strength and stabilize or decrease curve size. Seven adolescents with AIS (5 female 2 male; mean 14 yrs +/- 2.6 yrs; mean Cobb 28 degrees +/- 6 degrees range 20 degrees -37 degrees) underwent four months of supervised trunk rotational strength training, and repeat strength test. Trunk strength in both directions increased significantly after training (p0.05). Average Cobb angle decreased to 23 degrees +/- 11 degrees (range 6 degrees -35 degrees). Four individuals showed reduction (5 degrees) in their original curve, and 3 remained the same (+/-5 degrees). The strength training protocol significantly increased isometric rotational strength and scoliosis was stabilized short term.

Improving the angle of trunk inclination (ATI) is important for achieving optimum clinical deformity correction in adolescent idiopathic scoliosis. Three concave apical implant techniques were reviewed in combination with the use of concave rib osteotomies. Rib osteotomy improved the ATI correction significantly when using apical wiring techniques.

Trunk rotational strength asymmetry has been suggested in adolescents with idiopathic scoliosis (IS), but is unconfirmed. The sitting isometric trunk rotational strength, at neutral and 18 degrees or 36 degrees of right or left pre-rotation, of a group of healthy adolescent females (CG), n=12, is compared with a group of female adolescents with IS (ISG), n= 14. Torque values were normalized to lean body weight. There is a significant weakness when rotating towards the concavity found in patients with AIS at the 36 lo (p 0.07 marginal), 18 lo (p0.03) and neutral positions (p0.02), with no side strength asymmetry found in a cohort of healthy adolescents without AIS.

To determine how pelvic rotation in the transverse plane relates to coronal plane anatomical landmark location. The problem this addresses is the observation that iliac crest medial lateral width as seen in the coronal plane Cobb is often asymmetrical in patients with idiopathic scoliosis before treatment, and sometimes after treatment.A pelvis was marked with radiographically opaque markers at symmetrical sites in the ilium, sacrum and acetabulum; mounted in a jig; and radiographed at varying degrees of transverse and sagittal plane angulation. The medial lateral distance from two similar landmarks on opposite sides of the pelvis was then determined and a left/right ratio correlated with the degrees of transverse plane angulation. In addition, a theoretically derived equation was developed to describe the effect of pelvic shape on the degree of transverse plane rotation.The left/right ratio for the distance from the sacro iliac joint to the anterior superior iliac spine proved to be the most reliable for determining the degree of pelvic rotation in the transverse plane. The relationship is nearly linear up to 25 rotation and is little influenced by the degree of sagittal plane angulation. Based on theoretical considerations, the importance of the anterior to posterior angular relationship of the two coronal plane landmarks measured influences the degree of rotation but not the linear relationship.Within limits the transverse plane rotation of the pelvis can be determined by a left/right ratio of the distances between two similar landmarks on each side of the pelvis.

To determine whether trunk deformity correction is stable over time.Thirty-seven patients (5M, 32 F) average age 16 years, 3 months (range, 10 to 38) met inclusion crieteria of primary posterios instrumentation (ISOLA) and arthrodesis with x-ray and surface topography measurements [Posterior Trunk Symmetry Index (POTSI)] and [Suzuki Hump Sum (SHS)] pre-operatively and at 2 years follow up. For 30 patients measurements were also available post-operatively. Patient's average pre, post, and two-year measurements were: Largst Cobb 65 degrees (+/- 12), 21 degrees (+/- 8), and 21 degrees (+/- 17); POTSI 53 (+/- 29), 28 (+/- 12); and 22 degrees (+/- 10); and SHS 18 (+/- 11), 12 (+/- 7), and 12 (+/- 7), and 12 (+/- 6). Statistical analysis was done with the sign test, comparing only patients with data at the intervals studied. Surface topography measurements were considered to be unchanged/tied unless they increased or decreased by more than 8 for POTSI and 3.5 for SHS, Significance was set at p0.05.POTSI changes were pre-to post operative: 20 improved (I), 3 worsened (W), and 7 tied (T) (p0.01): pre to two years: 30 (I), 4 (W), and 3 (T) (p0.01): and from post to two years: 14 (I), 3 (W) and 13 (T) (p0.01). SHS changes were pre to post to two years: 18 (I), 2 (W), and 11 (T) (p0.01); pre to two years: 23 (I), 2 (W), and 11 (T) (p0.01); ad post to two years: 4(I), 6 (W), and 20 T (ns).Trunk deformity improvement following surgery is stable or improved over time with surgical techniques utilized.

To determine whether either spine or trunk deformity measurements correlate with patients quality of life questionnaire responses.Forty five pre operative patients (5M, 40F), average age 15 years, 9 months (range, 10-20) met the inclusion criteria of age (or = 20 years), Posterior Trunk Symmetry Index (POTSI) and Suzuki Hump Sum (SHS) determination from surface topography, and Scoliosis Research Society-22 (SRS-22)patient questionnaire completion. Average measurement and measurement ranges were largest Cobb 62 degrees (range, 40-137 degrees), POTSI 49 (range, 17-149), SHS 16 (5-32), and SRS-22 subtotal score 3.86 (range, 4.7-2.35). The individual SRS-22 domain scores were function 4.13 (4.80-2.20), pain 4.01 (5-1.60), self image 3.34 (4.4-1.80) and mental health 4.01 (5-1.80). (Scale 5 Best-1 Worst). Correlations between deformity and questionnaire measurements were determined, p0.01 considered significant.Spine deformity (Cobb) correlated with the SRS-22 subtotal scores (cc-04207, p0.005) and with the function and self image SRS-22 domain scores: cc0.5182, p0.001) and cc-0.3981, p0.01 respectively. Neither trunk deformity score correlated with the SRS-22 Score: POTSI versus SRS-22 (cc 0.0449, ns) and SHS versus SRS-22 (cc-0.0311, ns)Spine deformity correlates well with quality of life questionnaire responses whereas trunk deformity magnitude does not. This is somewhat surprising as it is the trunk deformity that the patient can they themselves see. These findings illustrate the pitfalls of assuming what is important to the patient based on clinical measurements.

STUDY DESIGN Retrospective case series. OBJECTIVES To determine the influence of spine and trunk deformity on preoperative idiopathic scoliosis patients' health-related quality of life questionnaire responses. SUMMARY OF BACKGROUND DATA Management recommendations for patients with idiopathic scoliosis during adolescence are based heavily on spine deformity and to some extent trunk deformity magnitude. However, the manner in which these objective measures influence the patients' perception of their condition is unclear. METHODS Of 67 consecutive preoperative patients, 61 (91%) had completed the Scoliosis Research Society-22 health-related quality of life questionnaire and had been studied with posterior exposure surface topography. Their average age was 15 years, 6 months (range 10 years, 10 months-20 years, 10 months), and the average maximum Cobb was 63 degrees (range 40-137 degrees). Correlations between spine and trunk deformity measures and Scoliosis Research Society-22 scores were determined by the Pearson correlation coefficient, with P < 0.01 considered significant. RESULTS For the study group, spine deformity (Cobb) correlated significantly only with Scoliosis Research Society-22 function (r = -0.39, P = 0.0022) domain. Neither coronal nor transverse plane trunk deformity composite scores correlated with any Scoliosis Research Society-22 scores. The Hump Index component of the transverse plane Suzuki Hump Sum composite score was the only trunk measurement to correlate significantly (function r = -0.45, P = 0.003; self image, r = -0.36, P = 0.0040). The strongest correlations occurred when the single thoracic curves, King classifications III and IV, were combined: Cobb versus function r = -0.53, P = 0.0027; Cobb versus self-image r = -0.46, P = 0.0099; and Hump Index versus function r = -0.60, P = 0.0005. There were no significant correlations between either spine deformity or any trunk deformity measure with Scoliosis Research Society-22 responses for either the double or thoracolumbar curve pattern groups. CONCLUSION Both spine and upper thoracic transverse plane trunk deformity significantly influenced preoperative idiopathic scoliosis patients' perception of function and self-image, but not pain or mental health. However, in spite of a fairly rigorous standard of proof, P < or = 0.01, the significant r values ranged from -0.33 to -0.68, suggesting that there are factors other than spine and trunk deformity influencing the idiopathic scoliosis patients' health-related quality of life questionnaire responses. Future studies are necessary to define these factors.

STUDY DESIGN Prospective observational study. OBJECTIVE To determine the discriminant validity of the Scoliosis Research Society-22 (SRS-22) health-related quality-of-life (HRQL) questionnaire for idiopathic scoliosis patients based on curve pattern and curve size. SUMMARY OF BACKGROUND DATA An important psychometric attribute of the HRQL questionnaire is the capacity to discriminate between and among patients with differing condition severity. METHOD Three study groups, with subjects ranging in age from 10 to 16 years, were set up: a control group (C) of 19 persons with scoliosis suspected but unproven with an average age of 13 years; a nonsurgical group (NS) of 68 patients with an average age of 14 years and an average scoliosis (Cobb) of 30 degrees; and a presurgical group (PS) of 32 patients with an average age of 14 years and an average scoliosis of 61 degrees. The NS group was subdivided into untreated (NSU) (n = 54) and braced (NSB) patients (n = 14). Also created were subgroups of the NS and PS groups having similar curve sizes: nonsurgical similar (NSS) and presurgery similar (PSS). Statistical significance of the SRS-22 domain scores by comparison groups was tested by ANOVA. Relationships between the SRS-22 questionnaire and scoliosis deformity measurements were calculated using the Pearson Correlation Coefficients. RESULTS There were no significant differences between the control (C) and nonsurgical (NS) groups. The presurgical group (PS) scored significantly lower in the pain and self-image domains than the C or NS groups and lower than group C in the mental health domain. A subgroup of the nonsurgical group (NSS) with curves comparable to the presurgical subgroup (PSS) had significantly better self-image scores. There were no significant correlations between SRS-22 scores and curve pattern. For persons with scoliosis, curve size (Cobb) correlated with pain, self-image, and function; trunk asymmetry correlated with self-image. CONCLUSION The SRS-22 HRQL questionnaire successfully discriminated among persons with no scoliosis or moderate scoliosis and large scoliosis. It did not discriminate among patients with single, double, or triple curves. Self-image and, to a lesser extent, pain and function domain scores correlated with radiographic and trunk asymmetry severity. The SRS-22 HRQL questionnaire may be useful in choosing nonsurgical versus surgical treatment in borderline cases.

STUDY DESIGN Outcome study to determine response distribution, internal consistency, reproducibility, and concurrent validity of the Scoliosis Research Society-22 (SRS-22) health-related quality-of-life (HRQL) questionnaire. OBJECTIVES Further refinement of an HRQL questionnaire specific for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Previous experience with the original and modified SRS HRQL questionnaires suggested a need for further refinement and more complete validation. METHODS The SRS-22 and Short Form 36 (SF-36) HRQL questionnaires were mailed to 83 previously surveyed postoperative idiopathic scoliosis patients. RESULTS Fifty-eight (70%) patients returned the first set of questionnaires. Their average age at surgery was 14.6 years, and their average follow-up interval since surgery was 10.8 years. Fifty-one (88%) of the 58 returned the second set of questionnaires an average of 28 days later. The psychometric attributes of the instruments were comparable: score distribution, SRS-22 56.9% ceiling and 1.7% floor, SF-36 79.3% ceiling and 1.7% floor; internal consistency (Cronbach alpha), SRS-22 0.92 to 0.75, SF-36 0.91 to 0.36; and reproducibility (intraclass correlation coefficient), SRS-22 0.96 to 0.85, SF-36 0.92 to 0.61. Concurrent validity, determined by Pearson Correlation Coefficients between SRS-22 and SF-36 domains, was 0.70 or greater ( < 0.0001) for 17 relevant comparisons. CONCLUSION The SRS-22 HRQL questionnaire is reliable with internal consistency and reproducibility comparable to SF-36. In addition, it demonstrated concurrent validity when compared to SF-36. It is shorter and more focused on the health issues related to idiopathic scoliosis than SF-36.