The clinical impact of global coronal malalignment is underestimated in adult patients with thoracolumbar scoliosis

Plais, Nicolas; Bao, Hongda; Lafage, Renaud; Gupta, Munish C.; Smith, Justin S.; Shaffrey, Christopher I.; Burton, Douglas C.; Ames, Christopher P.; Klineberg, Eric O.; Bess, Shay; Schwab, Frank J.; Lafage, Virginie

doi:10.1007/s43390-020-00046-z

Cited by 29 publications

(20 citation statements)

References 22 publications

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“…39 Recent reports have begun to study the role of coronal alignment parameters, as CM has been shown to lead to significant pain, disability, and poor cosmesis. [39][40][41][42][43] CCSM is an even less studied phenomenon in ASD, with a 3 patient case series of such patients describing good correction results, but without much PRO data. 44 With 18% of our cohort classified as CCSM, a sizeable number of ASD patients may fall into this category.…”

Section: Discussionmentioning

confidence: 99%

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Zuckerman

Lai

Shen

et al. 2021

Global Spine Journal

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Objective: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval. Study Design: Retrospective Cohort. Methods: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed. Results: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved ( P < .001). In all patients, the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; P < .001). Subgroup analysis: ≥55 years had an improved median ODI (18 vs. 8; P = .047) and an improved percent achieving ODI MCID (73% vs. 84%, P = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; P = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; P = .032). Conclusions: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.

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Section: Discussionmentioning

confidence: 99%

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Zuckerman

Lai

Shen

et al. 2021

Global Spine Journal

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“…Both lumbosacral fractional curve correction and major curve correction in the mid-lumbar spine are critical for the postoperative coronal balance; mismatch between them may result in the aggravation of the coronal imbalance at postoperative [11,[28][29][30]. Wang reported that three patients had worsening of coronal balance due to straightening of the major curve without addressing the fractional curve adequately [15].…”

Section: Discussionmentioning

confidence: 99%

Posterior column osteotomy plus unilateral cage strutting for correction of lumbosacral fractional curve in degenerative lumbar scoliosis

Wang

Sun

et al. 2020

J Orthop Surg Res

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Background Inadequate release of the posterior spinal bone elements may hinder the correction of the lumbosacral fractional curve in degenerative lumbar scoliosis, since the lumbosacral junction tends to be particularly rigid and may already be fused into an abnormal position. The purpose of this study was to evaluate the surgical outcome and complications of posterior column osteotomy plus unilateral cage strutting technique on lumbosacral concavity for correction of fractional curve in degenerative lumbar scoliosis patients. Methods Thirty-two degenerative lumbar scoliosis patients with lumbosacral fractional curve more than 15° that were surgically treated by posterior column osteotomy plus unilateral cage strutting technique were retrospectively reviewed. The patients’ medical records were reviewed to identify demographic and surgical data, including age, sex, body mass index, back pain, leg pain, Oswestry Disability Index, operation time, blood loss, and instrumentation levels. Radiological data including coronal balance distance, Cobb angle, lumbosacral coronal angle, sagittal vertical axis, lumbar lordosis, and lumbosacral lordotic angle were evaluated before and after surgery. Cage subsidence and bone fusion were evaluated at 2-year follow-up. Results All patients underwent the operation successfully; lumbosacral coronal angle changed from preoperative 20.1 ± 5.3° to postoperative 5.8 ± 5.7°, with mean correction of 14.3 ± 4.4°, and the correction was maintained at 2-year follow-up. Cobb’s angle and coronal balance distance decreased from preoperative to postoperative; the correction was maintained at 2-year follow-up. Sagittal vertical axis decreased, and lumbar lordosis increased from preoperative to postoperative; the correction was also maintained at 2-year follow-up. Lumbosacral lordotic angle presented no change from preoperative to postoperative and from postoperative to 2-year follow-up. Postoperatively, there were 8 patients with lumbosacral coronal angle more than 10°, they got the similar lumbosacral coronal angle correction, but presented larger preoperative Cobb and lumbosacral coronal angle than the other 24 patients. No cage subsidence was detected; all patients achieved intervertebral bone fusion and inter-transverse bone graft fusion at the lumbosacral region at 2-year follow-up. Conclusion Posterior column osteotomy plus unilateral cage strutting technique on the lumbosacral concavity facilitate effective correction of the fractional curve in degenerative lumbar scoliosis patients through complete release of dural sac as well as the asymmetrical intervertebral reconstruction by cage.

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“…24 Though CVA to the left was considered negative and to the right is positive, absolute values were used given the lack of clinical difference between left or right CM. In accordance with prior literature, CM was defined at a threshold of CVA ≥ 3 cm, [9][10][11] Similarly, though SVA can be negative or positive in relation to where C7 lies compared to the superior posterior aspect of S1, absolute values were used to standardize the malalignment; however, positive and negative values were used for each regression analysis. Additional radiographic variables included: pelvic obliquity (angle of line between superior iliac crest and horizontal) and leg length discrepancy (difference in height from femoral head to tibial plafond on full-body x-rays).…”

Section: Independent Variablesmentioning

confidence: 99%

“…Postoperative sagittal alignment targets are welldefined, with sagittal vertical axis (SVA) < 5 cm and pelvic incidence to lumbar lordosis within 10°. 6 However, coronal alignment goals are not fully understood, as previous thresholds to define CM range from a coronal vertical axis (CVA) of 2 cm, 7,8 3 cm, [9][10][11] 4 cm, 3,[12][13][14] to even 5 cm, 15 though most prior studies use a threshold value of 3 cm.…”

Section: Introductionmentioning

confidence: 99%

Be Prepared: Preoperative Coronal Malalignment Often Leads to More Extensive Surgery Than Sagittal Malalignment During Adult Spinal Deformity Surgery

et al. 2021

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Objective: To evaluate the effect of coronal alignment on: (1) surgical invasiveness and operative complexity and (2) postoperative complications.Methods: A retrospective, cohort study of adult spinal deformity patients was conducted. Alignment groups were: (1) neutral alignment (NA): coronal vertical axis (CVA) ≤ 3 cm and sagittal vertical axis (SVA) ≤ 5 cm; (2) coronal malalignment (CM) only: CVA > 3 cm; (3) Sagittal malalignment (SM) only: SVA > 5 cm; and (4) coronal and sagittal malalignment (CCSM): CVA > 3 cm and SVA > 5 cm.Results: Of 243 patients, alignment groups were: NA 115 (47.3%), CM 48 (19.8%), SM 38 (15.6%), and CCSM 42 (17.3%). Total instrumented levels (TILs) were highest in CM (14.5 ± 3.7) and CCSM groups (14 ± 4.0) (p < 0.001). More 3-column osteotomies (3COs) were performed in SM (21.1%) and CCSM (28.9%) groups than CM (10.4%) (p = 0.003). CM patients had more levels instrumented (p = 0.029), posterior column osteotomies (PCOs) (p < 0.001), and TLIFs (p = 0.002) than SM patients. CCSM patients had more TLIFs (p = 0.012) and higher estimated blood loss (EBL) (p = 0.003) than SM patients. CVA displayed a stronger relationship with TIL (p = 0.002), EBL (p < 0.001), and operative time (p < 0.001) than SVA, which had only one significant association with EBL (p = 0.010). Both SM/CCSM patients had higher readmissions (p = 0.003) and reoperations (p < 0.001) than CM patients.Conclusion: Amount of preoperative CM was a better predictor of surgical invasiveness than the amount of SM, despite 3COs more commonly performed in SM patients. CM patients had more instrumented levels, PCOs, and TLIFs than SM patients.

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The clinical impact of global coronal malalignment is underestimated in adult patients with thoracolumbar scoliosis

Cited by 29 publications

References 22 publications

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Posterior column osteotomy plus unilateral cage strutting for correction of lumbosacral fractional curve in degenerative lumbar scoliosis

Be Prepared: Preoperative Coronal Malalignment Often Leads to More Extensive Surgery Than Sagittal Malalignment During Adult Spinal Deformity Surgery

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