Kai-Ming G. Fu

Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up.

Study Design. Retrospective review of a prospective, multicenter study. Objective. The purpose of this study was to assess the prevalence and severity of leg pain in adults with scoliosis and to assess whether surgery significantly improved leg pain compared with nonoperative management. Summary of Background Data. Patients with adult scoliosis characteristically present with pain. The presence of leg pain is an independent predictor of a patients choice for operative over nonoperative care. Methods. Data were extracted from a prospective, multicenter database for adult spinal deformity. At enrollment and follow-up, patients complete the Oswestry Disability Index (ODI) and assessment of leg pain using the numerical rating scale (NRS) score, with 0 and 10 representing no pain and unbearable pain, respectively. Plan for operative or nonoperative treatment was made at enrollment. The vast majority of adult scoliosis patients seen in our surgical clinics have received nonoperative therapies and are being seen for a surgical evaluation. Patients are counseled regarding operative and nonoperative management options and are in general encouraged to maximize nonoperative treatments. Results. Two hundred eight (64%) of 326 adults with scoliosis had leg pain at presentation (mean NRS score = 4.7). Ninety-six patients with leg pain (46%) were managed operatively and 112 were treated nonoperatively. The operative group had higher baseline mean NRS score for leg pain (5.4 vs. 4.1, P < 0.001) and higher mean ODI (41 vs. 30, P < 0.001). At 2-year follow-up, nonoperative patients had no significant change in ODI or NRS score for leg pain (P = 0.2). In contrast, at 2-year follow-up surgically treated patients had significant improvement in mean NRS score for leg pain (5.4 vs. 2.2, P < 0.001) and ODI (41 vs. 24, P < 0.001). Compared with nonsurgically treated patients, at 2-year follow-up operative patients had lower mean NRS score for leg pain (2.2 vs. 3.8, P < 0.001) and mean ODI (24 vs. 31, P = 0.005). Conclusion. Despite having started with significantly greater leg pain and disability, surgically treated patients at 2-year follow-up had significantly less leg pain and disability than nonoperatively treated patients. Surgical treatment has the potential to provide significant improvement of leg pain in adults with scoliosis.

Correlation of higher preoperative American Society of Anesthesiology grade and increased morbidity and mortality rates in patients undergoing spine surgery

OBJECT Patients with varied medical comorbidities often present with spinal pathology for which operative intervention is potentially indicated, but few studies have examined risk stratification in determining morbidity and mortality rates associated with the operative treatment of spinal disorders. This study provides an analysis of morbidity and mortality data associated with 22,857 cases reported in the multicenter, multisurgeon Scoliosis Research Society Morbidity and Mortality database stratified by American Society of Anesthesiologists (ASA) physical status classification, a commonly used system to describe preoperative physical status and to predict operative morbidity. METHODS The Scoliosis Research Society Morbidity and Mortality database was queried for the year 2007, the year in which ASA data were collected. Inclusion criterion was a reported ASA grade. Cases were categorized by operation type and disease process. Details on the surgical approach and type of instrumentation were recorded. Major perioperative complications and deaths were evaluated. Two large subgroups--patients with adult degenerative lumbar disease and patients with major deformity--were also analyzed separately. Statistical analyses were performed with the chi-square test. RESULTS The population studied comprised 22,857 patients. Spinal disease included degenerative disease (9409 cases), scoliosis (6782 cases), spondylolisthesis (2144 cases), trauma (1314 cases), kyphosis (831 cases), and other (2377 cases). The overall complication rate was 8.4%. Complication rates for ASA Grades 1 through 5 were 5.4%, 9.0%, 14.4%, 20.3%, and 50.0%, respectively (p = 0.001). In patients undergoing surgery for degenerative lumbar diseases and major adult deformity, similarly increasing rates of morbidity were found in higher-grade patients. The mortality rate was also higher in higher-grade patients. The incidence of major complications, including wound infections, hematomas, respiratory problems, and thromboembolic events, was also greater in patients with higher ASA grades. CONCLUSIONS Patients with higher ASA grades undergoing spinal surgery had significantly higher rates of morbidity than those with lower ASA grades. Given the common application of the ASA system to surgical patients, this grade may prove helpful for surgical decision making and preoperative counseling with regard to risks of morbidity and mortality.

Clinical and Radiographic Evaluation of the Adult Spinal Deformity Patient

Among the prevalent forms of adult spinal deformity are residual adolescent idiopathic and degenerative scoliosis, kyphotic deformity, and spondylolisthesis. Clinical evaluation should include a thorough history, discussion of concerns, and a review of comorbidities. Physical examination should include assessment of the deformity and a neurologic examination. Imaging studies should include full-length standing posteroanterior and lateral spine radiographs, and measurement of pelvic parameters. Advanced imaging studies are frequently indicated to assess for neurologic compromise and for surgical planning. This article focuses on clinical and radiographic evaluation of spinal deformity in the adult population, particularly scoliosis and kyphotic deformities.

Standardized measures of health status and disability and the decision to pursue operative treatment in elderly patients with degenerative scoliosis.

OBJECTIVETreatment decision making in elderly patients with degenerative scoliosis is complex. Although most patients can be adequately treated with nonoperative therapies, a subset ultimately elects for surgical treatment. However, the factors that govern this transition are poorly understood. The objective of this study was to assess whether standardized measures of health status and disability may be useful in distinguishing those patients who elect for surgical treatment. METHODSThis study is a retrospective review of a prospective database of 139 consecutive patients aged older than 60 years (mean = 70 years), with degenerative scoliosis treated by a single surgeon. Patients with severe symptoms who had failed multimodality nonoperative care were considered for surgical intervention. The Scoliosis Research Society Questionnaire (SRS-30), 12-Item Short Form Health Survey (SF-12), Oswestry Disability Index (ODI) surveys, and Charlson Comorbidity Index (CCI) were collected at the time of presentation and compared between the operative and nonoperative groups. RESULTSThere were no statistically significant differences between the operative and nonoperative groups in terms of age and major radiographic parameters. Significant differences between the operative and nonoperative groups were found for all 3 self-assessment survey results, with those electing for operative intervention reporting worse scores for ODI (54 versus 40; P = .001), SRS-30 (2.7 versus 3.0; P = .01), SF-12 physical component summary (23 versus 29; P = .01), and SF-12 mental component summary (46 versus 52; P = .03). Unexpectedly, patients treated surgically had a higher level of comorbidity as measured by the CCI (2.0 versus 1.3; P = .003). CONCLUSIONSelf-assessments of health and disability distinguish elderly patients with degenerative scoliosis electing for surgery compared with those who continue nonoperative therapies. Standardized measures of health status and disability may be useful in identifying patients nearing the threshold of crossing over to surgical treatment.

Prevalence, Severity, and Impact of Foraminal and Canal Stenosis Among Adults With Degenerative Scoliosis

BACKGROUND Management approaches for adult scoliosis are primarily based on adults with idiopathic scoliosis and extrapolated to adults with degenerative scoliosis. However, the often substantially, but poorly defined, greater degenerative changes present in degenerative scoliosis impact the management of these patients. OBJECTIVE To assess the prevalence, severity, and impact of canal and foraminal stenosis in adults with degenerative scoliosis seeking operative treatment. METHODS A prospectively collected database of adult patients with deformity was reviewed for consecutive patients with degenerative scoliosis seeking surgical treatment, without prior corrective surgery. Patients completed the Oswestry Disability Index, SF-12, Scoliosis Research Society 22 questionnaire, and a pain numeric rating scale (0-10). Based on MRI or CT myelogram, the central canal and foraminae from T6 to S1 were graded for stenosis (normal or minimal/mild/moderate/severe). RESULTS Thirty-six patients were included (mean age, 68.9 years; range, 51-85). The mean leg pain numeric rating scale was 6.5, and the mean Oswestry Disability Index score was 53.2. At least 1 level of severe foraminal stenosis was identified in 97% of patients; 83% had maximum foraminal stenosis in the curve concavity. All but 1 patient reported significant radicular pain, including 78% with discrete and 19% with multiple radiculopathies. Of those with discrete radiculopathies, 76% had pain corresponding to areas of the most severe foraminal stenosis, and 24% had pain corresponding to areas of moderate stenosis. CONCLUSION Significant foraminal stenosis was prevalent in patients with degenerative scoliosis, and the distribution of leg pain corresponded to levels of moderate or severe foraminal stenosis. Failure to address symptomatic foraminal stenosis when surgically treating adult degenerative scoliosis may negatively impact clinical outcomes.

Surgical management of global sagittal deformity in ankylosing spondylitis

Ankylosing spondylitis (AS) is an inflammatory rheumatic disease whose primary effect is on the axial skeleton, causing sagittal-plane deformity at both the thoracolumbar and cervicothoracic junctions. In the present review article the authors discuss current concepts in the preoperative planning of patients with AS. The authors also review current techniques used to treat sagittal-plane deformity, focusing on pedicle subtraction osteotomy at the thoracolumbar junction, as well as cervical extension osteotomy at the cervicothoracic junction.

Multiple-Day Drainage when Using Bone Morphogenic Protein for Long-Segment Thoracolumbar Fusions Is Associated with Low Rates of Wound Complications

BACKGROUND Concerns over increased wound complication rates have been raised when bone morphogenic protein (BMP) is used as an adjunct for fusion in spinal surgery. This study evaluated 87 consecutive patients undergoing long-segment thoracolumbar spinal fusions with BMP to assess drain output and the rates of reoperation for infection or seroma. METHODS Inclusion criteria included patients undergoing 4 or more levels of posterior instrumented thoracolumbar fusion, use of BMP, age >18 years, and a perioperative follow-up of ≥60 days. Drain output, length of time of drainage, and need for reoperation for wound seroma or infection were reviewed. RESULTS A total of 87 patients met inclusion criteria and had a mean age of 58.5 years (SD 16, range 20 to 81). The average number of levels instrumented and arthrodesed with BMP was 9.2 (SD 3.7; range 4 to 18), and the average dose of BMP used was 31.2 mg (SD 9.6, range 12 to 48) or 2.6 large sponges. Patients required drainage for a mean of 4.9 days (SD 1.3, range 3 to 9). The average total output was 1923 mL (SD 865, range 530 to 4310 mL). The wound infection rate was 2.3% (2 cases of deep wound infection that required reoperation). There was one (1.1%) hematoma, and one (1.1%) sterile seroma, both requiring evacuation. No other wound complications were noted. CONCLUSIONS Use of BMP for long-segment posterior thoracolumbar fusions may be associated with significant drain output, requiring multiple days of drainage. However, when drained adequately, infections and seromas occur infrequently.

Coronal realignment and reduction techniques and complication avoidance.

Scoliosis is a broad term encompassing multiple pathologies with different etiologies. Patients may range from the infant with congenital deformity, to the adolescent with idiopathic scoliosis, to the elderly patient with severe degenerative scoliosis. Treatment must be tailored to individual circumstances and the pathoanatomy of each deformity. Various coronal reduction techniques have been described and will be discussed within this article. While scoliosis is generally considered a deformity in the coronal plane, often deformity is present in the sagittal and axial planes also. Treatment of these deformities can require osteotomies or vertebral column resections, techniques further discussed in accompanying articles.