surgical treatment analysis of 809 thoracolumbar and lumbar major adult deformity cases by a new...
Post on 22-Dec-2015
222 views
TRANSCRIPT
Surgical treatment analysis of 809 Surgical treatment analysis of 809 thoracolumbar and lumbar major adult thoracolumbar and lumbar major adult
deformity cases by a new adult deformity cases by a new adult scoliosis classification systemscoliosis classification system
Zorab Symposium 2006
F Schwab, JP Farcy, K Bridwell, S Berven, S Glassman, W Horton, M Shainline
Spinal Deformity Study Group
Background
Unlike pediatric and adolescent scoliosis, no accepted classification system exists for adult scoliosis
Scoliosis in the adult population– prevalence as high as 60%– significant pain and disability– Quality of life issues
Classification systems provide– Common language for communication– Correlation with clinical impact
treatment algorithms surgical guidelines
Skeletal maturity• Risser sign
PTPain MgmtBracingSurgery
Curve severity• Cobb angle• progression
Cosmesis
Pain
Disability
BackgroundAdult deformity: Treatment approach
Multi-center prospective studyMulti-center prospective study
Classification SystemClassification SystemApical level
Lumbar lordosis modifierIntervertebral subluxation modifier
Global Balance modifier
Clinical GroupClinical GroupScoliosis with apex T4 to L4Degenerative or idiopathic809 consecutive patients
Radiographic analysisRadiographic analysis full length, standing films
Cobb angle,apical level of deformity,
sagittal plane lumbar alignment
Health assessment Health assessment questionnairesquestionnaires
ODI / SRS-29 / SF-12
Background
1. Type
2. Modifiers
Lumbar LordosisLumbar Lordosis
A : marked >400
B : moderate 0-400
C : no lordosis, Cobb >00
Intervertebral SubluxationIntervertebral Subluxation
0 : none at any level+ : max = 1-6mm++ : max >7mm
Type IThoracic
only
Type IIUpper Thoracic
major
Type IIILower Thoracic
major
Type IVThoraco-lumbar
major
Type VLumbarmajor
no other curves
ApexT9-T10
ApexT9-T10
ApexT11-L1
ApexL2-L4
BackgroundAdult Scoliosis Classification
N Neutrally balanced <4cm
P Positively balanced 4-9.5cm
VP Very Positive >9.5cm
Global BalanceGlobal Balance
Reliable classificationReliable classification withwith significant significant
correlation to clinical correlation to clinical symptomssymptoms
Prediction of treatment Prediction of treatment patterns and surgical patterns and surgical
rates ???rates ???
PurposeAdult Scoliosis Classification
Materials & Methods
1. Clinical group1. Clinical group• Spinal Deformity Study Group database• Prospective, consecutive 809 patients review• Ages > 18 y.o.• Thoracolumbar or lumbar major scoliosis
•Type IV and Type V deformities only.
2. Health questionnaires2. Health questionnaires• Oswestry Disability Index (ODIODI) • Scoliosis Research Society instrument (SRS-22SRS-22)• Short From 12 (SF-12SF-12)
Materials & Methods
3. Radiographic parameters3. Radiographic parameters• Full-length standing films • Frontal Cobb angle, • Apical level, • Sagittal lumbar alignment (T12-S1),
Lumbar Lordosis
A : marked >40°B : moderate 0-40 °C : no lordosis, Cobb >0°
Intervertebral Subluxation0 : none at any level+ : max = 1-6mm++ : max >7mm
Sagittal Balance
N Neutrally balanced <4cmP Positively balanced 4-9.5cmVP Very Positive >9.5cm
4. Treatment approach4. Treatment approach • Surgical vs. non-surgical • If Surgical:
• Anterior, Posterior, circumferential• Use of osteotomies • Extension of fusion to sacrum
Materials & Methods
5. Data Analysis5. Data Analysis• Treatment Analysis regarding
• HRQOL measures• SRS-22, ODI, SF-12
• Correlation analysis• Classification types vs. treatment given
806 806 thoracolumbar/lumbar thoracolumbar/lumbar major deformitiesmajor deformities
– Type IV Type IV n=311 n=311 – Type V Type V n=495 n=495
– Mean age 53.1 y.o. (+/- 15.3)Mean age 53.1 y.o. (+/- 15.3)– 700 Females (87%) 700 Females (87%) – 106 Males (13%)106 Males (13%)
ResultsPatients Distribution
Rates of operative treatment
– Lordosis modifierLordosis modifier BB vs. vs. AA (51% vs. 37%, p<0.05), trend for A vs. C (46%) (51% vs. 37%, p<0.05), trend for A vs. C (46%)
– Subluxation modifierSubluxation modifier ++++ vs. vs. 00 (52% vs. 36 %, p<0.05), trend vs. + (42 %) (52% vs. 36 %, p<0.05), trend vs. + (42 %)
– Sagittal BalanceSagittal Balance NN vs. vs. VPVP: 39% vs. 59%, p<0.05: 39% vs. 59%, p<0.05
ResultsSurgical rates
92% highest level of fixation above apex of major curve.97% lowest level of fixation below apex of major curve.10% to level of sublux, 87% at least one level beyond
Fusion to sacrum
Apical LevelTrend for type V patients more likely to have fixation to sacrum (p=.074)
Lordosis Modifiermod B patients more likely fusion to sacrum than mod A patients (p=.041)
Sagittal Balance Modifierincreasing positive balance: more likely fixation extended to the sacrum. (mod N: 59%, mod P: 80%, mod VP: 88%) (all p<0.05)
ResultsTreatment Analysis: Type IV, V curves
Surgical ApproachSurgical Approach
Anterior only Anterior only – mostly lordosis modifier Amostly lordosis modifier A– Subluxation modifier 0Subluxation modifier 0– Sagittal balance modifier NSagittal balance modifier N
Circumferential:Circumferential:– trend most common trend most common
modifier Bmodifier B– Most commonly subluxation Most commonly subluxation
modifier ++modifier ++
Posterior only:Posterior only: – mostly lordosis modifier Cmostly lordosis modifier C– Sagittal balance modifier VPSagittal balance modifier VP
Use of osteotomiesUse of osteotomies
Lordosis modifierLordosis modifier A vs. C A vs. C – 25% vs. 50% p=0.0125% vs. 50% p=0.01
Sagittal balanceSagittal balance N vs. VP N vs. VP– 25% vs. 53% p=0.0125% vs. 53% p=0.01
ResultsTreatment Analysis: Type IV, V curves
TreatmentTreatment
• Good lordosis (modifier A) less likely to have surgery • Most likely to require surgery:
• loss of lordosis (C), • marked subluxation (++)• sagittal plane imbalance (VP)
If surgeryIf surgery
• Cross level of subluxation• Osteotomies to realign sagittal plane
• lordosis modifier C gets most likely to require osteotomy• fusion to sacrum: with increasing sagittal imbalance, lost lordosis
ResultsMain findings
Clinical ImpactClinical Impact established: established:– HRQOLHRQOL– Treatment….non-op vs. surgicalTreatment….non-op vs. surgical– Surgical strategy…we’re getting thereSurgical strategy…we’re getting there
How about results of treatment results of treatment ?Work toward surgical guidelines
2 yr
f/u
Discussion - ConclusionAdult scoliosis classification
Can we broaden to a:
Comprehensive Adult Deformity Comprehensive Adult Deformity ClassificationClassification
ReliableReliableClinical impactClinical impact
• disability• surgical rate
Surgical strategy ?Surgical strategy ?
Discussion - Conclusion
Adult scoliosis classification
Type I thoracic-only curve (no other curves)II upper thoracic major, apex T4-8 III lower thoracic major, apex T9-T10IV thoracolumbar major curve, apex T11-L1V lumbar major curve, apex L2-L4Type K no scoli (<100), principal sagittal plane deformity
Lumbar Lordosis A marked lordosis >400
Modifier B moderate lordosis 0-400
C no lordosis present Cobb >00
Subluxation 0 no intervertebral subluxation any levelModifier + maximal measured subluxation 1-6mm
++ maximal subluxation >7mm
Sagittal Balance N normal, <4cm positive SVA Modifier P positive, 4-9.5cm
VP very positive, >9.5cm
Classification of Adult Deformity
Refine ClassificationRefine Classification• Pelvic modifier• Co-morbidity index• Patient expectation scale
Longitudinal follow upLongitudinal follow up• who responds well to conservative care • who benefits (how much) from surgery
•Complications ?
Surgical analysis (2yr f/u)Surgical analysis (2yr f/u)• what strategies are most effective
Next StepsAdult scoliosis classification