Clinical and stereoradiographic analysis of adult spinal deformity with and without rotatory subluxation

Introduction: In degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory sublux-ation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis.Stereoradiography, recently developed for medical applications, provides full-body standing radiographsand 3D reconstruction of the spine, with low radiation dose.Hypothesis: 3D stereoradiography improves analysis of RS and of its relations with transverse plane andspinopelvic parameters and clinical impact.Material and methods: One hundred and thirty adults with lumbar ASD and full-spine EOS®radiographs(EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in thecoronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation(apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS(lateral listhesis > 5 mm) and without RS (without lateral listhesis exceeding 5 mm: non-RS). Correlationsbetween radiologic and clinical data were assessed.Results: RS patients were significantly older, with larger Cobb angle (37.4◦vs. 26.6◦, P = 0.0001), moresevere sagittal deformity, and greater apex AVR and TI (respectively: 22.9◦vs. 11.3◦, P 10◦without visible RS on 2D radiographs. RS patientsreported significantly more frequent low back pain and radiculalgia.Discussion: In this EOS®study, ASD patients with RS had greater coronal curvature and sagittal and trans-verse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosisand prognosis to guide management.Level of evidence: 4, retrospective study.Master’s grant from the French Orthopedic and Traumatologic Surgery Society (SOFCOT), without which this research would not have been possible

Three-Dimensional Analysis of Initial Brace Correction in the Setting of Adolescent Idiopathic Scoliosis

The three-dimensional nature of adolescent idiopathic scoliosis (AIS) necessitates a tridimensional assessment and management. Bracing constitutes the mainstay conservative treatment for mild adolescent idiopathic scoliosis. In the literature hitherto, there has been uncertainty regarding the behavior of the spine, pelvis, and vertebral orientations in the context of bracing, especially in the transverse plane. This poses a challenge to healthcare providers, patients, and their families, as brace treatment, although not as invasive as surgery, is laden with medical and psychological complications and could be considered traumatizing. Hence, a thorough understanding of initial three-dimensional spinal behavior in the context of bracing is important. The purpose of this retrospective study was to investigate the immediate 3D impact of Chêneau-type brace. Thirty-eight patients with AIS undergoing Chêneau-type bracing were included. Patients were stratified according to their structural curve topography into thoracic, thoracolumbar, and lumbar groups. 3D reconstruction of the spine using a dedicated biplanar stereoradiography software with and without the brace was performed. The examined anthropometric radiographic measures were pre- to in-brace variations and differences of spinopelvic parameters and vertebral orientations in the coronal, sagittal, and transverse planes. The complex impact of the Chêneau-type brace on different curves in three planes was delineated. In the coronal plane, the Cobb angle was significantly decreased in all types of curves, and the coronal tilt correction was concentrated in specific segments. The impact of the brace in this study on the sagittal profile was variable, including the loss of thoracic kyphosis and lumbar lordosis. In the transverse plane, an axial vertebral rotation change and detorsion above the apex occurred in the thoracolumbar curves. The results from this exploratory study could shed some light on the initial 3D spinal behavior in the context of bracing and may be of beneficial for treating physicians and brace makers

Bilateral psoas release for long standing hip-spine syndrome: surgical technique and case report

ABSTRACT: Background: Severe positive sagittal malalignment can potentially lead to shortening and contracture of the psoas and joint capsule in a flexed spinopelvic position. The utilization of bilateral psoas release to supplement sagittal spinal deformity correction in the same hospitalization was not reported in the literature. Case presentation: A 66-year-old patient presented with a 5-year history of severe global spinal deformity (sagittal vertical axis 220 mm, 60° spinopelvic mismatch) that did not improve on supine radiographs, and a modified Thomas test with more than 30° flexion contracture of bilateral hips. A 3-stage operation utilizing posterior spinal column osteotomies, anterior lumbar interbody fusion, and bilateral psoas releases was performed. Outcome: Her postoperative alignment significantly improved and she was pleased with her new posture and the ability to stand up straight. Conclusions: This report is the first to demonstrate safe and substantial correction of severe spinal deformities associated with bilateral hip flexion contracture in 1 hospitalization

Impact of Sacroiliac Belt Utilization on Balance in Patients with Low Back Pain

Low back pain (LBP) is a common problem which can affect balance and, in turn, increase fall risk. The aim of this investigation was to evaluate the impact of a Sacroiliac Belt (SB) on balance and stability in patients with LBP. Subjects with LBP and without LBP ("Asymptomatic") were enrolled. Baseline balance was assessed using the Berg Balance Scale. In a counterbalanced crossover design, LBP and Asymptomatic subjects were randomized to one of two groups: 1) start with wearing the SB (Serola Biomechanics, Inc.) followed by not wearing the SB or 2) start without wearing the SB followed by wearing the SB. For subjects in both groups, dynamic balance was then assessed using the Star Excursion Balance Test (SEBT) with each leg planted. Baseline balance was worse in LBP subjects (Berg 51/56) than Asymptomatic subjects (Berg 56/56) (p<0.01). SB significantly improved SEBT performance in LBP subjects regardless of which leg was planted (p<0.01). SB positively impacted Asymptomatic subjects' SEBT performance with the left leg planted (p=0.0002). The Serola Sacroiliac Belt positively impacted dynamic balance for subjects with low back pain. Further research is needed to examine additional interventions and outcomes related to balance in patients with back pain, and to elucidate the mechanisms behind improvements in balance related to sacroiliac belt utilization

Tridimensional Analysis of Rotatory Subluxation and Sagittal Spinopelvic Alignment in the Setting of Adult Spinal Deformity

International audienceStudy Design: Retrospective single-center.Objective : To investigate rotatory subluxation (RS) in adult spinal deformity (ASD) with three-dimensional (3D) stereoradiographic images and analyze relationships between RS, transverse plane parameters, spinopelvic parameters, and clinical outcomes.Background: Recent research has demonstrated that sagittal plane malalignment and listhesis correlate with ASD patient-reported outcomes. However, there is still a lack of knowledge regarding the clinical impact of 3D evaluation and rotatory subluxation. Recent developments in stereoradiography allow clinicians to obtain full-body standing radiographs with low-dose radiation and 3D reconstruction.Methods: One hundred thirty lumbar ASD patients underwent full-spine biplanar radiographs (EOS Imaging, Paris, France). Clinical outcomes were recorded. Using sterEOS software, spinopelvic parameters and lateral listhesis were measured. 3D transverse plane parameters included apical axial vertebral rotation, axial intervertebral rotation (AIR), and torsion index (sum of AIR in the curve). ASD patients were divided in three groups: AIR 10°. Groups were compared with respect to radiographic and clinical data. Correlations were performed between the transverse and sagittal plane parameters and clinical outcomes.Results: Patients with AIR >10° were significantly older, with larger Cobb angle (39.5°) and greater sagittal plane deformity (pelvic incidence–lumbar lordosis mismatch 11.7° and pelvic tilt 22.6°). The AIR >10° group had significantly greater apical vertebra axial rotation apex (24.8°), torsion index (45°), and upper-level AIR (21.5°) than the two other groups. Overall, 27% of AIR patients did not have two-dimensional (2D) lateral listhesis. Patients with AIR >10° had significantly worse Oswestry Disability Index and more low back pain.Conclusion : For patients in which lateral listhesis was unreadable in 2D imaging, rotatory subluxation was revealed using stereoradiography and at an earlier disease stage. Moreover, different 3D transverse plane parameters are related to different patient-reported outcomes. Therefore, axial rotation can be considered in evaluation of lumbar degenerative scoliosis severity and prognosis

Burst fracture treatment caudal to long posterior spinal fusion for adolescent idiopathic scoliosis utilizing temporary lumbo-pelvic fixation with restoration of lumbar mobility after instrumentation removal

ABSTRACT: Background: Thoracolumbar burst fractures are common traumatic spinal fractures. The goals of treatment include stabilization, prevention of neurologic compromise or deformity, and preservation of mobility. The aim of this case report is to describe the occurrence and treatment of an L4 burst fracture caudal to long posterior fusion for adolescent idiopathic scoliosis (AIS). Case report: A 15-year-old girl patient underwent posterior spinal fusion from T3–L3. The patient tolerated the procedure well and there were no complications. Seven years postoperatively, the patient reported to the emergency department with lumbar pain after fall from height. A burst fracture at L4 was diagnosed and temporary posterior instrumentation to the pelvis was performed. One-year postinjury, the hardware was removed with fixation replaced only into the fractured segment. Flexion/extension radiographs revealed restored motion. Conclusions: Treatment of fractures adjacent to fusion constructs may be challenging. This case demonstrates that avoiding fusion may lead to satisfactory outcomes and restoration of mobility after instrumentation removal

Impact of Myelopathy Severity and Degree of Deformity on Postoperative Outcomes in Cervical Spinal Deformity Patients

Objective Malalignment of the cervical spine can result in cord compression, leading to a myelopathy diagnosis. Whether deformity or myelopathy severity is stronger predictors of surgical outcomes is understudied. Methods Surgical cervical deformity (CD) patients with baseline (BL) and up to 1-year data were included. Modified Japanese Orthopaedic Association (mJOA) score categorized BL myelopathy (mJOA = 18 excluded), with moderate myelopathy mJOA being 12 to 17 and severe myelopathy being less than 12. BL deformity severity was categorized using the mismatch between T1 slope and cervical lordosis (TS-CL), with CL being the angle between the lower endplates of C2 and C7. Moderate deformity was TS-CL less than or equal to 25° and severe deformity was greater than 25°. Categorizations were combined into 4 groups: group 1 (G1), severe myelopathy and severe deformity; group 2 (G2), severe myelopathy and moderate deformity; group 3 (G3), moderate myelopathy and moderate deformity; group 4 (G4), moderate myelopathy and severe deformity. Univariate analyses determined whether myelopathy or deformity had greater impact on outcomes. Results One hundred twenty-eight CD patients were included (mean age, 56.5 years; 46% female; body mass index, 30.4 kg/m2) with a BL mJOA score of 12.8±2.7 and mean TS-CL of 25.9°±16.1°. G1 consisted of 11.1% of our CD population, with 21% in G2, 34.6% in G3, and 33.3% in G4. At BL, Neck Disability Index (NDI) was greatest in G2 (p=0.011). G4 had the lowest EuroQol-5D (EQ-5D) (p<0.001). Neurologic exam factors were greater in severe myelopathy (p<0.050). At 1-year, severe deformity met minimum clinically important differences (MCIDs) for NDI more than moderate deformity (p=0.002). G2 had significantly worse outcomes compared to G4 by 1-year NDI (p=0.004), EQ-5D (p=0.028), Numerical Rating Scale neck (p=0.046), and MCID for NDI (p=0.001). Conclusion Addressing severe deformity had increased clinical weight in improving patient-reported outcomes compared to addressing severe myelopathy

Acute spinal cord compression in the setting of chronic extramedullary hematopoiesis of the thoracic spine

Background: Though rare, pathologic extramedullary hematopoiesis (EMH) can occur in response to myeloproliferative disorders and may present as paravertebral masses. Case Description: We describe a 63-year-old female with unspecified thalassemia, hemochromatosis, and known asymptomatic extramedullary hematopoiesis of the thoracic spine who acutely developed severe spinal cord compression and a T9 vacuum phenomenon fracture 7 months after her initial diagnosis. Outcome: The patient was treated with urgent decompression and T9 kyphoplasty, which resulted in complete resolution of her neurological deficits. Conclusions: The timeline of symptomatology in the case suggests that asymptomatic patients with T-spine extramedullary hematopoiesis can develop progressive neurologic deterioration and atraumatic compression fractures culminating in acute spinal cord injury. While it may be appropriate to treat asymptomatic patients conservatively, surgical decompression must always remain a consideration