Adult spinal deformity : Imaging, diagnostics and outcome

Background Back pain originating from multiple spinal disorders is the leading cause of disability worldwide. Adult spinal deformity (ASD) is a complex three-dimensional entity of multiple anatomical and functional disorders and predisposes to decreased health-related quality of life (HRQoL). With rising life expectancy and a growing elderly population it is predicted that an increasing number of symptomatic ASD patients will need surgical treatment. It is noteworthy that the prevalence of different grades of ASD, impact on HRQoL and patient-reported outcome (PRO) of ASD surgery has not earlier been reported in the Finnish population. The aims of this study were to assess the reliability and repeatability of radiographic diagnostic imaging of ASD and to produce a culturally adapted and valid Finnish version of the Scoliosis Research Society (SRS) Questionnaire version 30 for spinal deformities. Thereafter the prevalence of ASD, applicability of a simplified version of the SRS-Schwab ASD classification and the Finnish SRS-30 were evaluated in a symptomatic adult patient cohort with prolonged degenerative spinal disorders. Finally, the long-term outcome, complications, patient satisfaction and predictive factors for poor outcome of ASD surgery, were investigated. Methods Over one year, a consecutive cohort of adult patients was recruited to Studies I-III after referral to the Central Hospital of Central Finland spine clinic due to prolonged degenerative spinal disease. 637 patients returned the completed HRQoL questionnaires and digital full spine radiographs were obtained. The radiographs of 49 patients were randomly selected for the reliability assessment, and a repeatability study of sagittal spinopelvic measurements with basic software tools was performed by three raters differing in their experience of image rating. The SRS-30 underwent translation and cross-cultural adaptation into Finnish and was subsequently validated and psychometrically tested among 274 patients. The SRS-Schwab ASD classification was graded and simplified dividing into mild, moderate and marked groups. The division was tested along with the Finnish SRS-30 questionnaire during evaluation of the prevalence and HRQoL of patients with sagittal malalignment among symptomatic adult patients with spinal degenerative disease but no pre-known deformity. The 79 patients in Study IV were operated during 2007-2016 in our clinic. The clinical and radiographic outcome, patient satisfaction, predictive factors for poor outcome and complications were analysed using the diagnostic tools renovated and tested in Studies I-III. Results The intra-and interrater reliability of the sagittal spinopelvic measurements proved reliable and repeatable with intraclass correlation coefficients (ICC) between 0.78-0.99 and standard error of measurement (SEM) of 0.80-6.2° or 2.2-5.8mm. Greater rater experience in performing the radiographic measurements decreases, and greater complexity of the measurement landmarks increases, intra- and inter-rater bias. The reproducibility and internal consistency (ICC 0.905, SEM 0.17, Cronbach α 0.885) of the Finnish version of the SRS-30 was good. The SRS-30 had discriminative validity in the pain, self-image and satisfaction with management domains compared with other questionnaires. A statistically significant difference between the moderate and marked deformity groups in the SRS-30 domains of function/activity (p=0.022) and self-image/appearance (p=0.016) was found. Of the 637 patients in the consecutive cohort, 25% had moderate and 11% marked spinal deformities. The patients with marked deformity were significantly older, more overweight and more physically inactive than the others in the study population. The 3-class categorization of the SRS-Schwab ASD classification determined well the severity of sagittal deformity and concomitant loss of function, activity (p=0.004), and self-image/appearance (p=0.030) measured with the SRS-30, and disability with the ODI (p=0.033). ASD operation decreased disability (ODI) and pain (VAS) significantly (p=0.001). Postoperative improvement in radiographic sagittal parameters was significant and maintained at 4-5 years of follow-up (p≤0.001). The mechanical failure of instrumentation of bone resulted in reoperation risk of 13.9% within the first and 29.8% during the 5-year follow-up. According to SRS-30, 49 (62.0%) patients were satisfied or very satisfied with the treatment and 57 (72.1%) would have the same operation again. Depression predicted poor outcome with an odds ratio of 6.97 (p=0.018). Conclusions The study comprised an unselected consecutive cohort of adult patients with prolonged degenerative spinal diseases, and thus the results can be generalized. Rater experience had a positive influence on the otherwise good reliability and repeatability of the spinopelvic measurements taken from full spine radiographs. The deformity-specific Finnish SRS-30 translation proved reliable and valid among the study cohort. The simplified categories of the SRS-Schwab ASD classification can detect different grades of deformity and related loss of HRQoL. Long-term radiographic and patient-reported clinical outcomes after the ASD surgery remained significantly better than preoperative scores. Risk for reoperation was highest during the first postoperative year. However good patient satisfaction and outcomes could be achieved irrespective of adverse effects. Depression was the only significant predictive factor for poor outcome after ASD surgery. Keywords: adult spinal deformity, ASD, scoliosis, kyphosis, full-spine radiograph, reliability, repeatability, validation, outcome, health-related quality of life, Scoliosis Research Society questionnaire 30, SRS-30, SRS-Schwab ASD classification, spine surgery, pelvic incidence, pelvic tilt, sagittal vertical axis, lumbar lordosis, thoracic kyphosisTausta Eri syistä johtuva selkäkipu on johtava toimintakykyhaitan aiheuttaja maailmassa. Aikuisen selän ryhtimuutos on anatomisten ja toiminnallisten muutosten aiheuttama kompleksi kolmiulotteinen kokonaisuus joka on yhteydessä heikentyneeseen terveyteen liittyvään elämänlaatuun (HRQoL). Rappeutumaan liittyvät ryhtimuutokset lisääntyvät iän mukana. Kasvanut eliniän odote ja iäkäs väestö ennustavat myös selän ryhtihäiriöiden kirurgisen hoidon tarpeen kasvua. Eri asteisten ryhtihäiriöiden esiintyvyyttä, vaikutusta elämänlaatuun tai leikkaushoidon tuloksia Suomessa ei ole aiemmin julkaistu. Myös suomenkielinen nimikkeistö kuvaamaan ryhtivirheitä on vakiintumatonta. Tutkimuksen tavoite oli tutkia koko rangan röntgenkuvasta mitattujen etu-takasuunnnan sagittaalista ryhtihäiriötä kuvaavien muuttujien luotettavuutta ja toistettavuutta sekä tuottaa suomalaisille rangan ryhtihäiriöpotilaille sovitettu pätevä tulosmittari: Scoliosis Research Society (SRS) kysely versio 30. Jatkossa tutkittiin selän ryhtimuutosten esiintyvyyttä, yksinkertaistetun SRS-Schwab ryhtivirheluokittelun ja SRS-30 kyselyn soveltuvuutta aikuispotilailla, joilla oli pitkittynyt rappeutumaan liittyvä selkä-alaraajakipuoireisto. Lopuksi arvioitiin ryhtiä korjaavan kirurgian pitkäaikaistuloksia, komplikaatioita, potilastyytyväisyyttä ja leikkauksen tulosta ennustavia tekijöitä. Menetelmät Tutkimusjoukko osatöihin I-III kerättiin vuoden aikana Keski-Suomen keskussairaalan selkäyksikköön pitkittyneen rappeutuman aiheuttaman selkäkivun vuoksi lähetetyistä 874 potilaan joukosta. 637 potilasta täytti hyväksytysti kaikki kyselylomakkeet ja heistä otettiin koko rangan röntgenkuva. Sagittaalisuunnan ranka-lantio-muuttujien mittausten luotettavuus ja toistettavuus röntgenohjelman perustyökaluilla tutkittiin satunnaisista 49 kuvasta kolmen eri kokemuksen omaavan mittaajan toimesta. SRS-30 suomenkielinen käännös vahvistettiin päteväksi ja testattiin psykometrisesti 274 potilaalla. SRS-Schwab ryhtivirheluokittelu pisteytettiin ja yksinkertaistettiin jakamalla lieviin, kohtalaisiin ja vaikeisiin ryhmiin. Ryhmät testattiin SRS-30 kyselyn rinnalla potilasjoukossa jonka ryhtihäiriöiden määrää ja vaikutusta arvioitiin osatyössä III. Keski-Suomen keskussairaalassa 2007-2016 leikattujen 79 selän ryhtihäiriöpotilaan kliininen ja kuvantamistulos, potilastyytyväisyys ja huonoa tulosta ennustavat tekijät analysoitiin osatyössä IV. Tulokset Sagittaalisten lantio-rankamuuttujien mittausten luotettavuus ja toistettavuus osoittautui hyväksi (toistettavuuskertoimet ICC 0.78-0.99, mittauksen keskivirhe SEM 0.80-6.2° tai 2.2-5.8 mm välillä). Mittaajan kokemus vähensi ja lukuisat, vaikeasti tunnistettavat maamerkit röntgenkuvassa lisäsivät mittausten välistä virhettä. Suomenkielisen SRS-30 kyselyn toistettavuus ja sisäinen yhtenevyys olivat hyvät (ICC 0.905, SEM 0.17, Cronbach α 0.885). SRS-30 oli pätevä erottelemaan kipua, minäkuvaa ja tyytyväisyyttä hoitoon suhteessa vertailumittareihin. Kohtalaista ja vaikeaa ryhtihäiriötä sairastavien SRS-30 toimintakyky (p=0.022) ja minäkuvaosioiden (p=0.016) välillä oli tilastollisesti merkitsevä ero. Perättäisessä valikoimattomassa 637 aikuispotilaan tutkimusjoukossa 25 %:lla oli kohtalainen ja 11%:lla vaikea selän ryhtihäiriö. Vaikeaa ryhtihäiriötä sairastavat olivat vanhempia, lihavampia ja vähemmän fyysisesti aktiivisia kuin muu tutkimusjoukko. Kolmiportainen SRS-Schwab-ryhtivirheluokitus erotteli hyvin potilaat ryhtihäiriön vaikeuden ja siihen liittyvän SRS-30 elämänlaatumittarin toimintakyvyn (p=0.004) ja minäkuvan (p=0.030) sekä Oswestryn toimintakymittarin tulosten (p=0.033) mukaan. Ryhtihäiriön leikkaushoito paransi merkitsevästi (p=0.001) toimintakykyä Oswestryn toimintakykymittarilla sekä vähensi selkä- ja alarajakipua kipujanalla mitattuna. Radiologiset lantio-selkämuuttujat paranivat leikkauksella merkitsevästi ja ero säilyi 4-5 vuoden seurannassa (p≤0.001). Luun tai instrumentaation pettäminen johti 13.9% uusintaleikkausriskiin ensimmäisenä leikkauksen jälkeisenä vuotena ja 29.8% riskiin viiden vuoden seurannassa. SRS-30 kysymysten perusteella 49(62%) potilaista oli tyytyväisiä leikkaukseen ja 57(72%) tulisi samassa tilanteessa leikkaukseen uudelleen. Depressio ennusti huonoa leikkaustulosta riskisuhteella 6.97(p=0.018). Johtopäätökset Tutkimusjoukko koostui perättäisistä, valikoimattomista aikuispotilaista, joilla oli pitkittynyt rappeutuman aiheuttama selkäsairaus ja tulos on siten yleistettävissä. Röntgenkuvan lukijan kokemus parantaa hyvää lantio-selkämuuttujien mittauksen luotettavuutta ja toistettavuutta erityisesti tarkasteltaessa useita ja vaikeasti määritettäviä maamerkkejä. Suomenkielinen SRS-30 kysely osoittautui luotettavaksi ja toistettavaksi tutkimusjoukossa. Kolmiportainen SRS-Schwab ryhtihäiriöluokitus erotteli hyvin ryhtivirheiden vaikeusasteet ja niihin liittyvän terveyshaitan. Pitkän ajan seurannassa radiologinen ja kliininen ryhtihäiriön leikkaustulos säilyi merkitsevästi lähtötilannetta parempana. Uusintaleikkauksen riski oli suurin ensimmäisen leikkauksenjälkeisen vuoden aikana. Kuitenkin suurin osa potilaista oli tyytyväisiä leikkaustulokseen komplikaatioista huolimatta. Masennus ennusti huonoa elämänlaatumittaritulosta ryhtihäiriöleikkauksen jälkeen. Avainsanat: aikuisen selän ryhtihäiriö, skolioosi, kyfoosi, koko rangan röntgenkuva, toistettavuus, luotettavuus, pätevyys, validointi, tulosmittari, toimintakyky, Scoliosis Research Society, SRS-30, SRS-Schwab luokitus, selkäkirurgia, lantion kiintokulma, lantion kallistuskulma, sagittaalinen pystyakseli, lannelordoos

Association between sagittal spinal alignment and mechanical complications after primary total hip arthroplasty : a systematic review

Objective: Total hip arthroplasty (THA) affects pelvic posture and spinal alignment. These postural changes may further predispose patients to mechanical complications (MCs) after THA. The aim of this study was to conduct a systematic review to investigate whether any high-quality studies have assessed the association between sagittal spinal alignment and MCs after primary THA. Methods: Inclusion criteria for studies were adult patients (age ≥18 years), primary THA, pre- and postoperative spinopelvic standing sagittal radiographs acquired preoperatively and at a minimum of 6-month follow-up, measurements of spinopelvic parameters, and reporting of possible MCs after THA. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Results: Six articles met the inclusion criteria. Although several studies confirmed the importance of spinal alignment when planning THA, these mainly investigated pelvic mobility as a risk factor for THA dislocation. Radiological follow-up imaging practices varied, and studies focused on different individual spinopelvic parameters. Conclusion: Based on our study findings, no conclusions can be drawn regarding the association between sagittal spinal alignment and MCs after primary THA. Further research is needed to improve our knowledge of the connection between MCs after THA and sagittal spinal alignment.publishedVersionPeer reviewe

Mechanical complications and reoperations after adult spinal deformity surgery : a clinical analysis with the GAP score

Purpose: Adult spinal deformity (ASD) surgery is prone to postoperative complications, leading to high reoperation rates. The global alignment and proportion (GAP) score is a novel method to predict mechanical complications (MC) based on the optimal parameters related to individual pelvic incidence. The aim of this study was to determine the cut-off point and the predictive value of the GAP score for those MCs that require reoperation. A secondary aim was to investigate the cumulative incidence of MCs requiring reoperation during a long follow-up period. Methods: In total, 144 ASD patients were operated at our institution due to marked symptomatic spinal deformity between 2008 and 2020. The cut-off point and the predictive value of the GAP score for the MCs that required reoperation and the cumulative incidence of reoperated MCs after index surgery were determined. Results: A total of 142 patients were included in the analysis. The risk for having an MC that required reoperation was significantly lower when the postoperative GAP score was < 5 (HR = 3.55, 95% CI: 1.40–9.02). The discriminative power of the GAP score to predict MCs that require reoperation was good with an AUC of 0.70 (95% CI: 0.58–0.81). The cumulative incidence of reoperated MCs was 18%. Conclusion: The GAP score was associated with the risk for MCs that require reoperation. The best predictive value for surgically treated MC was with the GAP score ≥ 5. The cumulative incidence of the reoperated MCs was 18%.publishedVersionPeer reviewe

Increased interleukin-6 and C-reactive protein levels after instrumented lumbar spine fusion in older patients

Purpose: Interleukin 6 (IL-6) and the acute phase C-reactive protein (CRP) blood concentrations after lumbar spine fusion may be affected by age. The purpose of this prospective observational study was to assess postoperative serum levels of pro-inflammatory IL-6 and CRP after instrumented lumbar spine fusion surgery. We hypothesized that older patients would have increased levels of IL-6 and CRP after surgery. Methods: IL-6 and high-sensitive CRP biochemical marker levels were measured before instrumented spinal fusion, and postoperatively at 1 and 3 days, 6 weeks, and 3 months. The 49 patients in this sample were divided into two groups: age 60 years (n = 26). Results: Acute changes in IL-6 high-sensitivity and CRP from preoperative levels to postoperative day (POD) 1 increased with age. Mean (95% CI) difference between the age-groups in changes of IL-6 at PODs 1 and 3 was 45 pg/ml (10-83, p = 0.014) and 20 pg/ml (5-36, p = 0.021), respectively. Mean (95% CI) difference between groups in changes of CRP at PODs 1 and 3 was 9.6 mg/l (-3.5 to 22.7, p = 0.47) and 24.8 mg/l (-17 to 67, p = 0.33), respectively. Both groups had decreased IL-6 and CRP levels at 6 weeks after surgery compared to the preoperative level. Conclusions: Elevation of IL-6 and CRP is stronger in patients over 60 years old after instrumented lumbar spinal fusion. The CRP and IL-6 are sensitive markers for acute postoperative inflammation. Even high acute CRP values do not necessarily indicate postoperative infection.Peer reviewe

Scoliosis Research Society (SRS-30) kyselykaavakkeen pätevyys selkä- ja alaraajakipuisilla aikuispotilailla

Scoliosis Research Society questionnaire version 30 (SRS-30) has originally been developed to measure disability and health related quality of life in patients with adolescent idiopathic scoliosis but it has proven valid also in adults with degenerative spinal disease. Degenerative spine disease has many phases and manifestations including disc degeneration, spondylarthrosis, spondylolistheses and compromise to neural tissue. The aim of this study was to test whether the SRS-30 questionnaire is valid in adults with different sources of pain: local back pain, radicular pain or their combination. Structural analysis of the SRS-30 and comparison with RAND-36 and ODI was performed. The deformity specific SRS-30 proved applicable to all adult patients with a degenerative spine condition regardless of the source of pain.nonPeerReviewe

DEPS-testin luotettavuus ja pätevyys aikuisilla selkäpotilailla

The Depression Scale (DEPS) is a patient-reported outcome instrument developed to recognize depressive symptoms. This study measured the psychometric properties of the DEPS among patients with degenerative spinal disease. Altogether 637 patients were included in the analysis. Main research question was whether the DEPS would meet pertinent psychometric criteria for reliability and validity. The results of analyses supported the DEPS instrument as a reliable and valid test to measure depressive symptoms among adult patients with spinal disease fulfilling the psychometric criteria.nonPeerReviewe

Aikuisten selän ryhtivirheet : leikkaushoidon pitkäaikaistulokset K-SKS:ssa

Adult patients with degenerative deformities (ASD) benefit surgical treatment when exercise and pain medication seize to control their symptoms. Disability and clinical symptoms are stronger drivers against surgical treatment of ASD than radiographic changes. We present the results of 79 adult patients’ corrective surgery for degenerative spinal deformity of after 1-10 year follow-up. PI-LL (pelvic incidence minus lumbar lordosis) mismatch remained stable after correction during follow-up. Global sagittal balance indicated by sagittal vertical axis (SVA) and T1 pelvic angle (TPA) started deteriorating after 2.5 years postoperatively. 26 (32.9%) patients required reoperation. 77.1% of the patients were satisfied with the treatment at follow-up and the most important single item was relief of pain. They had a statistically significant improvement postoperatively in Oswestry Disability Index and back and leg pain. Depression and multiple co-morbidities predicted poor result for surgery.nonPeerReviewe

Benefits of Lumbar Spine Fusion Surgery Reach 10 Years with Various Surgical Indications

Background Lumbar spine fusion (LSF) surgery is a viable form of treatment for several spinal disorders. Treatment effects are preferably to be endorsed in real-life settings. Methods This prospective study evaluated the 10-year outcomes of LSF. A population-based series of elective LSFs performed at 2 spine centers between January 2008 and June 2012 were enrolled. Surgeries for tumor, acute fracture or infection, neuromuscular scoliosis, or postoperative conditions were excluded. The following patient-reported outcome measures (PROMs) were collected at baseline, and 1, 2, 5, and 10 years postsurgery: VAS for back and leg pain, ODI, SF-36. Longitudinal measures of PROMs were analyzed using mixed-effects models. Results 683 patients met the inclusion criteria, and 630 (92%) of them completed baseline and at least one f-u PROMs, and they constituted the study population. Mean age was 61 (SD 12) years, 69% women. According to surgical indication, patients were stratified into degenerative spondylolisthesis (DS, n=332, 53%), spinal stenosis (SS, n=102, 16%), isthmic spondylolisthesis (IS, n=97, 15%), degenerative disc disease (DDD, n=52, 8%), and deformity (DF, n=47, 7%). All diagnostic cohorts demonstrated significant improvement at 1 year, followed by a partial loss of benefits by 10 years. ODI baselines and changes at 1 and 10 years were: (DS) 45, -21, and -14; (SS) 51, -24, and -13; (IS) 41, -24, and -20; (DDD) 50, -20, and -20; and (DF) 50, -21, and -16, respectively. Comparable patterns were seen in pain scores. Significant HRQoL achievements were recorded in all cohorts, greatest in physical domains, but also substantial in mental aspects of HRQoL. Conclusions Benefits of LSF were partially lost but still meaningful at 10 years of surgery. Long-term benefits seemed milder with degenerative conditions, reflecting the progress of the ongoing spinal degeneration. Benefits were most overt in pain and physical function measures.peerReviewe

Spinopelvic changes based on the simplified SRS-Schwab adult spinal deformity classification: relationships with disability and health-related quality of life in adult patients with prolonged degenerative spinal disorders

Study Design. Cross-sectional, observational study. Objective. To study the occurrence of sagittal malalignment, the adaptability of a simplified sagittal modifiers grading of the Scoliosis Research Society (SRS)-Schwab adult spinal deformity (ASD) classification, and the deformity-specific SRS questionnaire version 30 (SRS-30) in an unselected adult cohort with symptomatic degenerative spinal disorders. Summary of Background Data. The sagittal modifiers of the SRS-Schwab ASD classification correlate with health-related quality of life (HRQoL) measures in patients with ASD. The deformities and disabilities caused by sagittal malalignment in patients with common degenerative spinal disorders of multiple etiologies are rarely studied. A simplified and categorizing version of the SRS-Schwab ASD classification in relation to the Oswestry Disability Index (ODI) and the SRS-30 outcomes has not yet been developed. Methods. We recruited 874 consecutive patients with degenerative spinal disorders between March 2013 and February 2014. Full spine radiographs were taken and the patients divided into sagittal deformity severity groups: mild or none, moderate, and marked deformity. Participants completed the ODI, SRS-30, and a general health questionnaire. Results. We included 637 patients in the analysis. The severity of sagittal deformity was mild or none in 407 (63.9%) patients, moderate in 159 (25.0%), and marked in 71 (11.1%). Linearity across the modifier grades and deformity classes was found for ODI total score (P ¼ 0.033), and the function/activity (P ¼ 0.004) and self-image/appearance (P¼ 0.030) domains of the SRS-30. Age, body mass index, duration of symptoms, and the use of painkillers increased while physical activity, working, and educational status decreased significantly with deformity severity. Conclusion. Sagittal spinopelvic malalignment is significantly related to deterioration of the ODI and the SRS-30 in symptomatic adults with degenerative spinal disorders. The SRS-Schwab classification sagittal modifiers categorized into three groups is a practical tool to detect various clinically significant grades of deformity in a cohort with no recognized ASD.peerReviewe