ABSTRACT Objectives: Determine the most prevalent type of curve in our population, to quantify the radiographic parameters such as PT, IP, SS and compare the physical function according to ODI and SRS-22r. Methods: Retrospective, observational, longitudinal, single-center study, carried out from January 2010 to May 2015 at the Centro Médico ISSEMYM Ecatepec, Spine Surgery Service. Results: A total of 60 patients were obtained, 60% female, with curvatures according to SRS-Schwab, type T (28%), TL (46.6%), D (15%), N (10%), with a mean preoperative VAS of 7 for all curves and post-surgical 2 after 6 months. The SRS-22r preoperative test was 2.1 and postoperatively was 3.75, with p&lt;0.001. Conclusions: Deformities of the adult spine are a growing disease in our country. The surgical management of deformities requires proper clinical and radiographic planning. Patients undergoing surgical treatment in our study showed curvature type TL and demonstrated significant improvement in ODI and SRS-22r. Keywords: Scoliosis; Classification SRS-schwab; Sagittal balance; Radiographic criteria.  RESUMO Objetivos: Determinar o tipo de curva mais prevalente em nossa população, quantificar os parâmetros radiográficos, tais como PT, PI, SS e comparar a função física de acordo com ODI e SR

Abraham Isais Gomez

Amado Gonzalez Moga

Gabriel Huerta Hernandez

Galicia Luna

Juan Enrique Guzman Carranza

Leonardo Alvarez Vazquez

Victor Hugo Anaya Contreras

Victor Misael

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115
Study conducted at the Centro Medico ISSEMYM Ecatepec, Department of Spine Surgery, State of Mexico, Mexico.
Correspondence: Centro Médico ISSEMYM ECATEPEC, Servicio de Cirugía de Columna, Avenida del trabajo s/n, Colonia el Carmen, Estado de México. omnipen@gmail.com
GLOBAL BALANCE IN ADULT SPINAL DEFORMITIES.  
A STUDY OF 60 CASES
ALINHAMENTO GLOBAL EM DEFORMIDADES DA COLUNA VERTEBRAL DO ADULTO.  
UM ESTUDO DE 60 CASOS
BALANCE GLOBAL EN LAS DEFORMIDADES ESPINALES DEL ADULTO.  
UN ESTUDIO DE 60 CASOS
http://dx.doi.org/10.1590/S1808-185120161502155247
Victor Misael Galicia luna1, Juan enrique GuzMan carranza1, aMado Gonzalez MoGa1, Gabriel Huerta Hernandez1,  
abraHaM isais GoMez1, Victor HuGo anaya contreras1, leonardo alVarez Vazquez1
ABSTRACT
Objectives: Determine the most prevalent type of curve in our population, to quantify the radiographic parameters such as PT, IP, SS and 
compare the physical function according to ODI and SRS-22r. Methods: Retrospective, observational, longitudinal, single-center study, carried 
out from January 2010 to May 2015 at the Centro Médico ISSEMYM Ecatepec, Spine Surgery Service. Results: A total of 60 patients were 
obtained, 60% female, with curvatures according to SRS-Schwab, type T (28%), TL (46.6%), D (15%), N (10%), with a mean preoperative VAS 
of 7 for all curves and post-surgical 2 after 6 months. The SRS-22r preoperative test was 2.1 and postoperatively was 3.75, with p<0.001. 
Conclusions: Deformities of the adult spine are a growing disease in our country. The surgical management of deformities requires proper 
clinical and radiographic planning. Patients undergoing surgical treatment in our study showed curvature type TL and demonstrated significant 
improvement in ODI and SRS-22r.
Keywords: Scoliosis; Classification SRS-schwab; Sagittal balance; Radiographic criteria.
RESUMO
Objetivos: Determinar o tipo de curva mais prevalente em nossa população, quantificar os parâmetros radiográficos, tais como PT, PI, SS 
e comparar a função física de acordo com ODI e SRS-22r. Métodos: Estudo retrospectivo, observacional, longitudinal, em centro único, 
realizado no período de janeiro de 2010 a maio de 2015 no Centro Médico ISSEMYM Ecatepec, Serviço de Cirurgia da Coluna. Resultados: 
Reuniu-se um total de 60 pacientes, 60% do sexo feminino, com curvaturas, de acordo com o SRS-Schwab, tipo T (28%), TL (46,6%), D 
(15%), N (10%), com EVA média pré-operatória de 7 para todas as curvas e pós-cirúrgica de 2 depois de 6 meses. O teste SRS-22r pré-
-operatório foi de 2,1 e o pós-operatório foi de 3,75, com p < 0,001. Conclusões: As deformidades da coluna vertebral do adulto são uma 
doença crescente em nosso país. O tratamento cirúrgico das deformidades requer planejamento clínico-radiográfico adequado. Os pacientes 
submetidos ao tratamento cirúrgico em nosso estudo mostraram curvatura tipo TL e apresentaram melhora significativa de ODI e SRS-22r.
Descritores: Escoliose; Classificação SRS-Schwab; Equilíbrio sagital; Critérios radiográficos.
RESUMEN
Objetivos: Determinar el tipo de curva más frecuente en nuestra población, cuantificar los parámetros radiográficos como PT, PI, SS y comparar 
la función física de acuerdo al test de ODI y SRS-22r. Métodos: Estudio retrospectivo, observacional, longitudinal y unicéntrico, realizado en el 
periodo entre Enero de 2010 y Mayo de 2015 en el Centro Médico ISSEMYM Ecatepec, Servicio de Cirugía de Columna. Resultados: Se obtu-
vieron un total de 60 pacientes, 60% mujeres, con curvaturas, de acuerdo a la clasificación SRS-Schwab, tipo T (28%), tipo TL (46,6%), tipo D 
(15%), tipo N (10%), con una EVA prequirúrgica promedio de 7 para todo tipo de curvas y posquirúrgica de 2 a los 6 meses. El test de SRS-22r 
prequirúrgico fue de 2,1 y el posquirúrgico de 3,75 con p < 0,001. Conclusiones: Las deformidades espinales del adulto son una patología 
creciente en nuestro país. El manejo quirúrgico de las deformidades requiere una adecuada planeación clínico-radiográfica. Los pacientes 
sometidos a tratamiento quirúrgico en nuestro estudio mostraron una curvatura tipo TL y presentaron mejoría significativa del ODI y del SRS-22r.
Descriptores: Escoliosis; Clasificación SRS-Schwab; Balance sagital; Criterios radiográficos.
1. Centro Médico ISSEMYM Ecatepec, Estado de México, México.
oriGinal article / artiGo oriGinal /artículo oriGinal
INTRODUCTION
Adult scoliosis is defined as an abnormal curvature greater than 
10° in a patient older than 18 years of age who has reached 
skeletal maturity of Risser grade 5.1,2 Sometimes this results from 
a curvature that was present in childhood and never treated, and 
which consequently progressed.3,4 If scoliosis is present in an adult 
without any precedent of curvature in childhood, it is classified as 
degenerative (De Novo) adult scoliosis.5,6
As we age, there are changes in the spine due to the failure of 
the discogenic cascade and changes produced at the level of the 
facet joints that produce antero-, retro-, or laterolisthesis and lead 
to radicular compression.7
Worldwide, adult scoliosis has been referred to as affecting a very wide 
range that goes from 2% to 32%.6 It is estimated that approximately 
65% of the cases of scoliosis are idiopathic, 15% are congenital, and 
Article received in 12/11/2015, approved in 04/05/2016.
 Coluna/Columna. 2016;15(2):115-7
116
another 10% are secondary to neuromuscular diseases.8
In our country there are no statistics for this pathology, but we do 
know that it is a growing problem, as evidenced by the numbers from 
INEGI, since in the 50s there were only 554.000 patients over the age 
of 60, and in the 90s the number had practically tripled to 1.611,317 
residents, and in 2010 to 3.116,466 with a rate of aging of 31%.9
Because of this, and because the traditional Lenke classification for 
idiopathic scoliosis was not sufficient to cover this pathology,5 there 
were multiple attempts to classify it, those by Aebi in 2005,7 Schwab 
in 2006, and the SRS in 2011,10,11 to name a few.
Today, there is a great deal of interest in spinal pelvic balance as 
described by Roussouly and Gollogly12 and Lafage et al.,13,14 such 
that three sagittal modifiers of spino-pelvic balance were included in 
the 2013 classification of the Scoliosis Research Society—Schwab 
Adult Spinal Deformity Classification.
To determine the most prevalent curve in our population, to quantify 
radiographic parameters such as PT, PI, and SS, and to compare 
function according to the ODI and SRS 22r questionnaires.
MATERIAL AND METHODS 
Retrospective, observational, longitudinal, single-center study.
During the period between January 2010 and May 2015 in the 
Spine Surgery Service of the Centro Médico ISSEMYM Ecatepec.
This includes a total of 60 patients, all of whom signed the 
term of consent.
The approval of the Ethics Committee was not required for this 
retrospective study in our unit.
RESULTS 
In this study, we obtained a sample made up of (n) 60 patients, 24 
men, and 36 women. The average age was 68.5 ± 5.5 years.
Spinal deformity was classified according to the SRS-SCHWAB 
classification and the most common diagnosis was thoracolumbar 
scoliosis at 47%, followed by simple thoracic scoliosis at 28.33%, 
and, in last place at 10%, by sagittal deformities.
Radiographic measurements were taken as part of the pre-surgery 
planning protocol in order to classify the deformities and are 
displayed in Figure 1 below.
In turn, we also classified the type of lordosis present in the patients 
according to the classification of Pierre Roussouly and found that 
type 4 was the most common at 36.66%, followed by types 1 and 
3 with a total of 15 patients each, and finally by type 2 at only 8%.
Patient disability was measured prior to surgery using the ODI and 
SRS 22r tests. The results are displayed below. (Figure 2)
As we can see, the level of disability is high in both tests, which is 
the reason why patients accepted surgical treatment.
In terms of post-surgical results, we find an improvement in almost 
all the radiographic measurement taken, as can be seen in Figure 3.
Figure 1. Relationship between type of curve and preoperative modifiers 
of sagittal balance.
An improvement in disability scores is observed, but the improvement 
was only greater than 15 points in the postoperative ODI for type 
L curves. The Student’s t test for dependent variables yielded a p 
value<0.001 (CI 95% of the difference –0.8 to -0.3). (Figure 4)
Regarding the VAS, we can see in Figure 5 that the results decrease 
progressively to a VAS of between 2 and 3 for all types of curves.
Next, the results of the SRS 22r test show improvement. The 
Student’s t test for dependent variables yielded a p value < 0.001 
(CI 95% of the difference -0.8 to -.03). (Figure 6)
Complications included the dehiscence of a wound and a seroma, 
both of which were resolved without further complications.
DISCUSSION
In our study we found a greater incidence of spinal deformities in 
the group of women, with a percentage of 60%, which is not an 
overwhelming difference like that reported by Daubs et al.9 in their 
case series with 38 women and 8 men.
In this study we found that the most common type of curve 
was thoracolumbar with a total of 46.6%, which corresponds 
to that found by Bridwell et al.15 in their case series, and also 
corresponds to the changes found in the population pyramid 
with the increasing population older than 60 years of age, which 
agrees with the data reported by INEGI.
We found an average preoperative VAS of 7 for all types of curves 
and a 6-month postoperative VAS of 3.
Application of the SRS 22r test yielded a preoperative average of 2.1 
for all curves and increased to 3.75 postoperatively, similar to the 
findings of Crawford et al.16 who reported a change in the SRS 22r 
from 2.93 to 3.65 points following surgery. It is clear that the 
patients scored better because of an improvement in body image, 
but also because of better global balance, pain reduction, and 
therefore, a return to increased patient activity.
COBB PT SS PI
T 30 18 35 53
TL 25 22 45 67
D 40 20 40 60
N 15 10 42 61
70
60
50
40
30
20
10
0
T TL D N
Figure 2. Relationship between type of curve and disability according to 
ODI and SRS 22R scores.
N
D
TL
T
SRS 22R
ODI
0               10              20               30              40
Figure 3. Relationship between type of curve and postoperative modifiers 
of sagittal balance.
COBB PT SS PI
T 20 13 30 43
TL 10 12 35 47
D 30 15 30 45
N 5 11 35 46
50
45
40
35
30
25
20
15
10
5
0
T
TL
D
N
Coluna/Columna. 2016;15(2):115-7
117
CONCLUSION
Adult spinal deformities are a growing disease in our country. 
Surgical management of these deformities requires proper 
clinical and radiographic planning. The patients in our study who 
underwent surgical treatment for type L curvature showed significant 
improvement in ODI and SRS 22r scores.
ACKNOWLEDGEMENTS
To the ISSEMYM medical center for allowing us to work properly and 
also to have given us the opportunity to count on their resources for 
our study. To our patients for their trust. To my wife and children for 
their approval and love.
All the authors declare that there are no potential conflicts of 
interest regarding this article.
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Authors’ Contribution: Each author made significant individual contributions to the preparation of the manuscript. VMGL and 
JEGC  conception and design of the study. AGM and GHH  critical review and and design of the study. LAV, AIG Y VHAC  critical review 
analysis and interpretation of the data.
Figure 4. Pre- and postoperative disability according to ODI (Owestry 
Disability Index).
T                   TL                   D                   N
40
35
30
25
20
15
10
5
0
ODI PRE
ODI POST
Figure 5. Follow-up of postoperative pain using VAS (Visual Analog Scale).
N
D
TL
T
7
9
8
7 7
5
5
6
5
X
X
X
X
8
8
6
3
3
2
4
VAS PRE VAS POST VAS 3 MONTHS VAS 6 MONTHS
Figure 6. Measurement of disability according to SRS 22R, for all types of 
curves.
T TL D N
SRS 22R PRE SRS 22R POST
3
4
4,8
3,2
2,221,6
2,4
T                                     TL                                     D                                     N
GLOBAL BALANCE IN ADULT SPINAL DEFORMITIES. A STUDY OF 60 CASES
Coluna/Columna. 2016;15(2):115-7


A STUDY OF 60 CASES

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