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LindaRacine
09-23-2010, 10:42 AM
A Prospective Study of Degenerative Lumbar Scoliosis Among Community-Based Female Volunteers
Shizuo Jimbo; Tetsuya Kobayashi, MD, PhD; Kiyoshi Aono; Yuji Atsuta; Takeo Matsuno
Japan
Summary: A prospective study of 144 community-based female volunteers revealed pre-existing DLS in 29.9% at baseline
and the development of de novo DLS in 29.4% of those without baseline deformity during mean 12.1 years observation. DLS
of more than 15° was associated with significant decrease in lumbar lordosis and forward shift in C7 plumb. L4 tilt and vertebral
size were predictors of the progression of pre-existing DLS, and lateral osteophyte, disc wedge and vertebral size were
predictors of de novo DLS.
Introduction: Degenerative lumbar scoliosis (DLS) is among the most frequent spinal deformity in the aging spine, however,
development of this condition has not been elucidated. The purpose of this study was to clarify radiographic characteristics
and predictors of pre-existing and de novo DLS.
Methods: 144 community-based female volunteers aged 40+ years were recruited and followed for more than 8 years. Upright
entire spine radiograph was taken at baseline and at final follow-up, and radiographic measurements included; thoracic
kyphosis, lumbar lordosis, sacral inclination angle (SIA), sagittal balance (C7 plumb), coronal L4 endplate angle (L4 tilt), and
scoliotic angle by Cobb method. More than 10° of scoliosis was diagnosed as DLS. L4 vertebral size, lateral osteophyte formation
and lateral disc wedge were also recorded according to the previously-reported setting.
Results: Mean baseline age and follow-up period were 54.4 years and 12.1 years, respectively. Pre-existing DLS (pre-DLS) was
found in 42 subjects (29.2%) at baseline, with the magnitude of 10° to 14° in 34 and more than 15° (marked pre-DLS) in 8.
Marked pre-DLS subjects exhibited significantly smaller baseline values of lumbar lordosis (21.9° vs. 34.9°, p=0.0059), SIA (26.4°
vs. 36.9°, p=0.0026), and more forward C7 plumb (68.1mm vs. 21.3mm, p=0.0007) than those without pre-DLS. Among pre-
DLS, 12 subjects (29%) showed more than 5° progression in scoliosis. A Cox hazards model revealed L4 tilt (relative risk;RR 3.58,
95% confidence interval;CI 1.29-9.91) and vertebral size (RR 0.96, CI 0.92-0.99) to be the risk factors of progression of pre-DLS.
DLS has developed de novo in 30 subjects (29.4%) among those without baseline scoliosis. A Cox hazards model revealed
unilateral osteophyte formation (RR 22.68, CI 2.82-182.46), lateral disc wedge (RR 4.01, CI 1.13-14.17), and vertebral size (RR 1.17,
CI 1.03-1.35) to be unique independent predictors of the development of de novo DLS.
Conclusion: DLS of more than 15° was associated with significant modification in sagittal spinal alignment. Current results
indicated that patients with radiographic characteristics of asymmetrical disc degeneration were susceptible to the development
of de novo scoliosis.



Long Fusions to the Sacrum in Elderly Patients with Spinal Deformity
Charles H. Crawford, MD; Steven D. Glassman, MD; Leah Y. Carreon, MD, MSc; Keith H. Bridwell, MD
United States
Summary: From a prospective database for adult spinal deformity, our findings show that properly selected patients over 65
years of age who have substantial sagittal imbalance, a considerable disease burden and a lesser degree of mental distress can
obtain as much clinical benefit as their younger counterparts (<55 years of age) two-years following spinal deformity surgery
that requires fusion from the thoracic spine to the sacrum with segmental instrumentation and iliac fixation.
Introduction: Long spinal deformity fusions in elderly patients continue to be controversial. However, there is a growing
population of elderly patients with spinal deformities that may be optimally treated by surgery requiring fusion to the sacrum.
The purpose of this study is to evaluate patient reported outcomes in elderly (>65) adult deformity patients who had a posterior
instrumented reconstruction consisting of fusion from the thoracic spine to the sacrum with iliac fixation.
Methods: Patients in a prospective database for adult spinal deformity who had a posterior reconstruction with an instrumented
fusion from the thoracic spine to the sacrum that included iliac fixation with minimum two year follow-up were
identified. Patients who had a previous fusion were excluded. Two cohorts were compared: patients older than 65 and patients
younger than 55. Student’s t-test for independent groups was used to determine any significant differences between continuous
variables. Chi-square was used to compare categorical demographic variables between the two groups.
Results: The older group consisted of 15 patients with an average age of 71 years (range, 65-78 years). The younger group
consisted of 25 patients with an average age of 45 years (range, 30-55 years). The older group had a higher mean co-morbidity
score (4.6 vs. 2.1). Baseline SRS scores were similar between groups. Baseline SF-12 data showed lower PCS (22.1 vs. 32.0,
p=0.009) yet higher MCS (63.6 vs. 48.4, p<0.0001) in the older group. Although major curve magnitude was similar (47.1 vs.
42.6 degrees), the older group had more sagittal imbalance at baseline (115.7 vs. 54.2 mm, p=0.02). Number of levels fused,
operative time, blood loss and incidence of complications were similar between groups. Two-year improvements in SRS subscores,
SF-12 PCS and MCS were not significantly different between groups.
Conclusion: Properly selected patients over 65 years of age who have substantial sagittal imbalance, a considerable disease
burden and a lesser degree of mental distress can obtain as much clinical benefit as their younger counterparts two-years
following spinal deformity surgery that requires fusion from the thoracic spine to the sacrum with segmental instrumentation
and iliac fixation.


Clinical and Radiographic Factors that Distinguish Between the Best and Worst Outcomes of Scoliosis Surgery for
Adults 46-85 Years Old
Justin S. Smith, MD, PhD; Christopher I. Shaffrey, MD; Steven D. Glassman, MD; Leah Y. Carreon, MD, MSc; Frank J. Schwab, MD; Virginie
C. Lafage, PhD; Sigurd H. Berven, MD; Keith H. Bridwell, MD
United States
Summary: Older adult scoliosis patients treated surgically with the worst outcomes have higher pre-operative pain, narcotic
use, body mass index, and prevalence of depression/anxiety than those having the best outcomes. At follow-up they have
poorer coronal and sagittal balance. No other radiographic or surgical parameters distinguished between patients with the
best and worst outcomes.
Introduction: It remains unclear why some adults with scoliosis markedly improve with surgery, while others fail to improve.
Our objective was to assess for differences between older adult patients with the best and worst outcomes following surgery
for scoliosis.
Methods: This is a secondary analysis of a prospective multicenter deformity database. Inclusion criteria included: age 46-85,
Cobb angle >20°, no prior instrumentation and outcomes (ODI or SRS-22) at a minimum of 2 years following surgery. The best
and worst ~15% for each outcome measure at follow-up were selected for comparison.
Results: For ODI, best (ODI<5) and worst (ODI>40) groups consisted of 28 (15%) and 32 (17%) patients, respectively. For SRS-
22, best (SRS-22>4.5) and worst (SRS-22<3) groups consisted of 32 (17%) and 30 (16%) patients, respectively. Factors that were
statistically significantly different between the best and worst groups are summarized Table 1. These included higher pre-operative
levels of back pain, greater body mass index, and greater proportions of patients on narcotics and reporting depression
and anxiety in the worst group compared to the best group. On follow-up the worst group had statistically greater coronal and
sagittal imbalance than the best group. There were no statistically significant differences between the two groups in terms of
age, comorbidities, idiopathic vs de novo scoliosis, pre-operative or follow-up Cobb angle, pre-operative sagittal or coronal
balance, occurrence of minor or major complications, operative time, estimated blood loss, and need for revision surgery.
Conclusion: Older adult scoliosis patients treated surgically with the worst outcomes have higher pre-operative pain, narcotic
use, body mass index, and prevalence of depression/anxiety than those having the best outcomes. At follow-up they have
poorer coronal and sagittal balance. No other radiographic or surgical parameters distinguished between patients with the
best and worst outcomes.

hdugger
09-23-2010, 11:48 AM
Wow, that last study is really odd. So, even though they don't go in with any differences in balance or cobb angle, people who got into the surgery in pain/on narcotics/depressed come out with a greater imbalance. I can't begin to parse out what mechanism would cause that. Did they discuss what might underlie their results?

LindaRacine
09-23-2010, 01:26 PM
I agree that it's confusing, but I suspect there's a lot more to it. We'll just have to wait until publication. (I'm not in Japan at the meeting, unfortunately.)