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Surgical treatment analysis of 809 thoracolumbar and lumbar major adult deformity cases by a new adult scoliosis classif

Surgical treatment analysis of 809 thoracolumbar and lumbar major adult deformity cases by a new adult scoliosis classification system. F Schwab, JP Farcy, K Bridwell, S Berven, S Glassman, W Horton, M Shainline Spinal Deformity Study Group. Zorab Symposium 2006.

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Surgical treatment analysis of 809 thoracolumbar and lumbar major adult deformity cases by a new adult scoliosis classif

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  1. Surgical treatment analysis of 809 thoracolumbar and lumbar major adult deformity cases by a new adult scoliosis classification system F Schwab, JP Farcy, K Bridwell, S Berven, S Glassman, W Horton, M Shainline Spinal Deformity Study Group Zorab Symposium 2006

  2. Unlike pediatric and adolescent scoliosis, no acceptedclassification systemexists for adult scoliosis Background • Scoliosis in the adult population • prevalence as high as60% • significant pain and disability • Quality of life issues • Classification systems provide • Commonlanguagefor communication • Correlation withclinicalimpact • treatment algorithms • surgical guidelines

  3. Background Adult deformity: Treatment approach • Curve severity • Cobb angle • progression • Skeletal maturity • Risser sign Cosmesis PT Pain Mgmt Bracing Surgery Pain Disability

  4. Background Classification System Apical level Lumbar lordosis modifier Intervertebral subluxation modifier Global Balance modifier Multi-center prospective study Clinical Group Scoliosis with apex T4 to L4 Degenerative or idiopathic 809 consecutive patients Radiographic analysis full length, standing films Cobb angle, apical level of deformity, sagittal plane lumbar alignment Health assessment questionnaires ODI / SRS-29 / SF-12

  5. Background Adult Scoliosis Classification 1. Type Type I Thoracic only Type II Upper Thoracic major Type III Lower Thoracic major Type IV Thoraco-lumbar major Type V Lumbar major no other curves Apex T9-T10 Apex T11-L1 Apex L2-L4 Apex T9-T10 2. Modifiers Global Balance Lumbar Lordosis Intervertebral Subluxation A : marked >400 B : moderate 0-400 C : no lordosis, Cobb >00 0 : none at any level + : max = 1-6mm ++ : max >7mm N Neutrally balanced <4cm P Positively balanced 4-9.5cm VP Very Positive >9.5cm

  6. Purpose Adult Scoliosis Classification Reliable classificationwithsignificant correlation to clinical symptoms Prediction of treatment patterns and surgical rates ???

  7. Materials & Methods • 1. Clinical group • Spinal Deformity Study Group database • Prospective, consecutive809 patientsreview • Ages >18 y.o. • Thoracolumbarorlumbarmajorscoliosis • Type IV and Type V deformities only. • 2. Health questionnaires • Oswestry Disability Index (ODI) • Scoliosis Research Society instrument (SRS-22) • Short From 12 (SF-12)

  8. Materials & Methods Lumbar Lordosis Sagittal Balance Intervertebral Subluxation 0 : none at any level + : max = 1-6mm ++ : max >7mm A : marked >40° B : moderate 0-40 ° C : no lordosis, Cobb >0° N Neutrally balanced <4cm P Positively balanced 4-9.5cm VP Very Positive >9.5cm • 3. Radiographic parameters • Full-length standing films • Frontal Cobb angle, • Apical level, • Sagittal lumbar alignment (T12-S1),

  9. Materials & Methods • 4. Treatment approach • Surgical vs. non-surgical • If Surgical: • Anterior, Posterior, circumferential • Use of osteotomies • Extension of fusion to sacrum • 5. Data Analysis • Treatment Analysis regarding • HRQOL measures • SRS-22, ODI, SF-12 • Correlation analysis • Classification types vs. treatment given

  10. Results Patients Distribution 806 thoracolumbar/lumbar major deformities • Type IV n=311 • Type V n=495 • Mean age 53.1 y.o. (+/- 15.3) • 700 Females (87%) • 106 Males (13%)

  11. Results Surgical rates • Rates of operative treatment • Lordosis modifier • B vs. A (51% vs. 37%, p<0.05), trend for A vs. C (46%) • Subluxation modifier • ++ vs. 0 (52% vs. 36 %, p<0.05), trend vs. + (42 %) • Sagittal Balance • N vs. VP: 39% vs. 59%, p<0.05

  12. Results Treatment Analysis: Type IV, V curves 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 Level • Trend for type V patients more likely to have fixation to sacrum (p=.074) • Lordosis Modifier • mod B patients more likely fusion to sacrum than mod A patients (p=.041) • Sagittal Balance Modifier • increasing positive balance: more likely fixation extended to the sacrum. • (mod N: 59%, mod P: 80%, mod VP: 88%) (all p<0.05)

  13. Results Surgical Approach Anterior only mostly lordosis modifier A Subluxation modifier 0 Sagittal balance modifier N Circumferential: trend most common modifier B Most commonly subluxation modifier ++ Posterior only: mostly lordosis modifier C Sagittal balance modifier VP Use of osteotomies Lordosis modifier A vs. C 25% vs. 50% p=0.01 Sagittal balance N vs. VP 25% vs. 53% p=0.01 Treatment Analysis: Type IV, V curves

  14. Results Main findings • Treatment • 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 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

  15. Discussion - Conclusion Adult scoliosis classification • Clinical Impact established: • HRQOL • Treatment….non-op vs. surgical • Surgical strategy…we’re getting there 2 yr f/u How about results of treatment ? Work toward surgical guidelines

  16. Discussion - Conclusion Adult scoliosis classification • Reliable • Clinical impact • disability • surgical rate • Surgical strategy ? Can we broaden to a: Comprehensive Adult Deformity Classification

  17. Classification of Adult Deformity Type I thoracic-only curve (no other curves) II upper thoracic major, apex T4-8 III lower thoracic major, apex T9-T10 IV thoracolumbar major curve, apex T11-L1 V lumbar major curve, apex L2-L4 Type K no scoli (<100), principal sagittal plane deformity Lumbar LordosisA marked lordosis >400 Modifier B moderate lordosis 0-400 C no lordosis present Cobb >00 Subluxation0 no intervertebral subluxation any level Modifier + maximal measured subluxation 1-6mm ++ maximal subluxation >7mm Sagittal Balance Nnormal, <4cm positive SVA Modifier Ppositive, 4-9.5cm VPvery positive, >9.5cm

  18. Next Steps Adult scoliosis classification • Refine Classification • Pelvic modifier • Co-morbidity index • Patient expectation scale • Longitudinal follow up • who responds well to conservative care • who benefits (how much) from surgery • Complications ? • Surgical analysis (2yr f/u) • what strategies are most effective

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