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1.
George M. Ghobrial Nathan H. Lebwohl Barth A. Green Joseph P. Gjolaj 《The spine journal》2017,17(11):1594-1600
Background Context
Prior reports have compared posterior column osteotomies with pedicle subtraction osteotomies in terms of utility for correcting fixed sagittal imbalance in adolescent patients with deformity. No prior reports have described the use of multilevel Smith-Petersen Osteotomies (SPOs) alone for surgical correction in the adult spinal deformity (ASD) population.Purpose
The study aimed to determine the utility of multilevel SPOs in the management of global sagittal imbalance in ASD patients.Study Design/Setting
This is a retrospective observational study at a single academic center.Patient Sample
The sample included 85 ASD patients.Outcome Measures
This is a radiographic outcomes cohort study.Methods
The radiographs of 85 ASD patients were retrospectively evaluated before and after long-segment (>5 spinal levels) fusion and multilevel SPO (≥3 levels) for sagittal imbalance correction. The number of osteotomies, correction in regional lumbar lordosis (LL), and correction per osteotomy was evaluated. Independent predictors of correction per SPO were evaluated with a hierarchical linear regression analysis.Results
Eighty-five patients (mean age: 67.5±11 years) were identified with ASD (372 SPOs). The mean preoperative sagittal vertical axis (SVA) and T1 pelvic angle (TPA) were 8.16±6.75?cm and 25°±13.23°, respectively. The mean postoperative central sacral vertical line (CSVL) and SVA were 0.67±0.70?cm and 1.29±5.41?cm, respectively. The mean improvement in SVA was 6.29?cm achieved with a correction of approximately 5.05° per SPO. The mean LL restoration was 20.3°±13.9°, and 33(39%) patients achieved a final pelvic incidence minus lumbar lordosis (PI-LL) ≤10°. Fifty-four (64%) achieved a postoperative PI-LL ≤15°, 75 (88%) with a PI-LL ≤20°, and 85 (100%) achieved a PI-LL ≤25°. Correction per SPO was similar regardless of prior fusion (4.87° vs. 5.72° for revisions, p=.192). In a subgroup analysis of SVA greater than 10?cm, there was no significant difference in the final LL, thoracic kyphosis, PI-LL, SVA, CSVL, and TPA, as compared with SVA <10?cm. The LL was the only independent predictor of osteotomy correction per level (LL: β coefficient=?0.108, confidence interval: ?0.141 to 0.071, p<.0001).Conclusions
Multilevel SPOs are feasible for restoration of LL as well as sagittal and coronal alignment in the ASD population with or without prior instrumented fusion. 相似文献2.
Aaron J. Buckland Subaraman Ramchandran Louis Day Shay Bess Themistocles Protopsaltis Peter G. Passias Bassel G. Diebo Renaud Lafage Virginie Lafage Akhila Sure Thomas J. Errico 《The spine journal》2017,17(11):1601-1610
Background Context
Patients with degenerative lumbar stenosis (DLS) adopt a forward flexed posture in an attempt to decompress neural elements. The relationship between sagittal alignment and severity of lumbar stenosis has not previously been studied.Purpose
We hypothesized that patients with increasing radiological severity of lumbar stenosis will exhibit worsening sagittal alignment.Study Design
This is a cross-sectional study.Patient Sample
Our sample consists of patients who have DLS.Outcome Measures
Standing pelvic, regional, lower extremity and global sagittal alignment, and health-related quality of life (HRQoL) were the outcome measures.Methods
Patients with DLS were identified from a retrospective clinical database with corresponding full-body stereoradiographs. Exclusion criteria included coronal malalignment, prior spine surgery, spondylolisthesis>Grade 1, non-degenerative spinal pathology, or skeletal immaturity. Central stenosis severity was graded on axial T2-weighted magnetic resonance imaging (MRI) from L1–S1. Foraminal stenosis and supine lordosis was graded on sagittal T1-weighted images. Standing pelvic, regional, lower extremity, and global sagittal alignment were measured using validated software. The HRQoL measures were also analyzed in relation to severity of stenosis.Results
A total of 125 patients were identified with DLS on appropriate imaging. As central stenosis grade increased, patients displayed significantly increasing standing T1 pelvic angle, pelvic tilt, sagittal vertical axis, and pelvic incidence-lumbar lordosis (p<.05). No significant difference wasfound in pelvic incidence, supine lordosis, thoracic kyphosis, or T1 spinopelvic inclination between central stenosis groups. Despite similar supine lordosis between stenosis groups, patients with Grades 2 and 3 stenosis had less standing lordosis, suggesting antalgic posturing. Upper lumbar (L1–L3) stenosis predicted worse alignment than lower lumbar (L4–S1) stenosis.Increasing severity of foraminal stenosis was associated with reduced lumbar lordosis; however, no significant postural difference in lordosis, thoracolumbar, or lower extremity compensatory mechanisms were noted between foraminal stenosis groups. Stenosis grading did not predict worsening HRQoLs in central or foraminal stenosis.Conclusions
Severity of central lumbar stenosis as graded on MRI correlates with severity of sagittal malalignment. These findings support theories of sagittal malalignment as a compensatory mechanism for central lumbar stenosis. 相似文献3.
Hwee Weng Dennis Hey Gordon Chengyuan Wong Chloe Xiaoyun Chan Leok-Lim Lau Naresh Kumar Joseph Shantakumar Thambiah John Nathaniel Ruiz Ka-Po Gabriel Liu Hee-Kit Wong 《The spine journal》2017,17(6):830-836
Background Context
Knowledge of sagittal radiographic parameters in adolescent idiopathic scoliosis (AIS) patients has not yet caught up with our understanding of their roles in patients with adult spinal deformity. It is likely that more emphasis will be placed in restoring sagittal parameters for AIS patients in the future. Therefore, we need to understand how these parameters may vary in AIS to facilitate management plans.Purpose
This study aimed to determine the reproducibility of sagittal spinal parameters on lateral film radiographs in patients with AIS.Study Design/Setting
This was a retrospective, comparative study conducted in a tertiary health-care institution from January 2013 to February 2016 (3-year period).Patient Sample
All AIS patients who underwent deformity correction surgery from January 2013 to February 2016 and had two preoperative serial lateral radiographs taken within the time period of a month were included in the study.Outcome Measures
Radiographic sagittal spinal parameters including sagittal vertical axis (SVA), cervical lordosis (CL), thoracic kyphosis (TK), thoracolumbar alignment (TL), lumbar lordosis (LL); standard spinopelvic measurements such as pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS); as well as end and apical vertebrae of cervical, thoracic, and lumbar curves were the outcome measures.Methods
All patient data were pooled from electronic medical records, and X-ray images were retrieved from Centricity Enterprise Web. Averaged X-ray measurements by two independent assessors were analyzed by comparing two radiographs of the same patients performed within a 1-month time period. Chi-squared and Wilcoxon signed-rank tests were used for categorical and continuous variables.Results
The study cohort comprised 138 patients, 28 men and 110 women, with a mean age of 15 years (range 11–20). Between the two lateral X-rays, there was a mean difference of 0.79?cm in SVA (p<.001), 0.70° in LL (p=.033), and 0.73° in PT (p=.010). In the combined Lenke 1 and 2 subgroup, there was a similar 0.77?cm (p=.002), 0.79° (p=.009), and 1.49° (p=.001) mean difference in SVA, LL, and PT, respectively. Additionally, there was also a 1.85° (p=.009) and 1.76° (p=.006) mean difference seen in TL and SS, respectively. The overall profile of the sagittal curves remained largely similar, with only the lumbar apex shifting from L3 to L4 during the first and the second X-rays, respectively (p<.001). This occurred for the combined Lenke 1 and 2 subgroup as well (p<.001).Conclusion
Most radiographic sagittal spinal parameters in AIS patients are generally reproducible with some variations up to a maximum of 4°. This natural variation should be taken into account when interpreting these radiographic sagittal parameters so as to achieve the most accurate results in surgical planning. 相似文献4.
Louis Boissière Mitsuru Takemoto Anouar Bourghli Jean-Marc Vital Ferran Pellisé Ahmet Alanay Caglar Yilgor Emre Acaroglu Francisco Javier Perez-Grueso Frank Kleinstück Ibrahim Obeid 《The spine journal》2017,17(4):480-488
Background Context:
Many radiological parameters have been reported to correlate with patient's disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI?LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear.Purpose
This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management.Study Design
A retrospective review of a multicenter, prospective database was carried out.Patient Sample
The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb ≥20°), SVA ≥5?cm, thoracic kyphosis ≥60° or PT ≥25°. All patients with complete data at baseline were included.Outcome Measures
Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline.Methods
Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant.Results
Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and ?0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI?LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R2 values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models.Conclusion
GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs. 相似文献5.
Permsak Paholpak Alexander Nazareth Patrick C. Hsieh Zorica Buser Jeffrey C. Wang 《The spine journal》2017,17(9):1272-1284
Background Context
T1 slope is a novel thoracic parameter used to assess cervical spine sagittal balance. Thoracic index (TI) parameters including T1 slope and cervical sagittal alignment parameters may play an important role in degenerative cervical spondylolisthesis (DCS). Current literature regarding the relationship between TI and cervical sagittal alignment parameters in patients with DCS is limited.Purpose
(1) To evaluate the T1 slope, cervical sagittal alignment, and thoracic inlet parameter in patients with DCS using kinematic magnetic resonance imaging (kMRI), and (2) to find a correlation between the T1 slope, TI, and other cervical sagittal parameters in patients with DCS.Design/Setting
Retrospective kMRI study, Level III.Patient Sample
Fifty-two patients with DCS from 1,128 patients from a cervical kMRI database.Outcome Measures
T1 slope, C2–C7 angle, sagittal vertical axis C2–C7 (SVA C2–C7), cranial tilt, cervical tilt, neck tilt, and thoracic inlet angle (TIA).Methods
Cervical spine kMRIs of 52 patients with DCS (mean age 51.7±standard deviation) were analyzed in neutral, flexion, and extension positions. Patients with DCS were divided into two groups: anterolisthesis (N=33) and retrolisthesis (N=19). Each listhesis group was subclassified into grade 1 (slip 2–3?mm) and grade 2 (slip>3?mm).Results
Grade 2 retrolisthesis had the largest T1 slope followed by grade 1 retrolisthesis, grade 2 anterolisthesis, and grade 1 anterolisthesis. Significant differences were found between the anterolisthesis and the retrolisthesis groups in the neutral position (p=.025). The flexion position had the largest T1 slope and showed a significant difference with anterolisthesis in the neutral position (p=.041). Sagittal vertical axis C2–C7 showed strong correlation with cranial tilt in all DCS groups and all positions.Conclusions
In our study, T1 slope was larger in grade 2 DCS, and the retrolisthesis group had larger T1 slope than the anterolisthesis group. Presence of larger T1 slope was significantly correlated with larger cervical lordosis curvature. Furthermore, cranial tilt was strongly correlated with SVA C2–C7. 相似文献6.
Hwee Weng Dennis Hey Alex Quok An Teo Kimberly-Anne Tan Li Wen Nathaniel Ng Leok-Lim Lau Ka-Po Gabriel Liu Hee-Kit Wong 《The spine journal》2017,17(6):799-806
Background Context
The current prevailing school of thought in spinal deformity surgery is to restore sagittal balance with reference to the alignment of the spine when the patient is standing. This strategy, however, likely accounts for increased rates of proximal junctional failure.Purpose
The purpose of this study was to investigate the differences between the spine in standing and sitting positions as these may elucidate reasons for deformity correction failure.Study Design/Setting
A prospective, comparative study of 58 healthy patients presenting to a tertiary hospital over a 6-month period was carried out.Patient Sample
All patients presenting with a less than 3-month history of first episode lower back pain were included. Patients who had radicular symptoms, red flag symptoms, previous spine surgery, or visible spinal deformity during forward bending test were excluded. Pregnant patients were also excluded.Outcome Measures
Radiographic measurements including sagittal vertical axis (SVA), lumbar lordosis (LL), thoracolumbar angle (TL), thoracic kyphosis (TK), cervical lordosis (CL), pelvic incidence (PI), and pelvic tilt (PT) were collected. The sagittal apex and end vertebrae of all radiographs were also recorded.Methods
Basic demographic data (age, gender, and ethnicity) was recorded. Lateral standing and sitting radiographs were obtained using EOS technology. Statistical analysis was performed to compare standing and sitting parameters using chi-square tests for categorical variables and paired t tests for continuous variables.Results
Taking the standing position as the reference point, forward displacement of the SVA occurred during sitting by a mean of 6.39±3.87?cm (p<.001). This was accompanied by a reduction of LL and TK by a mean of 24.63±12.70° (p<.001) and 8.56±7.21°(p<.001), respectively. The TL became more lordotic by a mean of 3.25±7.30° (p<.001). The CL only reached borderline significance (p=.047) for increased lordosis by a mean of 3.45±12.92°. The PT also increased by 50% (p<.001). Despite relatively constant end vertebrae, the apex vertebra moved inferiorly for the thoracic curve (p<.006) and superiorly for the lumbar curve (p<.001) by approximately one vertebral level each.Conclusions
Sagittal spinal alignment changes significantly between standing and sitting positions. Understanding these differences is crucial to avoid overcorrection of LL, which may occur if deformity correction is based solely on the spine's standing sagittal profile. 相似文献7.
E. Kyung Shin Chi Heon Kim Chun Kee Chung Yunhee Choi Dahae Yim Whei Jung Sung Bae Park Jung Hyeon Moon Won Heo Sung-Mi Kim 《The spine journal》2017,17(2):175-182
Background Context
Lumbar spinal stenosis (LSS) is the most common lumbar degenerative disease, and sagittal imbalance is uncommon. Forward-bending posture, which is primarily caused by buckling of the ligamentum flavum, may be improved via simple decompression surgery.Purpose
The objectives of this study were to identify the risk factors for sagittal imbalance and to describe the outcomes of simple decompression surgery.Study Design
This is a retrospective nested case-control studyPatient Sample
This was a retrospective study that included 83 consecutive patients (M:F=46:37; mean age, 68.5±7.7 years) who underwent decompression surgery and a minimum of 12 months of follow-up.Outcome Measures
The primary end point was normalization of sagittal imbalance after decompression surgery.Methods
Sagittal imbalance was defined as a C7 sagittal vertical axis (SVA) ≥40?mm on a 36-inch-long lateral whole spine radiograph. Logistic regression analysis was used to identify the risk factors for sagittal imbalance. Bilateral decompression was performed via a unilateral approach with a tubular retractor. The SVA was measured on serial radiographs performed 1, 3, 6, and 12 months postoperatively. The prognostic factors for sagittal balance recovery were determined based on various clinical and radiological parameters.Results
Sagittal imbalance was observed in 54% (45/83) of patients, and its risk factors were old age and a large mismatch between pelvic incidence and lumbar lordosis. The 1-year normalization rate was 73% after decompression surgery, and the median time to normalization was 1 to 3 months. Patients who did not experience SVA normalization exhibited low thoracic kyphosis (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02–1.10) (p<.01) and spondylolisthesis (HR, 0.33; 95% CI, 0.17–0.61) before surgery.Conclusions
Sagittal imbalance was observed in more than 50% of LSS patients, but this imbalance was correctable via simple decompression surgery in 70% of patients. 相似文献8.
Hwee Weng Dennis Hey Chengyuan Gordon Wong Eugene Tze-Chun Lau Kimberly-Anne Tan Leok-Lim Lau Ka-Po Gabriel Liu Hee-Kit Wong 《The spine journal》2017,17(2):183-189
Background Context
Sitting spinal alignment is increasingly recognized as a factor influencing strategy for deformity correction. Considering that most individuals sit for longer hours in a “slumped” rather than in an erect posture, greater understanding of the natural sitting posture is warranted.Purpose
This study aimed to investigate the differences in sagittal spinal alignment between two common sitting postures: a natural, patient-preferred posture; and an erect, investigator-controlled posture that is commonly used in alignment studies.Design/Setting
This is a randomized, prospective study of 28 young, healthy patients seen in a tertiary hospital over a 6-month period.Patient Sample
Twenty-eight patients (24 men, 4 women), with a mean age of 24 years (range 19–38), were recruited for this study. All patients with first episode of lower back pain of less than 3 months' duration were included. The exclusion criteria consisted of previous spinal surgery, radicular symptoms, red flag symptoms, previous spinal trauma, obvious spinal deformity on forward bending test, significant personal or family history of malignancy, and current pregnancy.Outcome Measures
Radiographic measurements included sagittal vertical axis (SVA), lumbar lordosis (LL), thoracolumbar angle (TL), thoracic kyphosis (TK), and cervical lordosis (CL). Standard spinopelvic parameters (pelvic incidence, pelvic tilt [PT], and sacral slope) and sagittal apex and end vertebrae were also measured.Methods
Basic patient demographics (age, gender, ethnicity) were recorded. Lateral sitting whole spine radiographs were obtained using a slot scanner in the imposed erect and the natural sitting posture. Statistical analyses of the radiographical parameters were performed comparing the two sitting postures using chi-squared tests for categorical variables and paired t tests for continuous variables.Results
There was forward SVA shift between the two sitting postures by a mean of 2.9?cm (p<.001). There was a significant increase in CL by a mean of 11.62° (p<.001), and TL kyphosis by a mean of 11.48° (p<.001), as well as a loss of LL by a mean of 21.26° (p<.001). The mean PT increased by 17.68° (p<.001). The entire thoracic and lumbar spine has the tendency to form a single C-shaped curve with the apex moving to L1 (p=.002) vertebra in the majority of patients.Conclusions
In a natural sitting posture, the lumbar spine becomes kyphotic and contributes to a single C-shaped sagittal profile comprising the thoracic and the lumbar spine. This is associated with an increase in CL and PT, as well as a constant SVA. These findings lend insight into the body's natural way of energy conservation using the posterior ligamentous tension band while achieving sitting spinal sagittal balance. It also provides information on one of the possible causes of proximal junctional kyphosis or proximal junctional failure. 相似文献9.
Jae Hwan Cho Youn-Suk Joo Cheongsu Lim Chang Ju Hwang Dong-Ho Lee Choon Sung Lee 《The spine journal》2017,17(12):1794-1802
Background Context
Sagittal imbalance is associated with poor clinical outcomes in patients with degenerative lumbar disease. However, there is no consensus on the impact of posterior lumbar interbody fusion (PLIF) on local and global sagittal balance.Purpose
To reveal the effect of one- or two-level PLIF on global sagittal balance.Design/Setting
A retrospective case-control study.Patients Sample
This study included 88 patients who underwent a one- or two-level PLIF for spinal stenosis with spondylolisthesis.Outcome Measures
Clinical and radiological parameters were measured pre- and postoperatively.Methods
All patients were followed up for >2 years. Clinical outcomes included a visual analog scale, Oswestry Disability Index, and EuroQol 5-dimension questionnaire (EQ-5D). Radiological parameters were measured using whole-spine standing lateral radiographs. Fusion, loosening, subsidence rates, and adverse events were also evaluated. Patients were divided into two groups according to their preoperative C7–S1 sagittal vertical axis (SVA): Group N: SVA≤5?cm vs Group I: SVA>5?cm; they were also divided according to postoperative changes in C7–S1 SVA. Clinical and radiological outcomes were compared between the groups.Results
All clinical outcomes and radiological parameters improved postoperatively. C7–S1 SVA improved (?1.6?cm) after L3–L5 fusion, but it was compromised (+3.6?cm) after L4–S1 fusion (p=.001). Preoperative demographic and clinical data showed no difference except in the anxiety or depression domain of EQ-5D. No differences were found in postoperative clinical outcomes. Lumbar lordosis, pelvic tilt, and thoracic kyphosis slightly improved in Group N, whereas C7–S1 SVA decreased from 9.5?cm to 3.8?cm (p<.001) in Group I. Furthermore, all sagittal parameters improved in Group I. On comparing the postoperative changes in C7–S1 SVA, we found that the decreasing trend in the postoperative C7–S1 SVA was related to a larger preoperative C7–S1 SVA (p=.030) and a more proximal level fusion (L3–L5 vs L4–S1, p=.033).Conclusions
Global sagittal balance improved after short-level lumbar fusion surgery in patients having spinal stenosis with spondylolisthesis who showed preoperative sagittal imbalance. Restoration of sagittal balance predominantly occurred after L3–L4, L4–L5, or L3–L5 PLIF. However, no such restoration was observed after L5–S1 or L4–S1 PLIF. Thus, we could anticipate sagittal balance restoration after performing PLIF at L3–L4 or L4–L5 level. However, caution is required when planning for L5–S1 fusion if preoperative sagittal imbalance is present. 相似文献10.
Yoshitaka Matsubayashi Hirotaka Chikuda Yasushi Oshima Yuki Taniguchi Yoh Fujimoto Takachika Shimizu Sakae Tanaka 《The spine journal》2017,17(5):622-626
Background Context
Previous studies have indicated that the T1 slope correlates with cervical lordosis. In contrast, the specific impact of the C7 sagittal vertical axis (C7SVA) on cervical lordosis remains unknown.Purpose
This study aimed to investigate the specific role of C7SVA in cervical lordosis.Study Design/Setting
This was a retrospective radiographic study.Patient Sample
Forty-eight consecutive patients who underwent lateral standing radiography of the entire spine were retrospectively reviewed.Outcome Measures
Radiographic parameters included occipito (Oc)-C7, Oc–C2, C2–C7, C2–C4, and C5–C7 angles; T1 slope; C7SVA; T1 pelvic angle (TPA); pelvic incidence; pelvic tilt; and sacral slope.Methods
The radiographs of 96 consecutive patients who underwent lateral standing radiography of the entire spine in June 2015 in our hospital were retrospectively reviewed. Patients having cervical deformities, having undergone cervical fusion, and under 18 years of age were excluded. A total of 48 Asian patients (14 men and 34 women; mean age, 54.6 years) were eligible. Pathologies included scoliosis, myelopathy, thoracolumbar deformity, and spondylosis. Spearman rank correlation coefficients were used to examine correlations between the parameters. The relationship between C5–C7 lordosis and the radiographic parameters was calculated using the forward stepwise multivariate regression analysis. The authors do not have financial associations relevant to this article.Results
C7SVA correlated with the Oc–C7 (r=0.42) and C2–C7 (r=0.50) angles. However, the correlation coefficient was smaller than that between the T1 slope and Oc–C7 (r=0.83) or C2–C7 (r=0.76) angles. When the C2–C7 angle was divided into C2–C4 and C5–C7 angles, C7SVA correlated with the C5–C7 (r=0.63) angle but not with the C2–C4 angle. The correlation coefficient between the C5–C7 angle and C7SVA was higher than that between the C5–C7 angle and T1 slope (r=0.53) or the C5–C7 angle and TPA (r=0.60). Using radiographic parameters and age, multiple regression analysis revealed that only C7SVA affected the C5–C7 angle.Conclusions
C7SVA was the only radiographic parameter that affected the C5–C7 angle. Both T1 slope and C7SVA are key to the shape of the cervical sagittal alignment. The results of this study can be a starting point to improve our understanding of cervical sagittal alignment. 相似文献11.
Mitsuru Yagi Hideaki Ohne Tsunehiko Konomi Kanehiro Fujiyoshi Shinjiro Kaneko Masakazu Takemitsu Masafumi Machida Yoshiyuki Yato Takashi Asazuma 《The spine journal》2017,17(3):409-417
Background Context
Gait patterns and their relationship to demographic and radiographic data in patients with adult spinal deformity (ASD) have not been fully documented.Purpose
This study aimed to assess gait pattern in patients with ASD and the effect of corrective spinal surgery on gait.Design/Setting
This is a prospective case series.Patient Sample
The gait patterns of 33 consecutive women with ASD (age 67.1 years; body mass index [BMI] 22.5±2.5?kg/m2, Cobb angle 46.8±18.2°, coronal vertical axis [CVA] 1.5±3.7?cm, C7 sagittal vertical axis [SVA] 9.1±6.4?cm, pelvic incidence minus lumbar lordosis [PI?LL] 38.2±22.1°, and lean volume of the lower leg, 5.5±0.6?kg) before and after corrective surgery were compared with those of 33 age- and gender-matched healthy volunteers.Outcome Measures
Scoliosis Research Society Patient Questionnaire (SRS22r), Oswestry Disability Index (ODI), and forceplate analysis.Methods
All subjects underwent gait analysis on a custom-built forceplate using optical markers placed on all joints and spinal processes. Dual X-ray absorptiometry scores were used to calculate the lean composition of the lower legs. Subjects with ASD were followed for at least 2 years post operation.Results
Preop mean values showed that patients with ASD had a significantly worse gait velocity (54±10?m/min vs. 70.7±12.9?m/min, p<.01) and stride (97.8±13.4?cm vs. 115.3±15.1?cm, p<.01), but no difference was observed in the stance-to-swing ratio. The right and left ground reaction force vectors were also discordant in the ASD group (vertical direction; r=0.84 vs. r=.97, p=.01). The hip range of motion (ROM) was also significantly decreased in ASD. Correlation coefficient showed moderate correlations between the preoperative gait velocity and the gravity line (GL), PI, ROM of the lower extremity joints, and lean volume, and between the stride and the lean volume, GL, and PI?LL. Gait pattern, stride, and velocity all improved significantly in the patients with ASD after surgery, but were still not as good as in healthy volunteers. The SRS22r satisfaction domain correlated moderately with postoperative gait velocity (r=0.34).Conclusions
The patients with ASD had an asymmetric gait pattern and impaired gait ability compared with healthy volunteers. Gait ability correlated significantly with the GL, spinopelvic alignment, lower extremity joint ROM, and lean volume. The surgical correction of spinopelvic alignment and exercises to build muscle strength may improve the gait pattern and ability in patients with ASD. 相似文献12.
Hwee Weng Dennis Hey Kimberly-Anne Tan Christabel Shao-En Neo Eugene Tze-Chun Lau Denise Ai-Wen Choong Leok-Lim Lau Gabriel Ka-Po Liu Hee-Kit Wong 《The spine journal》2017,17(5):615-621
Background Context
Adult spinal deformity correction sometimes involves long posterior pedicle screw constructs extending from the lumbosacral spine to the thoracic vertebra. As fusion obliterates motion and places supraphysiological stress on adjacent spinal segments, it is crucial to ascertain the ideal upper instrumented vertebra (UIV) to minimize risk of proximal junctional failure (PJF). The T10 vertebra is often chosen to allow bridging of the thoracolumbar junction into the immobile thoracic vertebrae on the basis that it is the lowest immobile thoracic vertebra strut by the rib cage.Purpose
This study aimed to characterize the range of motion (ROM) of each vertebral segment from T7 to S1 to determine if T10 is truly the lowest immobile thoracic vertebra.Study Design/Setting
This is a prospective, comparative study.Patient Sample
Seventy-nine adults (mean age of 45.4 years) presenting with low back pain or lower limb radiculopathy or both, without previous spinal intervention, metastases, fractures, infection, or congenital deformities of the spine, were included in the study.Outcome Measures
A ROM >5° across two vertebral segments as determined by the Cobb method from radiographs.Methods
Lumbar flexion-extension and neutral erect radiographs were obtained in randomized order using a slot scanner. Segmental ROM was measured from T7–T8 to L5–S1 and analyzed for significant differences using t tests. Age, gender, radiographical indices such as standard spinopelvic parameters, sagittal vertical axis (SVA), C7–T12 SVA, T1 slope, thoracic kyphosis (TK), and lumbar lordosis (LL) were studied via multivariate analysis to identify predictive factors for >5° change in ROM at the various segmental levels. There were no sources of funding and no conflicts of interest associated with this study.Results
In the thoracolumbar spine, significant decreases in ROM when compared with the adjacent caudad segment occurs up to T9–T10, with mean total ROM of 1.98±1.47° (p<.001) seen in T9–T10, 2.19±1.67° (p<.001) in T10–T11, and 3.92±3.21°(p<.001) in T11–T12. The total ROM of T8–T9 (2.53±1.79°) was not significantly different from that of T9–T10 (p=.261). At the thoracolumbar junction, absence of scoliosis (OR 11.37, p=.020), high pelvic incidence (OR 1.14, p=.046), and low T1 slope (OR 1.45, p=.030) were predictive of ROM >5°.Conclusions
Lumbar spine flexion-extension ROM decreases as it approaches the thoracolumbar junction. T10 is indeed the lowest immobile thoracic vertebra strut by the rib cage, and the last significant decrease in ROM is observed at T9–T10, in relation to T10–T11. However, because this also implies that a UIV of T10 would mean there is only one level of fixation above the relatively mobile segment, while respecting other factors that influence UIV selection, we propose the T9 vertebra as a more ideal UIV to fulfill the biomechanical concept of bridge fixation. However, this decision should still be taken on a case-by-case basis. 相似文献13.
Daipayan Guha Raphael Jakubovic Shaurya Gupta Naif M. Alotaibi David Cadotte Leodante B. da Costa Rajeesh George Chris Heyn Peter Howard Anish Kapadia Jesse M. Klostranec Nicolas Phan Gamaliel Tan Todd G. Mainprize Albert Yee Victor X.D. Yang 《The spine journal》2017,17(4):489-498
Background Context
Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy.Purpose
This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy.Design/Setting
This is a retrospective review of a prospectively collected cohort.Patient Sample
We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN.Outcome Measures
Clinical or radiographic screw accuracy (Heary and 2?mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes).Methods
We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2?mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes.Results
Acceptable screw accuracy was achieved for significantly fewer screws based on 2?mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2?mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75?mm-3.13° and 1.20?mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy.Conclusions
Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters. 相似文献14.
George M. Ghobrial Daniel G. Eichberg John Paul G. Kolcun Karthik Madhavan Nathan H. Lebwohl Barth A. Green Joseph P. Gjolaj 《The spine journal》2017,17(10):1499-1505
Background Context
Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long-segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology.Purpose
The study aimed to assess the incidence of PJK and PJF in patients treated with prophylactic polymethylmethacrylate (PMMA) cement augmentation at the uppermost instrumented vertebrae (UIV) and rostral adjacent vertebrae (UIV+1).Study Design/Setting
This is a retrospective cohort-matched surgical case series at an academic institutional setting.Patient Sample
Eighty-five adult patients over a 16-year enrollment period were identified with long-segment (>5 levels) posterior thoracolumbar instrumented fusions for ASD.Outcome Measures
Primary outcomes measures were PJK magnitude and PJF formation. Secondary outcomes measures were spinopelvic parameters, as well as global and regional sagittal alignment.Methods
The impact of adjunctive PMMA use in long-segment (≥5 levels) fusion for ASD was assessed in adult patients aged 18 and older. Patients were included with at least one of the following: lumbar scoliosis >20°, pelvic tilt >25°, sagittal vertical axis >5?cm, central sacral vertical line >2?cm, and thoracic kyphosis >60°. The frequency of PJF and the magnitude of PJK were measured radiographically preoperatively, postoperatively, and at maximum follow-up in controls (Group A) and PMMA at the UIV and UIV+1 (Group B).Results
Eighty-five patients (64±11.1 years) with ASD were identified: 47 control patients (58±10.6) and 38 patients (71±6.8) treated with PMMA at the UIV and UIV+1. The mean follow-up was 27.9 and 24.2 months in Groups A and B, respectively (p=.10). Preoperative radiographic parameters were not significantly different, except the pelvic tilt which was greater in Group A (26.6° vs. 31.4°, p=.03). Postoperatively, the lumbopelvic mismatch was greater in Group B (14.6° vs. 7.9°, p=.037), whereas the magnitude of PJK was greater in controls (9.36° vs. 5.65°, p=.023). The incidence of PJK was 36% (n=17) and 23.7% (n=9) in Groups A and B, respectively (p=.020). The odds ratio of PJK with vertebroplasty was 0.548 (95% confidence interval=0.211 to 1.424). Proximal junctional kyphosis was observed in 6 (12.8%) controls only (p=.031). The UIV+1 angle, a measure of PJK, was significantly greater in controls (10.0° vs. 6.8°, p=.02). No difference in blood loss was observed. No complications were attributed to PMMA use.Conclusions
The use of prophylactic vertebral cement augmentation at the UIV and rostral adjacent vertebral segment at the time of deformity correction appears to be preventative in the development of proximal junctional kyphosis and failure. 相似文献15.
Hwee Weng Dennis Hey Cheung-Kue Kim Won-Gyu Lee Hyung-Suk Juh Ki-Tack Kim 《The spine journal》2017,17(12):1837-1845
Background Context
The aim of spinal deformity correction is to restore the spine's functional alignment by balancing it in both the sagittal and coronal planes. Regardless of posture, the ideal coronal profile is straight, and therefore readily assessable.Purpose
This study compares two radiological methods to determine which better predicts postoperative standing coronal balance.Study Design/Setting
We conducted a single-center, radiographic comparative study between 2011 and 2015.Patient Sample
A total of 199 patients with a mean age of 55.1 years were studied. Ninety patients with degenerative lumbar scoliosis (DLS) and 109 ankylosing spondylitis (AS) were treated with posterior surgery during this period.Outcome Measures
Baseline clinical and radiographic parameters (sagittal and coronal) were recorded. Comparison was performed between the new supra-acetabular line (central sacral vertical line [CSVL1]) and conventional supra-iliac line (CSVL2) perpendicular methods of coronal balance assessment. These methods were also compared with the gold standard standing C7 plumb line.Methods
Each patient underwent standardized operative procedures and had perioperative spine X-rays obtained for assessment of spinal balance. Adjusted multivariate analysis was used to determine predictors of coronal balance.Results
Significant differences in baseline characteristics (age, gender, and radiographic parameters) were found between patients with DLS and AS. CSVL1, CSVL2, and C7 plumb line differed in all the perioperative measurements. These three radiological methods showed a mean right coronal imbalance for both diagnoses in all pre-, intra-, and postoperative radiographs. The magnitude of imbalance was the greatest for CSVL2 followed by CSVL1 and subsequently the C7 plumb line. A larger discrepancy between CSVL and C7 plumb line measurements intraoperatively than those postoperatively suggests a postural effect on these parameters, which is greater for CSVL2. Multivariate analysis identified that in DLS, the preoperative C7 plumb line was predictive of its postoperative value. CSVL1, but not CSVL2, was predictive of the postoperative C7 plumb line in patients with AS.Conclusions
The supra-acetabular line (CSVL1) is better, although not ideal, as compared with the supra-iliac line (CSVL2) in determining coronal balance. Because CSVL1 still cannot be relied on with a high predictive value, it is imperative that future studies continue to identify better intraoperative markers for achieving coronal balance. 相似文献16.
Felisa Sánchez-Mariscal Alejandro Gomez-Rice Tamara Rodríguez-López Lorenzo Zúñiga Javier Pizones Ana Núñez-García Enrique Izquierdo 《The spine journal》2017,17(1):56-61
Background Context
Most of the papers correlate sagittal radiographic parameters with health-related quality of life (HRQOL) scores for patients with scoliosis. However, we do not know how changes in sagittal profile influence clinical outcomes after surgery in adult population operated for mainly frontal deformity.Purpose
This study aimed to analyze spinal sagittal profile in a population operated on adult idiopathic scoliosis (AS) and to describe variations in sagittal parameters after surgery and the association between those variations and clinical outcomes.Design/Setting
This is a historical cohort study.Patient Sample
We included in this study 40 patients operated on AS, older than 40 at the time of surgery (mean age 54.9), and with more than 2-year follow-up (mean 7.4 years).Outcome Measures
Full-length free-standing radiographs, Scoliosis Research Society 22 (SRS22) and Short Form 36 (SF36) instruments, and satisfaction with outcomes were available at final follow-up.Methods
Sagittal preoperative and final follow-up radiographic parameters, radiographic correlation with HRQOL scores at final follow-up, and association between satisfaction and changes in sagittal profile were analyzed. A multivariate analysis was performed. No funds were received for this article.Results
Preoperatively, the spinal sagittal plane tended to exhibit kyphosis. Most sagittal parameters did not improve at final follow-up with respect to preoperative values. We saw, after univariate analysis, that worse sagittal profile leads to worse HRQOL, but after multivariate analysis, only spinal tilt (ST) persisted as possible predictor for worse SRS activity scores. Frontal Cobb significantly improved. Most patients (82%) were satisfied with final outcomes. Variations in sagittal profile parameters did not differ between satisfied and dissatisfied patients.Conclusions
Although most sagittal plane parameters did not improve after surgery, surgical treatment in AS achieves a high satisfaction rate. Good clinical results do not correlate with improving sagittal plane parameters. Sagittal profile measurements are not helpful to decide surgical treatment in patients with mainly frontal deformity. 相似文献17.
Zhiwei Yang Fang Xie Jianxin Zhang Zhuowen Liang Zhe Wang Xueyu Hu Zhuojing Luo 《The spine journal》2017,17(12):1812-1818
Background Context
The lumbar spine latericumbent and full-length lateral standing radiographs are most commonly used to assess lumbar disorder. However, there are few literatures on the difference and correlation of the sagittal parameters between the two shooting positions.Purpose
The study aimed to investigate the difference of sagittal parameters in spine lateral radiographs between latericumbent and upright positions, identify the correlation, and establish a preliminary linear fitting formula.Study Design
The study is a prospective study on radiographic evaluation of sagittal alignment using latericumbent and upright positions.Patient Sample
One hundred fifty-seven patients were recruited from the orthopedics clinic of a single medical center.Outcome Measure
Angle measurement, the intra- and interobserver measurement reliability of measurement, and analysis of the angle measurement were carried out.Method
The sagittal alignment of 157 patients were assessed using Surgimap software from two kinds of lateral radiographs to acquire the following parameters: lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), L4–L5 intervertebral angle (IVA4–5), L4–L5 intervertebral height index (IHI4–5), and PI–LL. The Kolmogorov-Smirnov test, paired t test, Pearson correlation analysis, and multivariate linear regression analysis were used to analyze the data.Results
The results showed significantly statistical difference in LL, SS, PT, IVA4–5, and PI–LL, except for PI and IHI4–5, between the two positions. There was a significant relativity between standing LL and latericumbent LL (r=0.733, p<.01), PI (r=0.611, p<.01), and SS (r=0.626, p<.01). The predictive formula of standing LL was 12.791+0.777 latericumbent LL+0.395 latericumbent PI?0.506 latericumbent SS (adjusted R2=0.619, p<.05).Conclusion
Not all of sagittal parameters obtained from two positions are identical. Thus, the full-spine lateral standing films are difficult to be replaced. The surgeon should give sufficient consideration to the difference between the two views. We may primarily predict standing LL with the formula when we could not get whole-spine lateral standing radiographs. 相似文献18.
Donald E. Fry Susan M. Nedza Michael Pine Agnes M. Reband Chun-Jung Huang Gregory Pine 《The spine journal》2017,17(11):1641-1649
Background Context
Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs.Purpose
To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery.Study Design/Setting
To identify the significant risk factors associated with AOs and to develop risk models that measure performance.Patient Sample
Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012–2014 Medicare limited dataset.Outcome Measures
The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models.Methods
Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals.Results
There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%.Conclusions
Differences among hospitals defines opportunities for care improvement. 相似文献19.
Sanghyun Han Seung-Jae Hyun Ki-Jeong Kim Tae-Ahn Jahng Subum Lee Seung-Chul Rhim 《The spine journal》2017,17(7):962-968
Background Context
Little is known about the effect of rod stiffness as a risk factor of proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery.Purpose
The aim of this study was to compare radiographic outcomes after the use of cobalt chrome multiple-rod constructs (CoCr MRCs) and titanium alloy two-rod constructs (Ti TRCs) for ASD surgery with a minimum 1-year follow-up.Study Design
Retrospective case-control study in two institutes.Patient Sample
We included 54 patients who underwent ASD surgery with fusion to the sacrum in two academic institutes between 2002 and 2015.Outcome Measures
Radiographic outcomes were measured on the standing lateral radiographs before surgery, 1 month postoperatively, and at ultimate follow-up. The outcome measures were composed of pre- and postoperative sagittal vertical axis (SVA), pre- and postoperative lumbar lordosis (LL), pre- and postoperative thoracic kyphosis (TK)+LL+pelvic incidence (PI), pre- and postoperative PI minus LL, level of uppermost instrumented vertebra (UIV), evaluation of fusion after surgery, the presence of PJK, and the occurrence of rod fracture.Materials and Methods
We reviewed the medical records of 54 patients who underwent ASD surgery. Of these, 20 patients had CoCr MRC and 34 patients had Ti TRC. Baseline data and radiographic measurements were compared between the two groups. The Mann-Whitney U test, the chi-square test, and the Fisher exact test were used to compare outcomes between the groups.Results
The patients of the groups were similar in terms of age, gender, diagnosis, number of three-column osteotomy, levels fused, bone mineral density, preoperative TK, pre- and postoperative TK+LL+PI, SVA difference, LL change, pre- and postoperative PI minus LL, and location of UIV (upper or lower thoracic level). However, there were significant differences in the occurrence of PJK and rod breakage (PJK: CoCr MRC: 12 [60%] vs. Ti TRC: 9 [26.5%], p=.015; occurrence of rod breakage: CoCr MRC: 0 [0%] vs. Ti TRC: 11 [32.4%], p=.004). The time of PJK was less than 12 months after surgery in the CoCr MRC group. However, 55.5% (5/9) of PJK developed over 12 months after surgery in the Ti TRC group.Conclusions
Increasing the rod stiffness by the use of cobalt chrome rod and can prevent rod breakage but adversely affects the occurrence and the time of PJK. 相似文献20.
Masashi Uehara Jun Takahashi Shota Ikegami Hiroyuki Hashidate Shugo Kuraishi Masayuki Shimizu Toshimasa Futatsugi Hiroki Oba Keijiro Mukaiyama Nobuhide Ogihara Hiroki Hirabayashi Hiroyuki Kato 《The spine journal》2017,17(2):190-195