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When to operate on Adult Scoliosis patients and when to say ‘No’

When to operate on Adult Scoliosis patients and when to say ‘No’. Frank Schwab, MD Jean-Pierre Farcy, MD New York University School of Medicine. What is Adult Scoliosis?. What is Adult Scoliosis?. Coronal plane deformity Sagittal plane deformity Imbalance/malalignment Focal Regional

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When to operate on Adult Scoliosis patients and when to say ‘No’

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  1. When to operate on Adult Scoliosis patients and when to say ‘No’ Frank Schwab, MD Jean-Pierre Farcy, MD New York University School of Medicine

  2. What is Adult Scoliosis?

  3. What is Adult Scoliosis? • Coronal plane deformity • Sagittal plane deformity • Imbalance/malalignment • Focal • Regional • Global Adolescent deformity in an adult AISA De-novo deformity…of aging DDS

  4. Scoliosis Prevalence • AIS 2-4% of screened pediatric population • Adult >60% of screened elderly population# Demographics : Life expectancy, birth rates…. Significant growth of aging population segment # Schwab et al. SPINE 2005 May 1;30(9):1082-5

  5. Adolescent Idiopathic Scoliosis:surgical treatment Classification • Lenke • King • Curve severity • Cobb angle • progression • Skeletal maturity • Risser sign • Curve pattern • apex • distribution • sagittal • overhang Surgical strategy

  6. Classification ? Adult Scoliosis Scoliosis:treatment approach • Curve severity • Cobb angle • progression • Skeletal maturity • Risser sign Cosmesis PT Pain Mgmt Bracing Surgery Pain Disability

  7. The aging spine Spine skeletal maturity 30’s disc degen. MRI changes 50’s facet DJD disc collapse Stable spine ankylosis Unfavorable degeneration stenosis spondylo deformity Adult Scoliosis

  8. Progressive collapse Stable ankylosis

  9. Adult Scoliosis / Deformity What are the disability / pain generators ? • 98 patients(Schwab,Farcy. SPINE 2004) • adult scoliosis, all levels • SF-36 • radiographic-clinical analysis • 325 patients(Schwab, Farcy. SDSG. SRS 2004) • thoracolumbar/lumbar scoliosis • SRS instrument, ODI • radiographic-clinical correlation

  10. Significant Spondylolisthesis Lateral Subluxation Lumbar lordosis Thoracolumbar alignment Apical level Sagittal Balance (SVA) Not significant Coronal Cobb Age Adolescent vs. de-novo degenerative scoliosis Adult Scoliosis : Clinical impact Statistically significant: SRS-22, ODI, SF-12/36

  11. Adult Scoliosis: the disability / pain generators plain radiographs • Apical level of deformity (lumbar dominant) • Lumbar lordosis T12-S1 • Maximal intervertebral subluxation (frontal/sagittal) • Sagittal balance (PlC7-S1 offset) Selected for high clinical impact: SRS, ODI, SF-36 (excluding fractures or other pathologies…)

  12. Classification of Adult Deformity Schwab et al. SPINE 2006 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

  13. Adult Scoliosis 947 patients: (86% female, 14% male) Average age 48 years (SD 18) Coronal Cobb mean 460 (SD 19) ODI SRS Lordosis Subluxation Global Balance

  14. Adult Scoliosis / Deformity Thus….deformity = disability ? Yes, certain aspects … … Not coronal Cobb angle Coronal/Sagittal • Focal: subluxation • Regional: loss of lordosis • Global: sagittal imbalance Sagittal plane

  15. Young adult: AISA >500 thoracic >300 lumbar (progressive) Progression with disability Curve progression likely Disability later (potential) More difficult to treat later Depending upon age Surgical risks greater later Cosmetic concerns Adult Scoliosis / Deformity: Why surgery ? Weinstein S,. Spine 24(24), 1999

  16. Pain unacceptable Disability unacceptable Risk/Benefit ratio - favorable Older Adult: AISA = DDS Pain/disability failed conservative care Adult Scoliosis / Deformity: Why surgery ?

  17. ? Sure success Don’t do it Adult Scoliosis / Deformity If the justification for surgery is acceptable…. …..when is it really reasonable to operate

  18. Adult Scoliosis / Deformity Not a candidate for surgery: • young AISA…no disability, mild/mod curve, happy • patient who does not want surgery • patient is unlikely to survive surgery • patient does not understand risk/benefit • unrealistic expectations • planned operation is not reasonable • experience, team, environment

  19. Adult Scoliosis / Deformity Possibly Excellent candidate for surgery: • young AISA…progressive, severe curve (>700) DDS or AISA older adult: Perfectly isolated pain generator, failed extensive non-operative care • Well informed, wishes to pursue operative care • Excellent health • Realistic expectations, highly motivated • team has abundant experience only excellent results with planned intervention

  20. Adult Scoliosis / Deformity The common cases: • Patient might consider surgery with certain assurances • Health is acceptable (not ideal), • Pain generators present (there are several), • Non-operative care tried (variable participation and response), • Expectations are overall rather realistic. • The surgeon comfortable with intervention ?

  21. When to operate on Adult Scoliosis patients and when to say No How can we select the best patients for surgery ?(and how to optimize the chances of a successful outcome) • non-operative care vs. surgery • If surgery…which strategy/approach • Specific treatment algorithms lacking • few studies to guide us….where is the data ?

  22. Adult Scoliosis: Thoracolumbar / Lumbar Deformity Who gets surgery…and what type ?(n=809) Operative rates • Lordosis • Lost lordosis vs. good lordosis (B vs. A) 51% vs 37%, p<0.05 • Subluxation modifier • Marked subluxation vs. none (++ vs. 0) 52% vs. 36 %, p<0.05 • Sagittal Balance • Well balanced versus marked imbalance (N vs. VP) 39% vs.59%, p<0.05

  23. Adult Scoliosis: Thoracolumbar / Lumbar Deformity • Who gets surgery…and what type ? • Use of osteotomies • Lordosis >400lordo vs. no lordo : 25% vs. 50% p=0.01 • Sagittal balance no imbalance vs. >9.5cm : 25% vs. 53% p=0.01 • Surgical Approach • Anterior only: no lost lordosis, no subluxation Circumferential: some lost lordosis, marked subluxation Posterior only: marked loss of lordosis, marked sagittal imbalance • Fusion to sacrum • Lordosis Loss of lordosis more likely fusion to sacrum (p = .041) • Sagittal Balance increasing positive balance: more fixation to sacrum. • (<4cm: 59%, 4-9.5cm: 80%, >9.5cm: 88%) (all p<0.05)

  24. Adult Scoliosis: Thoracolumbar / Lumbar Deformity How about surgical outcomes ? • 111patients 1-year follow up • 45 patients 2-year follow up • Adult Thoracolumbar / Lumbar major curves • Surgical treatment, complete data • Full-length standing x-rays (0,12,24 months) • SRS, ODI, SF-12

  25. 2-year Surgical outcome: Lordosis modifier Lumbar LordosisA marked lordosis >400 Modifier B moderate lordosis 0-400 C no lordosis present Cobb >00 Lordosis modifier ‘C’…most improved

  26. 2-year Surgical outcome: sagittal balance (surgical approach) Sagittal Balance Nnormal, <4cm positive SVA Modifier Ppositive, 4-9.5cm VPvery positive, >9.5cm posterior N with anterior approach did worst (VP posterior-only also not so good) P, VP did best with circumferential fusion

  27. 2-year Surgical outcome: sagittal balance (fixation to sacrum) VP without fixation to sacrum got worse P and VP did best with fixation to sacrum (no difference for N)

  28. 2-year Surgical outcome: osteotomy or not ? Patients who had osteotomy did better !

  29. Baseline to Two-Year Changes: Significant Interaction ODI / SRS Total Score by lordosis • patients with no lordosis (C) greatest improvement, • Patients with marked lordosis (A) little or no improvement • ODI / SRS Total Scoreby sagittal balance by surgical approach • well balanced least disabled, fused short of sacrum did best • very imbalance (VP) most disabled and worse off if not fused to sacrum • SF-12v2 / SRS Total Scoreby Subluxation • significant subluxation (++,+) more improvement than no subluxation • SF-12v2 PCS / SRS Total scoreby Osteotomy Status • patients with osteotomy had lower baseline scores • At 2 years f/u, patients with an osteotomy had higher scores

  30. Adult Scoliosis: Thoracolumbar / Lumbar Deformity Follow-up data • When is improvement clinically significant ? • Set a bar of 10-point increase in SRS score • From 100pt. Scale • Assumption of patient perceived improvement • Minimal Clinically Important Difference • Berven et al.

  31. Minimum 10 point SRS instrument improvement

  32. Minimum 10 point SRS instrument improvement Loss of lumbar lordosis…greater likelihood of clinical success

  33. Minimum 10 point SRS instrument improvement At 2-yr follow up: greater imbalance patients more likely to have successful outcome

  34. Minimum 10 point SRS instrument improvement Patients having osteotomies more likely to have successful outcome

  35. Minimum 10 point SRS instrument improvement Patients with lower baseline scores more likely to achieve significant improvement

  36. When to operate on Adult Scoliosis patients and when to say No How can we select the best patients for surgery ?(and how to optimize the chances of a successful outcome) Can we predict who will have successful surgery ?

  37. Gender Age Apical Modifier Lordosis Modifier Subluxation Modifier Sagittal Balance Surgical Approach Osteotomy Fixation to Sacrum SF-12v2 Physical Component Summary SF-12v2 Mental Component Summary SRS Total Score Oswestry Disability Index Predictive Models Outcome ?

  38. Models to predict Clinical Improvement with Surgery

  39. Follow-up data: Conclusions The winners • Greater disability at start (SRS, ODI, SF-12) • Male • Subluxation >6mm • Lost lumbar lordosis <400 • Osteotomy • Who benefits least • minimal baseline disability (SRS, ODI, SF-12) • No subluxation, no marked sagittal imbalance • Good lordosis, >400 • Lack of osteotomy

  40. apex Regional deformity Global sagittal balance SRS, ODI, SF-12 Surgical approach osteotomy gender Focal deformity When to operate on Adult Scoliosis patients and when to say No How can we select the best patients for surgery ?(and how to optimize the chances of a successful outcome)

  41. Adult Scoliosis / Deformity: next steps Refine Classification Predictive outcomes model + SRS ODI SF-12/36 Treatment Algorithm

  42. Thank you….

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