Adult scoliosis surgery outcomes: a systematic review

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  • Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Object

Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements.

Methods

A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery,” “adult spine deformity surgery,” “outcomes,” and “complications.” Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major curve (coronal scoliosis or lumbar lordosis Cobb angle as reported), major curve correction, Oswestry Disability Index (ODI) scores, Scoliosis Research Society (SRS) instrument scores, complications, and pseudarthroses were recorded.

Results

Forty-nine articles were obtained and included in this review; 3299 patient data points were analyzed. The mean age was 47.7 years, and the mean follow-up period was 3.6 years. The average major curve correction was 26.6° (for 2188 patients); for 2129 patients, it was possible to calculate average curve reduction as a percentage (40.7%). The mean total ODI was 41.2 (for 1289 patients), and the mean postoperative reduction in ODI was 15.7 (for 911 patients). The mean SRS-30 equivalent score was 97.1 (for 1700 patients) with a mean postoperative decrease of 23.1 (for 999 patients). There were 897 reported complications for 2175 patients (41.2%) and 319 pseudarthroses for 2469 patients (12.9%).

Conclusions

Surgery for adult scoliosis is associated with improvement in radiographic and clinical outcomes at a minimum 2-year follow-up. Perioperative morbidity includes an approximately 13% risk of pseudarthrosis and a greater than 40% incidence of perioperative adverse events. Incidence of perioperative complications is substantial and must be considered when deciding optimal disease management. Although the quality of published studies in this area has improved, particularly in the last few years, the current review highlights the lack of routine use of standardized outcomes measures and assessment in the adult scoliosis literature.

Abbreviations used in this paper: ODI = Oswestry Disability Index; SRS = Scoliosis Research Society; USPSTF = U.S. Preventive Services Task Force.

Object

Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements.

Methods

A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery,” “adult spine deformity surgery,” “outcomes,” and “complications.” Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major curve (coronal scoliosis or lumbar lordosis Cobb angle as reported), major curve correction, Oswestry Disability Index (ODI) scores, Scoliosis Research Society (SRS) instrument scores, complications, and pseudarthroses were recorded.

Results

Forty-nine articles were obtained and included in this review; 3299 patient data points were analyzed. The mean age was 47.7 years, and the mean follow-up period was 3.6 years. The average major curve correction was 26.6° (for 2188 patients); for 2129 patients, it was possible to calculate average curve reduction as a percentage (40.7%). The mean total ODI was 41.2 (for 1289 patients), and the mean postoperative reduction in ODI was 15.7 (for 911 patients). The mean SRS-30 equivalent score was 97.1 (for 1700 patients) with a mean postoperative decrease of 23.1 (for 999 patients). There were 897 reported complications for 2175 patients (41.2%) and 319 pseudarthroses for 2469 patients (12.9%).

Conclusions

Surgery for adult scoliosis is associated with improvement in radiographic and clinical outcomes at a minimum 2-year follow-up. Perioperative morbidity includes an approximately 13% risk of pseudarthrosis and a greater than 40% incidence of perioperative adverse events. Incidence of perioperative complications is substantial and must be considered when deciding optimal disease management. Although the quality of published studies in this area has improved, particularly in the last few years, the current review highlights the lack of routine use of standardized outcomes measures and assessment in the adult scoliosis literature.

Abbreviations used in this paper: ODI = Oswestry Disability Index; SRS = Scoliosis Research Society; USPSTF = U.S. Preventive Services Task Force.

The number of surgical treatment options for skeletally mature patients with spine deformities has expanded over the past several decades.1 Advances in operative techniques, along with an understanding of biomechanics and advances in instrumentation, has allowed for the development of many surgical approaches to adult scoliosis. To determine the “best” approach to treat patients with adult deformity, clinicians must be familiar with risks and benefits of surgical intervention. Unfortunately, randomized controlled trials comparing operative with nonoperative management are lacking.13 Outcomes for adult deformity surgery are largely reported in reference to a specific surgical technique or in relation to a particular surgeon or surgical group. Investigators have used varying classifications of clinical outcomes and procedure-related complications, making analysis of the literature difficult.

The purpose of this systematic review was to synthesize existing data on the outcomes of surgical intervention for adult spine deformity. Four specific questions regarding outcome were proposed as follows: 1) What is the benefit of surgery for adult scoliosis in terms of correction of curve at a minimum 2-year follow-up? 2) What is the benefit of surgery for adult scoliosis based on standard clinical outcomes measures at a minimum 2-year follow-up? 3) What is the rate of complication with adult scoliosis surgery? 4) What is the rate of pseudarthrosis with adult scoliosis surgery?

Methods

Literature Review

A query of the PubMed and MEDLINE databases was performed to identify articles pertinent to the aforementioned clinical questions. First, a search of PubMed using the key words “adult scoliosis surgery outcomes” and “adult spine deformity surgery outcomes” was performed and returned 361 articles. The query was further limited to the English-language literature (341 articles) and a patient age of 19 years or older (334 articles). Abstracts from these articles were reviewed, and those that reported a minimum 2-year follow-up, average patient age older than 18 years, or did not specify either parameter in the abstract were retained for more detailed review. This yielded 44 articles for detailed review. A minimum 2-year follow-up was specified to include chronic or sub-acute complications (for example, pseudarthrosis) and to account for any loss of curve correction.

Next, a search of MEDLINE was performed to identify any pertinent articles published between 1950 and 2009 that were not identified in the previous PubMed search. A search for the key words “adult scoliosis and outcomes” (29 articles), “adult spine deformity and outcomes” (31 articles), and “adult scoliosis and complications” (59 articles) was performed. Abstracts from these searches yielded 14 additional articles for detailed review that were not identified previously in the PubMed search. Thus, 58 articles were identified by abstract for detailed review of methods and results. Nine of these articles were excluded from analysis due to failure to meet the minimum follow-up, patient age criteria, or report postoperative outcomes. Forty-nine articles were ultimately included in the analysis (Table 1).2,4,8–11,15–27,29,30,34–43,45–49,51–63

TABLE 1:

Literature review of postoperative radiographic and clinical outcomes for adult patients undergoing surgery for scoliosis with a minimum 2-year follow-up

Authors & YearLevel of EvidenceStudy DesignTotal No. of PatientsMean Age (yrs)Mean FU (yrs)Mean ODISRS-30 EquivalentMajor Curve Reduction (°)Major Curve Reduction (%)No. of ComplicationsNo. of Pseudarthroses
Bridwell et al., 2009IIprospective, matched cohort8560220114295231
Smith et al., 2009IIprospective1475123593
Khan et al., 2009IIIretrospective14653.7108408741
Rose et al., 2009IIprospective, matched cohort3438.3311129.54700
Kim et al., 2009IIIretrospective6247.910.3254
Glassman et al., 2009IIIprospective cohort28350222.8111
Peelle et al., 2008IIIretrospective30403.390185000
Wu et al., 2008IIIretrospective2664.2325.89.1552
Weistroffer et al., 2008IIIretrospective50549.73512
Chang et al., 2008IIIretrospective8366.1298.442.21263
Deviren et al., 2008IIIretrospective1537.53.969346740
Kim et al., 2008IIIretrospective4849.63.774.42542104
Wang et al., 2008IIIretrospective13312.5476.953.95940
Kim et al., 2007IIIretrospective12557.14.567.5125121
Buchowski et al., 2007IIIprospective10854.8229.597.132.265150
Daubs et al., 2007IIIretrospective46674.22526
Kim et al., 200737IIIretrospective3553.15.826483773138
Bomback et al., 2007IIIretrospective1730224123445222
Pateder et al., 2007IIIretrospective18060.54.525.3504220
Bess et al., 2007IIretrospective, matched cohort56493.611419.335217
Kim et al., 200639IIIretrospective144523.9107.1152934
DeWald & Stanley, 2006IIIretrospective3872.42.5244
Yang et al., 2006IIIprospective3540.8274.420.618160
Kim et al., 200638IIIretrospective23240.8290.640
Boachie-Adjei et al., 2006IIIretrospective244844040170
Tsuchiya et al., 2006IIIretrospective6736.2620.123
Suk et al., 2005IIIretrospective25382236051
Glattes et al., 2005IIIretrospective81455.3114.1
Chang et al., 2005IIIretrospective6634.83.696.739.242440
Kim et al., 2005IIIretrospective9642.25.991.9373916
Brown et al., 2004IIIretrospective16492.72343
Rhee et al., 2003IIIretrospective42472117.5252330
Bridwell et al., 200316IIIprospective3353.4234.291.232.931248
Berven et al., 20038IIIretrospective25584.5102191795
Ali et al., 2003IIIretrospective2848.52386150
Bridwell et al., 200317IIIretrospective2752.4251.2134.133247
Shapiro et al., 2003IIIretrospective1629.53.444.374.43650120
Murrey et al., 2002IIIretrospective59474.520.7100
Ahn et al., 2002IIIprospective8354.44.640.138836
Wang et al., 2002IIIretrospective2226.84.726.64841
Emami et al., 2002IIIretrospective5454.94.7569.219.5384810
Smith et al., 2002IIIretrospective1537.55.1106.9346660
Eck et al., 2001IIIretrospective584351427135
Lapp et al., 2001IIIretrospective4442.63.52138135
Buttermann et al., 2001IIIretrospective105444.1606543
Simmons et al., 1993IIIretrospective49412.83247200
van Dam et al., 1987IIIretrospective91313.521321322
Kostuik & Hall, 1983IIIretrospective4544.33.519.5346510
Swank et al., 1981IIIretrospective22230.73.6273311726

The quality of evidence in the selected articles was classified using the USPSTF system for ranking evidence.31 Articles were reviewed for data on methodology (retrospective vs prospective), number of patients, mean patient age, and mean follow-up. Data regarding change in major curve at last follow-up in degrees and as a percentage of the initial curve were recorded if available. A major curve was defined as the coronal scoliosis Cobb angle or lumbar lordosis Cobb angle as reported in the study. Clinical outcomes data based on postoperative ODI scores, change in ODI scores from preoperative, postoperative SRS instrument scores, and change in SRS scores from preoperative was also recorded when available. Finally, the number of complications and pseudarthroses were tallied.

Statistical Analysis

Descriptive statistics were calculated using the JMP statistical package (version 7.02, SAS Institute). Because of variability in the type of SRS instrument used by different investigators (SRS-22, SRS-24, SRS-29, or SRS-30), SRS scores were converted to SRS-30 score equivalents for purposes of statistical analysis. Weighted averages of age, length of follow-up, ODI, change in ODI, SRS-30 equivalent score, change in SRS-30 equivalent score, curve reduction in degrees, and curve reduction as a percentage of the original curve were calculated. Complications were not uniformly reported; classification (that is, minor vs major) was variable as was reporting of multiple complications in the same patient. Therefore, complication incidence was calculated by tallying the total number of complications reported divided by total number of patients in those studies that reported complications. The incidence of pseudarthrosis was calculated in a similar fashion: the number of pseudarthroses reported divided by total number of patients in those studies reporting pseudarthroses.

Results

A total of 49 articles reporting data in 3299 patients were reviewed. Of the 49 articles reviewed, none were classified as Level I evidence according to USPSTF criteria. Four articles met criteria for Level II evidence as well-designed matched cohort studies or multiple time series with and without intervention. The remaining 45 articles were descriptive studies and therefore classified as Level III evidence. Eight studies were conducted in a prospective fashion, and the other 41 series were conducted in a retrospective manner. Only 4 articles reported on all specified outcome measures.

The average age of the patients included in this review was 47.7 years (Fig. 1). The average length of follow-up was 3.6 years (Fig. 2). Thirty-nine studies reported preoperative and postoperative major curve Cobb angles (for 2188 patients). At a minimum 2-year follow-up, the average reduction of the major curve was 26.6° (Fig. 3), or 40.7% as a percentage of the original curve (where this calculation was available; for 2129 patients).

Fig. 1.
Fig. 1.

Bar graph illustrating age distribution (in years) of patients in 49 reviewed series encompassing 3299 patients.

Fig. 2.
Fig. 2.

Bar graph illustrating distribution of average follow-up period of patients in 49 reviewed series including data from 3299 patients.

Fig. 3.
Fig. 3.

Bar graph illustrating distribution of average curve reduction of patients as reported in 39 reviewed series with data from 2188 patients at a minimum 2-year follow-up.

Fifteen studies, including data from 1289 patients, used total ODI as a measure of clinical outcomes. The average ODI for patients in these studies was 41.2. Eleven studies including data from 911 patients reported both preoperative and postoperative ODIs. The average decrease in ODI from preoperative testing to latest follow-up in these studies was 15.7.

Twenty-six studies with data from 1700 patients used an SRS instrument to measure clinical outcomes at follow-up. Scores were converted to SRS-30 equivalent scores for purposes of comparison and analysis. The average SRS-30 score of patients in these series was 97.1. Ten studies, with data from 999 patients, reported both preoperative and postoperative SRS scores. The average decrease in SRS-30 scores in these patients was 23.1.

Forty-one articles reported on complications associated with surgery; 897 complications were reported in 2175 patients, giving a pooled incidence of 41.2% for patients in these series. Thirty-nine articles (2469 patients) reported on pseudarthroses. There were 319 pseudarthroses in these articles, giving a rate of 12.9%.

Discussion

An adult spine coronal deformity may develop de novo in the mature skeleton or progress from untreated adolescent scoliosis. Estimates of prevalence vary from 1 to 9% of the adult population.12 Adult patients present more often with pain or neurological symptoms than their adolescent counterparts, and surgery is generally indicated for patients with significant deformity-related pain or progressive curves.32 Several authors have reported high rates of patient satisfaction and functional improvement with operative treatment.3,4,23,32

Historically, outcomes in the adult deformity literature have been reported in reference to specific procedures, pathology, or primary surgeon.10,11,27,57 This is reflected in the current review in that the majority of studies included were classified as Level III evidence (descriptive studies) according to USPSTF criteria. Although several prospective and matched cohort studies have been performed, definitive randomized controlled trials are lacking.13,15,63 There has been a trend toward increasing quality in evidence and methodology of publications in this area, particularly in the past few years. Three of 4 Level II studies included in the current review were published in 2009. In addition, 5 of 8 prospective studies in this review were published in 2007 or later; all 8 were published in 2002 or later.

The aim of the current study was to review different series to generate more powerful estimates of the effect of surgery for adult scoliosis. The current review focuses on the ODI and the SRS outcome instruments because these were the most consistently used measures. Complications and pseudarthroses, a significant cause of pain and reoperation in these patients,38,39 were included in the review rather than limiting it to only potential benefits of surgery. The inclusion criterion of a 2-year minimum follow-up was specified to increase the capture of sub-acute and chronic events (for example, pseudarthrosis or loss of curve correction).

Correction of Curve

Cobb angle correction varied from 9.1 to 53.9° (mean correction 26.6°). As a percentage of the original curve, correction ranged from 1 to 87% (mean 40.7%). The natural history of untreated spinal deformity is progression of the curve, and this has been illustrated by several comparative series.15,44 Unlike adolescent scoliosis in which bracing can prevent progression of the curve, no such utility has been found in the skeletally mature patient.33

Clinical Outcome Measurements

There was no consensus in the reviewed literature on the measurement of clinical outcomes. At least 9 separate formal instruments were used in the reviewed series. The most commonly used instruments were the ODI (15 studies) and SRS outcomes instrument (26 studies). Several versions of the SRS instrument were used, including SRS-24, SRS-29, SRS-30, and the SRS-22 (the modified SRS instrument). However, only 21 studies (42.9%) reported both preoperative and postoperative scores.

The ODI is a widely used and validated instrument for outcomes measurement of a variety of pathological conditions.28 The average postoperative ODI in the 15 series that reported them was 41.2. This correlates with a clinical picture of moderate to severe disability. In their review of 947 adults with spinal deformity, Schwab et al.50 found a mean ODI score of 30 suggesting that the patients in the current review were more disabled by their disease than the general adult scoliosis population.

The difference in ODI scores that correlates with significant clinical improvement ranges from 4 to 15 points.28 Eleven studies in the current review reported both preoperative and postoperative ODI scores. For the 911 patients in these 11 studies, there was an average decrease of 15.7 points (range 3.1–32.3 points) after surgery, suggesting that significant clinical improvement did occur in patients in those series.

Several versions of the SRS are commonly used and have been previously validated in adults and children with scoliosis.5,7,14 Several variations of the SRS format were used by investigators to report outcomes; the difference in SRS versions is primarily inclusion or exclusion of certain groups of questions. For purposes of comparison, it was necessary to convert scores to the SRS-30 scale. To our knowledge, there has been no previous validation of such a conversion. Using this method, the average SRS-30 equivalent score of patients in the 26 studies using a version of the SRS instrument was 97.1. In the aforementioned study by Schwab et al., the average SRS-22 score was 67, which is equivalent to a score of 100.5 on the SRS-30 scale, suggesting minimal difference between patients in these series and the general adult scoliosis population.

Bago et al.6 recently reported that the minimal important difference, the difference in score correlating to a patient's self-perceived improvement in outcome for raw SRS scores is approximately 13 points. The average decrease in SRS-30 equivalent score found in the 10 studies that reported both pre- and postoperative SRS scores was 23.1 points. This difference represents a significant improvement in patient-reported outcome at a minimum 2-year follow-up for patients who underwent surgery in those series.

Eight series reported use of both ODI and SRS score as measures of outcome, 14 reported ODI alone, 25 reported SRS score alone, and 13 reported neither. The ability to compare outcomes in the scoliosis literature is limited by the lack of consensus on which measurement instrument to use, a consistent method of pre- and postoperative assessment, and whether to include clinical outcomes data in such series at all. An agreement on these standards seems overdue as performance measures in surgery become increasingly important.

Complications and Pseudarthroses

The incidence of reported complications in the reviewed articles ranged from 0 to 53%. There was no consensus regarding the classification or categorization of complications. Several authors divided complications into major or minor categories while others reported early versus late complications.15,16,52,63 The method used in this systematic review may overestimate the true incidence of complications. Several series reported only the number of complications and did not specify whether multiple complications occurred in the same patient. For analysis, the incidence of complication was calculated as the total number of complications divided by the number of patients in those series reporting complications. This formula implicitly assumes that multiple complications did not occur in the same patient. Therefore, this approach may not accurately reflect overall incidence of perioperative adverse events in these series.

The rate of pseudarthroses in the reviewed series ranged from 0 to 41%.20,45 This range is slightly broader than other estimates, although the overall rate in the current review of 12.9% is similar to previously published rates.12

Conclusions

The current review analyzes outcomes data for adult spine deformity surgery with a minimum 2-year follow-up. The average major curve correction in these series was 26.6°, or about 40.7% correction of the original curve. Based on the most commonly reported clinical outcomes measures, the ODI and SRS instrument, surgery for adult scoliosis appears to improve clinical outcomes at a minimum 2-year follow-up. Although the quality of studies in this area has improved, particularly in the past few years, this review highlights the lack of routine use of standardized outcome measures and methods for preoperative and postoperative assessment in the current literature. Such standardization should be expanded to include methods of complication classification and reporting.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: S Yadla, JK Ratliff, JS Harrop. Acquisition of data: S Yadla. Analysis and interpretation of data: S Yadla, MG Maltenfort, JK Ratliff, JS Harrop. Drafting the article: S Yadla, MG Maltenfort, JK Ratliff, JS Harrop. Critically revising the article: S Yadla, MG Maltenfort, JK Ratliff, JS Harrop. Reviewed final version of the manuscript and approved it for submission: S Yadla, MG Maltenfort, JK Ratliff, JS Harrop. Statistical analysis: MG Maltenfort.

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    • Export Citation
  • 33

    Heary RF, , Bono CM, & Kumar S: Bracing for scoliosis. Neurosurgery 63:3 Suppl 125130, 2008

  • 34

    Khan SN, , Hofer MA, & Gupta MC: Lumbar degenerative scoliosis: outcomes of combined anterior and posterior pelvis surgery with minimum 2-year follow-up. Orthopedics 2009. (http://www.orthosupersite.com/view.asp?rID=38060) [Accessed January 5, 2010]

    • Search Google Scholar
    • Export Citation
  • 35

    Kim YB, , Lenke LG, , Kim YJ, , Kim YW, , Blanke K, & Stobbs G, : The morbidity of an anterior thoracolumbar approach: adult spinal deformity patients with greater than five-year follow-up. Spine (Phila Pa 1976) 34:822826, 2009

    • Search Google Scholar
    • Export Citation
  • 36

    Kim YB, , Lenke LG, , Kim YJ, , Kim YW, , Bridwell KH, & Stobbs G: Surgical treatment of adult scoliosis: is anterior apical release and fusion necessary for the lumbar curve?. Spine (Phila Pa 1976) 33:11251132, 2008

    • Search Google Scholar
    • Export Citation
  • 37

    Kim YJ, , Bridwell KH, , Lenke LG, , Cheh G, & Baldus C: Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976) 32:21892197, 2007

    • Search Google Scholar
    • Export Citation
  • 38

    Kim YJ, , Bridwell KH, , Lenke LG, , Cho KJ, , Edwards CC II, & Rinella AS: Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis. J Bone Joint Surg Am 88:721728, 2006

    • Search Google Scholar
    • Export Citation
  • 39

    Kim YJ, , Bridwell KH, , Lenke LG, , Rhim S, & Cheh G: Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine (Phila Pa 1976) 31:23292336, 2006

    • Search Google Scholar
    • Export Citation
  • 40

    Kim YJ, , Bridwell KH, , Lenke LG, , Rhim S, & Kim YW: Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1?. Spine (Phila Pa 1976) 32:26532661, 2007

    • Search Google Scholar
    • Export Citation
  • 41

    Kim YJ, , Bridwell KH, , Lenke LG, , Rinella AS, & Edwards C II: Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis. Spine (Phila Pa 1976) 30:468474, 2005

    • Search Google Scholar
    • Export Citation
  • 42

    Kostuik JP, & Hall BB: Spinal fusions to the sacrum in adults with scoliosis. Spine (Phila Pa 1976) 8:489500, 1983

  • 43

    Lapp MA, , Bridwell KH, , Lenke LG, , Daniel Riew K, , Linville DA, & Eck KR, : Long-term complications in adult spinal deformity patients having combined surgery a comparison of primary to revision patients. Spine (Phila Pa 1976) 26:973983, 2001

    • Search Google Scholar
    • Export Citation
  • 44

    Li G, , Passias P, , Kozanek M, , Fu E, , Wang S, & Xia Q, : Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine (Phila Pa 1976) 34:21652170, 2009

    • Search Google Scholar
    • Export Citation
  • 45

    Murrey DB, , Brigham CD, , Kiebzak GM, , Finger F, & Chewning SJ: Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976) 27:23382345, 2002

    • Search Google Scholar
    • Export Citation
  • 46

    Pateder DB, , Kebaish KM, , Cascio BM, , Neubaeur P, , Matusz DM, & Kostuik JP: Posterior only versus combined anterior and posterior approaches to lumbar scoliosis in adults: a radiographic analysis. Spine (Phila Pa 1976) 32:15511554, 2007

    • Search Google Scholar
    • Export Citation
  • 47

    Peelle MW, , Boachie-Adjei O, , Charles G, , Kanazawa Y, & Mesfin A: Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis. Spine J 8:897903, 2008

    • Search Google Scholar
    • Export Citation
  • 48

    Rhee JM, , Bridwell KH, , Lenke LG, , Baldus C, , Blanke K, & Edwards C, : Staged posterior surgery for severe adult spinal deformity. Spine (Phila Pa 1976) 28:21162121, 2003

    • Search Google Scholar
    • Export Citation
  • 49

    Rose PS, , Lenke LG, , Bridwell KH, , Mulconrey DS, , Cronen GA, & Buchowski JM, : Pedicle screw instrumentation for adult idiopathic scoliosis: an improvement over hook/hybrid fixation. Spine (Phila Pa 1976) 34:852858, 2009

    • Search Google Scholar
    • Export Citation
  • 50

    Schwab F, , Farcy JP, , Bridwell K, , Berven S, , Glassman S, & Harrast J, : A clinical impact classification of scoliosis in the adult. Spine (Phila Pa 1976) 31:21092114, 2006

    • Search Google Scholar
    • Export Citation
  • 51

    Shapiro GS, , Taira G, & Boachie-Adjei O: Results of surgical treatment of adult idiopathic scoliosis with low back pain and spinal stenosis: a study of long-term clinical radiographic outcomes. Spine (Phila Pa 1976) 28:358363, 2003

    • Search Google Scholar
    • Export Citation
  • 52

    Simmons ED Jr, , Kowalski JM, & Simmons EH: The results of surgical treatment for adult scoliosis. Spine (Phila Pa 1976) 18:718724, 1993

  • 53

    Smith JA, , Deviren V, , Berven S, & Bradford DS: Does instrumented anterior scoliosis surgery lead to kyphosis, pseudarthrosis, or inadequate correction in adults?. Spine (Phila Pa 1976) 27:529534, 2002

    • Search Google Scholar
    • Export Citation
  • 54

    Smith JS, , Shaffrey CI, , Berven S, , Glassman S, , Hamill C, & Horton W, : Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:8694, 2009

    • Search Google Scholar
    • Export Citation
  • 55

    Suk SI, , Chung ER, , Lee SM, , Lee JH, , Kim SS, & Kim JH: Posterior vertebral column resection in fixed lumbosacral deformity. Spine (Phila Pa 1976) 30:E703E710, 2005

    • Search Google Scholar
    • Export Citation
  • 56

    Swank S, , Lonstein JE, , Moe JH, , Winter RB, & Bradford DS: Surgical treatment of adult scoliosis. A review of two hundred and twenty-two cases. J Bone Joint Surg Am 63:268287, 1981

    • Search Google Scholar
    • Export Citation
  • 57

    Tsuchiya K, , Bridwell KH, , Kuklo TR, , Lenke LG, & Baldus C: Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 31:303308, 2006

    • Search Google Scholar
    • Export Citation
  • 58

    van Dam BE, , Bradford DS, , Lonstein JE, , Moe JH, , Ogilvie JW, & Winter RB: Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation. Spine (Phila Pa 1976) 12:3236, 1987

    • Search Google Scholar
    • Export Citation
  • 59

    Wang ST, , Ma HL, , Lin CF, , Liu CL, , Yu WK, & Lo WH: Surgical treatment of adult idiopathic scoliosis - comparison of two instrumentations. Int Orthop 26:207210, 2002

    • Search Google Scholar
    • Export Citation
  • 60

    Wang Y, , Zhang Y, , Zhang X, , Huang P, , Xiao S, & Wang Z, : A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases. Eur Spine J 17:361372, 2008

    • Search Google Scholar
    • Export Citation
  • 61

    Weistroffer JK, , Perra JH, , Lonstein JE, , Schwender JD, , Garvey TA, & Transfeldt EE, : Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine (Phila Pa 1976) 33:14781483, 2008

    • Search Google Scholar
    • Export Citation
  • 62

    Wu CH, , Wong CB, , Chen LH, , Niu CC, , Tsai TT, & Chen WJ: Instrumented posterior lumbar interbody fusion for patients with degenerative lumbar scoliosis. J Spinal Disord Tech 21:310315, 2008

    • Search Google Scholar
    • Export Citation
  • 63

    Yang BP, , Ondra SL, , Chen LA, , Jung HS, , Koski TR, & Salehi SA: Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5:917, 2006

    • Search Google Scholar
    • Export Citation

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Contributor Notes

Address correspondence to: Sanjay Yadla, M.D., Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, Pennsylvania 19107. email: sanjay.yadla@jeffersonhospital.org.
  • View in gallery

    Bar graph illustrating age distribution (in years) of patients in 49 reviewed series encompassing 3299 patients.

  • View in gallery

    Bar graph illustrating distribution of average follow-up period of patients in 49 reviewed series including data from 3299 patients.

  • View in gallery

    Bar graph illustrating distribution of average curve reduction of patients as reported in 39 reviewed series with data from 2188 patients at a minimum 2-year follow-up.

  • 1

    Aebi M: The adult scoliosis. Eur Spine J 14:925948, 2005

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    Ahn UM, , Ahn NU, , Buchowski JM, , Kebaish KM, , Lee JH, & Song ES, : Functional outcome and radiographic correction after spinal osteotomy. Spine (Phila Pa 1976) 27:13031311, 2002

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    Albert TJ, , Purtill J, , Mesa J, , McIntosh T, & Balderston RA: Health outcome assessment before and after adult deformity surgery. A prospective study. Spine (Phila Pa 1976) 20:20022005, 1995

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    Ali RM, , Boachie-Adjei O, & Rawlins BA: Functional and radiographic outcomes after surgery for adult scoliosis using third-generation instrumentation techniques. Spine (Phila Pa 1976) 28:11631170, 2003

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    Asher MA, , Min Lai S, & Burton DC: Further development and validation of the Scoliosis Research Society (SRS) outcomes instrument. Spine (Phila Pa 1976) 25:23812386, 2000

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    Bago J, , Perez-Grueso FJ, , Les E, , Hernandez P, & Pellise F: Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis. Eur Spine J 18:18981904, 2009

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  • 7

    Berven S, , Deviren V, , Demir-Deviren S, , Hu SS, & Bradford DS: Studies in the modified Scoliosis Research Society Outcomes Instrument in adults: validation, reliability, and discriminatory capacity. Spine (Phila Pa 1976) 28:21642169, 2003

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  • 8

    Berven SH, , Deviren V, , Smith JA, , Hu SH, & Bradford DS: Management of fixed sagittal plane deformity: outcome of combined anterior and posterior surgery. Spine (Phila Pa 1976) 28:17101716, 2003

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  • 9

    Bess RS, , Lenke LG, , Bridwell KH, , Cheh G, , Mandel S, & Sides B: Comparison of thoracic pedicle screw to hook instrumentation for the treatment of adult spinal deformity. Spine (Phila Pa 1976) 32:555561, 2007

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    • Export Citation
  • 10

    Boachie-Adjei O, , Ferguson JA, , Pigeon RG, & Peskin MR: Transpedicular lumbar wedge resection osteotomy for fixed sagittal imbalance: surgical technique and early results. Spine (Phila Pa 1976) 31:485492, 2006

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  • 11

    Bomback DA, , Charles G, , Widmann R, & Boachie-Adjei O: Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome. Spine J 7:399405, 2007

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  • 12

    Bradford DS, , Tay BK, & Hu SS: Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976) 24:26172629, 1999

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  • 13

    Bridwell KH, , Berven S, , Edwards C II, , Glassman S, , Hamill C, & Schwab F: The problems and limitations of applying evidence-based medicine to primary surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 32:19 Suppl S135139, 2007

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  • 14

    Bridwell KH, , Berven S, , Glassman S, , Hamill C, , Horton WC III, & Lenke LG, : Is the SRS-22 instrument responsive to change in adult scoliosis patients having primary spinal deformity surgery?. Spine (Phila Pa 1976) 32:22202225, 2007

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  • 15

    Bridwell KH, , Glassman S, , Horton W, , Shaffrey C, , Schwab F, & Zebala LP, : Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976) 34:21712178, 2009

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  • 16

    Bridwell KH, , Lewis SJ, , Edwards C, , Lenke LG, , Iffrig TM, & Berra A, : Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976) 28:20932101, 2003

    • Search Google Scholar
    • Export Citation
  • 17

    Bridwell KH, , Lewis SJ, , Lenke LG, , Baldus C, & Blanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 85:454463, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Brown KM, , Ludwig SC, & Gelb DE: Radiographic predictors of outcome after long fusion to L5 in adult scoliosis. J Spinal Disord Tech 17:358366, 2004

    • Search Google Scholar
    • Export Citation
  • 19

    Buchowski JM, , Bridwell KH, , Lenke LG, , Kuhns CA, , Lehman RA Jr, & Kim YJ, : Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976) 32:22452252, 2007

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    • Export Citation
  • 20

    Buttermann GR, , Glazer PA, , Hu SS, & Bradford DS: Anterior and posterior allografts in symptomatic thoracolumbar deformity. J Spinal Disord 14:5466, 2001

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    • Export Citation
  • 21

    Chang KW, , Chen YY, , Lin CC, , Hsu HL, & Pai KC: Closing wedge osteotomy versus opening wedge osteotomy in ankylosing spondylitis with thoracolumbar kyphotic deformity. Spine (Phila Pa 1976) 30:15841593, 2005

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  • 22

    Chang KW, , Cheng CW, , Chen HC, , Chang KI, & Chen TC: Closing-opening wedge osteotomy for the treatment of sagittal imbalance. Spine (Phila Pa 1976) 33:14701477, 2008

    • Search Google Scholar
    • Export Citation
  • 23

    Daubs MD, , Lenke LG, , Cheh G, , Stobbs G, & Bridwell KH: Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine (Phila Pa 1976) 32:22382244, 2007

    • Search Google Scholar
    • Export Citation
  • 24

    Deviren V, , Patel VV, , Metz LN, , Berven SH, , Hu SH, & Bradford DS: Anterior arthrodesis with instrumentation for thoracolumbar scoliosis: comparison of efficacy in adults and adolescents. Spine (Phila Pa 1976) 33:12191223, 2008

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  • 25

    DeWald CJ, & Stanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality. Spine (Phila Pa 1976) 31:19 Suppl S144S151, 2006

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  • 26

    Eck KR, , Bridwell KH, , Ungacta FF, , Riew KD, , Lapp MA, & Lenke LG, : Complications and results of long adult deformity fusions down to l4, l5, and the sacrum. Spine (Phila Pa 1976) 26:E182E192, 2001

    • Search Google Scholar
    • Export Citation
  • 27

    Emami A, , Deviren V, , Berven S, , Smith JA, , Hu SS, & Bradford DS: Outcome and complications of long fusions to the sacrum in adult spine deformity: luque-galveston, combined iliac and sacral screws, and sacral fixation. Spine (Phila Pa 1976) 27:776786, 2002

    • Search Google Scholar
    • Export Citation
  • 28

    Fairbank JC, & Pynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:29402952, 2000

  • 29

    Glassman SD, , Schwab F, , Bridwell KH, , Shaffrey C, , Horton W, & Hu S: Do 1-year outcomes predict 2-year outcomes for adult deformity surgery?. Spine J 9:317322, 2009

    • Search Google Scholar
    • Export Citation
  • 30

    Glattes RC, , Bridwell KH, , Lenke LG, , Kim YJ, , Rinella A, & Edwards C II: Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976) 30:16431649, 2005

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    • Export Citation
  • 31

    Harris RP, , Helfand M, , Woolf SH, , Lohr KN, , Mulrow CD, & Teutsch SM, : Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med 20:3 Suppl 2135, 2001

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  • 32

    Heary RF: Evaluation and treatment of adult spinal deformity. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:918, 2004

    • Search Google Scholar
    • Export Citation
  • 33

    Heary RF, , Bono CM, & Kumar S: Bracing for scoliosis. Neurosurgery 63:3 Suppl 125130, 2008

  • 34

    Khan SN, , Hofer MA, & Gupta MC: Lumbar degenerative scoliosis: outcomes of combined anterior and posterior pelvis surgery with minimum 2-year follow-up. Orthopedics 2009. (http://www.orthosupersite.com/view.asp?rID=38060) [Accessed January 5, 2010]

    • Search Google Scholar
    • Export Citation
  • 35

    Kim YB, , Lenke LG, , Kim YJ, , Kim YW, , Blanke K, & Stobbs G, : The morbidity of an anterior thoracolumbar approach: adult spinal deformity patients with greater than five-year follow-up. Spine (Phila Pa 1976) 34:822826, 2009

    • Search Google Scholar
    • Export Citation
  • 36

    Kim YB, , Lenke LG, , Kim YJ, , Kim YW, , Bridwell KH, & Stobbs G: Surgical treatment of adult scoliosis: is anterior apical release and fusion necessary for the lumbar curve?. Spine (Phila Pa 1976) 33:11251132, 2008

    • Search Google Scholar
    • Export Citation
  • 37

    Kim YJ, , Bridwell KH, , Lenke LG, , Cheh G, & Baldus C: Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976) 32:21892197, 2007

    • Search Google Scholar
    • Export Citation
  • 38

    Kim YJ, , Bridwell KH, , Lenke LG, , Cho KJ, , Edwards CC II, & Rinella AS: Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis. J Bone Joint Surg Am 88:721728, 2006

    • Search Google Scholar
    • Export Citation
  • 39

    Kim YJ, , Bridwell KH, , Lenke LG, , Rhim S, & Cheh G: Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine (Phila Pa 1976) 31:23292336, 2006

    • Search Google Scholar
    • Export Citation
  • 40

    Kim YJ, , Bridwell KH, , Lenke LG, , Rhim S, & Kim YW: Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1?. Spine (Phila Pa 1976) 32:26532661, 2007

    • Search Google Scholar
    • Export Citation
  • 41

    Kim YJ, , Bridwell KH, , Lenke LG, , Rinella AS, & Edwards C II: Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis. Spine (Phila Pa 1976) 30:468474, 2005

    • Search Google Scholar
    • Export Citation
  • 42

    Kostuik JP, & Hall BB: Spinal fusions to the sacrum in adults with scoliosis. Spine (Phila Pa 1976) 8:489500, 1983

  • 43

    Lapp MA, , Bridwell KH, , Lenke LG, , Daniel Riew K, , Linville DA, & Eck KR, : Long-term complications in adult spinal deformity patients having combined surgery a comparison of primary to revision patients. Spine (Phila Pa 1976) 26:973983, 2001

    • Search Google Scholar
    • Export Citation
  • 44

    Li G, , Passias P, , Kozanek M, , Fu E, , Wang S, & Xia Q, : Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine (Phila Pa 1976) 34:21652170, 2009

    • Search Google Scholar
    • Export Citation
  • 45

    Murrey DB, , Brigham CD, , Kiebzak GM, , Finger F, & Chewning SJ: Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976) 27:23382345, 2002

    • Search Google Scholar
    • Export Citation
  • 46

    Pateder DB, , Kebaish KM, , Cascio BM, , Neubaeur P, , Matusz DM, & Kostuik JP: Posterior only versus combined anterior and posterior approaches to lumbar scoliosis in adults: a radiographic analysis. Spine (Phila Pa 1976) 32:15511554, 2007

    • Search Google Scholar
    • Export Citation
  • 47

    Peelle MW, , Boachie-Adjei O, , Charles G, , Kanazawa Y, & Mesfin A: Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis. Spine J 8:897903, 2008

    • Search Google Scholar
    • Export Citation
  • 48

    Rhee JM, , Bridwell KH, , Lenke LG, , Baldus C, , Blanke K, & Edwards C, : Staged posterior surgery for severe adult spinal deformity. Spine (Phila Pa 1976) 28:21162121, 2003

    • Search Google Scholar
    • Export Citation
  • 49

    Rose PS, , Lenke LG, , Bridwell KH, , Mulconrey DS, , Cronen GA, & Buchowski JM, : Pedicle screw instrumentation for adult idiopathic scoliosis: an improvement over hook/hybrid fixation. Spine (Phila Pa 1976) 34:852858, 2009

    • Search Google Scholar
    • Export Citation
  • 50

    Schwab F, , Farcy JP, , Bridwell K, , Berven S, , Glassman S, & Harrast J, : A clinical impact classification of scoliosis in the adult. Spine (Phila Pa 1976) 31:21092114, 2006

    • Search Google Scholar
    • Export Citation
  • 51

    Shapiro GS, , Taira G, & Boachie-Adjei O: Results of surgical treatment of adult idiopathic scoliosis with low back pain and spinal stenosis: a study of long-term clinical radiographic outcomes. Spine (Phila Pa 1976) 28:358363, 2003

    • Search Google Scholar
    • Export Citation
  • 52

    Simmons ED Jr, , Kowalski JM, & Simmons EH: The results of surgical treatment for adult scoliosis. Spine (Phila Pa 1976) 18:718724, 1993

  • 53

    Smith JA, , Deviren V, , Berven S, & Bradford DS: Does instrumented anterior scoliosis surgery lead to kyphosis, pseudarthrosis, or inadequate correction in adults?. Spine (Phila Pa 1976) 27:529534, 2002

    • Search Google Scholar
    • Export Citation
  • 54

    Smith JS, , Shaffrey CI, , Berven S, , Glassman S, , Hamill C, & Horton W, : Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:8694, 2009

    • Search Google Scholar
    • Export Citation
  • 55

    Suk SI, , Chung ER, , Lee SM, , Lee JH, , Kim SS, & Kim JH: Posterior vertebral column resection in fixed lumbosacral deformity. Spine (Phila Pa 1976) 30:E703E710, 2005

    • Search Google Scholar
    • Export Citation
  • 56

    Swank S, , Lonstein JE, , Moe JH, , Winter RB, & Bradford DS: Surgical treatment of adult scoliosis. A review of two hundred and twenty-two cases. J Bone Joint Surg Am 63:268287, 1981

    • Search Google Scholar
    • Export Citation
  • 57

    Tsuchiya K, , Bridwell KH, , Kuklo TR, , Lenke LG, & Baldus C: Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 31:303308, 2006

    • Search Google Scholar
    • Export Citation
  • 58

    van Dam BE, , Bradford DS, , Lonstein JE, , Moe JH, , Ogilvie JW, & Winter RB: Adult idiopathic scoliosis treated by posterior spinal fusion and Harrington instrumentation. Spine (Phila Pa 1976) 12:3236, 1987

    • Search Google Scholar
    • Export Citation
  • 59

    Wang ST, , Ma HL, , Lin CF, , Liu CL, , Yu WK, & Lo WH: Surgical treatment of adult idiopathic scoliosis - comparison of two instrumentations. Int Orthop 26:207210, 2002

    • Search Google Scholar
    • Export Citation
  • 60

    Wang Y, , Zhang Y, , Zhang X, , Huang P, , Xiao S, & Wang Z, : A single posterior approach for multilevel modified vertebral column resection in adults with severe rigid congenital kyphoscoliosis: a retrospective study of 13 cases. Eur Spine J 17:361372, 2008

    • Search Google Scholar
    • Export Citation
  • 61

    Weistroffer JK, , Perra JH, , Lonstein JE, , Schwender JD, , Garvey TA, & Transfeldt EE, : Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine (Phila Pa 1976) 33:14781483, 2008

    • Search Google Scholar
    • Export Citation
  • 62

    Wu CH, , Wong CB, , Chen LH, , Niu CC, , Tsai TT, & Chen WJ: Instrumented posterior lumbar interbody fusion for patients with degenerative lumbar scoliosis. J Spinal Disord Tech 21:310315, 2008

    • Search Google Scholar
    • Export Citation
  • 63

    Yang BP, , Ondra SL, , Chen LA, , Jung HS, , Koski TR, & Salehi SA: Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5:917, 2006

    • Search Google Scholar
    • Export Citation

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