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Emmanuelle Ferrero, Barthelemy Liabaud, Jensen K. Henry, Christopher P. Ames, Khaled Kebaish, Gregory M. Mundis, Richard Hostin, Munish C. Gupta, Oheneba Boachie-Adjei, Justin S. Smith, Robert A. Hart, Ibrahim Obeid, Bassel G. Diebo, Frank J. Schwab and Virginie Lafage

timing of revision surgery (up to 2 years postoperatively). Radiographic Measurement Radiographs were analyzed using validated software (Spineview, ENSAM Paris-Tech). 34 Sagittal spinopelvic radiographic parameters included cervical lordosis, T2–12 thoracic kyphosis (TK), LL, PI-LL mismatch, and pelvic parameters (PI, PT, and sacral slope). 46 Global sagittal alignment parameters included SVA and T-1 spinopelvic inclination (T1SPi) ( Fig. 1 ). The 3CO resection angle was defined as the change in the angle formed by the upper endplate of the vertebra below the 3CO and

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Themistocles S. Protopsaltis, Justin K. Scheer, Jamie S. Terran, Justin S. Smith, D. Kojo Hamilton, Han Jo Kim, Greg M. Mundis Jr., Robert A. Hart, Ian M. McCarthy, Eric Klineberg, Virginie Lafage, Shay Bess, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames and International Spine Study Group

A dult spinal deformity has been studied extensively in the literature with a majority of publications focusing on thoracolumbar deformity and its effect on health-related quality of life (HRQOL) measures. 1 , 3 , 6 , 7 , 10 , 11 , 13 , 14 , 16 , 17 Among patients with thoracolumbar deformities, positive sagittal alignment has been associated with pain and disability. 2 , 7 , 11 , 13 , 16 Few studies have correlated validated health measures and positive cervical sagittal alignment. 16 , 17 Tang et al. 16 demonstrated that a C2–7 sagittal vertical axis

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Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Frank Schwab, Justin K. Scheer, Themistocles Protopsaltis, Eric Klineberg, Munish Gupta, Richard Hostin, Kai-Ming G. Fu, Gregory M. Mundis Jr., Han Jo Kim, Vedat Deviren, Alex Soroceanu, Robert A. Hart, Douglas C. Burton, Shay Bess, Christopher P. Ames and the International Spine Study Group

Slover J , Abdu WA , Hanscom B , Weinstein JN : The impact of comorbidities on the change in short-form 36 and Oswes-try scores following lumbar spine surgery . Spine (Phila Pa 1976) 31 : 1974 – 1980 , 2006 41 Smith JS , Bess S , Shaffrey CI , Burton DC , Hart RA , Hostin R , : Dynamic changes of the pelvis and spine are key to predicting postoperative sagittal alignment after pedicle subtraction osteotomy: a critical analysis of preoperative planning techniques . Spine (Phila Pa 1976) 37 : 845 – 853 , 2012 42 Smith JS , Fu

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Joshua Bakhsheshian, Justin K. Scheer, Jeffrey L. Gum, Richard Hostin, Virginie Lafage, Shay Bess, Themistocles S. Protopsaltis, Douglas C. Burton, Malla Kate Keefe, Robert A. Hart, Gregory M. Mundis Jr., Christopher I. Shaffrey, Frank Schwab, Justin S. Smith, Christopher P. Ames and The International Spine Study Group


Mental disease burden can have a significant impact on levels of disability and health-related quality of life (HRQOL) measures. Therefore, the authors investigated the significance of mental health status in adults with spinal deformity and poor physical function.


A retrospective analysis of a prospective multicenter database of 365 adult spinal deformity (ASD) patients who had undergone surgical treatment was performed. Health-related QOL variables were examined preoperatively and at the 2-year postoperative follow-up. Patients were grouped by their 36-Item Short Form Health Survey mental component summary (MCS) and physical component summary (PCS) scores. Both groups had PCS scores ≤ 25th percentile for matched norms; however, the low mental health (LMH) group consisted of patients with an MCS score ≤ 25th percentile, and the high mental health (HMH) group included patients with an MCS score ≥ 75th percentile.


Of the 264 patients (72.3%) with a 2-year follow-up, 104 (28.5%) met the inclusion criteria for LMH and 40 patients (11.0%) met those for HMH. The LMH group had a significantly higher overall rate of comorbidities, specifically leg weakness, depression, hypertension, and self-reported neurological and psychiatric disease processes, and were more likely to be unemployed as compared with the HMH group (p < 0.05 for all). The 2 groups had similar 2-year postoperative improvements in HRQOL (p > 0.05) except for the greater improvements in the MCS and the Scoliosis Research Society-22r questionnaire (SRS-22r) mental domain (p < 0.05) in the LMH group and greater improvements in PCS and SRS-22r satisfaction and back pain domains (p < 0.05) in the HMH group. The LMH group had a higher rate of reaching a minimal clinically important difference (MCID) on the SRS-22r mental domain (p < 0.01), and the HMH group had a higher rate of reaching an MCID on the PCS and SRS-22r activity domain (p < 0.05). On multivariable logistic regression, having LMH was a significant independent predictor of failure to reach an MCID on the PCS (p < 0.05). At the 2-year postoperative follow-up, 14 LMH patients (15.1%) were categorized as HMH. Two LMH patients (2.2%), and 3 HMH patients (7.7%) transitioned to a PCS score ≥ 75th percentile for age- and sex-matched US norms (p < 0.01).


While patients with poor mental and physical health, according to their MCS and PCS scores, have higher medical comorbidity and unemployment rates, they still demonstrate significant improvements in HRQOL measurements postoperatively. Both LMH and HMH patient groups demonstrated similar improvements in most HRQOL domains, except that the LMH patients had difficulties in obtaining improvements in the PCS domain.

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Virginie Lafage, Neil J. Bharucha, Frank Schwab, Robert A. Hart, Douglas Burton, Oheneba Boachie-Adjei, Justin S. Smith, Richard Hostin, Christopher Shaffrey, Munish Gupta, Behrooz A. Akbarnia and Shay Bess

sagittal alignment to maintain upright posture. Recently, increased PT has also been shown to correlate with worse HRQOL scores. 11 In certain cases of sagittal malalignment, a corrective osteotomy can be performed to restore balance. Pedicle subtraction osteotomy is an increasingly used technique to correct sagittal plane deformities and can obtain approximately 25° of increased lordosis when performed in the lumbar spine. 4 , 12 , 23 One of the challenges of the PSO technique is accurately predicting the postoperative spinopelvic alignment. Achieving spinopelvic

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Frank J. Schwab, Ashish Patel, Christopher I. Shaffrey, Justin S. Smith, Jean-Pierre Farcy, Oheneba Boachie-Adjei, Richard A. Hostin, Robert A. Hart, Behrooz A. Akbarnia, Douglas C. Burton, Shay Bess and Virginie Lafage

in SS (9.5° ± 9° vs 8.1° ± 10.1°, respectively, p = 0.59), or postoperative SS (32.4° ± 10.6° vs 35.5° ± 11.3°, respectively, p = 0.30). Discussion Sagittal spinopelvic malalignment is a major cause of pain and loss of function associated with ASD. 1 , 13 , 21 Surgical restoration of optimal sagittal alignment is indicated for symptomatic patients and has demonstrated superior clinical and radiographic outcomes compared with nonoperative management. 5 , 32 Previous studies have shown that realignment of SVA and PT is critical to optimize clinical outcomes

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Samantha R. Horn, Peter G. Passias, Cheongeun Oh, Virginie Lafage, Renaud Lafage, Justin S. Smith, Breton Line, Neel Anand, Frank A. Segreto, Cole A. Bortz, Justin K. Scheer, Robert K. Eastlack, Vedat Deviren, Praveen V. Mummaneni, Alan H. Daniels, Paul Park, Pierce D. Nunley, Han Jo Kim, Eric O. Klineberg, Douglas C. Burton, Robert A. Hart, Frank J. Schwab, Shay Bess, Christopher I. Shaffrey, Christopher P. Ames and the International Spine Study Group

line through the sacral midpoint to the center of the 2 femoral heads). FIG. 1. Schematic of the measured sagittal alignment parameters for the cervical ( left ) and global spinopelvic ( right ) spinal regions. CBVA = chin-brow vertical angle; cSVA = cervical sagittal vertical axis; C2–7 CL = cervical lordosis; TK = thoracic kyphosis; LL = lumbar lordosis; SVA = sagittal vertical axis; PT = pelvic tilt; PI = pelvic incidence. Figure is available in color online only. Defining a Poor Outcome A poor outcome was defined as having all 3 of the following categories met: 1

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sagittal alignment on MRI. In addition, no study has shown clinical superiority of flexion-extension xrays compared to upright static xrays in order to diagnose a lumbar anterolisthesis. Methods We retrospectively evaluated all patients presenting to spine clinic for degenerative lumbar conditions for 24 consecutive months who had an MRI, upright lateral, as well as flexion-extension radiographs at our institution. Comparing radiographic reads by a musculoskeletal radiologist, the incidence of degenerative spondylolisthesis found on dynamic flexion

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deformation of non-operative spine fractures and identify predictive variables of angular change. Summary of Background Data Loss of normal sagittal alignment of the spine is a common sequela following thoracolumbar injuries. Patients treated non-operatively are especially at risk; however knowledge of the natural history of these injuries and predictors of deformation over time remains limited. Methods Patients with thoracolumbar fractures were identified via a trauma database. The angular change about the fracture site was determined comparing initial CT

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greater Charlson comorbidity index (1.1 vs 0.85) than NONOP (n=446), respectively (p<0.05). OP had worse HRQOL scores on all surveys than NONOP (p<0.05). OP and NONOP had similar coronal alignment (p<0.05). OP had worse sagittal spinopelvic alignment for all measures than NONOP except cervical lordosis, TK and pelvic incidence (PI). OP had greater percentage of pure sagittal classification (type S; OP=23%, NON=14%; p<0.05). OP had worse grades for all modifier categories: PT (26% vs 16%), PI-lumbar lordosis mismatch (37% vs 21%) and global sagittal alignment (29% vs 9