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Manish K. Kasliwal, Justin S. Smith, Christopher I. Shaffrey, Leah Y. Carreon, Steven D. Glassman, Frank Schwab, Virginie Lafage, Kai-Ming G. Fu and Keith H. Bridwell

activity levels that could be affected by a definitive fusion of the entire deformity. However, even with careful selection, a subset of patients who undergo limited procedures can later become symptomatic because of deformity progression, worsening sagittal or coronal imbalance, failure of the previous fusion, new instability, or adjacent segment degeneration. 6 , 32 , 51 A revision surgery rate as high as 67% has been reported following decompression and segmental fixation in patients with adult degenerative scoliosis. 6 , 51 Considering that revision spine surgery

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Justin S. Smith, Thomas J. Buell, Christopher I. Shaffrey, Han Jo Kim, Eric Klineberg, Themistocles Protopsaltis, Peter Passias, Gregory M. Mundis Jr., Robert Eastlack, Vedat Deviren, Michael P. Kelly, Alan H. Daniels, Jeffrey L. Gum, Alex Soroceanu, Munish Gupta, Doug Burton, Richard Hostin, Robert Hart, Virginie Lafage, Renaud Lafage, Frank J. Schwab, Shay Bess and Christopher P. Ames

deformities. 2–6 Early reports of surgery for ACSD focused on the most severe forms of ACSD and were often associated with very high rates of morbidity. 7–9 As advances have been made in spinal instrumentation and surgical techniques, as well as improvements in anesthesia, critical care, and perioperative management, a renewed interest in treating these often complex deformities has developed. 10–17 Recent advances have included development of a standardized nomenclature for soft-tissue release and osteotomies for cervical deformity correction, 18 creation of the novel

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Justin S. Smith, Eric Klineberg, Virginie Lafage, Christopher I. Shaffrey, Frank Schwab, Renaud Lafage, Richard Hostin, Gregory M. Mundis Jr., Thomas J. Errico, Han Jo Kim, Themistocles S. Protopsaltis, D. Kojo Hamilton, Justin K. Scheer, Alex Soroceanu, Michael P. Kelly, Breton Line, Munish Gupta, Vedat Deviren, Robert Hart, Douglas C. Burton, Shay Bess, Christopher P. Ames and the International Spine Study Group

, surgical treatment may be an option for patients who have unsatisfactory improvement. Multiple recent reports have demonstrated the potential of surgical treatment of ASD to provide significant improvement in pain, disability, and HRQOL. 5 , 6 , 25 , 48 , 49 , 53–57 , 60 However, these procedures are often complex and may be associated with high rates of complications. 4 , 6 , 14 , 15 , 17 , 22 , 39 , 44 , 45 , 50–52 , 55 , 58 , 61 , 63 Previously reported studies of ASD surgery complications have been limited by retrospective design, single-surgeon or single

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Justin S. Smith, Ellen Shaffrey, Eric Klineberg, Christopher I. Shaffrey, Virginie Lafage, Frank J. Schwab, Themistocles Protopsaltis, Justin K. Scheer, Gregory M. Mundis Jr., Kai-Ming G. Fu, Munish C. Gupta, Richard Hostin, Vedat Deviren, Khaled Kebaish, Robert Hart, Douglas C. Burton, Breton Line, Shay Bess, Christopher P. Ames and The International Spine Study Group

great advances, an important source of complications and patient morbidity remains the inherent limitations of the durability of spinal implants. 1 , 3 , 4 , 6 , 13–17 , 19–21 , 23 , 25–27 , 30 , 32 , 33 , 38 , 44–47 , 50 , 51 Although development of rod fracture may have significant consequences for patients, including pain, loss of deformity correction, and the need for revision surgery, the literature regarding rod fracture remains relatively limited. 1 , 4 , 9 , 11 , 15 , 19 , 23 , 29 , 38 , 49 , 51 , 52 Previous reports discussing rod fracture have many

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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

and worthwhile to pursue. An important part of this risk-benefit analysis and of patient counseling is the discussion regarding reasonable expectations. Previous reports suggest that surgery for selected patients with ASD can provide approximately 60% relief of back and leg pain and approximately 40% improvement in disability at 2-year follow-up compared with baseline levels. 46 , 47 Although these results offer simple objective measures that may be useful for patient counseling, it is important to recognize that they are based on averages of large groups of

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Antonio A. Faundez and Jean Charles Le Huec

tangent to the S-1 endplate (reflecting the sacral slope) ( Fig. 1 ). The mean SSA angle in the asymptomatic population is 131° ± 8°. 2 It decreases when the spine is sagittaly out of balance and increases when the spine is better balanced again after a corrective surgery. For this reason, the SSA is a better indicator of restored postoperative sagittal balance than the SVA alone. In their study, Lafage and colleagues found a greater PT decrease when the PSO was done more distally in the lumbar spine. If they had measured the SSA, they could have shown that a more

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Christopher P. Ames, Justin S. Smith, Justin K. Scheer, Shay Bess, S. Samuel Bederman, Vedat Deviren, Virginie Lafage, Frank Schwab and Christopher I. Shaffrey

Treatment Health-related quality of life scores following surgery for adult spinal deformity are strongly correlated with the achievement of spinal SA and CA. 8 , 12 Traditionally, the SVA and C7-CSVL offset have been used to assess SA and CA, respectively, with the goal of corrective surgery to achieve an SVA and a CA < 4 cm each. Recently, however, Lafage et al. 23 reported that T1SPI more accurately correlated with HRQOL scores than did SVA. These authors also reported that increased PT values reflected pelvic retroversion and correlated with worsening HRQOL scores

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Alex Soroceanu, Douglas C. Burton, Bassel Georges Diebo, Justin S. Smith, Richard Hostin, Christopher I. Shaffrey, Oheneba Boachie-Adjei, Gregory M. Mundis Jr., Christopher Ames, Thomas J. Errico, Shay Bess, Munish C. Gupta, Robert A. Hart, Frank J. Schwab, Virginie Lafage and International Spine Study Group

rates following ASD surgery, 3 , 12 , 13 , 27 , 39 , 57 , 63 , 68 with complication rates as high as 95%. 39 Several studies have examined the impact of obesity on the surgical treatment of spinal pathologies and reported increased surgical-site infections for obese patients in the context of elective lumbar spinal fusion for degenerative conditions. 15 , 47 When looking at overall complications in the context of lumbar and cervical spine surgery, the effect of obesity is more controversial. Whereas some authors have associated obesity with increased complication

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Michael Y. Wang, Stacie Tran, G. Damian Brusko, Robert Eastlack, Paul Park, Pierce D. Nunley, Adam S. Kanter, Juan S. Uribe, Neel Anand, David O. Okonkwo, Khoi D. Than, Christopher I. Shaffrey, Virginie Lafage, Gregory M. Mundis Jr., Praveen V. Mummaneni and the MIS-ISSG Group

T he morbidity of adult spinal deformity (ASD) surgery has been well proven through several large multiinstitutional studies. 6 , 9 , 14 Although these operations carry inherent risk, the benefits of such interventions have been shown as well, provided that the tenets of the surgical goals have been met. 2 , 10 , 11 Given these conditions, substantial enthusiasm has been demonstrated for minimally invasive surgery (MIS) options. 5 , 7 , 18 , 22 Various technical methods have been developed to achieve these ends, including 1) leveraging alternate access routes

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Justin K. Scheer, Justin S. Smith, Frank Schwab, Virginie Lafage, Christopher I. Shaffrey, Shay Bess, Alan H. Daniels, Robert A. Hart, Themistocles S. Protopsaltis, Gregory M. Mundis Jr., Daniel M. Sciubba, Tamir Ailon, Douglas C. Burton, Eric Klineberg, Christopher P. Ames and The International Spine Study Group

T he surgical management of adult spinal deformity (ASD) can provide significant improvements in pain, disability, and health-related quality of life (HRQOL). 6 , 7 , 28 , 34 , 36–38 , 40–45 However, these procedures are technically demanding and are associated with a high complication rate. The patient population suitable for these complicated surgeries continues to increase, including patients of advanced age. 2 , 16 , 17 , 27 The reported complication rates in the literature are varied and range from 14% to 71%. 11 , 13 , 39 , 47 , 48 It has been