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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 K. Scheer, Jessica A. Tang, Justin S. Smith, Frank L. Acosta Jr., Themistocles S. Protopsaltis, Benjamin Blondel, Shay Bess, Christopher I. Shaffrey, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher P. Ames and the International Spine Study Group

bodies from C-2 to C-7 and then summing the segmental angles for an overall cervical curvature angle. Translation of the cervical spine in the sagittal plane is measured through the cervical SVA, for which there are different methods of measurement. Both C-2 SVA ( Figs. 2 and 3 left ) and C-7 SVA have been used to define sagittal alignment globally by measuring the distance between the C-2 and C-7 plumb lines, respectively, from the posterior superior corner of the sacrum. Cervical SVA can also be defined regionally using the distance between a plumb line dropped

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Justin K. Scheer, Peter G. Passias, Alexandra M. Sorocean, Anthony J. Boniello, Gregory M. Mundis Jr., Eric Klineberg, Han Jo Kim, Themistocles S. Protopsaltis, Munish Gupta, Shay Bess, Christopher I. Shaffrey, Frank Schwab, Virginie Lafage, Justin S. Smith, Christopher P. Ames and The International Spine Study Group

, all of the demographic differences were similar between patients with and without preoperative cervical malalignment, with the exception of CK. Patients with CK were significantly younger by an average of 10 years. This result is in line with both Park et al. 20 and Smith et al. 25 The study by Park and colleagues assessed the effect of age on cervical sagittal alignment in 100 asymptomatic subjects and found that the C2–7 lordosis increased with age. Smith et al. also found that patients with CK were significantly younger than those without CK in a large

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Christopher P. Ames, Justin S. Smith, Robert Eastlack, Donald J. Blaskiewicz, Christopher I. Shaffrey, Frank Schwab, Shay Bess, Han Jo Kim, Gregory M. Mundis Jr., Eric Klineberg, Munish Gupta, Michael O’Brien, Richard Hostin, Justin K. Scheer, Themistocles S. Protopsaltis, Kai-Ming G. Fu, Robert Hart, Todd J. Albert, K. Daniel Riew, Michael G. Fehlings, Vedat Deviren, Virginie Lafage and International Spine Study Group

posterosuperior corner of the C-7 vertebral body. The horizontal line with an arrow represents the C2–7 SVA. Given the significant impact of sagittal alignment on HRQOL among patients with thoracolumbar spinal deformities, and the studies of Tang et al. 54 and Smith et al. 45 demonstrating correlations between cervical sagittal alignment and multiple measures of HRQOL, the C2–7 SVA was selected as a modifier for the CSD classification. Based on regression analysis from Tang et al., a C2–7 SVA threshold of 4 cm was found to correlate with moderate disability based on the

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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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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

fracture, the retrospective study suggested that residual postoperative sagittal malalignment and greater BMI may be associated with greater risk of rod fracture. The present prospective study confirms the added risk of rod fracture with greater BMI and confirms that sagittal spinopelvic alignment may also be a risk factor, but instead of postoperative residual sagittal malalignment, the present study suggests that it is the magnitude of sagittal alignment correction that may be a more important factor. The findings of the present study demonstrate a markedly higher

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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

posterior, respectively, to the posterosuperior corner of the S-1 vertebral body. The T-1 spinopelvic inclination 30 and the T9SPI are alternative measures of SA. These measures are angles between the vertical plumb line extended from the bicoxofemoral axis and lines drawn from the vertebral body center of T-1 or T-9 to the center of the bicoxofemoral axis ( Fig. 3 right ). Since the T-1 and T-9 inclinations are angles rather than measured lines, they are not prone to radiographic magnification issues. Sagittal alignment is also assessed through regional measures of

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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

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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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Dominic Maggio, Tamir T. Ailon, Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Frank Schwab, Regis W. Haid Jr., Themistocles Protopsaltis, Eric Klineberg, Justin K. Scheer, Shay Bess, Paul M. Arnold, Jens Chapman, Michael G. Fehlings, Christopher Ames, AOSpine North America and International Spine Study Group

S urgical planning to address seemingly isolated lumbar pathology may lead to suboptimal results if a patient’s global spinal alignment is not taken into account. In recent years, there has been a greater appreciation of the interaction between different regions of the spine and the pelvis in producing harmonious global alignment. Malalignment in 1 region may result in compensatory changes in an adjacent (or even distant) region. This is particularly true in the setting of deformity surgery wherein correction of sagittal alignment can result in reciprocal

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Taemin Oh, Justin K. Scheer, Robert Eastlack, Justin S. Smith, Virginie Lafage, Themistocles S. Protopsaltis, Eric Klineberg, Peter G. Passias, Vedat Deviren, Richard Hostin, Munish Gupta, Shay Bess, Frank Schwab, Christopher I. Shaffrey and Christopher P. Ames

A dult spinal deformity (ASD) is a pathological condition defined as spinal malalignment in the axial, coronal, or sagittal plane and is derivative of congenital, iatrogenic, degenerative, or idiopathic etiology. 30 The restoration of sagittal alignment, as established by the sagittal vertical axis (SVA; target < 5 cm) and pelvic tilt (PT; target < 20°) on sagittal radiography, is important in surgical deformity correction. 6 , 21 , 22 Although coronal plane correction also has clinical relevance, sagittal corrections appear to have greater importance, 5