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  • Author or Editor: Frank Schwab x
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Antonio A. Faundez and Jean Charles Le Huec

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Michael Akbar, Haidara Almansour, Renaud Lafage, Bassel G. Diebo, Bernd Wiedenhöfer, Frank Schwab, Virginie Lafage and Wojciech Pepke

OBJECTIVE

The goal of this study was to investigate the impact of thoracic and lumbar alignment on cervical alignment in patients with adolescent idiopathic scoliosis (AIS).

METHODS

Eighty-one patients with AIS who had a Cobb angle > 40° and full-length spine radiographs were included. Radiographs were analyzed using dedicated software to measure pelvic parameters (sacral slope [SS], pelvic incidence [PI], pelvic tilt [PT]); regional parameters (C1 slope, C0–C2 angle, chin-brow vertical angle [CBVA], slope of line of sight [SLS], McRae slope, McGregor slope [MGS], C2–7 [cervical lordosis; CL], C2–7 sagittal vertical axis [SVA], C2–T3, C2–T3 SVA, C2–T1 Harrison measurement [C2–T1 Ha], T1 slope, thoracic kyphosis [TK], lumbar lordosis [LL], and PI-LL mismatch); and global parameters (SVA). Patients were stratified by their lumbar alignment into hyperlordotic (LL > 59.7°) and normolordotic (LL 39.3° to 59.7°) groups and also, based on their thoracic alignment, into hypokyphotic (TK < −33.1°) and normokyphotic (TK −33.1° to −54.9°) groups. Finally, they were grouped based on their global alignment into either an anterior-aligned group or a posterior-aligned group.

RESULTS

The lumbar hyperlordotic group, in comparison to the normolordotic group, had a significantly larger LL, SS, PI (all p < 0.001), and TK (p = 0.014) and a significantly smaller PI-LL mismatch (p = 0.001). Lumbar lordosis had no influence on local cervical parameters.

The thoracic hypokyphotic group had a significantly larger PI-LL mismatch (p < 0.002) and smaller T1 slope (p < 0.001), and was significantly more posteriorly aligned than the normokyphotic group (−15.02 ± 8.04 vs 13.54 ± 6.17 [mean ± SEM], p = 0.006). The patients with hypokyphotic AIS had a kyphotic cervical spine (cervical kyphosis [CK]) (p < 0.001). Furthermore, a posterior-aligned cervical spine in terms of C2–7 SVA (p < 0.006) and C2–T3 SVA (p < 0.001) was observed in the thoracic hypokyphotic group.

Comparing patients in terms of global alignment, the posterior-aligned group had a significantly smaller T1 slope (p < 0.001), without any difference in terms of pelvic, lumbar, and thoracic parameters when compared to the anterior-aligned group. The posterior-aligned group also had a CK (−9.20 ± 1.91 vs 5.21 ± 2.95 [mean ± SEM], p < 0.001) and a more posterior-aligned cervical spine, as measured by C2–7 SVA (p = 0.003) and C2–T3 SVA (p < 0.001).

CONCLUSIONS

Alignment of the cervical spine is closely related to thoracic curvature and global alignment. In patients with AIS, a hypokyphotic thoracic alignment or posterior global alignment was associated with a global cervical kyphosis. Interestingly, upper cervical and cranial parameters were not statistically different in all investigated groups, meaning that the upper cervical spine was not recruited for compensation in order to maintain a horizontal gaze.

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Thomas J. Buell, Shay Bess, Ming Xu, Frank J. Schwab, Virginie Lafage, Christopher P. Ames, Christopher I. Shaffrey and Justin S. Smith

OBJECTIVE

Proximal junctional kyphosis (PJK) is, in part, due to altered segmental biomechanics at the junction of rigid instrumented spine and relatively hypermobile non-instrumented adjacent segments. Proper application of posteriorly anchored polyethylene tethers (i.e., optimal configuration and tension) may mitigate adjacent-segment stress and help prevent PJK. The purpose of this study was to investigate the impact of different tether configurations and tensioning (preloading) on junctional range-of-motion (ROM) and other biomechanical indices for PJK in long instrumented spine constructs.

METHODS

Using a validated finite element model of a T7–L5 spine segment, testing was performed on intact spine, a multilevel posterior screw-rod construct (PS construct; T11–L5) without tether, and 15 PS constructs with different tether configurations that varied according to 1) proximal tether fixation of upper instrumented vertebra +1 (UIV+1) and/or UIV+2; 2) distal tether fixation to UIV, to UIV−1, or to rods; and 3) use of a loop (single proximal fixation) or weave (UIV and/or UIV+1 fixation in addition to UIV+1 and/or UIV+2 proximal attachment) of the tether. Segmental ROM, intradiscal pressure (IDP), inter- and supraspinous ligament (ISL/SSL) forces, and screw loads were assessed under variable tether preload.

RESULTS

PS construct junctional ROM increased abruptly from 10% (T11–12) to 99% (T10–11) of baseline. After tethers were grouped by most cranial proximal fixation (UIV+1 vs UIV+2) and use of loop versus weave, UIV+2 Loop and/or Weave most effectively dampened junctional ROM and adjacent-segment stress. Different distal fixation and use of loop versus weave had minimal effect. The mean segmental ROM at T11–12, T10–11, and T9–10, respectively, was 6%, 40%, and 99% for UIV+1 Loop; 6%, 44%, and 99% for UIV+1 Weave; 5%, 23%, and 26% for UIV+2 Loop; and 5%, 24%, and 31% for UIV+2 Weave.

Tethers shared loads with posterior ligaments; consequently, increasing tether preload tension reduced ISL/SSL forces, but screw loads increased. Further attenuation of junctional ROM and IDP reversed above approximately 100 N tether preload, suggesting diminished benefit for biomechanical PJK prophylaxis at higher preload tensioning.

CONCLUSIONS

In this study, finite element analysis demonstrated UIV+2 Loop and/or Weave tether configurations most effectively mitigated adjacent-segment stress in long instrumented spine constructs. Tether preload dampened ligament forces at the expense of screw loads, and an inflection point (approximately 100 N) was demonstrated above which junctional ROM and IDP worsened (i.e., avoid over-tightening tethers). Results suggest tether configuration and tension influence PJK biomechanics and further clinical research is warranted.

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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

This paper is a narrative review of normal cervical alignment, methods for quantifying alignment, and how alignment is associated with cervical deformity, myelopathy, and adjacent-segment disease (ASD), with discussions of health-related quality of life (HRQOL). Popular methods currently used to quantify cervical alignment are discussed including cervical lordosis, sagittal vertical axis, and horizontal gaze with the chin-brow to vertical angle. Cervical deformity is examined in detail as deformities localized to the cervical spine affect, and are affected by, other parameters of the spine in preserving global sagittal alignment. An evolving trend is defining cervical sagittal alignment. Evidence from a few recent studies suggests correlations between radiographic parameters in the cervical spine and HRQOL. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is critical. The article details mechanisms by which cervical kyphotic deformity potentially leads to ASD and discusses previous studies that suggest how postoperative sagittal malalignment may promote ASD. Further clinical studies are needed to explore the relationship of cervical malalignment and the development of ASD. Sagittal alignment of the cervical spine may play a substantial role in the development of cervical myelopathy as cervical deformity can lead to spinal cord compression and cord tension. Surgical correction of cervical myelopathy should always take into consideration cervical sagittal alignment, as decompression alone may not decrease cord tension induced by kyphosis. Awareness of the development of postlaminectomy kyphosis is critical as it relates to cervical myelopathy. The future direction of cervical deformity correction should include a comprehensive approach in assessing global cervicalpelvic relationships. Just as understanding pelvic incidence as it relates to lumbar lordosis was crucial in building our knowledge of thoracolumbar deformities, T-1 incidence and cervical sagittal balance can further our understanding of cervical deformities. Other important parameters that account for the cervical-pelvic relationship are surveyed in detail, and it is recognized that all such parameters need to be validated in studies that correlate HRQOL outcomes following cervical deformity correction.

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Carolyn J. Sparrey, Jeannie F. Bailey, Michael Safaee, Aaron J. Clark, Virginie Lafage, Frank Schwab, Justin S. Smith and Christopher P. Ames

The goal of this review is to discuss the mechanisms of postural degeneration, particularly the loss of lumbar lordosis commonly observed in the elderly in the context of evolution, mechanical, and biological studies of the human spine and to synthesize recent research findings to clinical management of postural malalignment. Lumbar lordosis is unique to the human spine and is necessary to facilitate our upright posture. However, decreased lumbar lordosis and increased thoracic kyphosis are hallmarks of an aging human spinal column. The unique upright posture and lordotic lumbar curvature of the human spine suggest that an understanding of the evolution of the human spinal column, and the unique anatomical features that support lumbar lordosis may provide insight into spine health and degeneration. Considering evolution of the skeleton in isolation from other scientific studies provides a limited picture for clinicians. The evolution and development of human lumbar lordosis highlight the interdependence of pelvic structure and lumbar lordosis. Studies of fossils of human lineage demonstrate a convergence on the degree of lumbar lordosis and the number of lumbar vertebrae in modern Homo sapiens. Evolution and spine mechanics research show that lumbar lordosis is dictated by pelvic incidence, spinal musculature, vertebral wedging, and disc health. The evolution, mechanics, and biology research all point to the importance of spinal posture and flexibility in supporting optimal health. However, surgical management of postural deformity has focused on restoring posture at the expense of flexibility. It is possible that the need for complex and costly spinal fixation can be eliminated by developing tools for early identification of patients at risk for postural deformities through patient history (genetics, mechanics, and environmental exposure) and tracking postural changes over time.

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Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Benjamin Blondel, Frank Schwab, Richard Hostin, Robert Hart, Brian O'Shaughnessy, Shay Bess, Serena S. Hu, Vedat Deviren, Christopher P. Ames and International Spine Study Group

Object

Sagittal spinopelvic malalignment is a significant cause of pain and disability in patients with adult spinal deformity. Surgical correction of spinopelvic malalignment can result in compensatory changes in spinal alignment outside of the fused spinal segments. These compensatory changes, termed reciprocal changes, have been defined for thoracic and lumbar regions but not for the cervical spine. The object of this study was to evaluate postoperative reciprocal changes within the cervical spine following lumbar pedicle subtraction osteotomy (PSO).

Methods

This was a multicenter retrospective radiographic analysis of patients from International Spine Study Group centers. Inclusion criteria were as follows: adults (>18 years old) with spinal deformity treated using lumbar PSO, a preoperative C7–S1 plumb line greater than 5 cm, and availability of pre- and postoperative full-length standing radiographs.

Results

Seventy-five patients (60 women, mean age 59 years) were included. The lumbar PSO significantly improved sagittal alignment, including the C7–S1 plumb line, C7–T12 inclination, and pelvic tilt (p <0.001). After lumbar PSO, reciprocal changes were seen to occur in C2–7 cervical lordosis (from 30.8° to 21.6°, p <0.001), C2–7 plumb line (from 27.0 mm to 22.9 mm), and T-1 slope (from −38.9° to −30.4°, p <0.001). Ideal correction of sagittal malalignment (postoperative sagittal vertical alignment < 50 mm) was associated with the greatest relaxation of cervical hyperlordosis (−12.4° vs −5.7°, p = 0.037). A change in cervical lordosis correlated with changes in T-1 slope (r = −0.621, p <0.001), C7–T12 inclination (r = 0.418, p <0.001), T12–S1 angle (r = −0.339, p = 0.005), and C7–S1 plumb line (r = 0.289, p = 0.018). Radiographic parameters that correlated with changes in cervical lordosis on multivariate linear regression analysis included change in T-1 slope and change in C2–7 plumb line (r2 = 0.53, p <0.001).

Conclusions

Adults with positive sagittal spinopelvic malalignment compensate with abnormally increased cervical lordosis in an effort to maintain horizontal gaze. Surgical correction of sagittal malalignment results in improvement of the abnormal cervical hyperlordosis through reciprocal changes.

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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

Sagittal spinal misalignment (SSM) is an established cause of pain and disability. Treating physicians must be familiar with the radiographic findings consistent with SSM. Additionally, the restoration or maintenance of physiological sagittal spinal alignment after reconstructive spinal procedures is imperative to achieve good clinical outcomes. The C-7 plumb line (sagittal vertical axis) has traditionally been used to evaluate sagittal spinal alignment; however, recent data indicate that the measurement of spinopelvic parameters provides a more comprehensive assessment of sagittal spinal alignment. In this review the authors describe the proper analysis of spinopelvic alignment for surgical planning. Online videos supplement the text to better illustrate the key concepts.

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The comprehensive anatomical spinal osteotomy and anterior column realignment classification

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Juan S. Uribe, Frank Schwab, Gregory M. Mundis Jr., David S. Xu, Jacob Januszewski, Adam S. Kanter, David O. Okonkwo, Serena S. Hu, Deviren Vedat, Robert Eastlack, Pedro Berjano and Praveen V. Mummaneni

OBJECTIVE

Spinal osteotomies and anterior column realignment (ACR) are procedures that allow preservation or restoration of spine lordosis. Variations of these techniques enable different degrees of segmental, regional, and global sagittal realignment. The authors propose a comprehensive anatomical classification system for ACR and its variants based on the level of technical complexity and invasiveness. This serves as a common language and platform to standardize clinical and radiographic outcomes for the utilization of ACR.

METHODS

The proposed classification is based on 6 anatomical grades of ACR, including anterior longitudinal ligament (ALL) release, with varying degrees of posterior column release or osteotomies. Additionally, a surgical approach (anterior, lateral, or posterior) was added. Reliability of the classification was evaluated by an analysis of 16 clinical cases, rated twice by 14 different spine surgeons, and calculation of Fleiss kappa coefficients.

RESULTS

The 6 grades of ACR are as follows: grade A, ALL release with hyperlordotic cage, intact posterior elements; grade 1 (ACR + Schwab grade 1), additional resection of the inferior facet and joint capsule; grade 2 (ACR + Schwab grade 2), additional resection of both superior and inferior facets, interspinous ligament, ligamentum flavum, lamina, and spinous process; grade 3 (ACR + Schwab grade 3), additional adjacent-level 3-column osteotomy including pedicle subtraction osteotomy; grade 4 (ACR + Schwab grade 4), 2-level distal 3-column osteotomy including pedicle subtraction osteotomy and disc space resection; and grade 5 (ACR + Schwab grade 5), complete or partial removal of a vertebral body and both adjacent discs with or without posterior element resection. Intraobserver and interobserver reliability were 97% and 98%, respectively, across the 14-reviewer cohort.

CONCLUSIONS

The proposed anatomical realignment classification provides a consistent description of the various posterior and anterior column release/osteotomies. This reliability study confirmed that the classification is consistent and reproducible across a diverse group of spine surgeons.

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Michael P. Kelly, Michael A. Kallen, Christopher I. Shaffrey, Justin S. Smith, Douglas C. Burton, Christopher P. Ames, Virginie Lafage, Frank J. Schwab, Han Jo Kim, Eric O. Klineberg, Shay Bess and the International Spine Study Group

OBJECTIVE

After using PROsetta Stone crosswalk tables to calculate Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores, the authors sought to examine 1) correlations with Scoliosis Research Society–22r (SRS-22r) scores, 2) responsiveness to change, and 3) the relationship between baseline scores and 2-year follow-up scores in adult spinal deformity (ASD).

METHODS

PROsetta Stone crosswalk tables were used to converted SF-36 scores to PROMIS scores for pain and physical function in a cohort of ASD patients with 2-year follow-up. Spearman correlations were used to evaluate the relationship of PROMIS scores with SRS-22r scores. Effect size (ES) and adjusted standardized response mean (aSRM) were used to assess responsiveness to change. Linear regression was used to evaluate the association between baseline scores and 2-year follow-up scores.

RESULTS

In total, 425 (425/625, 68%) patients met inclusion criteria. Strong correlations (all |r| > 0.7, p < 0.001) were found between baseline and 2-year PROMIS values and corresponding SRS-22r domain scores. PROMIS-PI showed a large ES (1.09) and aSRM (0.88), indicating good responsiveness to change. PROMIS-PF showed a moderate ES (0.52) and moderate aSRM (0.69), indicating a moderate responsiveness to change. Patients with greater baseline pain complaints were associated with greater pain improvement at 2 years for both SRS-22r Pain (B = 0.39, p < 0.001) and PROMIS-PI (B = 0.45, p < 0.001). Higher functional scores at baseline were associated with greater average improvements in both SRS-22r Activity (B = 0.62, p < 0.001) and PROMIS-PF (B = 0.40, p < 0.001).

CONCLUSIONS

The authors found strong correlations between the SRS-22r Pain and Activity domains with corresponding PROMIS-PI and -PF scores. Pain measurements showed similar and strong ES and aSRM while the function measurements showed similar, moderate ES and aSRM at 2-year follow-up. These data support further exploration of the use of PROMIS–computer adaptive test instruments in ASD.

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Bassel G. Diebo, Jonathan H. Oren, Vincent Challier, Renaud Lafage, Emmanuelle Ferrero, Shian Liu, Shaleen Vira, Matthew Adam Spiegel, Bradley Yates Harris, Barthelemy Liabaud, Jensen K. Henry, Thomas J. Errico, Frank J. Schwab and Virginie Lafage

OBJECTIVE

Sagittal malalignment requires higher energy expenditure to maintain an erect posture. Because the clinical impact of sagittal alignment is affected by both the severity of the deformity and recruitment of compensatory mechanisms, it is important to investigate new parameters that reflect both disability level and compensatory mechanisms for all patients. This study investigated the clinical relevance of the global sagittal axis (GSA), a novel measure to evaluate the standing axis of the human body.

METHODS

This is a retrospective review of patients who underwent full-body radiographs and completed health-related quality of life (HRQOL) questionnaires: Oswestry Disability Index (ODI), Scoliosis Research Society–22, EuroQol-5D (EQ-5D), and the visual analog scale for back and leg pain. The GSA was defined as the angle formed by a line from the midpoint of the femoral condyles to the center of C-7, and a line from the midpoint between the femoral condyles to the posterior superior corner of the S-1 sacral endplate. After evaluating the correlation of GSA/HRQOL with sagittal parameters, linear regression models were generated to investigate how ODI and GSA related to radiographic parameters (T-1 pelvic angle, pelvic retroversion, knee flexion, and pelvic posterior translation).

RESULTS

One hundred forty-three patients (mean age 44 years) were included. The GSA correlated significantly with all HRQOL (up to r = 0.6 with EQ-5D) and radiographic parameters (up to r = 0.962 with sagittal vertical axis). Regression between ODI and sagittal radiographic parameters identified the GSA as an independent predictor (r = 0.517, r2 = 0.267; p < 0.001). Analysis of standardized coefficients revealed that when controlling for deformity, the GSA increased with a concurrent decrease in pelvic retroversion (−0.837) and increases in knee flexion (+0.287) and pelvic posterior translation (+0.193).

CONCLUSIONS

The GSA is a simple, novel measure to assess the standing axis of the human body in the sagittal plane. The GSA correlated highly with spinopelvic and lower-extremities sagittal parameters and exhibited remarkable correlations with HRQOL, which exceeded other commonly used parameters.