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Justin F. Fraser, Russel C. Huang, Federico P. Girardi, and Frank P. Cammisa Jr.

Sagittal- or coronal-plane deformity considerably complicates the diagnosis and treatment of lumbar spinal stenosis. Although decompressive laminectomy remains the standard operative treatment for uncomplicated lumbar spinal stenosis, the management of stenosis with concurrent deformity may require osteotomy, laminectomy, and spinal fusion with or without instrumentation. Broadly stated, the surgery-related goals in complex stenosis are neural decompression and a well-balanced sagittal and coronal fusion. Deformities that may present with concurrent stenosis are scoliosis, spondylolisthesis, and flatback deformity. The presentation and management of lumbar spinal stenosis associated with concurrent coronal or sagittal deformities depends on the type and extent of deformity as well as its impact on neural compression. Generally, clinical outcomes in complex stenosis are optimized by decompression combined with spinal fusion. The need for instrumentation is clear in cases of significant scoliosis or flatback deformity but is controversial in spondylolisthesis. With appropriate selection of technique for deformity correction, a surgeon may profoundly improve pain, quality of life, and functional capacity. The decision to undertake surgery entails weighing risk factors such as age, comorbidities, and preoperative functional status against potential benefits of improved neurological function, decreased pain, and reduced risk of disease progression. The purpose of this paper is to review the pathogenesis, presentation, and treatment of lumbar spinal stenosis complicated by scoliosis, spondylolisthesis, or flat-back deformity. Specific attention is paid to surgery-related goals, decision making, techniques, and outcomes.

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Christopher K. Kepler, Amit K. Sharma, Russel C. Huang, Dennis S. Meredith, Federico P. Girardi, Frank P. Cammisa Jr., and Andrew A. Sama


Lateral transpsoas interbody fusion (LTIF) permits anterior column lumbar interbody fusion via a direct lateral approach. The authors sought to answer 3 questions. First, what is the effect of LTIF on lumbar foraminal area? Second, how does interbody cage placement affect intervertebral height? And third, how does the change in foraminal area and cage position correlate with changes in Oswestry Disability Index (ODI) and 12-Item Short Form Health Survey (SF-12) scores?


Included patients underwent LTIF with or without posterior instrumentation and received preoperative and postoperative CT scans. Disc heights, neural foraminal area between adjacent-level pedicles, and anteroposterior cage position were measured from sagittal CT images. Preoperative and postoperative ODI and SF-12 scores were matched with the change in foraminal area from the clinically most severely affected side for analysis of the relationship between outcomes instruments and change in foraminal area.


Average foraminal area increased by 36.2 mm2, or 35% of the preoperative area (p < 0.01), without statistically significant differences by side, level, or anteroposterior cage position. Preoperative anterior and posterior disc heights measured 6.2 mm and 3.7 mm, respectively, compared with postoperative measurements of 9.8 mm (p < 0.01) and 6.3 mm (p < 0.01), respectively, without significant differences by level or cage position. Despite significant overall improvement in ODI and SF-12 scores, there was no correlation with foraminal area increase.


Average foraminal area increased approximately 35% after cage placement without variation based on cage position. While ODI and SF-12 scores increased significantly, there was no significant association with cage position or foraminal area change, likely attributable to the multifactorial nature of preoperative pain.

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Philip K. Louie, Basel Sheikh Alshabab, Michael H. McCarthy, Sohrab Virk, James E. Dowdell, Michael E. Steinhaus, Francis Lovecchio, Andre M. Samuel, Kyle W. Morse, Frank J. Schwab, Todd J. Albert, Sheeraz A. Qureshi, Sravisht Iyer, Yoshihiro Katsuura, Russel C. Huang, Matthew E. Cunningham, Yu-Cheng Yao, Karen Weissmann, Renaud Lafage, Virginie Lafage, and Han Jo Kim


The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology.


The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience.


The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559–0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606–0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531–0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%.


This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.