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Praveen V. Mummaneni, Paul Park, Christopher I. Shaffrey, Michael Y. Wang, Juan S. Uribe, Richard G. Fessler, Dean Chou, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Robert K. Eastlack, Pierce D. Nunley, Neel Anand, Michael S. Virk, Lawrence G. Lenke, Khoi D. Than, Leslie C. Robinson, Kai-Ming Fu, and the International Spine Study Group (ISSG)


Minimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.


A modified algorithm was developed that incorporates a patient’s preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.


Over a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.


The MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.

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Yoji Ogura, Jeffrey L. Gum, Alex Soroceanu, Alan H. Daniels, Breton Line, Themistocles Protopsaltis, Richard A. Hostin, Peter G. Passias, Douglas C. Burton, Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Renaud Lafage, Eric O. Klineberg, Han Jo Kim, Andrew Harris, Khaled Kebaish, Frank Schwab, Shay Bess, Christopher P. Ames, Leah Y. Carreon, and the International Spine Study Group (ISSG)


The shared decision-making (SDM) process provides an opportunity to answer frequently asked questions (FAQs). The authors aimed to present a concise list of answers to FAQs to aid in SDM for adult spinal deformity (ASD) surgery.


From a prospective, multicenter ASD database, patients enrolled between 2008 and 2016 who underwent fusions of 5 or more levels with a minimum 2-year follow-up were included. All deformity types were included to provide general applicability. The authors compiled a list of FAQs from patients undergoing ASD surgery and used a retrospective analysis to provide answers. All responses are reported as either the means or the proportions reaching the minimal clinically important difference at the 2-year follow-up interval.


Of 689 patients with ASD who were eligible for 2-year follow-up, 521 (76%) had health-related quality-of-life scores available at the time of that follow-up. The mean age at the initial surgery was 58.2 years, and 78% of patients were female. The majority (73%) underwent surgery with a posterior-only approach. The mean number of fused levels was 12.2. Revision surgery accounted for 48% of patients. The authors answered 12 FAQs as follows:

1. Will my pain improve? Back and leg pain will both be reduced by approximately 50%.

2. Will my activity level improve? Approximately 65% of patients feel improvement in their activity level.

3. Will I feel better about myself? More than 70% of patients feel improvement in their appearance.

4. Is there a chance I will get worse? 4.1% feel worse at 2 years postoperatively.

5. What is the likelihood I will have a complication? 67.8% will have a major or minor complication, with 47.8% having a major complication.

6. Will I need another surgery? 25.0% will have a reoperation within 2 years.

7. Will I regret having surgery? 6.5% would not choose the same treatment.

8. Will I get a blood transfusion? 73.7% require a blood transfusion.

9. How long will I stay in the hospital? You need to stay 8.1 days on average.

10. Will I have to go to the ICU? 76.0% will have to go to the ICU.

11. Will I be able to return to work? More than 70% will be working at 1 year postoperatively.

12. Will I be taller after surgery? You will be 1.1 cm taller on average.


The above list provides concise, practical answers to FAQs encountered in the SDM process while counseling patients for ASD surgery.

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Justin K. Scheer, Virginie Lafage, Justin S. Smith, Vedat Deviren, Richard Hostin, Ian M. McCarthy, Gregory M. Mundis, Douglas C. Burton, Eric Klineberg, Munish C. Gupta, Khaled M. Kebaish, Christopher I. Shaffrey, Shay Bess, Frank Schwab, Christopher P. Ames, and the International Spine Study Group (ISSG)


Spinal osteotomies for adult spinal deformity correction may include resection of all 3 spinal columns (pedicle subtraction osteotomy [PSO] and vertebral column resection [VCR]). The relationship between patient age and health-related quality of life (HRQOL) outcomes for patients undergoing major spinal deformity correction via PSO or VCR has not been well characterized. The goal of this study was to characterize that relationship.


This study was a retrospective review of 374 patients who had undergone a 3-column osteotomy (299 PSOs and 75 VCRs) and were part of a prospectively collected, multicenter adult spinal deformity database. The consecutively enrolled patients were drawn from 11 sites across the United States. Health-related QOL outcomes, according to the visual analog scale (VAS), Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36, physical component score [PCS] and mental component score), and Scoliosis Research Society-22 questionnaire (SRS), were evaluated preoperatively and 1 and 2 years postoperatively. Differences and correlations between patient age and HRQOL outcomes were investigated. Age groupings included young (age ≤ 45 years), middle aged (age 46–64 years), and elderly (age ≥ 65 years).


In patients who had undergone PSO, age significantly correlated (Spearman's correlation coefficient) with the 2-year ODI (ρ = 0.24, p = 0.0450), 2-year SRS function score (ρ = 0.30, p = 0.0123), and 2-year SRS total score (ρ = 0.30, p = 0.0133). Among all patients (PSO+VCR), the preoperative PCS and ODI in the young group were significantly higher and lower, respectively, than those in the elderly. Among the PSO patients, the elderly group had much greater improvement than the young group in the 1- and 2-year PCS, 2-year ODI, and 2-year SRS function and total scores. Among the VCR patients, the young age group had much greater improvement than the elderly in the 1-year SRS pain score, 1-year PCS, 2-year PCS, and 2-year ODI. There was no significant difference among all the age groups as regards the likelihood of reaching a minimum clinically important difference (MCID) within each of the HRQOL outcomes (p > 0.05 for all). Among the PSO patients, the elderly group was significantly more likely than the young to reach an MCID for the 1-year PCS (61% vs 21%, p = 0.0077) and the 2-year PCS (67% vs 17%, p = 0.0054), SRS pain score (57% vs 20%, p = 0.0457), and SRS function score (62% vs 20%, p = 0.0250). Among the VCR patients, the young group was significantly more likely than the elderly patients to reach an MCID for the 1-year (100% vs 20%, p = 0.0036) and 2-year (100% vs 0%, p = 0.0027) PCS scores and 1-year (60% vs 0%, p = 0.0173) and 2-year (70% vs 0%, p = 0.0433) SRS pain scores.


The PSO and VCR are not equivalent surgeries in terms of HRQOL outcomes and patient age. Among patients who underwent PSO, the elderly group started with more preoperative disability than the younger patients but had greater improvements in HRQOL outcomes and was more likely to reach an MCID at 1 and 2 years after treatment. Among those who underwent VCR, all had similar preoperative disabilities, but the younger patients had greater improvements in HRQOL outcomes and were more likely to reach an MCID at 1 and 2 years after treatment.

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Thomas J. Buell, Justin S. Smith, Christopher I. Shaffrey, Han Jo Kim, Eric O. Klineberg, Virginie Lafage, Renaud Lafage, Themistocles S. Protopsaltis, Peter G. Passias, Gregory M. Mundis Jr., Robert K. Eastlack, Vedat Deviren, Michael P. Kelly, Alan H. Daniels, Jeffrey L. Gum, Alex Soroceanu, D. Kojo Hamilton, Munish C. Gupta, Douglas C. Burton, Richard A. Hostin, Khaled M. Kebaish, Robert A. Hart, Frank J. Schwab, Shay Bess, Christopher P. Ames, and the International Spine Study Group (ISSG)


The impact of global coronal malalignment (GCM; C7 plumb line–midsacral offset) on adult spinal deformity (ASD) treatment outcomes is unclear. Here, the authors’ primary objective was to assess surgical outcomes and complications in patients with severe GCM, with a secondary aim of investigating potential surgical target coronal thresholds for optimal outcomes.


This is a retrospective analysis of a prospective multicenter database. Operative patients with severe GCM (≥ 1 SD above the mean) and a minimum 2-year follow-up were identified. Demographic, surgical, radiographic, health-related quality of life (HRQOL), and complications data were analyzed.


Of 691 potentially eligible operative patients (mean GCM 4 ± 3 cm), 80 met the criteria for severe GCM ≥ 7 cm. Of these, 62 (78%; mean age 63.7 ± 10.7 years, 81% women) had a minimum 2-year follow-up (mean follow-up 3.3 ± 1.1 years). The mean ASD–Frailty Index was 3.9 ± 1.5 (frail), 50% had undergone prior fusion, and 81% had concurrent severe sagittal spinopelvic deformity with GCM and C7–S1 sagittal vertical axis (SVA) positively correlated (r = 0.313, p = 0.015). Surgical characteristics included posterior-only (58%) versus anterior-posterior (42%) approach, mean fusion of 13.2 ± 3.8 levels, iliac fixation (90%), 3-column osteotomy (36%), operative duration of 8.3 ± 3.0 hours, and estimated blood loss of 2.3 ± 1.7 L. Final alignment and HRQOL significantly improved (p < 0.01): GCM, 11 to 4 cm; maximum coronal Cobb angle, 43° to 20°; SVA, 13 to 4 cm; pelvic tilt, 29° to 23°; pelvic incidence–lumbar lordosis mismatch, 31° to 5°; Oswestry Disability Index, 51 to 37; physical component summary of SF-36 (PCS), 29 to 37; 22-Item Scoliosis Research Society Patient Questionnaire (SRS-22r) Total, 2.6 to 3.5; and numeric rating scale score for back and leg pain, 7 to 4 and 5 to 3, respectively. Residual GCM ≥ 3 cm was associated with worse SRS-22r Appearance (p = 0.04) and SRS-22r Satisfaction (p = 0.02). The minimal clinically important difference and/or substantial clinical benefit (MCID/SCB) was met in 43%–83% (highest for SRS-22r Appearance [MCID 83%] and PCS [SCB 53%]). The severity of baseline GCM (≥ 2 SD above the mean) significantly impacted postoperative SRS-22r Satisfaction and MCID/SCB improvement for PCS. No significant partial correlations were demonstrated between GCM or SVA correction and HRQOL improvement. There were 89 total complications (34 minor and 55 major), 45 (73%) patients with ≥ 1 complication (most commonly rod fracture [19%] and proximal junctional kyphosis [PJK; 18%]), and 34 reoperations in 22 (35%) patients (most commonly for rod fracture and PJK).


Study results demonstrated that ASD surgery in patients with substantial GCM was associated with significant radiographic and HRQOL improvement despite high complication rates. MCID improvement was highest for SRS-22r Appearance/Self-Image. A residual GCM ≥ 3 cm was associated with a worse outcome, suggesting a potential coronal realignment target threshold to assist surgical planning.