Surgical treatment of pathological loss of lumbar lordosis (flatback) in patients with normal sagittal vertical axis achieves similar clinical improvement as surgical treatment of elevated sagittal vertical axis

Clinical article

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  • 1 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • 2 Department of Orthopaedic Surgery, University of California Davis, Sacramento, California;
  • 3 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York;
  • 4 University of California San Diego, School of Medicine, San Diego, California;
  • 5 San Diego Center for Spinal Disorders, La Jolla, California;
  • 6 Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas; 
  • 7 Departments of Orthopedic Surgery and
  • 12 Neurological Surgery, University of California San Francisco, California;
  • 8 Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland;
  • 9 Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, Oregon;
  • 10 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
  • 11 Rocky Mountain Hospital for Children, Denver, Colorado
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Object

Increased sagittal vertical axis (SVA) correlates strongly with pain and disability for adults with spinal deformity. A subset of patients with sagittal spinopelvic malalignment (SSM) have flatback deformity (pelvic incidence–lumbar lordosis [PI-LL] mismatch > 10°) but remain sagittally compensated with normal SVA. Few data exist for SSM patients with flatback deformity and normal SVA. The authors' objective was to compare baseline disability and treatment outcomes for patients with compensated (SVA < 5 cm and PI-LL mismatch > 10°) and decompensated (SVA > 5 cm) SSM.

Methods

The study was a multicenter, prospective analysis of adults with spinal deformity who consecutively underwent surgical treatment for SSM. Inclusion criteria included age older than 18 years, presence of adult spinal deformity with SSM, plan for surgical treatment, and minimum 1-year follow-up data. Patients with SSM were divided into 2 groups: those with compensated SSM (SVA < 5 cm and PI-LL mismatch > 10°) and those with decompensated SSM (SVA ≥ 5 cm). Baseline and 1-year follow-up radiographic and health-related quality of life (HRQOL) outcomes included Oswestry Disability Index, Short Form–36 scores, and Scoliosis Research Society–22 scores. Percentages of patients achieving minimal clinically important difference (MCID) were also assessed.

Results

A total of 125 patients (27 compensated and 98 decompensated) met inclusion criteria. Compared with patients in the compensated group, patients in the decompensated group were older (62.9 vs 55.1 years; p = 0.004) and had less scoliosis (43° vs 54°; p = 0.002), greater SVA (12.0 cm vs 1.7 cm; p < 0.001), greater PI-LL mismatch (26° vs 20°; p = 0.013), and poorer HRQOL scores (Oswestry Disability Index, Short Form-36 physical component score, Scoliosis Research Society-22 total; p ≤ 0.016). Although these baseline HRQOL differences between the groups reached statistical significance, only the mean difference in Short Form–36 physical component score reached threshold for MCID. Compared with baseline assessment, at 1 year after surgery improvement was noted for patients in both groups for mean SVA (compensated –1.1 cm, decompensated +4.8 cm; p ≤ 0.009), mean PI-LL mismatch (compensated 6°, decompensated 5°; p < 0.001), and all HRQOL measures assessed (p ≤ 0.005). No significant differences were found between the compensated and decompensated groups in the magnitude of HRQOL score improvement or in the percentages of patients achieving MCID for each of the outcome measures assessed.

Conclusions

Decompensated SSM patients with elevated SVA experience significant disability; however, the amount of disability in compensated SSM patients with flatback deformity caused by PI-LL mismatch but normal SVA is underappreciated. Surgical correction of SSM demonstrated similar radiographic and HRQOL score improvements for patients in both groups. Evaluation of SSM should extend beyond measuring SVA. Among patients with concordant pain and disability, PI-LL mismatch must be evaluated for SSM patients and can be considered a primary indication for surgery.

Abbreviations used in this paper:HRQOL = health-related quality of life; MCID = minimal clinically important difference; PI-LL = pelvic incidence–lumbar lordosis; SF-36 = Short Form–36; SSM = sagittal spinopelvic malalignment; SRS-22 = Scoliosis Research Society–22; SVA = sagittal vertical axis.

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Contributor Notes

Address correspondence to: Justin S. Smith, M.D., Ph.D., Department of Neurosurgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908. email: jss7f@virginia.edu.

Please include this information when citing this paper: published online April 25, 2014; DOI: 10.3171/2014.3.SPINE13580.

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