Evaluation of coronal alignment from the skull using the novel orbital–coronal vertical axis line

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  • 1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;
  • | 2 Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
  • | 3 Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at NewYork-Presbyterian, New York, New York
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OBJECTIVE

When treating patients with adult spinal deformity (ASD), radiographic measurements evaluating coronal alignment above C7 are lacking. The current objectives were to: 1) describe the new orbital–coronal vertical axis (ORB-CVA) line that evaluates coronal alignment from cranium to sacrum, 2) assess correlation with other radiographic variables, 3) evaluate correlations with patient-reported outcomes (PROs), and 4) compare the ORB-CVA with the standard C7-CVA.

METHODS

A retrospective cohort study of patients with ASD from a single institution was undertaken. Traditional C7-CVA measurements were obtained. The ORB-CVA was defined as the distance between the central sacral vertical line and the vertical line from the midpoint between the medial orbital walls. The ORB-CVA was correlated using traditional coronal measurements, including C7-CVA, maximum coronal Cobb angle, pelvic obliquity, leg length discrepancy (LLD), and coronal malalignment (CM), defined as a C7-CVA > 3 cm. Clinical improvement was analyzed as: 1) group means, 2) minimal clinically important difference (MCID), and 3) minimal symptom scale (MSS) (Oswestry Disability Index < 20 or Scoliosis Research Society–22r Instrument [SRS-22r] pain + function domains > 8).

RESULTS

A total of 243 patients underwent ASD surgery, and 175 had a 2-year follow-up. Of the 243 patients, 90 (37%) had preoperative CM. The mean (range) ORB-CVA at each time point was as follows: preoperatively, 2.9 ± 3.1 cm (−14.2 to 25.6 cm); 1 year postoperatively, 2.0 ± 1.6 cm (−12.4 to 6.7 cm); and 2 years postoperatively, 1.8 ± 1.7 cm (−6.0 to 11.1 cm) (p < 0.001 from preoperatively to 1 and 2 years). Preoperative ORB-CVA correlated best with C7-CVA (r = 0.842, p < 0.001), maximum coronal Cobb angle (r = 0.166, p = 0.010), pelvic obliquity (r = 0.293, p < 0.001), and LLD (r = 0.158, p = 0.006). Postoperatively, the ORB-CVA correlated only with C7-CVA (r = 0.629, p < 0.001) and LLD (r = 0.153, p = 0.017). Overall, 155 patients (63.8%) had an ORB-CVA that was ≥ 5 mm different from C7-CVA. The ORB-CVA correlated as well and sometimes better than C7-CVA with SRS-22r subdomains. After multivariate logistic regression, a greater ORB-CVA was associated with increased odds of complication, whereas C7-CVA was not associated with any of the three clinical outcomes (complication, readmission, reoperation). A larger difference between the ORB-CVA and C7-CVA was significantly associated with readmission and reoperation after univariate and multivariate logistic regression analyses. A threshold of ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes.

CONCLUSIONS

The ORB-CVA correlated well with known coronal measurements and PROs. ORB-CVA was independently associated with increased odds of complication, whereas C7-CVA was not associated with any outcomes. A ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes.

ABBREVIATIONS

AdIS = adult idiopathic scoliosis; ASD = adult spinal deformity; AUC = area under the receiver operating characteristic curve; CM = coronal malalignment; CSVL = central sacral vertical line; CVA = coronal vertical axis; EBL = estimated blood loss; LLD = leg length discrepancy; MCID = minimal clinically important difference; MSS = minimal symptom scale; ODI = Oswestry Disability Index; ORB-CVA = orbital-CVA; PRO = patient-reported outcome; SRS-22r = Scoliosis Research Society–22r Instrument; SVA = sagittal vertical axis; 3CO = three-column osteotomy.

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  • 1

    Schwab F, Ungar B, Blondel B, et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37(12):10771082.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Bao H, Yan P, Qiu Y, Liu Z, Zhu F. Coronal imbalance in degenerative lumbar scoliosis: prevalence and influence on surgical decision-making for spinal osteotomy. Bone Joint J. 2016;98-B(9):12271233.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Lewis SJ, Keshen SG, Kato S, Dear TE, Gazendam AM. Risk factors for postoperative coronal balance in adult spinal deformity surgery. Global Spine J. 2018;8(7):690697.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Tanaka N, Ebata S, Oda K, Oba H, Haro H, Ohba T. Predictors and clinical importance of postoperative coronal malalignment after surgery to correct adult spinal deformity. Clin Spine Surg. 2020;33(7):E337E341.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bao H, Liu Z, Zhang Y, et al. Sequential correction technique to avoid postoperative global coronal decompensation in rigid adult spinal deformity: a technical note and preliminary results. Eur Spine J. 2019;28(9):21792186.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Plais N, Bao H, Lafage R, et al. The clinical impact of global coronal malalignment is underestimated in adult patients with thoracolumbar scoliosis. Spine Deform. 2020;8(1):105113.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Daubs MD, Lenke LG, Bridwell KH, et al. Does correction of preoperative coronal imbalance make a difference in outcomes of adult patients with deformity? Spine (Phila Pa 1976). 2013;38(6):476483.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Ploumis A, Simpson AK, Cha TD, Herzog JP, Wood KB. Coronal spinal balance in adult spine deformity patients with long spinal fusions: a minimum 2- to 5-year follow-up study. J Spinal Disord Tech. 2015;28(9):341347.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Negrini A, Vanossi M, Donzelli S, Zaina F, Romano M, Negrini S. Spinal coronal and sagittal balance in 584 healthy individuals during growth: normal plumb line values and their correlation with radiographic measurements. Phys Ther. 2019;99(12):17121718.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Lau D, Haddad AF, Deviren V, Ames CP. Asymmetrical pedicle subtraction osteotomy for correction of concurrent sagittal-coronal imbalance in adult spinal deformity: a comparative analysis. J Neurosurg Spine. 2020;33(6):822829.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Chan AK, Lau D, Osorio JA, et al. Asymmetric pedicle subtraction osteotomy for adult spinal deformity with coronal imbalance: complications, radiographic and surgical outcomes. Oper Neurosurg (Hagerstown). 2020;18(2):209216.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Berjano P, Lamartina C. Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J. 2014;23(9):18151824.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976). 2005;30(6):682688.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Obeid I, Berjano P, Lamartina C, Chopin D, Boissière L, Bourghli A. Classification of coronal imbalance in adult scoliosis and spine deformity: a treatment-oriented guideline. Eur Spine J. 2019;28(1):94113.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hey HWD, Tan KA, Chin BZ, Liu G, Wong HK. Comparison of whole body sagittal alignment during directed vs natural, relaxed standing postures in young, healthy adults. Spine J. 2019;19(11):18321839.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Sugrue PA, McClendon J Jr, Smith TR, et al. Redefining global spinal balance: normative values of cranial center of mass from a prospective cohort of asymptomatic individuals. Spine (Phila Pa 1976). 2013;38(6):484489.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Kim YC, Cui JH, Kim KT, et al. Novel radiographic parameters for the assessment of total body sagittal alignment in adult spinal deformity patients. J Neurosurg Spine. 2019;31(3):372379.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Yilgor C, Sogunmez N, Boissiere L, et al. Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am. 2017;99(19):16611672.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Baum GR, Ha AS, Cerpa M, et al. Does the Global Alignment and Proportion score overestimate mechanical complications after adult spinal deformity correction? J Neurosurg Spine. 2021;34(1):96102.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Kim YH, Park Y, Chung KJ. Considerations for the management of medial orbital wall blowout fracture. Arch Plast Surg. 2016;43(3):229236.

  • 21

    Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG. The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976). 2007;32(24):27642770.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Ames CP, Smith JS, Scheer JK, et al. Impact of spinopelvic alignment on decision making in deformity surgery in adults: A review. J Neurosurg Spine. 2012;16(6):547564.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66(8):271273.

  • 24

    Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):29402952.

  • 25

    Asher MA, Lai SM, Glattes RC, Burton DC, Alanay A, Bago J. Refinement of the SRS-22 Health-Related Quality of Life questionnaire Function domain. Spine (Phila Pa 1976). 2006;31(5):593597.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Crawford CH III, Glassman SD, Bridwell KH, Berven SH, Carreon LY. The minimum clinically important difference in SRS-22R total score, appearance, activity and pain domains after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976). 2015;40(6):377381.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Kelly MP, Lurie JD, Yanik EL, et al. Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis. J Bone Joint Surg Am. 2019;101(4):338352.

  • 28

    Liu S, Diebo BG, Henry JK, et al. The benefit of nonoperative treatment for adult spinal deformity: identifying predictors for reaching a minimal clinically important difference. Spine J. 2016;16(2):210218.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J. 2008;8(6):968974.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Yuksel S, Ayhan S, Nabiyev V, et al. Minimum clinically important difference of the health-related quality of life scales in adult spinal deformity calculated by latent class analysis: is it appropriate to use the same values for surgical and nonsurgical patients? Spine J. 2019;19(1):7178.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Jann B. Plotting regression coefficients and other estimates. Stata J. 2014;14(4):708737.

  • 32

    Gomez-Rice A, Madrid C, Izquierdo E, Marco-Martinez F, Tresguerres JAF, Sanchez-Mariscal F. Is the cranial sagittal vertical axis (Cr-SVA) a better midterm predictor of clinical results than C7-SVA in adult patients operated on spinal deformity after a minimum 2-year follow-up? Clin Spine Surg. 2021;34(1):E32E38.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Buell TJ, Smith JS, Shaffrey CI, et al. Multicenter assessment of surgical outcomes in adult spinal deformity patients with severe global coronal malalignment: determination of target coronal realignment threshold. J Neurosurg Spine. 2021;34(3):399412.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Passias PG, Soroceanu A, Scheer J, et al. Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up. Spine J. 2015;15(8):17561763.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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