11/4/16 DISCLOSURES Review boards: Spine Deformity, CORR When - - PDF document

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When degenerative problems become deformity cases

Serena S. Hu, MD Professor and Vice Chair Chief, Spine Service Department of Orthopedic Surgery and, by courtesy, Neurological Surgery Stanford University

DISCLOSURES

• Review boards: Spine Deformity, CORR
• AOA Board of Directors; SRS Committee Chair
• Consulting: Nuvasive

DEGENERATIVE SPINE DISEASE

• Disc degeneration
• Loss of disc height and lumbar lordosis
• May be asymmetricà tilted vertebra
• Spondylolisthesisà can be rotatory
• Facet disease
• Asymmetry can cause rotation
• Can lead to lateral listhesis

DEGENERATIVE SPINE DISEASE

• Can be caused by spinal deformity
• Asymmetric loading
• Accelerated facet and disc degeneration
• Foraminal or central stenosis
• Can be caused by surgical sequelae
• Adjacent segment kyphosis
• Lateral listhesis, spondylolisthesis
• Flatback

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CATEGORIES

• Degenerative spine with deformity
• Degenerative spine with potential for deformity
• Degenerative spine with unanticipated development of deformity

CATEGORIES

• Degenerative spine with deformity: should have considered the deformity
• Degenerative spine with potential for deformity: should be aware of the potential

for deformity

• Degenerative spine with unanticipated development of deformity: sometimes you

just get unlucky

CATEGORIES

• Degenerative spine with deformity: should have considered the deformity
• Degenerative spine with potential for deformity: should be aware of the potential

for deformity

• Degenerative spine with unanticipated development of deformity: sometimes you

just get unlucky

CATEGORIES

• Degenerative spine with deformity: should have considered the deformity
• Degenerative spine with potential for deformity: should be aware of the potential

for deformity

• Degenerative spine with unanticipated development of deformity: sometimes you

just get unlucky

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CATEGORIES

• Degenerative spine with deformity: should have considered the deformity
• Degenerative spine with potential for deformity: should be aware of the potential

for deformity

• Degenerative spine with unanticipated development of deformity: sometimes you

just get unlucky

• Degenerative cases treated without current understanding of sagittal balance

DEGENERATIVE SPINE WITH DEFORMITY

Bend to R

• 73 yo M with L4-5 stenosis, degen spondylo, decomp to left, fully flexible
• Should we address the deformity?
• Decompress only?
• Decompress and fuse L4-5?
• Decomp L4-5, fuse to TL junction?
• A/XLIF’s, decomp L4-5, fuse L2-L5?
• 73 yo M with L4-5 stenosis, degen spondylo, decomp to left, fully flexible
• Should we address the deformity?
• Decompress only?
• Decompress and fuse L4-5?
• Decomp L4-5, fuse to TL junction?
• A/XLIF’s, decomp L4-5, fuse L2-L5?
• Parkinson’s disease

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MISSING THE BOAT: DEFORMITY WAS IGNOREDà DEFORMITY WORSENED

REVISION REQUIRED

• 57 yo chronic

pain patient

• Presented to MD

with back pain and problems with leaning forward and to the side

• L5-S1 ALIF

, L2-L5 XLIF

• Min invasive

PSF

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• L5-S1 ALIF

, L2-L5 XLIF

• Min invasive

PSF

• Thinking you

know how to do a deformity

• peration but

totally not getting the concept

• Underwent

revision PSF with PSO and proximal extension of fusion

• Still has chronic

back pain but now is a happy chronic pain patient 54 YO F, FOOT DROP, NEVER NOTICED SCOLI BEFORE

LIMITED

DECOMPRESSION/FUSION TO MAINTAIN MOBILITY (GOLF)

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6 YEARS LATER PRESENT WITH QUADS WEAKNESS, L3-4 STENOSIS CAN YOU TREAT THE FRACTIONAL CURVE ONLY?

4/2005: had laminotomy L4-5 for stenosis

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• 2010: lumbar and fractional curves have progressed, spondylo slightly worse,

stenosis recurred.

• Now what? Decomp and fuse…
• L4-5?
• L5-S1?
• L3-S1?
• L2-S1?
• T10-S1?

SHOULD WE CONSIDER THE DEFORMITY?

Underwent decompression only Mild LBP Min change in scoliosis Satisfied with functional outcome

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SHOULD WE HAVE ADDRESS THE DEFORMITY?

4/08 12/08

SHOULD WE CONSIDER THE DEFORMITY?

53yo F , s/p c laminaplasty, LE claudication

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7/08 postop 11/08 4/09 11/10

58 YO WF S/P WC INJURY IN PARKS SERVICE IN 1995, DISABLED FROM LBP SINCE

• Referred by pain management

doctor for scoliosis management

• Takes long acting pain meds
• Neuro intact
• PMHx: depression

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RX

• PT
• Neurology work up
• Bracing
• Chiropractor
• Narcotics, pain management
• Psychologic counseling

2013 25° 2015 45° 2016 52° 2012 20°

• Patient informed that

since she had severe back pain prior developing scoliosis, surgery would not helpl back pain.

• Pt still challenging WC
• ALIF L4-5, L5-S1,

hyperlordotic cages

• PSF T10-IL, PMMA

augmentation T10, v- plasty T9

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MULTIPLE TIMES RE-OPERATED FOR ADJACENT SEGMENT DISEASE

2000 2005 2008

ADJACENT SEGMENT DISEASE

2000 2005 2008 2010

• Underwent PSO
• Resolved her leg

symptoms

• Now taking less

pain meds than she had in years

• Thinking about

returning to work 6 m post op

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RADIOGRAPHIC EVALUATION

• Scoliosis
• Sagittal balance
• Neurologic compression
• Instability
• Relationship of spine to

pelvis

• Pelvic incidence: fixed
• Pelvic tilt
• Sacral slope
• Significant
• Spondylolisthesis
• Lateral Subluxation
• Lumbar lordosis
• Thoracolumbar alignment
• Sagittal Alignment (SVA)
• Not significant
• Coronal Cobb
• Age
• Adolescent vs. de-novo scoliosis

Statistically significant: SRS-22, ODI, SF-12/36 Slides courtesy of Virginie Lafage and Frank Schwab T Thoracic only

with lumbar curve < 30°

L TL / Lumbar only

with thoracic curve <30°

D Double Curve

with at least one T and one TL/L, both > 30°

N No Coronal Curve

All coronal curves <30 °

4 Coronal Curve Types Global alignment 0 : SVA < 4cm + : SVA 4 to 9.5cm ++ : SVA > 9.5cm 3 Sagittal Modifiers Pelvic Tilt 0 : PT<20° + : PT 20-30° ++ : PT>30° PI minus LL 0 : within 10° +: moderate 10-20° ++ : marked >20°

SRS-SCHWAB CLASSIFICATION 2012 PI MINUS LL LL PI

• #1 most important parameter
• Correlation with

– SRS (appearance, activity, total) – ODI (Walk, stand) – SF12 (PCS)

• r-values

– 0.42<r<0.482 – p<0.000

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PI MINUS LL

10 20 30 40 50

LL < PI - 10deg LL > PI - 10deg

SF-12 Physical Component Score Group Subdivision

• LL < PI – 10deg
• LL > PI – 10 deg

Increase of PCS

• 30 to 42
• p < 0.001

Decrease of ODI

• Total
• Walking
• Lifting

SVA AND T1SPI

• Second most important parameter
• Correlation with
• SRS (appearance, activity, total)
• ODI
• SF12 (PCS)
• r-values
• 0.40<r<0.46
• (p<0.0001)
• T1 tilt had greater correlation with HRQOL

compared to SVA. SVA

C7 T1

T1 Tilt

PELVIC TILT

• Third most important parameter
• Correlation with
• SRS (appearance, activity, total)
• ODI (Walk, stand)
• SF12 (PCS)
• Correlations with HRQOL
• 0.37<r<0.41
• p<0.000

Increased Retroversion

EXAMPLE OF CLASSIFICATION

Double curve Type D PI-LL = 3° Grade 0 PT = 24° Grade + SVA = -4.5cm Grade 0

Type D, PT +

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EXAMPLE OF CLASSIFICATION

Thoracic curve Type T PI-LL = 51° Grade ++ PT = 50° Grade ++ SVA = 13cm Grade ++

Type T, PI-LL++, PT ++, SVA ++

IMPACT OF CHANGE IN CLASSIFICATION GRADE ON HRQOL

Change in PT grade does impact the likelihood of reaching MCID

Chi Square ODI PCS SRS Activity SRS Pain SRS Appearance SRS Mental Change in PT grade 0.002 0.085 0.005 0.32 <0.001 0.779

Change in SVA grade does impact the likelihood of reaching MCID

Chi Square ODI PCS SRS Activity SRS Pain SRS Appearance SRS Mental Change in SVAT grade 0.001 0.122 0.001 0.063 <0.001 0.624

Change in PI-LL grade does impact the likelihood of reaching MCID

Chi Square ODI PCS SRS Activity SRS Pain SRS Appearance SRS Mental Change in PI- LL grade 0.011 0.037 <0.001 0.006 <0.001 0.035

• 71 yo healthy male, avid road biker
• Disabling leg pain, R> L, prevents

walking, but does not affect his riding

• Multiple level stenosis, L3-4, L4-5
• Decompression v decompression and

fusion?

• 71 yo healthy male, avid road biker
• Disabling leg pain, R> L, prevents

walking, but does not affect his riding

• Multiple level stenosis, L3-4, L4-5
• Offered decompression and fusion L3-

S1

• Declined for minimally invasive

decompression

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30° 37°

• Leg symptoms return 6 mon

post op, intractable by 9 mon

• Revision decompression,

fusion L2-S1

• Did not appreciate PI v LL, but

he has 50° lordosis, most would consider adequate in 2006

• 5 years later, we extend him to

L1, still trying to maintain mobility for his active life

• In 2011, we maintain his

lordosis at 50°, but could have measured his PI at 78°

• He continues to do well. He

walks with a slight crouch, but even when I ask him, he doesn’t notice

• 5 years later, we extend him to

L1, still trying to maintain mobility for his active life

• In 2011, we maintain his

lordosis at 50°, but could have measured his PI at 78°

• He continues to do well. He

walks with a slight crouch, but even when I ask him, he doesn’t notice… ....good thing he’s a rider, not a walker

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• During a long trip to Europe,

he develops TL pain and notices his stomach is sticking out more and his clothes aren’t fitting as well

2011 2016 2011 2016

OPTIONS

• PT
• He’ll lose too much motion and

isn’t that disabled

• Extend proximally to T10, aggressive

SPO to maximize lordosis

• Anterior or lateral interbodies to

maximize lordosis, extend proximally to T10

• PSO and proximal extension to T10

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• Presented all options

and pros and cons

• Sought second opinions
• Elected PSO with

proximal extension

• Rode 84 mi with 8200 ft
• f climb as pre-birthday

ride

• PI 71
• LL 75
• Pleased with progress

WHEN TO CONSIDER THE DEFORMITY?

• Decompression with deformity
• Decompression in concavity
• Decompression with lateral listhesis
• Concomitant neurological diagnosis
• If the patient has coronal decompensation
• If the patient has fixed sagittal imbalance
• If the patient has loss of lumbar lordosis
• If the patient’s deformity has worsened and fusion is needed within or

adjacent to curve

• In other words, nearly always!
• Avoid creating deformity
• Avoidance is preferable to treating an iatrogenic deformity

THANK YOU