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

11/4/16 DISCLOSURES • Review boards: Spine Deformity, CORR When degenerative problems become deformity cases • AOA Board of Directors; SRS Committee Chair • Consulting: Nuvasive Serena S. Hu, MD Professor and Vice Chair Chief, Spine Service Department of Orthopedic Surgery and, by courtesy, Neurological Surgery Stanford University DEGENERATIVE SPINE DISEASE DEGENERATIVE SPINE DISEASE • Disc degeneration • Can be caused by spinal deformity • Loss of disc height and lumbar lordosis • Asymmetric loading • May be asymmetric à tilted vertebra • Accelerated facet and disc degeneration • Spondylolisthesis à can be rotatory • Foraminal or central stenosis • Can be caused by surgical sequelae • Facet disease • Adjacent segment kyphosis • Asymmetry can cause rotation • Lateral listhesis, spondylolisthesis • Can lead to lateral listhesis • Flatback 1

11/4/16 CATEGORIES CATEGORIES • Degenerative spine with deformity • Degenerative spine with deformity: should have considered the deformity • Degenerative spine with potential for deformity • Degenerative spine with potential for deformity: should be aware of the potential for deformity • Degenerative spine with unanticipated development of deformity: sometimes you • Degenerative spine with unanticipated development of deformity just get unlucky CATEGORIES CATEGORIES • Degenerative spine with deformity: should have considered the deformity • Degenerative spine with deformity: should have considered the deformity • Degenerative spine with potential for deformity: should be aware of the potential • Degenerative spine with potential for deformity: should be aware of the potential for deformity for deformity • Degenerative spine with unanticipated development of deformity: sometimes you • Degenerative spine with unanticipated development of deformity: sometimes you just get unlucky just get unlucky 2

11/4/16 CATEGORIES DEGENERATIVE SPINE WITH DEFORMITY • 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 Bend to R • 73 yo M with L4-5 stenosis, degen spondylo, decomp to left, fully flexible • 73 yo M with L4-5 stenosis, degen spondylo, decomp to left, fully flexible • Should we address the deformity? • Should we address the deformity? • Decompress only? • Decompress only? • Decompress and fuse L4-5? • Decompress and fuse L4-5? • Decomp L4-5, fuse to TL junction? • Decomp L4-5, fuse to TL junction? • A/XLIF’s, decomp L4-5, fuse L2-L5? • A/XLIF’s, decomp L4-5, fuse L2-L5? • Parkinson’s disease 3

11/4/16 MISSING THE BOAT: DEFORMITY WAS IGNORED à DEFORMITY REVISION REQUIRED WORSENED • L5-S1 ALIF , • 57 yo chronic L2-L5 XLIF pain patient • Min invasive PSF • Presented to MD with back pain and problems with leaning forward and to the side 4

11/4/16 • Underwent • L5-S1 ALIF , revision PSF with L2-L5 XLIF PSO and • Min invasive proximal PSF extension of fusion • Thinking you • Still has chronic know how to back pain but do a now is a happy deformity chronic pain operation but patient totally not getting the concept L IMITED 54 YO F, FOOT DROP, NEVER DECOMPRESSION/FUSION TO NOTICED SCOLI BEFORE MAINTAIN MOBILITY (GOLF) 5

11/4/16 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 6

11/4/16 • 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 7

11/4/16 SHOULD WE HAVE ADDRESS THE DEFORMITY? 4/08 12/08 SHOULD WE CONSIDER THE DEFORMITY? 53yo F , s/p c laminaplasty, LE claudication 8

11/4/16 11/08 7/08 postop 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 9

11/4/16 RX PT • Neurology work up • Bracing • Chiropractor • • Narcotics, pain management • Psychologic counseling • 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 2013 25 ° 2012 20 ° 2016 52 ° 2015 45 ° 10

11/4/16 MULTIPLE TIMES RE-OPERATED FOR ADJACENT SEGMENT DISEASE ADJACENT SEGMENT DISEASE 2000 2005 2000 2005 2008 2010 2008 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 11

11/4/16 RADIOGRAPHIC EVALUATION • Scoliosis • Sagittal balance • Significant • Spondylolisthesis • Neurologic compression • Lateral Subluxation • Instability • Lumbar lordosis • Relationship of spine to • Thoracolumbar alignment pelvis • Sagittal Alignment (SVA) • Not significant • Pelvic incidence: fixed • Coronal Cobb • Pelvic tilt • Age • Sacral slope • Adolescent vs. de-novo scoliosis Statistically significant: SRS-22, ODI, SF-12/36 Slides courtesy of Virginie Lafage and Frank Schwab SRS-SCHWAB CLASSIFICATION 2012 PI MINUS LL 3 Sagittal Modifiers 4 Coronal Curve Types PI minus LL • #1 most important parameter 0 : within 10 ° T Thoracic only +: moderate 10-20 ° with lumbar curve < 30 ° LL • Correlation with ++ : marked >20 ° – SRS (appearance, activity, total) L TL / Lumbar only – ODI (Walk, stand) Global alignment with thoracic curve <30 ° – SF12 (PCS) 0 : SVA < 4cm D Double Curve + : SVA 4 to 9.5cm with at least one T and one TL/L, ++ : SVA > 9.5cm • r-values both > 30 ° PI – 0.42<r<0.482 Pelvic Tilt – p<0.000 N No Coronal Curve 0 : PT<20 ° All coronal curves <30 ° + : PT 20-30 ° ++ : PT>30 ° 12

11/4/16 SVA AND T1SPI PI MINUS LL Second most important parameter Group Subdivision C7 • T1 • LL < PI – 10deg SF-12 Physical Component Score • LL > PI – 10 deg Correlation with • 50 Increase of PCS SRS (appearance, activity, total) • 40 • 30 to 42 ODI • • p < 0.001 30 SF12 (PCS) • 20 Decrease of ODI r-values • • Total 10 • Walking 0.40<r<0.46 • 0 • Lifting • (p<0.0001) LL < PI - 10deg LL > PI - 10deg SVA T1 Tilt T1 tilt had greater correlation with HRQOL • compared to SVA. PELVIC TILT EXAMPLE OF CLASSIFICATION Third most important parameter • Correlation with • Increased Retroversion SRS (appearance, activity, total) • ODI (Walk, stand) Double curve Type D • PI-LL = 3 ° Grade 0 SF12 (PCS) • PT = 24 ° Grade + SVA = -4.5cm Grade 0 Correlations with HRQOL • Type D, PT + • 0.37<r<0.41 • p<0.000 13

11/4/16 IMPACT OF CHANGE IN CLASSIFICATION GRADE ON EXAMPLE OF CLASSIFICATION HRQOL SRS SRS SRS SRS Chi Square ODI PCS Activity Pain Appearance Mental Change in PT 0.002 0.085 0.005 0.32 <0.001 0.779 grade Change in PT grade does impact the likelihood of reaching MCID Thoracic curve Type T PI-LL = 51 ° Grade ++ SRS SRS SRS SRS Chi Square ODI PCS PT = 50 ° Grade ++ Activity Pain Appearance Mental Change in SVA = 13cm Grade ++ 0.001 0.122 0.001 0.063 <0.001 0.624 SVAT grade Type T, PI-LL++, PT ++, Change in SVA grade does impact the likelihood of reaching MCID SVA ++ SRS SRS SRS SRS Chi Square ODI PCS Activity Pain Appearance Mental Change in PI- 0.011 0.037 <0.001 0.006 <0.001 0.035 LL grade Change in PI-LL grade does impact the likelihood of reaching MCID • 71 yo healthy male, avid road biker 71 yo healthy male, avid road biker • • Disabling leg pain, R> L, prevents Disabling leg pain, R> L, prevents • walking, but does not affect his riding walking, but does not affect his riding • Multiple level stenosis, L3-4, L4-5 Multiple level stenosis, L3-4, L4-5 • • Decompression v decompression and • Offered decompression and fusion L3- fusion? S1 • Declined for minimally invasive decompression 14

11/4/16 • 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 37 ° 30 ° 5 years later, we extend him to • • 5 years later, we extend him to L1, still trying to maintain L1, still trying to maintain mobility for his active life mobility for his active life • In 2011, we maintain his • In 2011, we maintain his lordosis at 50 ° , but could lordosis at 50 ° , but could have measured his PI at 78 ° have measured his PI at 78 ° • He continues to do well. He • He continues to do well. He walks with a slight crouch, but walks with a slight crouch, but even when I ask him, he even when I ask him, he doesn’t notice doesn’t notice… ....good thing he’s a rider, not a walker 15