Positive Sagittal Balance and Management Strategies in Adult Spinal Deformities

Volume 1 | Issue 1 | Apr – June 2016 | Page 33-38|Charanjit Singh Dhillon1

Authors :Charanjit Singh Dhillon[1]

[1] MIOT Center for Spine Surgery, MIOT International, Chennai

Address of Correspondence
Dr Charanjit Singh Dhillon. MS, DNB, FNB Spine, D-Ortho,
Director MIOT Center for Spine Surgery, MIOT International, Chennai. India
Email: drdhillonc@hotmail.com


Human Spine has adapted a curved morphology to compensate for the upright posture. Normally these curves are sagittally balanced and a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1. A positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Figure 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often. The article covers the diagnosis and also details of surgical management. In absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success.
Keywords: Positive Sagittal Balance, Smith-Petersen Osteotomy, Pedicle Subtraction Osteotomy, Vertebral Column Resection

Ever since man has assumed an erect posture and bipedal gait, a series of morphological changes have taken place in the homosapien vertebral column to adapt to this new challenge of upright posture. One of the most distinctive adaptive changes seen in human spinal column has been the assumption of a gentle ‘S’ curve in sagittal plane with thoracic kyphosis [TK] interposed between cervical and lumbar lordosis [LL]. These curves work like a coiled spring to absorb shock, maintain an upright balance and allow the spine to withstand great amounts of stress than what a straight column would otherwise absorb. At the same time it still allows for a wide range of movements in the cervical and the lumbar region to optimize the use of extremities while still maintaining an upright stance with the head centered over the pelvis and finally over both feet. In most individuals with a disease free and deformity free sagittally balanced spine, a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1[1] (Fig. 1).

Figure 1 and 2

This is the most ergonomically favorable position for the spine to maintain an erect posture in the most energy-efficient manner. However, with progressively larger deviations from this ideal position, the endeavor to remain upright increases exponentially, thereby warranting greater muscular effort and energy to maintain standing balance[2]. By convention, positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. Conversely, negative sagittal balance occurs when the C7 plumb line falls posterior to this point[3]. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Fig. 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often.

Positive sagittal imbalance can occur due to destruction of the vertebral body by trauma, tumor or infection. It may also result from loss of LL as a consequence of multilevel degenerative disc disease, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis or osteoporosis[5]. Secondary causes include iatrogenic flat back syndrome resulting from failure of restoration of the appropriate LL according to the patient’s Pelvic incidence[PI]. Rarely, sagittal imbalance may be seen following spinal fusion surgery through an area of pseudarthrosis or through a degenerated segment adjacent to a previous fusion. In the past the use of distraction instrumentations such as the Harrington rods was the frequent cause of iatrogenic flat back syndrome[6]. Positive sagittal imbalance due to congenital deformities is outside the preview of this symposium on adult deformities.

Barrey et al. [7] described three stages of compensatory mechanisms corresponding to the severity of the sagittal imbalance: balanced, balanced with compensatory mechanisms and imbalanced spine. In the initial stages when positive sagittal imbalance begins, the pelvis retroversion takes place in an attempt to push the C7 plumb line backwards behind the femoral heads resulting in extension of the hips[7-9]. At this stage the PI determines the global capacity of pelvis retroversion and consequent compensatory capability. In patients with higher PI the pelvis can tilt more and compensate better than patients with a low PI[10]. The full body is now balanced but it is a compensated balance, which is less efficient[11]. At the same time the posterior spinal muscles act as a posterior tension band (trying to restore some LL) pulling the adjacent segments of the lower dorsal spine into hyperextension. In young patients with flexible spines this hyperextension leads to reduction of TK. Spine hyperextension is an energy consuming process that generates increase of stresses on posterior structures resulting in risk of retrolisthesis, facet joints overstress and even sometimes isthmic lysis (Fig. 3) [11]. When pelvis retroversion and spine hyperextension are not enough to keep the C7 plumb line behind the femoral heads, the only solution to keep the gravity line between the two feet is to bend the knees. This process needs good psoas and quadriceps muscles activity, which is again energy consuming and not an efficient situation. When the knee flexion also fails to keep the C7 plumb line behind the femoral heads, a stage of decompensation (imbalance) is reached and an external aid (e.g., crutches, walker) is often required to maintain upright posture[11].

Figure 3

Imaging Studies
Standard full-length anteroposterior and lateral radiographs should be performed in all patients with suspected sagittal imbalance. Horton et al[12] reported the ‘clavicle position’ in which the patient stands with both hips and knees fully extended, the elbows fully flexed, the wrists flexed with the hands in a relaxed fist placed into the supraclavicular fossa without any external support as the best patient position for the study of sagittal deformity. Sagittal imbalance is basically determined by the C7 plumb line offset from the posterior-superior corner of S1 (Fig. 2). An offset >2.5 cm anteriorly or posteriorly is considered to be abnormal[13]. Different components such as TK, LL and PI are also measured to define the overall sagittal balance[14]. Dynamic lateral radiographs with the spine in full flexion and full extension helps to assess the mobility of discs in the kyphotic segment and hence plan appropriate surgical management. Alternately, some surgeons use traction views to assess spine mobility.

Nonsurgical Management
Symptomatic patients with sagittal imbalance are often unresponsive to nonsurgical treatment. Physical therapy programs, bracing, facet joint injections, selective nerve root blocks and epidural steroid injections[15] are often ineffective in decompensated patients.

Surgical Management
Surgery is the mainstay of treatment for patients with sagittal deformity[15]. Indications include failure of nonsurgical treatment, kyphosis progression, significant back pain, radicular symptoms and exhaustion due to effort to maintain upright stance. The goals of surgery are to achieve a solid fusion with a balanced spine in both sagittal and coronal planes, relieve pain, and prevent progression of imbalance. Several studies have shown that adequate restoration of sagittal plane alignment is necessary to significantly improve clinical outcome and avoid pseudarthrosis[16,17]. Prior to surgery, the patient should be evaluated for risk factors such as pulmonary and cardiac disease, osteoporosis, smoking, and malnutrition. Careful consideration should be given to especially elderly patients due to higher incidence of pseudarthrosis and complications[17,18]. Relative contraindications to major spinal reconstructive surgery include psychiatric disease, uncontrolled diabetes, osteoporosis, substantial cardiopulmonary disease, and poor family or social support[19]. Flexibility of the spine should be assessed radiologically using long-cassette standing and supine AP and lateral radiographs and lateral dynamic flexion and extension radiographs. Patients’ standing sagittal imbalance may decrease in supine or prone position due to mobile segments. Bridwell[20] classified spinal deformities into three categories based on curve flexibility: totally flexible, partially flexible through mobile segments, and fixed deformity with no correction in the recumbent position. Flexible deformities can be addressed with anterior-posterior or posterior only surgery not requiring any osteotomy[6]. Sagittal balance is improved by lengthening the anterior column, either through an anterior or a posterior approach, using cages, structural allograft or autograft. The posterior column is then shortened with laminectomies (when there is evidence of stenosis), facetectomies and fusion with compression instrumentation to correct kyphosis. Fixed deformities can be managed by anterior-only, combined anterior and posterior or posterior-only approaches. Spinal osteotomies like the Smith-Petersen osteotomy[SPO], pedicle subtraction osteotomy [PSO], and vertebral column resection[VCR] are often employed to correct the stiff apical kyphotic segment. The amount of correction needed determines the type of osteotomy warranted (Fig. 4). With recent advances in instrumentation and techniques, posterior-only approaches have become more popular. Numerous studies support the safety and efficacy of a posterior-only approach for the treatment of most spinal deformities[21,22]. Fusion across the L5-S1 junction is mandatory in the presence of lumbosacral pathology, such as postlaminectomy defects, lumbar spinal stenosis, oblique take-off of L5, and L5-S1 disc degeneration to reduce the risk of pseudoathrosis and loss of fixation[22].

Figure 4

Smith-Petersen Osteotomy [SPO]
In 1945, Smith-Petersen and associates[23] were the first to describe a posterior osteotomy for correction of fixed sagittal deformity in patients with rheumatoid arthritis. In 1946, La Chapelle[24] described a modification of Smith-Petersen’s technique by adding an anterior release in a case of ankylosing spondylitis. The use of this osteotomy for the treatment of flat back deformity was first reported by Moe and Denis in 1977[25]. In 1984 Ponte[26] described multiple chevron osteotomies with spinal instrumentation in a patient with Scheuermann’s disease.

The surgical technique involves removal of all the posterior ligaments (supraspinous, interspinous, and ligamentum flavum) and facets to produce a posterior release. Dissection is then performed laterally to decompress the nerve roots. The lamina is beveled to allow sufficient room for the dura and nerve roots after closure of the osteotomy. The osteotomy hinges at the posterior border of the vertebral body and creates hyperextension by closing the posterior elements and opening the anterior elements providing sagittal plane realignment. Posterior segmental pedicle screw instrumentation is used to maintain closure of the osteotomy (Fig. 5). It should be emphasized that either a mobile disc or an anterior release is required to allow lengthening of the anterior column.

Figure 5 and 6
The SPO should be considered for patients with C7 plumb line that is less than 7 cm positive[27]. Amount of correction provided by a single SPO is in the range of 4-10° depending on the disc height and the mobility of the disc. One degree of correction is usually achieved per millimeter of bone resected posteriorly[27]. The SPO is technically easier and safer than other osteotomies offering a reduction in operative time, blood loss and risk of neurological complications, although rupture of the great vessels has been reported following anterior-column lengthening in an unfortunate case[23].For the patient requiring 10° to 20° of lordosis or 6-8 cm of correction of the C7 plumb line, it is more appropriate to perform multiple SPOs than one PSO, unless the fixed deformity is fused anteriorly[27].

Pedicle-Subtraction osteotomy [PSO]
In 1963, Scudese and Calabro[28] were the first to describe a monosegmental intravertebral closing wedge posterior osteotomy of the lumbar spine. Later, Thomasen[29] reported on 11 patients with ankylosing spondylitis treated with posterior closing wedge osteotomies. In the same year, Heining et al[30] described an eggshell osteotomy as a variant of the PSO. The PSO is performed by removing the posterior elements and both pedicles, performing a transpedicular V shaped wedge osteotomy of the vertebral body, and closing the osteotomy by hinging on the anterior cortex (Fig. 6) achieving bone-on-bone contact in the posterior, middle, and anterior columns[31]. Central canal enlargement is critical to avoid neurologic injury during closure of the osteotomy. Posterior segmental pedicle screw instrumentation is used to maintain the correction. Instrumentation of at least three vertebral levels above and below the osteotomy is recommended[32]. The PSO has the advantage of obtaining correction through all the three spinal columns, while the posterior and middle columns shorten, this osteotomy does not lengthen the anterior column avoiding stretch on the major vessels and viscera anterior to the spine[33]. An average of 30º to 40º correction can be achieved with one level PSO[34]. The ideal candidates for a PSO are patients with a fixed sagittal imbalance of more than 10 cm and those patients who have circumferential fusion along multiple segments, which would contradict multiple SPOs(Fig. 7)[27].

Figure 7

Although PSOs are more technically demanding and more prone to complications than SPOs, PSOs provide satisfactory clinical and radiologic outcomes in long-term follow-up. Kim et al[34] in a series of 35 PSOs reported their good results with 87% patient satisfaction and 69% restoration of function after more than 5 years of follow-up. Cho et al[35] compared one level of PSO with three levels of SPOs in their study and reported that an average total kyphosis correction was 31.7º for PSO group and the improvement in the sagittal imbalance (11.2 ± 7.2 cm) was much better than multiple SPOs. Blood loss was significantly higher in PSO group but there was no statistical difference between one level PSO and three levels of SPO groups with respect to operating times. Regarding neurological complications, Buchowski et al[36] reported a postoperative immediate neurological deficit rate of 11.1% which subsequently reduced to 2.8% during follow up. Deficits were mostly unilateral and never proximal to osteotomy site, often did not correspond to the level of osteotomy, and surprisingly were not detected by neuromonitoring[36].

Figure 8

Vertebral Column Resection [VCR]
VCR was first described in 1922 by MacLennan[37] as a combined anterior and posterior procedure and was popularized by Bradford and Tribus[38] as a method of correcting severe coronal deformity and combined coronal and sagittal deformity. It is indicated in rigid severe deformities of the spine such as congenital kyphosis, rigid multiplanar deformities, sharp angulated deformities, posttraumatic deformities and spondyloptosis. The VCR technique is a challenging procedure involving the complete resection of the posterior elements and the vertebral body including adjacent discs of one or more levels (Fig. 8) providing controlled manipulation of both the anterior and posterior columns simultaneously. It can be performed using either combined anterior and posterior approaches or a posterior-only approach[39]. Of all the spinal osteotomies, VCR provides the greatest amount of correction. Suk et al[40] reported a correction of 61.9o in the coronal plane and 45.2o in the sagittal plane in their series of 70 patients after VCR. In their series of 35 patients, Lenke[41] reported major curve improvements of 55o in global kyphosis cases, 58o in angular kyphosis cases and 54o in kyphoscoliosis cases after VCR. Vertebral column resection through a posterior-only [PVCR] approach has become popular in the recent years. Suk[40] and Lenke[41] popularized the use of PVCR for severe deformities of the spinal column. PVCR enables simultaneous manipulation and control of both anterior and posterior spinal columns and thus provides better correction than other types of osteotomies. It is a single procedure compared to combined anterior and posterior VCR, reducing the total operating time and the amount of blood loss and also avoiding opening of the thoracic cage and pleura. Avoiding anterior surgery may be very beneficial for patients with severe pulmonary function compromise because of severe thoracic deformity[27]. Inspite of all advantages, PVCR is a technically demanding procedure. One major concern with PVCR is the potential for neurologic complications, which may result from direct neurologic injury during bone resection or deformity correction. Neurologic complications may also result from subluxation of the spinal column, dural buckling and compression of the spinal cord by residual bone or soft tissues in the canal after correction[27]. Suk[40] reported a 34.3% overall rate of complications and a 17.1% rate of neurological complications. Lenke[41] reported a similar 40% overall rate of complications and an 11.4% rate for neurological complications. Hamzaoglu[39] reported neurological complications of 7.84%.

Figure 9


With rising life expectancy the number of patients seeking consultation for pain due to sagittal imbalance is increasing. In the absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success. SPO, PSO and VCR all play an important role in the armamentarium of the spine deformity surgeon. However, each of these procedures are technically demanding and carries a certain amount of risks. Appropriate preoperative optimization of the patient as well as preoperative surgical planning are critical in order to avoid potential complications. Surgical achievement of the ideal spinopelvic alignment parameters is the desired goal. Nevertheless, even a partial improvement in these parameters is very likely to translate into substantial clinical benefits.


1 Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989; 14: 717-721
2 Dubousset J. Three-dimensional analysis of the scoliotic deformity, in Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY: Raven Press, 1994, pp 479-496.
3 Vedantam R, Lenke LG, Keeney JA, et al. Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults. Spine 1998; 23: 211-225
4 Gelb DE, Lenke LG, Bridwell KH, et al. An analysis of sagittal spinal alignment in 10° asymptomatic middle and older aged volunteers. Spine 1995; 20: 1351-1358.
5 Kim KT, Lee SH, Suk KS, Lee JH, Im YJ. Spinal pseudarthrosis in advanced ankylosing spondylitis with sagittal plane deformity: Clinical characteristics and outcome analysis. Spine 2007; 32: 1641-1647
6 Bridwell KH, Lenke LG, Lewis SJ. Treatment of spinal stenosis and fixed sagittal imbalance. Clin Orthop Relat Res 2001; 384: 35-44
7 Barrey C, Jund J, Noseda O, Roussouly P. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A com-parative study about 85 cases. Eur Spine J 2007; 16: 1459-1467
8 Barrey C, Jund J, Perrin G, Roussouly P. Spinopelvic alignment of patients with degenerative spondylolisthesis. Neurosurg 2007; 61: 981-986
9 Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal spine and pelvis using shape and orientation parameters. J Spinal Disord Tech 2005; 18: 40-47
10 Barrey C, Roussouly P, Perrin G, Le Huec JC. Sagittal balance disorders in severe degenerative spine. Can we identify the com-pensatory mechanisms? Eur Spine J 2011 Sep; 20 Suppl 5: 626-633
11 Le Huec JC, Charosky S, Barrey C, Rigal J, Aunoble S. Sagittal imbalance cascade for simple degenerative spine and consequenc¬es: algorithm of decision for appropriate treatment. Eur Spine J 2011 Sep; 20 Suppl 5: 699-703
12 Horton WC, Brown CW, Bridwell KH,Glassman SD, Suk SI, Cha CW. Is there an optimal patient stance for obtaining a lateral 36” radiograph? A critical comparison of three techniques. Spine 2005; 30: 427-433
13 Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size: A prospective con¬trolled clinical study. Spine 1994; 19: 1611-1618
14 Hammerberg EM, Wood KB. Sagittal profile of the elderly. J Spi¬nal Disord Tech 2003; 16: 44-50
15 Bradford DS, Tay BK, Hu SS. Adult scoliosis. Surgical indications, operative management, complications, and outcomes. Spine 1999; 24: 2617-2629
16 Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbal¬ance. J Bone Joint Surg Am 2003; 85: 454-463
17 Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G. Pseudarthro¬sis in long adult spinal deformity instrumentation and fusion to the sacrum: Prevalence and risk factor analysis of 144 cases. Spine 2006; 31: 2329-2336
18 Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM. Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine 1999; 24: 1712-1720
19 Hu SS, Berven SH. Preparing the adult deformity patient for spi¬nal surgery. Spine 2006; 31(19 suppl): S126-S131
20 Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. verterbral column resection for spinal deformity. Spine 2006; 31(19 suppl): S171-S178
21 Pateder DB, Kebaish KM, Cascio BM, Neubaeur P, Matusz DM, Kostuik JP. Posterior only versus combined anterior and posterior approaches to lumbar scoliosis in adults: A radiographic analysis. Spine 2007; 32: 1551-1554
22 Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Mini¬mum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine 2006; 31: 303-308
23 Smith-Petersen MN, Larson CB, Aufranc OE. Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res 1969; 66: 6-9
24 La Chapelle EH. Osteotomy of the lumbar spine for correction of kphosis in case of ankylosing spondtlitis. JBJS 1946; 28: 851-858
25 Moe JH, Denis F. Abstract: The iatrogenic loss of lumbar lordo¬sis. Orthopedic Transactions 1977; 1: 131
26 Ponte A, Vero B, Siccardi GL. Surgical treatment of Scheuer¬mann’s kyphosis. In: Winter RB (ed) Progress in spinal pathology: kyphosis. Aulo Gaggi 1984 Bologna, pp 75–80
27 Enercan M, Ozturk C, Kahraman S, Sarıer M, Hamzaoglu A, Ala¬nay A. Osteotomies/spinal column resections in adult deformity. Eur Spine J 2013 Mar; 22 Suppl 2: S254-64
28 Scudese VA, Calabro JJ. Vertebral wedge osteotomy for correction of rheumatoid (ankylosisng) spondylitis. JAMA 1963; 186:627-631
29 Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop Relat Res 1985 194: 142-152
30 Heining CA. Eggshell procedure. In: Luque ER (ed) Segmental spinal instrumentation. Thorofare, Slack, pp 221-230
31 Bridwell KH, Lewis SJ, Rinella A, Lenke LG, Baldus C, Blanke K: Pedicle subtraction osteotomy for the treatment of fixed sagit¬tal imbalance: Surgical technique. J Bone Joint Surg Am 2004; 86(suppl 1): 44-50
32 Kim KT, Lee SH, Suk KS, Lee JH, Im YJ. Spinal pseudarthrosis in advancedankylosing spondylitis with sagittal plane deformity: Clinical characteristics and outcome analysis. Spine 2007; 32: 1641-1647
33 Henry Halm. Pedicle subtraction osteotomy for correction of congenital scoliokyphosis. Eur Spine J 2011; 20:995–996
34 Kim JY, Bridwell KH, Lenke GL, Cheh GE, Baldus C. Results of lumbar pedicle substraction osteotomies of fixed sagittal im¬balance a minimum 5-year follow-up study. Spine 2007; 32(20): 2189-2197
35 Cho KJ, Bridwell KH, Lenke GL, Berra A, Baldus C. Comparison of Smith-Petersen versus pedicle substraction osteotomy for cor-rection of fixed sagittal imbalance. Spine 2005; 30(18): 2030-2037
36 Buchowski JM, Bridwell KH, Lenke LG, Kuhns CA, Lehman RA, Kim JY, Stewart D, Baldus C. Neurologic complications of lumbar pedicle subtraction osteotomy a 10-year assessment. Spine 2007; 32(20): 2245-2252
37 MacLennan A. Scoliosis. BMJ 1922; 2: 865-866
38 Bradford DS, Tribus CB. Vertebral column resection for the treat¬ment of rigid coronal decompensation. Spine 1997; 22: 1590-1599
39 Hamzaoglu A, Alanay A, Ozturk C, Sarier M, Karadereler S, Ganiyusufoglu K. Posterior vertebral column resection in severe spinal deformities. Spine 2011; 36(5): 340-344
40 Suk SI, Chung ER, Kim JH et al. Posterior vertebral column re¬section for severe rigid scoliosis. Spine 2005; 30(14): 1682-1687
41 Lenke LG, O’Leary PT, Bridwell KH, Sides BA, Koester LA, Blanke KM. Posterior vertebral column resection for severe pedi¬atric deformity: minimum two-year follow-up of thirty-five con¬secutive patients. Spine 2009; 34: 2213-2221.

How to Cite this Article: Dhillon CS. Positive sagittal balance and management strategies in adult Spinal deformities. International Journal of Spine Apr – June 2016;2(1):33-38 .


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Shoulder Balance and Scoliosis

Volume 1 | Issue 1 | Apr – June 2016 | Page 31-32|Ketan Khurjekar[1].

Authors :Ketan Khurjekar[1]

Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India

Address of Correspondence

Dr Ketan Khurjekar
Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India

Email: kkhurjekar@googlemail.com


Abstract: Shoulder imbalance is a fairly new outcome variable that is been associated with complex spinal deformities. The presentation of should imbalance is variable and depends on the extent, severity of primary curve, compensatory curves and overall balance of the spine both in sagittal and coronal planes (rotatory planes). It is definitely an important outcome measure in terms of satisfactory patient outcome, however factors that affect it are still unclear and more studies are required. Current article focusses on the basics of shoulder imbalance and currently available methods of measuring it.
Key Words: Adult spinal deformity, shoulder imbalance, cosmoses.

Shoulder Balance and Scoliosis
Scoliosis though termed as a coronal deviation in normal architecture of spine, it is often found that there is sagittal imbalance associated with the rotation of the spinal column. Scoliosis is a 3-D deformity and its rotation element was not taken into consideration till recent times. Sagittal imbalance or coronal deviation along with rotational mal-alignment gives obnoxious spinal deformity and severity is perceived more because of shoulder imbalance. Shoulder imbalance is reported as difference in shoulder asymmetry. Residual shoulder asymmetry ruins the result of good anatomical Cobb to Cobb correction. Patient undergoing spinal fusion surgery did not do well unless the sagittal Balance is corrected. It plays important role in cosmesis achieved after surgery. It is unclear, that which factors of scoliosis complex determines the shoulder balance. How does preoperative severity of shoulder imbalance affect the post operative outcome still remains speculative. Why only proximal thoracic and main thoracic curve are given significance when we talk about shoulder balance is topic of discussion? Just as a corollary, for years abnormal abdominal reflex was considered to be indicator of intraspinal problem. Yngve demonstrated that abnormality of abdominal refelex was seen in 27 % of normal individuals[1]. Shoulder imbalance associated with proximal curve, dictates the long fusion surgery till T2 which balances out the shoulder and helps achieve good cosmetic correction. If left shoulder is higher > 5 mm in right proximal thoracic curve, then including proximal thoracic curve in instrumentation is mandatory. As per Lenke et al, if left shoulder is higher in a right proximal thoracic curve, upper instrumented vertebra (UIV) would be T2. If right shoulder is higher, then UIV would be T4. If both shoulders are equal, then fusion would be restricted to T3 [2]. Pelvic girdle is base of spine foundation. Any deviation or malalignment of spine is noted as abnormal pelvic tilt. But pectoral girdle has no direct attachment. So it has been postulated that correction of chest wall deformities can correct shoulder level and Scapulae to give desired shoulder balance [3].
Few of the Current practices of measuring shoulder Imbalance [4]
· Curve pattern on standing AP and Lateral (whole Spine Scannograms) are mandatory to measure shoulder asymmetry
· T1 tilt- Positive T1 tilt is defined as the angulation of upper end plate of T1 to the horizontal with the proximal vertebral body up and right lower vertebral body down
· Clavicle Angle- Intersection of horizontal line and tangential line connecting the higher two points of each clavicle. Positive clavicle angle means left clavicle is up and right clavicle is down
· T1-ICL correlation- T1 vertebral tilt and intercoracoid line (ICL) tilt have simplified measurement of shoulder balance. T1-ICL relationship is concordant or discordant. Relationship is concordant if T1 is tilted to the same side as that of ICL. Similarly it is discordant if T1 has tilted in opposite direction of ICL [3].
· Coracoid Height Difference- Difference between two horizontal lines drawn from each coracoid will tell us about Coracoid Height difference.
· Trapezius length- Showed weak correlation with post-operative shoulder balance
· First rib- Clavicle height- Vertical distance of first rib apex to superior clavicle
· RSH- radiographic Shoulder height- Graded height difference of Soft tissue shadow directly superior to acromio-clavicular joint in AP view. When imbalance is more than 3 cm, it is called as Significant Shoulder Imbalance. Moderate imbalance would be 2 to 3 cm and less than 1 cm would be minimal shoulder imbalance.
In a series of 112 cases, Kuklo et al4 concluded that the clavicle angle and not the T1 tilt is the best predictor of preoperative and post operative shoulder balance. Standing Proximal Cobb and side bending Cobb is considered as essential part of survey.
Determination of UIV would have bearing on post-op shoulder balance. Whether to stop at T2 or T3 or T4 is unclear. Suk et al has suggested that neutral vertebra of the proximal thoracic curve should be selected as UIV irrespective of shoulder level particularly when all pedicle screw construct is used [5]. However above findings are true if the curve T1-ICL concordant. Means if the T1 is tilted along with the proximal curve then depressing the neutral vertebra or T1 will get the shoulder balanced. As against that, if the proximal thoracic curve is T1-ICl discordant, then depressing T1 will further enhance the shoulder imbalance [3]. Only radiological shoulder balance doesn’t correlate with the clinical appearance. Correcting T1 tilt radiologically will correct Shoulder balance has proven to be myth beyond doubt. Researchers from Turkey evaluated shoulder balance radiologically and clinically in healthy adults and proved that shoulder balance in healthy adults doesn’t exist [6].
Healthy adolescent patients almost 19 % had asymmetric shoulders and almost 72 % had side to side difference of < 1 cm. None of the individuals ever complained of shoulder imbalance. The radiological shoulder balance parameters reliably reflect the clinical appearance. Coracoid height difference is taken into consideration when shoulders are included in radiographs and clavicular tilt angle is considered when shoulders are obviated. Researchers from Japan have classified shoulder balance broadly into medial and lateral shoulder height asymmetry. Medial differences reflected in trapezial prominence created by upward tilted proximal ribs and tilted T1. Lateral shoulder height asymmetry correlates weakly with clavicular angle. Correlation of trapezial prominence is more predictable to compare after scoliosis surgery [7]. Shoulder balance is considered as paramount indicator in cosmesis correction. It has significant impact of patient’s self-perception [8]. Generally anterior shoulder balance is perceived by patient and posterior shoulder balance is perceived by clinician. From patient’s perspective, achieving anterior shoulder balance is vital. Both, anterior and posterior shoulder balance were thought to be correlating equally. Unlike, it is showing weak correlation and it is recommended for clinicians and surgeons to evaluate both sided in planning deformity correction, particularly Lenke type 2 curves [8]. Chinese workers have affirmed that radiologic parameters alone will not guide post-operative shoulder balance. We should pay more attention to clinical cosmetic correction than only radiological angle restoration to get proper shoulder balance. We should not only include shoulder height but should also include the shoulder angle, axilla angle and areal balance between left and right shoulder. Qiu et al has suggested that estimate of shoulder height, which is intersection of clavicle and rib cage is the most reliable landmark. It will guide in assessing shoulder balance to better extent [9]. To Summarise, the shoulder balance is an area of complexity with many researchers with their experienced thought process. The common mandate is to get satisfactory cosmetic correction of scoliosis for patient as well as clinician.


1. Yngve D. Abdominal reflexes J Pediatric orthop. 1997: 17(1): 105-108
2. Lenke LG, Bridwell KH, O’Brien MF, et al. Recognition and treatment of proximal thoracic curve in adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation. Spine. 1994;19:1589-1597
3. Menon KV, Tahasildar N, Pillay HM, Ambuselvum M, Jayachandren RK. Patterns of Shoulder Balance in Idipopathic Scoliosis. J Spinal Disord Tech 2014;27:401-408
4. Kuklo TR, Lenke LG, Graham EJ, Won DS, Sweet FA, Blanke KM, Bridwell KH. Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2002 Sep 15;27(18):2013-20.
5. Suk SI, Kim WJ, Lee CS, Lee SM, Kim JH, Chung ER, Lee JH. Indications of proximal thoracic curve fusion in thoracic adolescent idiopathic scoliosis: recognition and treatment of double thoracic curve pattern in adolescent idiopathic scoliosis treated with segmental instrumentation. Spine (Phila Pa 1976). 2000 Sep 15;25(18):2342-9..
6. Akel I, Pekmezci M, Hayran M, Genc Y, Kocak O, Derman O, Erdogan I, Yazici M. Evaluation of shoulder balance in the normal adolescent population and its correlation with radiological parameters. Eur Spine J. 2008;17: 348-354.
7. Ono T, Bastrom TP, Newton PO. Defining 2 components of shoulder imbalance. Spine 2012; 37: E1511-E1516
8. Yang s, Feuchtbaum, Werner BC, Cho W, Reddi V, Arlet V. Does anterior shoulder balance in adolescent idiopathic scoliosis correlate with posterior shoulder balance clinically and radiologically. Eur Spine J. 2012: 21: 1978-1983
9. Qiu XS, Ma WW, Li WG, Wang B, Yu Y, Zhu ZZ, Qian BP, Zhu F, Sun X, Ng BK, Cheng JC, Qiu Y. Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve. Eur Spine J. 2009 Jan;18(1):45-51.

How to Cite this Article: Khurjekar K. Shoulder Balance and Scoliosis. International Journal of Spine Apr – June 2016;2(1):31-32 .


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Management Strategies and Selection of Fusion Levels in Adult Spinal Deformities

Volume 1 | Issue 1 | Apr – June 2016 | Page 25-30|Kshitij Chaudhary[1], Ranjith Unnikrishnan[2].

Authors :Kshitij Chaudhary[1], Ranjith Unnikrishnan[2]

[1] Department of Spine Surgery, Mumbai, Maharashtra, India
[2] Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

Address of Correspondence
Dr. Kshitij Chaudhary
206-3A, Vaishali nagar, KK Marg, Jacob Circle, Mahalaxmi East
Mumbai 400011.
Email: chaudhary.kc@gmail.com


Abstract: Adult spinal deformity (ASD) is fast becoming a global spinal epidemic. Decision making in adult deformity is a complex process and with each passing year, the treatment protocols are evolving as new evidence comes to light. The decision to choose surgery is not only complex but also patient specific. The surgical options can be broadly classified into three groups in order of increasing complexity and surgical invasiveness: 1) focal decompression only, 2) decompression with limited fusion, and 3) fusion of the entire curve. Of the many controversies plaguing adult spinal deformity, choosing end levels of fusion is the subject matter of ongoing debate. This narrative review makes an attempt to provide general guidelines for selecting fusion levels based on the current evidence.
Key Words: Adult spinal deformity, surgery, degenerative scoliosis, fusion levels, review

As the world’s population ages, adult spinal deformity (ASD) is fast becoming a global spinal epidemic. Although accurate estimates are difficult, the prevalence is reported to be as high as 60% in individuals older than 60 years [1]. Adult deformity can be of two types. Adult idiopathic scoliosis represents patients who have a history of idiopathic scoliosis in childhood that present with symptoms related to degenerative arthritis within the curve. Degenerative or De novo scoliosis represents patients without preexisting spinal deformity who present with spinal deformity secondary to degenerative spinal changes [2]. It is hypothesized that asymmetric disc degeneration and facet arthritis with lateral and/or rotatory listhesis is responsible for the development of de novo scoliosis in adults. Usually, the age of presentation of patients with degenerative scoliosis is in the 6th decade. The typical presentation is either axial back pain or radiculopathy (radicular or neurogenic claudication). With severe deformity, patients may present with a change in body habitus, abnormal posture and may complain of ill-fitting clothes. One of the fundamental difference between treating adolescent deformity and adult deformity is that the treatment choice is guided by the clinical presentation rather than radiological parameters. Although precise therapeutic guidelines for treating these patients are not defined, clinicians should take into consideration certain general evidence-based principles when treating these patients. Decision making in adult deformity is a complex process and with each passing year, the treatment protocols are evolving as new evidence comes to light. In general, with exception of patients presenting with acute neurological deterioration, nonoperative treatment is the first option offered to patients. The surgical options can be broadly classified into three groups in order of increasing complexity and surgical invasiveness: 1) focal decompression only, 2) decompression with limited fusion, and 3) fusion of the entire curve [3]. Surgery is indicated in patients who fail conservative care and continue have ongoing back pain, neurological symptoms or deformity progression. The decision to choose surgery is not only complex but also patient specific. Innumerable factors need to be considered before finalizing on surgery, and the patient should be part of this decision-making process. Of the many controversies plaguing adult spinal deformity, choosing end levels of fusion is the subject matter of ongoing debate. While limited fusion and decompression is associated with lower postoperative complications, these patients may soon become symptomatic due to adjacent segment degeneration if the fusion levels are not chosen wisely. Extensive fusion of the entire deformity not only carries a significant surgical risk, but is also associated with complications related to selection of end-levels of fusion. At the distal end the debate is whether to fuse or not to fuse to sacrum. At the proximal end, proximal junctional kyphosis remains a risk and, therefore, choice of upper end-level of fusion requires special attention. This review article makes an attempt to provide general guidelines for selecting fusion levels based on the current evidence.

Radiographic evaluation of ASD patient:
Standing full spine radiographs:
Standing radiographs are of paramount importance. Patients with spinal deformity should be evaluated using full spine radiographs that include the external auditory canal and the femoral heads. The position of the arms with 30º shoulder flexion has the least impact on sagittal alignment [4].
Frontal Radiograph
1. Cobb angle: measure for all curves, including fractional curves. Identify stable, neutral and end vertebrae.
2. Lateral listhesis: adjacent vertebrae are relatively neutral in relation to each other
3. Rotatory listhesis: cephalad vertebra is rotated compared to the caudad vertebra
4. Coronal balance: offset of the C7 in relation to the central sacral vertical line is measured, with offsets of more than 5 cm considered as abnormal.
5. Clavicle angle: angle between a line joining two clavicles (most cephalad points of both clavicles) and the horizontal reference line. It is a measure of shoulder imbalance.
6. Pelvic obliquity: angle between the highest points of iliac crest or sacral ala and the horizontal reference line. If there is a pelvic obliquity it is imperative to rule out an oblique take off of L5 and limb length inequality.

Lateral Radiograph
1. Thoracic kyphosis: as measured from T4 to T12. (Fig. 1)
2. Lumbar lordosis: as measured from L1 to S1. (Fig. 1)
3. Global Sagittal balance (Fig. 1): These parameters have been shown to correlate with self-reported pain and disability (HRQOL measures) [5,6].
a. Sagittal C7 plumbline is drawn from the centroid of C7. Measure the horizontal offset of from this plumbline and the posterior superior corner of S1.
b. T1 and T9 spinopelvic parameters: these are angles between the the vertical plumbline dropped from the center of T1 or T9 vertebral body and the line joining this center to the center of the femoral axis. These are a measure of sagittal imbalance.
4. Pelvic parameters (Fig 2): Pelvic incidence is a morphological parameter that remains relatively constant throughout adulthood. It is the sum of sacral slope and pelvic tilt (PI=SS+PT) which vary according to the pelvic position. Normative values are: 52º for PI, 12º for PT and 40º for SS [7].
5. Anterior or posterior vertebral subluxation.
6. Osteophytes and status of disc collapse: These are markers or stability of a particular motion segment

Figure 1

Adult spinal deformity classification:
Unlike the widely popular and established Lenke classification for adolescent idiopathic scoliosis, the classification systems for adult spinal deformity continue to evolve as increasing evidence accumulates. The attempt is to try to link the classification system to a treatment algorithm that can reliably predict the outcome of surgical intervention. The adult spinal deformity committee of the Scoliosis Research Society has developed the SRS-Schwab Adult Spinal Deformity classification that has been shown to be comprehensive and predictive of outcomes and complications in the management of ASD [8].
Flexibility films
When planning a surgery, it is important to assess the flexibility of the deformity. It is extremely useful to compare the standing radiographs with the supine films. Supplementary radiographs such as push-prone films, traction, and bending films may also be useful. Silva and Lenke have categorized curve flexibility into three categories: flexible, stiff and stuck. “Flexible” deformities will correct passively by at least 50% and will not require additional release procedures. “Stiff” deformities correct 25-50% and may require an anterior release or posterior facet resections (Ponte osteotomies). “Stuck” deformities are quite rigid and need three column osteotomy [3].

Figure 2

MRI and CT scan
MRI is useful to evaluate the spinal canal in patients with neurological symptoms. The location of spinal stenosis has important implications on surgical treatment. CT myelogram may be useful in patient with contraindications to MRI. In patient with severe deformity, multiplaner CT reconstruction may give more information compared to MRI. Osteophytosis and autofused segments are readily diagnosed on CT scan and this too has ramifications on surgical treatment.

Surgical options

1) Decompression without fusion:
Although this is an attractive option for the elderly with comorbidities, it can be successfully employed in only a subset of patients. It is ideal for a patient with neurological symptoms (radicular pain) with little or no back pain. The nature of stenosis should be either central canal or lateral recess, and it should be possible to perform a limited decompression to achieve nerve decompression. Foraminal stenosis requires wider destabilizing bony resection and is usually not suitable for decompression only procedure. Besides, if the comparison between standing and supine films suggest a collapsing nature of the deformity, this option is not ideal. Radiographically, these curves should be mild (<15-20º) with a reasonable global sagittal balance and no lumbar kyphosis. The segments that need decompression should be stable as indicated by the presence of osteophytes or collapsed disc space and should not demonstrate subluxation (>2mm) on dynamic or standing radiographs. However, decompression may result in curve progression and worsening of symptoms, especially if done at the apex of the deformity.

2) Decompression with limited fusion within the deformity:

This option involves performing a limited fusion in the area of decompression. This is suitable for a patient with predominant leg pain (neurogenic claudication) who will require extensive decompression (e.g. severe lateral recess or foraminal stenosis, previous laminectomy, dynamic stenosis). The curve should be relatively small (<30º) without significant lumbar kyphosis or global imbalance. If there is an indication of segmental instability (vertebral subluxation >2mm, anterior, lateral or rotatory) without significant osteophytes or disc settling the segment should be fused.

Choosing fusion levels in limited fusion
The concern in limited fusion is accelerated degeneration of adjacent segment leading to spinal stenosis and progression of deformity. At the proximal end, it is advisable to include the adjacent segment that has a rotary subluxation or segmental kyphosis within the fusion [9]. Fusion from apex to sacrum have been shown to have poorer outcomes, hence if possible, fusion should not stop at the apex of the deformity [10]. At the proximal end, a decision must be made whether to extend fusion to sacrum. Frequently, the concavity of the fractional curve (L4 to S1) results in foraminal stenosis at L5-S1. Therefore, if the decompression involved L5-S1 segment the fusion should extend to the sacrum. Preexisting pathology (listhesis, pars defect) or severe disc degeneration are indications for extending fusion to the sacrum.
Hansraj et al in a large cohort of symptomatic spinal stenosis with degenerative scoliosis <20º, reported a 95% success rate (no revision surgery) of decompression alone surgery at four years follow-up [11]. Transfeldt et al compared three surgical groups: decompression only, limited fusion and full curve correction. Full curve correction group had the highest complication rate, the worst Oswestry results but it was second best in patient satisfaction. Decompression alone had the lowest complication rate but the lowest patient satisfaction rate. Limited fusion had intermediate results between these two groups [10]. Another retrospective study by Daubs et al found that in patients with curves <30º limited fusion groups outperformed the decompression only group for up to 5 years [12].

3) Fusion of entire deformity with or without decompression

This is indicated in patients with significant back pain with or without leg pain as a result of spinal deformity. Typically, these curves are large (>45º), with significant segmental subluxations (>2mm) or instability. The goal of curve correction is to restore global and regional imbalance. Literature indicates that proper restoration of the sagittal profile is critical for improvement of postoperative outcomes as measured by HRQOL scores [13].
The goals of surgery are to correct the deformity to achieve the following:
1) Lumbar lordosis should be corrected to within 10º of the pelvic incidence (PI-LL = ±10 degrees)
2) Sagittal vertical axis should be restored within 5 cm of the posterior superior corner of sacrum
3) Pelvic tilt should be restored to less than 25º
Surgimap software is an excellent graphical tool for preoperative planning to achieve these goals [14]. Depending on the flexibility of the deformity, various release procedures, ranging from facetectomy to three column osteotomy are employed to achieve these goals.

a) Proximal fusion level:
The most feared complication at the proximal end of the construct is PJK (proximal junctional kyphosis). Proper selection of proximal fusion level or the upper instrumented vertebra (UIV) may help reduce the risk of this complication

1) The UIV should be a stable vertebra. Preferable horizontal rather than tilted vertebra.
2) Evaluate the adjacent segment for spinal stenosis, olisthesis, facet arthropathy, and disc degeneration. One should consider including such level within the fusion.
3) Avoid stopping that the apex of focal or regional kyphosis. Physiological apex in the thoracic spine is around T6 and it is better to stop short (T10) or go beyond this level (T4 or above).
4) Avoid stopping in thoracolumbar region, if the thoracic spine has vertebral compression fractures or thoracic hyperkyphosis.
5) Shoulder balance needs to be considered. Unlike adolescent curves, the compensatory curves in adult deformity do not correct with reduction of the primary deformity. The compensatory curves may be stiffer due to degenerative changes and may require inclusion in the fusion to achieve should symmetry.
It is disputable whether to stop the fusion at T10 or L1/L2. Often the stable vertebra is going to be T12. It is a transitional area, and hence most authors recommend bypassing the area and going to T10, which is in a more stable region of the spine even if it means increasing the extent of surgery. Kuklo et al reported that only two of the 20 patients had good to excellent results when stopping at L1 or L2 [15]. However, Kim et al compared three groups with UIV of T9, T11, and L1 and found no difference in outcome at 4.5 years. [16] Cho et al concluded that there was no difference in adjacent segment problems between fusion to T10 and fusion to T11 or T12. They concluded that fusion to T11 or T12 was acceptable when UIV was above the upper end vertebra [17].

b) Distal fusion level
In degenerative scoliosis, the most common radiographic anomaly is L3-4 rotatory subluxation with a fixed tilt of L4-5. Hence, it is usually not possible to stop at L3 or L4 in degenerative scoliosis. Therefore, the options available for distal fusion level are L5, sacrum, or pelvis.

L5 or Sacrum?

This decision can be difficult and challenging. Advantages of stopping at L5 are preservation of lumbosacral motion, reduced stress on SI joints, lower operative time and lower nonunion rate [18]. However, stopping at L5 may be associated with adjacent segment disease and increase in sagittal imbalance as the L5-S1 disc collapses and goes into kyphosis. Edwards et al found adjacent segment disease in L5-S1 to be 61% out of which approximately 2/3rd had an increase in SVA by more than 5cm. Extension of fusion to sacrum was performed in 23% patients, and a further 17% were offered surgery, but they declined [19]. Contrary to the popular notion that deep seated L5 is relatively stable, this study found that loss of L5 fixation was not uncommon in such patients.
Obtaining fusion to sacrum can be a challenge and many have reported a significant nonunion rate [20,21]. In addition, it adds to the surgical burden and increases surgical time and blood loss. Bridwell [22] has recommend that fusion should extend to sacrum in the following situations:
1. L5-S1 spondylolisthesis
2. Central or foraminal stenosis at L5-S1
3. Oblique take off of L5 >15 degrees
4. Severe L5-S1 disc degeneration

L5 or pelvis?

Much of the ongoing debate has shifted from L5 versus S1 to a choice between L5 versus pelvis. Several studies have reported S1 screw failure and pseudarthrosis in patients with long fusion to the sacrum [23-25]. Iliac fixation, particularly with iliac screws, has gained popularity in the recent years. The downside of iliac screws could be their potential for loosening, implant prominence, and pain which may necessitate a hardware removal. However, this complication is not very common [18]. Some authors advocate an interbody fusion at L5-S1 (TLIF or ALIF) in addition to sacro-plevic fusion in patients with long constructs (>3 levels) to reduce failure rate due to pseudarthrosis [7].

Indications for extending fixation to pelvis are: [26]
1) Long construct: There is no clear definition of a long construct, but many surgeons recommend including the pelvis if the UIV is L2 or above.
2) Inability to achieve a good coronal or sagittal balance intraoperatively.
3) Poor sacral fixation (e.g. in osteoporosis)
4) High risk of pseudarthrosis (e.g. smokers, diabetics)
5) Inability to achieve a good interbody fusion at L5-S1
6) In patients undergoing three column osteotomies in the lower lumbar spine.

Minimally invasive techniques:
Minimally invasive, muscle sparing, tubular techniques are becoming popular to treat lumbar degenerative disorders. They have especially been useful in adult deformity patients to achieve decompression without damaging midline structures and help preserve the posterior tension band. They can also be used for limited fusion operations to reduce the surgical footprint and may reduce adjacent segment problems. However, in long constructs, it is still debatable whether minimally invasive techniques are as effective as open techniques in restoring sagittal and coronal balance [27].

Table 1

Case examples:

Case 1: (Fig. 3 and 4) Decompression with limited fusion
A 62-year old woman presented with predominant leg side neurogenic claudicatory pain attributed to foraminal stenosis (L4-5 and L5-S1) in the concavity of the fractional curve. The patient had failed all conservative measures. Standing radiographs (Fig. 3a) demonstrate a left sided lumbar curve of 25º with a fractional curve from L4 to sacrum of 18º. Supine films (Fig. 3b) show that the lumbar curve corrects to 19º and the fractional curve reduces to 10º. This suggests that the foraminal stenosis at L4-5 and L5-S1 is dynamic in nature, and a simple decompression is not going to relieve her of her symptoms. The lumbar lordosis is 50º, and it is within 10 degrees of the pelvic incidence (56º) (Figure 3c). The pelvic tilt is 7º. The global sagittal and coronal balance is normal. There is rotatory subluxation between L3-4 and anterior subluxation of L4-5 that is more than 2mm (Figure 3a), which is an indication for fusion to extend to L3 even though she does not have spinal stenosis at L3-4. Fusion was extended to sacrum as L5-S1 level had symptomatic stenosis (Fig. 3a). A TLIF procedure was added at L5-S1 level to improve foraminal height as well as to improve fusion rate. Satisfactory tricortical purchase was obtained in the sacrum and hence iliac fixation was deferred.

Figure 3 and 4

Case 2: (Fig. 5 and 6) Focal decompression with full curve correction using a long construct
A 74-year man presented with significant neurogenic claudication in both legs and severe back pain that has been unresponsive to conservative measures. The patient did not have any focal neurological deficit. Standing radiographs revealed 52º left lumbar curve with a fractional curve of 17º (Fig. 5a). There was a severe coronal imbalance (+8cm). Lateral standing radiographs showed positive sagittal imbalance (SVA +7cm), lumbar lordosis of -17º, and pelvic incidence of 59º. There was some amount of compensatory pelvic retroversion as indicated by a high pelvic tilt (PT 29º) (Fig. 5b). The goal of surgery was to achieve neural decompression as well as to restore global and regional balance (ideal postoperative alignment should have PT of <25º, PI-LL= ±10º and SVA <5cm). Surgery involved laminectomy and decompression of neural structures from L3 to S1 and posterior instrumented fusion from T10 to Pelvis (Fig. 6a). The flexibility and supine films showed 30% correction and posterior Ponté osteotomies were performed to release the deformity. The stable vertebra was T11 on preoperative radiographs and hence fusion was extended to T10, which is relatively stable segment due to its connection to the rib cage. There was no hyperkyphosis and hence fusion was not extended to the upper thoracic spine. As the fusion construct was long, additional iliac fixation was added to protect the S1 screw and improve the chances of achieving a successful lumbosacral fusion. Postoperative standing radiographs show a good restoration of coronal and sagittal balance. The lumbar lordosis is restored to -49º. Pelvic incidence minus lumbar lordosis is 11 degrees and there is improvement in pelvic tilt to 22º. SVA improved from +7cm to +1cm (Fig. 6).

Figure 5 and 6


The treatment of adult spinal deformity, surgical decision making and selection of fusion levels remains a complex and controversial process. Surgery in this population is risky and fraught with complications. Over the last few decades, our knowledge regarding these deformities has taken a quantum leap. However, there is still a lot of ground to cover. Therapeutic guidelines and classification system will evolve as researchers continue to search for answers.


1. Schwab F, Dubey A, Gamez L, Fegoun El AB, Hwang K, Pagala M, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine 2005;30:1082–5.
2. Aebi M. The adult scoliosis. Eur Spine J 2005;14:925–48.
3. Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 2010;28:E1.
4. Vedantam R, Lenke LG, Bridwell KH, Linville DL, Blanke K. The effect of variation in arm position on sagittal spinal alignment. Spine 2000;25:2204–9.
5. Glassman SD, Bridwell KH, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine 2005;30:2024–9.
6. Lafage VC, Schwab F, Patel A, Hawkinson N, Farcy J-P. Pelvic Tilt and Truncal Inclination. Spine 2009;34:E599–E606.
7. Blondel B, Wickman AM, Apazidis A, Lafage VC, Schwab F, Bendo JA. Selection of fusion levels in adults with spinal deformity: an update. Spine J 2013. doi:10.1016/j.spinee.2012.11.046.
8. Schwab F, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D, et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine 2012;37:1077–82. doi:10.1097/BRS.0b013e31823e15e2.
9. Cho K-J, Suk S-I, Park S-R, Kim J-H, Kim S-S, Lee T-J, et al. Short fusion versus long fusion for degenerative lumbar scoliosis. Eur Spine J 2008;17:650–6. doi:10.1007/s00586-008-0615-z.
10. Transfeldt EE, Topp R, Mehbod A, Winter RB. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine 2010;35:1872–5. doi:10.1097/BRS.0b013e3181ce63a2.
11. Hansraj KK, Cammisa FP, O’Leary PF, Crockett HC, Fras CI, Cohen MS, et al. Decompressive surgery for typical lumbar spinal stenosis. Clin Orthop Relat Res 2001:10–7.
12. Daubs MD, Lenke LG, Bridwell KH, Cheh G, Kim YJ, Stobbs G. Decompression alone versus decompression with limited fusion for treatment of degenerative lumbar scoliosis in the elderly patient. Evidence-Based Spine-Care Journal 2012;3:27–32.
13. Blondel B, Schwab F, Ungar B, Smith JS, Bridwell KH, Glassman SD, et al. Impact of magnitude and percentage of global sagittal plane correction on health-related quality of life at 2-years follow-up. Neurosurgery 2012;71:341–8–discussion348.
14. Akbar M, Terran J, Ames CP, Lafage VC, Schwab F. Use of surgimap spine in sagittal plane analysis, osteotomy planning, and correction calculation. Neurosurg Clin N Am 2013;24:163–72.
15. Kuklo TR. Principles for selecting fusion levels in adult spinal deformity with particular attention to lumbar curves and double major curves. Spine 2006;31:S132–8.
16. Kim YJ, Bridwell KH, Lenke LG, Rhim S, Kim Y-W. Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine 2007;32:2653–61.
17. Cho K-J, Suk S-I, Park S-R, Kim J-H, Jung J-H. Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 2013;22:394–401.
18. Polly DW, Hamill CL, Bridwell KH. Debate: to fuse or not to fuse to the sacrum, the fate of the L5-S1 disc. Spine 2006;31:S179–84. doi:10.1097/01.brs.0000234761.87368.ee.
19. Edwards CC, Bridwell KH, Patel A, Rinella AS, Jung Kim Y, Berra ABA, et al. Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc. Spine 2003;28:2122–31.
20. Eck KR, Bridwell KH, Ungacta FF, Riew KD, Lapp MA, Lenke LG, et al. Complications and results of long adult deformity fusions down to l4, l5, and the sacrum. Spine 2001;26:E182–92.
21. Edwards CC, Bridwell KH, Patel A, Rinella AS, Berra A, Lenke LG. Long adult deformity fusions to L5 and the sacrum. A matched cohort analysis. Spine 2004;29:1996–2005.
22. Bridwell KH. Selection of instrumentation and fusion levels for scoliosis: where to start and where to stop. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 2004;1:1–8.
23. Harimaya K, Mishiro T, Lenke LG, Bridwell KH, Koester LA, Sides BA. Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs. Spine 2011;36:1701–10.
24. Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine 2006;31:303–8.
25. Tumialán LM, Mummaneni PV. Long-segment spinal fixation using pelvic screws. Neurosurgery 2008;63:183–90.
26. Shen FH, Mason JR, Shimer AL, Arlet VM. Pelvic fixation for adult scoliosis. Eur Spine J 2012;22:265–75.
27. Graham RB, Sugrue PA, Koski TR. Adult Degenerative Scoliosis. Clin Spine Surg. 2016 Apr;29(3):95-107.

How to Cite this Article: Chaudhary K, Unnikrishnan R Management strategies and selection of fusion levels in adult spinal deformities.. International Journal of Spine Apr – June 2016;2(1):25-30 .


(Abstract)      (Full Text HTML)      (Download PDF)

Complications Encountered in Surgical Management Adult Spinal Deformities- Prevention and Management- A Retrospective Study in 193 Patients

Volume 1 | Issue 1 | Apr – June 2016 | Page 21-24|Hitesh N Modi[1], Bharat R Dave[1].

Authors :Hitesh N Modi[1], Bharat R Dave[1]

[1] Department of Spine Surgery, Zydus Hospital, Thaltej, Ahmedabad, GUJ and # Stavya Spine Hospital and Research Institute, Ellisbridge, Ahmedabad, GUJ.

Address of Correspondence
Dr. Hitesh N. Modi, Department of Spine Surgery, Zydus Hospital, SG highway, Thaltej, Ahmedabad, GUJ, INDIA. Email: modispine@gmail.com


Background: Adult spinal deformity surgery is often associated with increased number of postoperative complications. Purpose of study was to elaborate encountered complications and possible ways to prevent and avoid such complications during surgery.
Methods: This was a retrospective analytical study in 193 patients with adult spinal deformity operated between 2010 and 2014 with decompression and multilevel pedicle screw fixation. Average age of patients was 64.5 years with minimum follow-up of 12 months. Clinical results were evaluated by excellent-good, fair and poor results on regular follow-up. Complications were elaborated in detail with possible causes and ways to prevent or avoid such complications to occur in future.
Results: There were 133 (69%) patients with excellent or good results while 35 (18%) patients with fair and 25 (13%) patients with poor results. There was 24.8% (n=48 out of 193) complication rate was found in the study. There were 20, 10, 6, 5, 3, 2, 1 and1 patients had persistent symptoms, respiratory difficulty, proximal junction kyphosis, dural puncture, deaths, wound infection, foot drop and renal failure, respectively. Reason for such complications were discussed in detail and precautions implemented in future surgeries.
Conclusion: There are higher postoperative complications rates noted in adult spinal deformity surgeries. Most common complications were proximal junctional kyphosis, respiratory difficulty and persistent symptoms postoperatively. Proper preoperative preparation and precautions to avoid such complications are necessary before surgical decision.
Key Words: Adult spinal deformity, surgical correction, postoperative complications, preventive measures.

Surgeries, in earlier phase, were developed primarily to address and treat injuries or traumas causing death if not treated. Later on, as advances in surgeries progressed, it was focused to improve quality of life. Major advances in surgeries in recent era focused on overcome obstacles of bleeding, infection and pain as well as improved quality of life and earliest return to work without any disability [1]. Therefore surgical indications are found to be an elective application, including the complex conditions such as spinal deformity that typically affect quality of life rather than being an immediate threat to life. Adult spinal deformity is a significant problem for many patients affecting their quality of life, in particularly, the elderly people. India has around 100 million elderly at present and the number is expected to increase to 323 million, constituting 20 per cent of the total population, by 2050,” the report jointly brought out by United Nations Population Fund (UNFPA) and Help Age International said. Similarly in US also the number of elderly patients has been projected to increase to 19.6% from current 12.4% by the year 2030 [2]. Spinal deformity is a major morbidity in elderly population, with pain and balance problems associated with spinal deformity often representing a significant obstacle to mobility in this age group [3]. Nonsurgical management for adult or degenerative spinal deformity is likely underreported. While it is hypothesized that a majority of spinal deformity patients are treated non operatively by their primary physicians, and increasing number of patients are opting for surgery now days [4]. Adult deformity surgery in older patients is becoming an increasingly common and requested procedure. Average life expectancy is rising with an increased expectation for extended quality of life. However, despite improved technical capabilities, complications remain a common occurrence and a significant concern in adult deformity surgery. There are many literatures published showing favorable results with adult spinal deformity surgeries; however, actual prevalence of complications varies widely [5-9]. Several reports have reported a complication rate of greater than 40% in the literature. A meta-analysis published by Yadla et al, who reviewed 3299 patients, found a 41.2% complication rate [10]. In another multicenter retrospective series of 306 primary lumbar adult or degenerative scoliosis patients older than 50, Charosky et al have shown an overall complication rate of 39% [11]. Daubs et al, in their series of 46 complex adult deformity patients aged 60 years or older, presented a complication rate of 37% [12]. In patients older than 70, Lonergan et al reported 95% of patients experiencing a complication of some type [13]. It is also important to note that variety of complications reported in literature varies in terms of minor or major complication. The purpose of this article was to identify commonly associated complications encountered during adult or degenerative scoliosis surgery, to identify and elaborate the risk factors and methods to overcome and avoid such complications. In addition we aimed at literature review of such complications to educate about it to our patients prior to surgery.

Material and Methods
This is a retrospective analytical study of 193 patients operated for degenerative or adult spinal deformity between 2010 and 2014. Average age of patients was 64.5 (SD=10.5) years (Table 1).


All patients were operated by both the authors. The indications of surgery were primarily chronic mechanical low back pain, radicular symptoms, lumbar stenosis and degenerative scoliosis. All patients were explained about possible outcome with extent of surgery as well as longer recovery time than the routine. Additionally all patients were put on calcium supplementation medications prior to the surgery. All patients were operated with pedicle screw fixation and posterolateral fusion along with decompression of affected lumbar spine and correction of spinal deformity to achieve sagittal balance. All surgeries were performed with open surgical technique with wide subperisteal exposure of all operative levels till the tips of transverse processes which was followed by free-hand pedicle screw instrumentation and attempting curve correction by facetectomy with rod derogation maneuver. Decompression laminectomy with or without discectomies were performed at the only affected levels with bilateral foramina decompression. Pedicure subtraction osteotomy was performed in only indicated patients where there was gross sagittal imbalance with kyphotic deformity noted. Postoperative follow-up was done at 6weeks, 3, 6, 12 months and yearly thereafter. There was follow-up of patients apart from protocol also if there is any complication or urgent assistance needed. Results were analyzed using relief in symptoms and improvement in quality of life as well as VAS score for pain. Results were divided in to excellent and good results that had postoperative recovery in their symptoms more than 80% and 60-80%, respectively. If patient had recovery in symptoms by 40-60% and less than 40%, there were categorized in to fair and poor results accordingly. Perioperative and postoperative complications were specifically recorded and studied in detail for this study. Complications that were recorded from operative period to three months postoperative period were included in perioperative complications [14]. Complications seen after three months were included in postoperative complications. Revisions after complications were also studied separately to identify the cause.

Results and Complications
Average follow-up was 24.1 months (SD= 9.1) with minimum follow-up 12 months. There were 28 patients having at least one level listless, 69 patients with two or less level severe stenosis, and rest 96 patients having problems at more than two levels along with degenerative scoliosis (Table 1).


There were 5 patients with associated dorsolumbar stenosis (tendom stenosis), one with cervical myelopathy, one with intra-dural tumor, and eight with associated compression fractures and three with discitis apart from main pathology of stenosis or instability. All pathologies were addressed and operated along with correction of degenerative scoliosis and decompression of stenotic part or stabilization of instability. Evaluation of our results at the final follow-up shows that there were 133 (69%) patients with excellent or good results while 35 (18%) patients with fair and 25 (13%) patients with poor results (Table 2).


Evaluating our complications (Table 2), there were three (who were included in poor results) deaths (1.5%); out of them one was due to pulmonary embolism and rest two were due to postoperative cardiac events. There was one patient from fair results who needed hemodialysis for acute renal shut down during perioperative period which recovered after 4 weeks with 21 cycles of hemodialysis. Six (3.1%) patients were having adjacent level degeneration or implant loosening causing myelopathy symptoms that required revision surgery (Fig 1-2).

Figure 1 and 2

On further evaluating them, all of them were having severe osteoporosis of bone marrow density for wrist and hip scan. All of them were kept of Teriperatide injections for at least one year and after that they did not have any further squeals. One patient had postoperative foot drop which recovered partially over a period of three months as implant positioning were found adequate on postoperative CT scan. This patient had having severely stenotic preoprerative canal size, and therefore, reason for foot drop was mainly due to handling of roots. There were five (2.6%) dural punctures during surgery which were repaired uneventfully. There were only two (1%) patients with postoperative wound infections; one with superficial and one with deep infections. Both were healed after debridement and appropriate antibiotics. Both patients were having positive urine culture due to prolonged catheterization postoperatively. There were 10 (5.2%) patients with postoperative oxygen saturation stays below 90% mainly due to pain and obesity that decreased vital capacity. They were treated with nasal oxygen masks and active spirometry exercise without any further complications. There were 20 patients (10.4%) with persistent back pain and tingling or numbness in legs that affected their daily life infrequently. However, on further evaluating their MRI or CT scans there was no causative factors found out. They have been treated with medications, physiotherapy and reassurance. All patients were mobilized during the hospital stay with the help of physiotherapists after 24-48 hours of surgery as postoperative back pain was controlled. All patients were give training by physiotherapists for postural changes, mobilization, back strengthening exercises, toilet training and avoidance to bending forward and sitting on floor.

Advances in pre-operative optimization, operative techniques and perioperative management have made surgical intervention a reasonable alternative for an increasing number of patients. Multiple investigators have reported substantial benefit of surgery with respect to pain, self-image, function, and ability to perform physical activities [10,15]. These benefits have been demonstrated despite the complexity of spinal realignment procedures and a substantial perioperative complication rate. There is a large body of evidence demonstrating positive mid- to long-term outcomes following surgical intervention for adult spinal deformity [16]. Yadla et al [10] found that operative intervention for adult spinal deformity is associated with improvement in both radiographic and clinical outcomes at a minimum 2-year follow-up. Similarly we have also found in our study that there was significant improvement in clinical as well as radiological parameters in our patient groups which has proven the benefits of surgery. In our study we have found overall 24.8% complications which is almost similar to the rate published in literature [1,12,13,17,18]. Postoperative deterioration in pulmonary functions in form of decrease in FEV1 is a major concern causing increased respiratory efforts and decreased oxygen saturation. There is an inevitable natural decline in pulmonary function with ageing, which may be more pronounced in patients with untreated spinal deformity [19]. Lehman et al. [20] demonstrated significant decline in all measures of pulmonary function (5-6% decline compared with predicted age-related decline) following deformity surgery with a clinically significant decline (a decline of >10% inFEV1) in pulmonary function in 27% of the patients of their series of 164 patients operated for adult spinal deformity. However, they did not evaluate immediate postoperative FEV1. In our series we have found decreased oxygen saturation and increased respiratory efforts postoperatively mainly due to obesity and post-operative pain as well as use of opioid analgesics which might cause respiratory depression. We therefore, give 30 degree prope-up position with nasal oxygen and encouragement of spirometry exercise once patient is able to follow the commands soon after surgery. With maintaining this protocol none of our patients had any long-term respiratory infections or difficulty. Additionally to start with preoperative spirometry exercise is also welcome to avoid and treat such conditions postoperatively. Proximal junctional kyphosis (PJK) or degeneration with implant loosening is also a known and well described complication in literature. In recent review article by Lau et al [17] suggested that the reported incidence of PJK ranged widely, from 5% to 46% in patients undergoing spinal instrumentation and fusion for adult spinal deformity. It is reported that 66% of PJK occurs within 3 months and 80% within 18 months after surgery. The reported revision rates due to PJK range from 13% to 55%. In our case series we have found over all 3.1% of proximal level problems and out of which we did revision surgery for five patients. One patient did not want to go ahead with revision surgery eventually developed spastic paraplegia. While other five patients who underwent revision surgery eventually improved without any further sequel. Additionally we have started Teriperatide injections to all of them to develop bone mass as their BMD suggested of having osteroporosis. Later on we have followed a protocol of starting Teriperatide injection (explained before surgery) postoperatively and maintaining that we had not found significant complications related with PJK [21,22]. Additionally we also explained our patients to avoid sitting of floor and bending forward to prevent PJK. In another review article by Soroceanu et al [23] included 245 patients to identify implant related complications after adult spinal deformity surgery. They found out 31.7% patients have had some sort of implant related complications and52.6% of those patients required reoperation. Rod breakage accounted for 47% of the implant-related complications, and proximal junctional kyphosis accounted for 54.5% of radiographical complications. In our series although we found out PJK, we did not find any patients have had complications such as rod breakage or mal-positioning of implants that needs revision. In another recent article by Sandquist et al. [24] suggested that their unique technique of multilevel segmental screw technique (MLSS) where a longer length pedicle screws was inserted from pedicle to upward direction crossing at least one or two segments to achieve stronger hold in one or two more vertebral levels; and thus decreasing chances of PJK in their series. However, we have not used this technique in any of our patients. There were other un-expected complications were also noted in our patient series such as acute renal shut down in one patient requiring hemodialysis. That patient was having hypertension as well as diabetes with renal compromise. Probable cause for ARF was identified as prolonged hypotension postoperatively has caused decreased renal perfusion resulting in to renal shut down. Therefore, we usually follow having blood pressure of minimum 100mm of Hg during surgery with constant watch on urine output. Postoperatively as well keeping Foley catheter in situ until patient starts walking and mobilizing to toilet would keep eye on volume and color of urine. If we feel color of urine is darker than what is expected, it would be always better to investigate for blood urea and creatinine level along with input output chart to correct immediately. There was one patient with acute pulmonary embolism postoperatively. Patient had long travel 24 hours before surgery with history of diabetes and previous heart disease. We then thereafter follow a protocol not to operate patients who have had long travel before 48 hours. We also investigate in form of venous Doppler study and postoperatively we also use DVT stockings to prevent such incidences unless patient starts walking independently postoperatively. We agree that this is a retrospective review study in patients with adult spinal deformity with primarily aimed at treating primary factors such as stenosis or instability along with correction of deformity. Minimum follow-up being only 12 months is also less if we wants to study all possible complications after such major surgery. However, large numbers of patient in our series is sufficient to explain and possible precautions to manage such patients postoperatively. Additionally our preoperative and postoperative precautionary steps in form of spirometry exercise, mobilization and anti DVT protocols, implementation of anti osteoporosis medications and avoidance as well as modification of life style might have prevented certain complications described in the literature. In spite of all shortcomings in the study, we think this would guide further to researchers and surgeons to keep complication rates lower after adult spinal deformity surgery.


1. Smith JS KM, Crawford A, Shaffrey CI. Outcomes, expectations and complication overview for the surgical treatment of adult and paediatric spinal deformity. Spine deformity preview 2012:4-14.
2. Federal interagency forum on aging-related statistics. Older American update: Key indicator of wellness. (<http://www.agingstats.gov/agingstatsdotnet/Main_site/Data/Data_2006.aspx>) 2006; [Accessed August 8, 2011 ].
3. Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976) 2009;34:2186-90.
4. Glassman SD, Berven S, Kostuik J, Dimar JR, Horton WC, Bridwell K. Nonsurgical resource utilization in adult spinal deformity. Spine (Phila Pa 1976) 2006;31:941-7.
5. Simmons ED, Jr., Kowalski JM, Simmons EH. The results of surgical treatment for adult scoliosis. Spine (Phila Pa 1976) 1993;18:718-24.
6. Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. Spine (Phila Pa 1976) 1993;18:1463-70.
7. Bradford DS, Tay BK, Hu SS. Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976) 1999;24:2617-29.
8. Baron EM, Albert TJ. Medical complications of surgical treatment of adult spinal deformity and how to avoid them. Spine (Phila Pa 1976) 2006;31:S106-18.
9. Burneikiene S, Nelson EL, Mason A, Rajpal S, Serxner B, Villavicencio AT. Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis. Surg Neurol Int;3:25.
10. Yadla S, Maltenfort MG, Ratliff JK, Harrop JS. Adult scoliosis surgery outcomes: a systematic review. Neurosurg Focus;28:E3.
11. Charosky S, Guigui P, Blamoutier A, Roussouly P, Chopin D. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976);37:693-700.
12. Daubs MD, Lenke LG, Cheh G, Stobbs G, Bridwell KH. Adult spinal deformity surgery: complications and outcomes in patients over age 60. Spine (Phila Pa 1976) 2007;32:2238-44.
13. Lonergan T, Place H, Taylor P. Acute Complications Following Adult Spinal Deformity Surgery in Patients Aged 70 Years and Older. J Spinal Disord Tech.
14. Modi HN, Suh SW, Hong JY, Cho JW, Park JH, Yang JH. Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation. Eur Spine J;19:384-93.
15. Smith JS, Shaffrey CI, Glassman SD, Berven SH, Schwab FJ, Hamill CL, Horton WC, Ondra SL, Sansur CA, Bridwell KH. Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine (Phila Pa 1976);36:817-24.
16. Paulus MC, Kalantar SB, Radcliff K. Cost and value of spinal deformity surgery. Spine (Phila Pa 1976);39:388-93.
17. Lau D, Clark AJ, Scheer JK, Daubs MD, Coe JD, Paonessa KJ, LaGrone MO, Kasten MD, Amaral RA, Trobisch PD, Lee JH, Fabris-Monterumici D, Anand N, Cree AK, Hart RA, Hey LA, Ames CP. Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976);39:2093-102.
18. Shapiro GS, Taira G, Boachie-Adjei O. Results of surgical treatment of adult idiopathic scoliosis with low back pain and spinal stenosis: a study of long-term clinical radiographic outcomes. Spine (Phila Pa 1976) 2003;28:358-63.
19. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am 1981;63:702-12.
20. Lehman RA, Jr., Kang DG, Lenke LG, Stallbaumer JJ, Sides BA. Pulmonary function following adult spinal deformity surgery: minimum two-year follow-up. J Bone Joint Surg Am;97:32-9.
21. Ohtori S, Inoue G, Orita S, Yamauchi K, Eguchi Y, Ochiai N, Kishida S, Kuniyoshi K, Aoki Y, Nakamura J, Ishikawa T, Miyagi M, Kamoda H, Suzuki M, Kubota G, Sakuma Y, Oikawa Y, Inage K, Sainoh T, Takaso M, Toyone T, Takahashi K. Comparison of teriparatide and bisphosphonate treatment to reduce pedicle screw loosening after lumbar spinal fusion surgery in postmenopausal women with osteoporosis from a bone quality perspective. Spine (Phila Pa 1976);38:E487-92.
22. Park JH, Kang KC, Shin DE, Koh YG, Son JS, Kim BH. Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture. Osteoporos Int;25:613-8.
23. Soroceanu A, Diebo BG, Burton D, Smith JS, Deviren V, Shaffrey C, Kim HJ, Mundis G, Ames C, Errico T, Bess S, Hostin R, Hart R, Schwab F, Lafage V. Radiographical and Implant-Related Complications in Adult Spinal Deformity Surgery: Incidence, Patient Risk Factors, and Impact on Health-Related Quality of Life. Spine (Phila Pa 1976);40:1414-21.
24. Sandquist L, Carr D, Tong D, Gonda R, Soo TM. Preventing proximal junctional failure in long segmental instrumented cases of adult degenerative scoliosis using a multilevel stabilization screw technique. Surg Neurol Int;6:112.

How to Cite this Article: Modi H, Dave BR. Complications encountered in surgical management adult spinal deformities- Prevention and management- a retrospective study in 193 patients. International Journal of Spine Apr – June 2016;1(1):21-24 .


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Osteoporosis And its Effect on Progression of Adult Spinal Deformities

Volume 1 | Issue 1 |Apr – June 2016 | Page 15-20|H S Chhabra[1], PK Kartik Yelamarthy[1].

Authors :H S Chhabra[1], PK Kartik Yelamarthy[1]

[1] Indian Spinal Injuries Centre, Sector C, Vasant Kunj,
New Delhi, India.

Address of Correspondence
Dr. H S Chhabra
Indian Spinal Injuries Centre, Sector C, Vasant Kunj, New Delhi, India.
Email Id:-dryelamarthykarthik@gmail.com


Adult spinal deformity may occur as the result of a number of conditions and patients may present with a heterogeneous group of symptoms. These include deformities in all 3 planes (coronal, sagital and axial) i.e scoliosis, kyphosis and rotational deformities. Clinical presentation varies and differs from pediatric deformities in that patients present more often with axial back pain and neurogenic claudication rather than a cosmetic deformity. Indications for treatment include pain, neurogenic symptoms, and progressive deformity. Larger deviations in the anterior, posterior or lateral plane will require greater energy use to maintain a standing position. Finally, progression outside of the “stable cone of economy” results in a loss of postural control and the need for external supports. The aim of this article is to analyze the role of osteoporosis in the progression of adult spinal deformity .We conducted a review of literature from Medline and searched for articles related to adult spinal deformities and osteoporosis. Osteoporosis along with progressive and asymmetric degeneration of the disc and facet joints has a role in progression of these deformities. Osteoporosis may also impact surgical options and can significantly impact the operative plan.
Keywords: Adult spinal deformity, osteoporosis, disc degeneration, deformity progression.

Spinal deformity is defined as a curvature in the spine where the alignment is outside of defined normal limits. Adult spinal deformity is one of the most challenging spinal disorders and by definition describes a complex spectrum of spinal deformities that present in adulthood including adult scoliosis, sagittal and coronal imbalance, and iatrogenic deformity, with or without spinal stenosis [1].Adult spinal deformity may occur as a result of a number of conditions, each of which ultimately lead to an imbalance of the structural support of the spinal column. Abnormal curvature may occur in the sagittal plane (kyphosis, lordosis) or in the coronal plane (scoliosis) causing imbalance in both planes . The magnitude of the curvature of the spine is measured using Cobb angle measurements. Axial plane deformity is measured by degrees of rotation from the frontal or sagittal plane [2]. Clinical presentation of adult spinal deformity varies greatly from minimal or no symptoms to severe pain with disability [3]. A majority of patients remain asymptomatic with radiographic findings alone. However, when patients begin to complain of symptoms, these may vary from mild back pain without radiculopathy to severe back pain with neurogenic claudication, radiculopathy, and walking intolerance.4 A complete patient assessment requires not only appropriate imaging studies but a complete history and physical exam. An adult deformity classification has been established by Schwab et al and applies radiographic parameters of disability[5]. As presented in Table 1. The presented adult deformity classification has a significant impact on surgical rates and operative strategy (approach, fusion to sacrum, and use of osteotomies). Through continued investigation, further refinement of the classification and formation of effective treatment algorithms are certain to emerge to guide the care of adults suffering from spinal deformity [5].

Scoliosis: A scoliosis is diagnosed in adult patients when it occurs or becomes relevant after skeletal maturity with a Cobb angle of more than 10 degrees in the frontal plain film [6,7].

Type 1: Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine
Type 2: Progressive idiopathic scoliosis in adult life of the thoracic, thoracolumbar, and/or lumbar spine
Type 3: Secondary degenerative scoliosis.
(a) Scoliosis following idiopathic or other forms of scoliosis or occurring in the context of a pelvic obliquity due to a leg length discrepancy, hip pathology or a lumbosacral transitional anomaly, mostly located in the thoracolumbar, lumbar or lumbosacral spine .
(b) Scoliosis secondary to metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures

Clinically, the most prominent groups are secondary (type 3) and primary (type 1)degenerative adult scoliosis. In elderly patients, all the three forms may be aggravated by osteoporosis [8,9,10].

Sagittal Plane Deformity: Age-related postural hyperkyphosis is an exaggerated anterior curvature of the thoracic spine, sometimes referred to as Dowager’s hump or gibbous deformity. This condition impairs mobility [22] and increases the risk of falls [23] and fractures [24]. Several types of postural deformities exist according to the number, severity, and location of vertebral fractures(upper or middle thoracic, thoracolumbar, or lumbar).Satoh et al. classified osteoporotic postural deformities into the following five groups based on changes of the physiological thoracic and lumbar curvature:[11]
1) normal posture without apparent change in spinal curve;
2) round back with increased thoracic kyphosis and normal lumbar lordosis;
3) hollow round back with increased thoracic kyphosis and lumbar lordosis;
4) whole kyphosis with extensive kyphosis from thoracic to lumbar spine; and
5) lower acute kyphosis with localized lumbar kyphosis with straight thoracic spine

Iatrogenic Spinal Deformity
Iatrogenic spinal deformities can cause either sagittal or coronal imbalance. They consist of flat back syndrome, post-laminectomy kyphosis and proximal junctional kyphosis(PJK).With the development of posterior segmental stabilization, the rates of flat back syndrome decreased [12,13,14,15,16]. A pathology known as junctional kyphosis also commonly calls for the use of instrumentation above the level of fusion in the thoraco-lumbar or cervico-thoracal vertebrae . Fusions that end at the level of the 7th and 8th thoracic vertebrae are known as the apex of thoracic kyphosis and may lead to junctional kyphosis. Post-laminectomy kyphosis is mostly seen after multi-level laminectomy procedures, especially in the cervical region and in cases of facetectomies with facet capsule destruction [17]. After cervical laminectomies in pediatric patients with incomplete bone development, post-laminectomy kyphosis is seen more commonly than in adult patients [17,18]. The rate of post-laminectomy kyphosis may become much greater in the population of pediatric patients with malignant intramedullary pathologies following radiotherapy treatment [17,19].

Natural History

Adult Scoliosis:
Idiopathic curves:(type 2 curves)[20]:
Lumbar curves of more than 300 degrees with apical vertebral rotation of more than 30% progressed the most. Right sided lumbar curves tended to progress twice as much as left lumbar curves. Also, marked vertebral rotation combined with translational shift (lateral olisthesis) was associated with significant curve progression. The thoracolumbar curve pattern manifested the most pronounced amount of apical vertebral rotation. The incidence of translatory shifts increased with time. Combined curves tended to balance with age, although lumbar part tended to progress more than the thoracic counter part. Weinstein and Ponsetti noted greater progression in lumbar curve if L5 was not well seated over the sacrum and apical vertebral rotation was more than 33% [48].

De novo curves (type 1 curves)[20]:
Robin et al analysed 554 individuals longitudinally for 7 to 13 years (315 women and 239 men, age range 50 to 84 yrs). 179 had curves exceeding 100. Fifty five (10%) developed denovo scoliosis during this period. Left sided curves were common in women. Sex ratio (F:M) increased with curve size. Rotatory olisthesis was found in 34% of patients, most common at L3-4 and L4-5 levels. As per a prospective study by Korovessis et al [21], risk factors directly related to curve progression were lateral olisthesis at the apical vertebra, a high Harrington factor (Cobb angle divided by number of vertebrae included in the curve) and the disc index.

Sagittal Plane Deformity:
The natural history of hyperkyphosis is not firmly established. Hyperkyphosis may develop from either muscle weakness and degenerative disc disease, leading to vertebral fractures and worsening hyperkyphosis, or from initial vertebral fractures that precipitate its development

Cause And Progression Of Adult Deformity (scoliosis, sagittal deformity, iatrogenic deformity)

The clinical syndrome of spinal osteoporosis is characterized by the occurrence of non-traumaticvertebral fractures and a disproportionately large amount of loss of trabecular bone necessary for the maintenance of vertebral strength [25,26].
Significant correlations exist between the bone mineral content, the compressive strength of the vertebrae [27,27,29], vertebral fractures, hyperkyphosis, and back pain. What remains unresolved is the role played by decreased vertebral bone mineral content in the development and progression of scoliosis in the adult. Shands and Eisberg noted a higher incidence of scoliosis in persons over 60years of age. Later, Vanderpool et al [30] reported scoliosis in 6%of persons over 50 years, and 36%more in those with osteoporosis. Those authors noted that scoliosis can arise in the elderly and is etiologically related to the higher incidence of metabolic bone disease. In an epidemiological study of routine anteropostenor (AP) chest and recumbent roentgenograms of the lower thoracic and lumbar spine, Robin et a1 .concluded that there was no basis for assuming a causal relationship between scoliosis and osteoporosis .But several theories could explain the association between fractures and scoliosis. Fractures may cause scoliosis, or, conversely scoliosis may cause fractures. Alternatively, scoliosis and fractures may be manifestations of the same underlying condition so that they would be expected to occur together frequently. The posterior spinal elements, facet joints. and ligamentous structures are not disrupted in osteoporotic compression fractures and may provide a fixed axis for sagittal and coronal spinal deformities. Yet this explanation does not account for the rotatory component of the deformity seen in osteoporotic patients. Mechanical factors that increase the forces applied to a vertebra increase the likelihood of that vertebra mechanically failing. Theoretically, a collagen abnormality may be responsible for osteoporosis and so called idiopathic scoliosis. Thus, several independent lines of evidence support the finding of a high concordance between osteoporosis and scoliosis. Fractures in osteoporotic or scoliotic patients would result from routine loading of an inherently weak spinal connective tissue [31].

The asymmetric degeneration of the disc and/or the facet joints leads to an asymmetric loading of the spinal segment and consequently of a whole spinal area. This again leads to an asymmetric deformity. Such a deformity again triggers asymmetric degeneration and induces asymmetric loading, creating a vicious cycle and enhancing curve progression. The destruction of structural spinal elements like discs, facet joints, and joint capsules responsible for stability leads to uni- or multi-segmental, multi-directional instability and can manifest as spondylolisthesis or translational or rotary olisthesis. The biological reaction is the formation of osteophytes at facet joint and vertebral end plates contributing to increasing narrowing of the spinal canal with facetjoint and ligamentum flavum hypertrophy and calcification. Effective narrowing of the spinal canal caliber causes central and lateral recess spinal stenosis [32,33]. Instability and collapse of the disc height leads to foraminal stenosis, with radicular pain or neurogenic claudication-type pain.

The asymmetric loading, coupled with degeneration, triggers a vicious cycle enhancing curve progression. This is fueled by common metabolic bone disorders like osteoporosis especially in post-menopause female patients leading to further asymmetric deformation and collapse in the weakened osteoporotic vertebra with subsequent curve progression[34].

Table 1

Sagittal Plane Deformity:
Sagittal postural deformities begin with localized kyphosis due to either fracture or asymptomatic insidious collapse at the thoracic and/or thoracolumbar spine . This increased kyphosis (round back) can be readily compensated by increasing lumbar lordosis, resulting in the formation of the hollow round back [35]. Compensated upper thoracic lordosis for wedged vertebral fractures at the thoracolumbar junction results in lower acute kyphosis .If progressing round back cannot be compensated by lumbar lordosis, kyphosis extends down to the lumbar region, resulting in whole kyphosis. Therefore, whole kyphosis cannot be compensated by other spinal segments. Because lumbar kyphosis is thought to be related to weakness of the spinal extensors [36], whole kyphosis usually forces the patient to use a cane while standing and walking [35]. These uncompensated conditions seemed to contribute impairment of all the domain scores in the whole kyphosis group, especially in the activities of daily living domain score, resulting in a significant reduction in the total quality of life score compared with other postural deformities.

Iatrogenic Deformity:
Risk factors for PJK included age at operation, low bone mineral density, shorter fusion constructs, upper instrumented vertebrae below L2, and inadequate restoration of global sagittal balance. Osteopenia/osteoporosis has been established as a significant risk factor for proximal junctional kyphosis. Both symptomatic and asymptomatic compression fractures that kyphose the spine are not uncommon in the elderly. In addition, the elderly tend to have more kyphosis in their thoracic spine. For this reason, longer instrumented fusions that span the entire thoracic spine are often needed [37]

Implications of Deformity Progession:
In the domain of spinal surgery, it is useful to recall important concepts that can serve as a foundation to understanding and treating deformity. Optimal alignment of bone structures and joints is critical for the efficient function of the musculoskeletal system. Furthermore, a complex interaction of the neurologic system and muscular recruitment is necessary for ergonomic balance and deliberate displacement of the human body. Therefore, it is important to consider that ideal spinal alignment allows an individual to assume standing posture with minimal muscular energy expenditure. Physiologic curvatures of the spine in the sagittal plane, the straight spine in the coronal plane, balanced tension of the spinal ligaments, and activation of intrinsic anterior and posterior musculature should permit extended pain free erect position. This concept is reflected in the “Cone of Economy” principle conceptualized by Jean Dubousset [46] (Figure 1). Within the center of the cone, the individual may remain in an ergonomically favorable erect position. However, larger deviations in the anterior posterior
or lateral plane will require greater energy use to maintain a standing position. Finally, progression outside of the “stable cone” results in a loss of postural control and the need for external supports.

Figure 1 and 2

In the setting of adult spinal deformity (ASD), structural or iatrogenic modifications to spinal alignment should be considered . Spinal malalignment in ASD challenges balance mechanisms used for maintenance of an upright posture to achieve the basic human needs of preserving level visual gaze and retaining the head over the pelvis. Progressive severity in skeletal malalignment might result in greater recruitment in muscular effort and greater energy expenditure to maintain the erect posture as well as use of compensatory mechanisms. Spinal malalignment to the extremes of the “Cone of Economy” leads to extreme muscular demand, fatigue, and significant pain as well as disability. Once a spinal deformity has reached
the level of marked loss in function and quality of life, surgical intervention is often recommended and requested [46,47]

Influence of Osteoporosis on Management of Adult Deformity
The surgical treatment is complicated by the weak bone where implants are more difficult to be anchored and fixed, making the instrumented fusion prone to instrumentation-related complications. Trabecular bone is predominantly affected by osteoporosis, and because the pedicle screw has cortical contact limited to the pedicle isthmus, a “windshield wiper” mode of failure typically leads to screw loosening [38]. Therefore, fixation strategies for osteoporotic bone are targeted either toward taking advantage of the relatively stronger cortical bone [39] or toward augmenting the fixation of a pedicle screw within the existing trabecular bone [40]. It should be recognized, however, that when sclerosis is associated with degeneration in patients with adult scoliosis, the local bone mineral density may be significantly increased, limiting the local effects of the systemic osteoporosis. Various methods have been used for treatment of the osteoporotic patient, including sublaminar wires and pediculolaminar fixation [41], both of which take advantage of cortical bone composition of the posterior spinal lamina. In addition, techniques to improve the fixation of pedicle screws within osteoporotic trabecular bone have also been developed including polymethylmethacrylate cement augmentation of pedicle screws [42]. Calcium sulfate paste may also be used, which has the theoretical advantage of becoming replaced by bone over time 43. Other alternatives have been investigated, including conical screws, hydroxyapatite-coated screws, and expandable screws. There is no consensus on the optimal screw diameter, length, or shape for fixation in osteoporotic bone. It has been demonstrated that with high insertional torque, the screw-strength is improved [44]. This may be attained by undertapping (or not tapping) the screw trajectory. Larger-diameter screws may offer increased contact with the cortical bone of the pedicle and, thus, increase insertional torque. However, this may potentially increase the risk of pedicle fracture particularly in this population. Longer screw length also can increase screw pull-out strength, particularly when there is “bicortical” purchase with the distal end of the screw passing through the anterior vertebral cortex. However, bicortical purchase increases the possibility of injury to abdominal or vascular structures and therefore is usually limited to the sacral region. An additional strategy is to use multiple points of fixation with a numerous pedicle screw construct thus providing for the spread and distribution of contact forces. Care should be taken to preserve the supraspinous ligament, intraspinous ligament, and ligamentum flavum between the rostral fused level and the adjacent segment as well as throughout the construct where possible. This may possibly prevent the development of junctional deformity and instability because it serves as a segment of high posterior tension. With extension of the fusion to the sacrum, utilization of multiple and bicortical screw fixation in addition to consideration of anterior column support at L5–S1 and/or iliac fixation should be considered. Larger diameters and increased lengths to 70 or 80 mm improve iliac screw pull-out strength. This improved caudal fixation in deformity patients has been found to be persistent in patients with a minimum of 5 years of follow-up [45]. In summary, several of the central tenets of spinal reconstruction are particularly important in the adult deformity patient population with poor bone quality. Appropriate balance reduces junctional forces, which diminishes the risk of both instrumentation failure and adjacent vertebral fractures. The surgeon should thus endeavor to balance the rostral and caudal ends of the construct. In addition, a meticulous fusion procedure, augmented with appropriate bone graft or bone graft substitutes, is especially important. This will support the development of a rapid and solid fusion such that long-term spinal stability will be ensured, relieving the requirements put upon the reconstruction instrumentation and its relatively poor interface with the osteoporotic bone.

Figure 3 and 4


Adult spinal deformity may occur as a result of a number of
conditions, each of which ultimately lead to an imbalance of the
structural support of the spinal column. These deformities can
occur in all 3 planes. The asymmetric loading, coupled with
degeneration is fuelled by osteoporosis in the progression of
adult spinal deformities. Osteoporosis also plays a role in
deciding the instrumentation to be used in management of these deformities.


1. Birknes JK, White AP, Albert TJ, Shaffrey CI, Harrop JS. Adult degenerative scoliosis: a review. Neurosurgery 2008;63(3, Suppl): 94–103
2. Curr Rev Musculoskelet Med. 2011 Dec; 4(4): 159–167
3. Schwab F, Lafage V, Farcy JP, et al. Surgical rates and operative outcome analysis in thoracolumbar and lumbar major adult scoliosis: application of the new adult deformity classification. Spine 2007;32:2723–2730
4. Sengupta K. Adult spinal deformity. In: Rao RD, Smuck M, eds. Orthopaedic Knowledge Update: Spine, 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012:349–367
5. Schwab F, Lafage V, Farcy JP, Bridwell K, Glassman S, Ondra S, Lowe T, Shainline M. Surgical rates and operative outcome analysis in thoracolumbar and lumbar major adult scoliosis: application of the new adult deformity classification. Spine (Phila Pa 1976). 2007 Nov 15;32(24):2723-30.
6. Schwab F, el-Fegoun AB, Gamez L, Goodman H, Farcy JP. A lumbar classification of scoliosis in the adult patient: preliminary approach. Spine (Phila Pa 1976). 2005 Jul 15;30(14):1670-3.
7. Aebi M. The adult scoliosis. Eur Spine J. 2005 Dec;14(10):925-48
8. Grubb SA, Lipscomb HJ. Diagnostic findings in painful adult scoliosis. Spine (Phila Pa 1976). 1992 May;17(5):518-27.
9. Healey JH, Lane JM. Structural scoliosis in osteoporotic women. Clin Orthop Relat Res. 1985 May;(195):216-23
10. Velis KP, Healey JH, Schneider R. Osteoporosis in unstable adult scoliosis. Clin Orthop Relat Res. 1988 Dec;(237):132-41.
11. Satoh K, Kasama F, Itoi E, et al. Clinical features of spinal osteoporosis: spinal deformity and pertinent back pain. Contemp Orthop. 1988;16:23–30
12. Bridwell KH, Betz R, Capelli AM, Huss G, Harvey C. Sagittal plane analysis in idiopathic scoliosis patients treated with Cotrel-Dubousset instrumentation. Spine (Phila Pa 1976). 1990 Sep;15(9):921-6.
13. Lenke LG, Bridwell KH, Baldus C, Blanke K, Schoenecker PL. Ability of Cotrel-Dubousset instrumentation to preserve distal lumbar motion segments in adolescent idiopathic scoliosis. J Spinal Disord. 1993 Aug;6(4):339-50.
14. Lenke LG, Bridwell KH, Baldus C, Blanke K, Schoenecker PL. Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1992 Aug;74(7):1056-67
15. Takahashi S, Delécrin J, Passuti N. Changes in the unfused lumbar spine in patients with idiopathic scoliosis. A 5- to 9-year assessment after cotrel-dubousset instrumentation. Spine (Phila Pa 1976). 1997 Mar 1;22(5):517-23
16. Wiggins WC, Ondra SL, Shaffray CI. Management of flat-back syndrome. Neurological Focus 2003; 15(3): 1-9.
17. Deutsch H, Haid RW, Rodts GE, Mummaneni PV. Postlaminectomy cervical deformity. Neurosurg Focus 2003;15(3): E5
18. Katsumi Y, Honma T, Nakamura T: Analysis of cervical instability resulting from laminectomies for removal of spinal cord tumor. Spine 1989;14:1171–1176.
19. Yeh JS, Sgouros S, Walsh AR, Hockley AD. Spinal sagittal malalignment following surgery for primary intramedullary tumours in children. Pediatr Neurosurg. 2001 Dec;35(6):318-24
20. The Lumbar Spine edited by Harry N. Herkowitz, International Society for Study of the Lumbar Spine
21. Korovessis P, Piperos G, Sidiropoulos P, Dimas A. Adult idiopathic lumbar scoliosis. A formula for prediction of progression and review of the literature. Spine (Phila Pa 1976). 1994 Sep 1;19(17):1926-32.
22. Kado DM, Huang MH, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and poor
physical functional ability in older community-dwelling men and women: the Rancho Bernardo
study. J Gerontol A Biol Sci Med Sci 2005;60:633–637.
23. Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci 2007;62:652–657
24. Huang MH, Barrett-Connor E, Greendale GA, Kado DM. Hyperkyphotic posture and risk of future osteoporotic fractures: the Rancho Bernardo study. J Bone Miner Res 2006;21:419–423
25. Mazess RB. Measurement of skeletal status by noninvasive methods. Calcif Tissue Int. 1979 Oct 31;28(2):89-92.
26. Nordin BE. Clinical significance and pathogenesis of osteoporosis. Br Med J. 1971 Mar 13;1(5749):571-6.
27. Hansson T, Roos B. Microcalluses of the trabeculae in lumbar vertebrae and their relation to the bone mineral content. Spine (Phila Pa 1976). 1981 Jul-Aug;6(4):375-80..
28. Hansson T, Roos B, Nachemson A. The bone mineral content and ultimate compressive strength of lumbar vertebrae. Spine (Phila Pa 1976). 1980 Jan-Feb;5(1):46-55..
29. Hansson T, Roos B. The relation between bone mineral content, experimental compression fractures, and disc degeneration in lumbar vertebrae. Spine (Phila Pa 1976). 1981 Mar-Apr;6(2):147-53.
30. Vanderpool DW, James JI, Wynne-Davies R. Scoliosis in the elderly. J Bone Joint Surg Am. 1969 Apr;51(3):446-55
31. Healey JH, Lane JM. Structural scoliosis in osteoporotic women. Clin Orthop Relat Res. 1985 May;(195):216-23
32.Benner B, Ehni G. Degenerative lumbar scoliosis. Spine 1979; 4:548
33. Ploumis A, Transfledt EE, Denis F. Degenerative lumbar scoliosis associated with spinal stenosis. Spine J. 2007 Jul-Aug;7(4):428-36.
34. Kotwal S, Pumberger M, Hughes A, Girardi F. Degenerative scoliosis: a review. HSS J. 2011 Oct;7(3):257-64.
35. Satoh K, Kasama F, Itoi E et al. Clinical features of spinal osteoporosis: spinal deformity and pertinent back pain. Contemp Orthop 1988;(16):23–30
36. Takemitsu Y, Harada Y, Iwahara T, Miyamoto M, Miyatake Y. Lumbar degenerative kyphosis. Clinical, radiological and epidemiological studies. Spine (Phila Pa 1976). 1988 Nov;13(11):1317-26.
37. Lau D, Clark AJ, Scheer JK, Daubs MD, Coe JD, Paonessa KJ, LaGrone MO, Kasten MD, Amaral RA, Trobisch PD, Lee JH, Fabris-Monterumici D, Anand N, Cree AK, Hart RA, Hey LA, Ames CP; SRS Adult Spinal Deformity Committee. Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976). 2014 Dec 1;39(25):2093-102.
38. Law M, Tencer AF, Anderson PA. Caudo-cephalad loading of pedicle screws: mechanisms of loosening and methods of augmentation. Spine (Phila Pa 1976). 1993 Dec;18(16):2438-43.
39. Coe JD, Warden KE, Herzig MA, McAfee PC. Influence of bone mineral density on the fixation of thoracolumbar implants. A comparative study of transpedicular screws, laminar hooks, and spinous process wires. Spine (Phila Pa 1976). 1990 Sep;15(9):902-7.
40. Tan JS, Kwon BK, Dvorak MF, Fisher CG, Oxland TR. Pedicle screw motion in the osteoporotic spine after augmentation with laminar hooks, sublaminar wires, or calcium phosphate cement: a comparative analysis. Spine (Phila Pa 1976). 2004 Aug 15;29(16):1723-30.
41. Hilibrand AS, Moore DC, Graziano GP. The role of pediculolaminar fixation in compromised pedicle bone. Spine (Phila Pa 1976). 1996 Feb 15;21(4):445-51..
42. Sarzier JS, Evans AJ, Cahill DW. Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines. J Neurosurg. 2002 Apr;96(3 Suppl):309-12
43. Rohmiller MT, Schwalm D, Glattes RC, Elalayli TG, Spengler DM. Evaluation of calcium sulfate paste for augmentation of lumbar pedicle screw pullout strength. Spine J. 2002 Jul-Aug;2(4):255-60..

44. Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, Spencer CW. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res. 1986 Feb;(203):99-112..
45. Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976). 2006 Feb 1;31(3):303-8.
46. Dubousset J. Three-dimensional analysis of the scoliotic deformity. In: Weinstein SL, ed. Pediatric Spine: Principles and Practice. New York, NY: Raven Press; 1994
47. Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2224-31.
48. Weinstein SL, Ponseti IV: Curve progression in idiopathic scoliosis. J Bone Joint Surg Am. 1983, 65: 447-455

How to Cite this Article:  Chhabra HS, Yelamarthy PKK. Osteoporosis and its effect on progression of Adult Spinal deformities. International Journal of Spine Apr – June 2016;1(1):15-20 .


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Golden Era for Spine Advancements

Volume 1 | Issue 1 | Apr – June 2016 | Page 1-2|Ketan Khurjekar[1], Shailesh Hadgaonkar[1], Ashok Shyam[1,2]

Authors :Ketan Khurjekar[1], Shailesh Hadgaonkar[1], Ashok Shyam[1],[2]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence
IJS Editorial Officie
A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [W]
Maharashtra, India.
Email: editor.ijspine@gmail.com

Spine surgery is at the cross roads and spine healthcare in India is growing steadily. Indian medical system is golden combination of all medical systems across the globe. Today India is the second most populous country in the world and leader in healthcare provider. Spine surgery practices in tier 1 and tier 2 cities in India are at par with the world standard and surgeons from these cities are making spine surgery feasible and affordable in smaller towns and cities as well. Most of the Spine Surgeons have undergone vigorous spine surgery training in India and in Western countries. They have mastered the skill sets and are now delivering it back home in India. The volume of cases every health care professional is tackling is sharpening their skills and making them master on global platform. Structured training which every Spine Surgeon has gone through and seen across the globe has been accepted and also imparted in India. Organisations like Association of Spine Surgeons of India, National Board of Examinations and AO Spine India have started long term spine surgery training programme to impart knowledge to young aspiring surgeons. Strong leadership from these organisation has helped develop comradeship among spine surgeons and sharing of knowledge. Gaining knowledge and imparting it to eligible candidate, creates more knowledge. That is exactly happening in India. Most spine surgeons are following good practices, and are applying their expertise for betterment of the society. It is not enough just to have skills and man power, we need good operation rooms, and we need best of anaesthetist and intensivist to enhance the result of challenging spine surgery cases. More important, to sustain good results of any surgery, we need good quality armamentaria, high definition microscopic Systems, advanced instrumentation systems and well equipped operation rooms. Today we have most of these things available at centres where spine patients are routinely operated. Even the smaller Hospital units are well equipped with most of the above necessary things. For the instance, a scoliosis surgery done in New York or a Cervical pedicle screw surgery done in Japan is been carried out exactly in the same manner with the same precision, with similar armamentaria and with the same implants in India. This scenario is giving confidence to the society; it is helping people to accept Spine surgery. We believe this is one of the most important change where spine surgery is rapidly gaining acceptance amongst all strate of society. Spine surgery was considered as taboo for many years and today situation is changing fast. With expert surgeons, good infrastructure the spine surgeries have become safer and has invoked confidence from our patients. We are standing at the Golden Era of Spine Advancement in the Country. Why our setups are unique, special and also appreciated internationally? Because we are delivering World class health care at affordable price. We have seen steady growth of spine surgery but we need to do more to achieve excellence. We have to reach out to masses with same precision and equal efficacy. Task is daunting but not impossible. We neither have National Health system, nor do we have majority population having individual Insurance protection. In India around 10 % population has personal Insurance coverage. But every person has access to affordable world class medical system. Affluent class and higher middle class person from the society gets a spine surgery done from a corporate set up, lower middle class personal has easy access to nursing home and weaker section of the society goes to Government, municipal or public hospital. The health care professional working in a municipal hospital is of a meritorious background. The surgical skills imparted are of high standards. No one is deprived of his own right. In NHS, one may have to wait for more than six months to get the surgery done while in some other country the Surgery may not be possible without sufficient insurance protection. We are doing the service to society without diluting precision in the surgery. Excellence in medical practices can be achieved by expertise in that particular field, structured training of that specialty, advanced technology based armamentaria and research. We have achieved first three things satisfactorily but research is yet to be in motion. To do so, we need to inculcate the habit of maintaining our registry, we need to establish data keeping system and preserve the record of every surgery to learn from these experiences. The next generation will stand tall on the shoulder of its predecessors. We are on the right path, but a lot of distance is yet to be covered. Starting this, International Spine Journal aims at establishing strong roots of research. ‘Training and Research by Publishing’ is the main goal of the Journal. It will be an exercise to inculcate the habit of maintaining records. Training through research will be a motto for next decade. Documentation and Research, the fourth dimension of achieving medical excellence is paramount to achieve Safe Spine Surgery.

Dr. Ketan Khurjekar | Dr. Shailesh Hadgaonkar | Dr. Ashok Shyam

How to Cite this Article: Khurjekar K, Hadgaonkar S, Shyam A. Golden Era for Spine Advancements. International Journal of Spine Apr – June 2016;1(1):1-2 .


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Decision Making in Surgical Management of Degenerative Scoliosis

Volume 1 | Issue 1 | Apr – June 2016 | Page 10-14|Kunal Shah[1], Manish Kothari[1], Abhay Nene[1].

Authors :Kunal Shah[1], Manish Kothari[1], Abhay Nene[1]

[1] Department of Spine Surgery, Wockhardt Hospital and Medical Research Centre Agripada, Dr Anand Rao Nair Road
Mumbai Central, Mumbai. India – 400008.

Address of Correspondence
Dr. Abhay Nene
Department of Spine Surgery, Wockhardt Hospital and Medical Research Centre Agripada, Dr Anand Rao Nair Road,Mumbai Central, Mumbai. India – 400008
Email: abhaynene@yahoo.com


Surgical management of degenerative scoliosis has no established guidelines. The options available range from decompression alone, decompression with limited fusion or decompression with global fusion. Major factors influencing the type of surgery are symptomatology, spinal deformity, and general condition of patient and local factors in spine. Selection of surgical option and also outcome of surgical options depend on radiological and clinical factors. Radiological factors affecting surgery are magnitude of curve, apical vertebra rotation or subluxation and sagittal imbalance. Clinical factors affecting outcome of surgery are amount of back pain compared to leg pain, patient willing to take risk of fusion surgery later, patient understanding of residual back pain, complications of surgery and general condition to cope with the surgery. Therefore a balance between benefits of surgery and complications should be evaluated before choosing the type of surgery. In this article we share our experience with literature review in management of such complex situations.
Keywords: Adult degenrative scoliosis, decision making, management.

The type of surgery to be performed in degenerative scoliosis is always been controversial. There is no general consensus on one type of surgery better than other. The goal of surgery is to relieve the leg pain/back pain and correct sagittal/coronal imbalance. The surgery can range from decompression alone, decompression with limited fusion or decompression with global fusion. The decision of type of surgery should be taken with all considerations based on clinical profile of patients, amount of restriction daily activities, general condition of patient and expectation out of surgery, so as to choose the most suitable surgery under given circumstances. Major factors influencing the type of surgery are symptomatology, spinal deformity, and general condition of patient and local factors in spine.

1) Symptomatology
Clinical presentation is variable ranging from no symptoms or minimal symptoms to severe pain associated with disability. Mainly the symptoms are deformity, back pain and radiculopathy/claudication or weakness. Back pain is the most common symptom of presentation in degenerative scoliosis. Pain is directly related to amount of degeneration of intervertebral disc and facet joints. Pain is not directly related to the size of curve, but associated with sagittal imbalance [1, 2]. Leg pain and neurological claudication are primary symptoms of degenerative scoliosis. Foraminal stenosis is most common in concave side of the curve caused due to facetal hypertrophy and lateral translation of vertebral body. Convex side symptoms are rare and can be attributed to stretching of nerve. Sagittal imbalance causes muscle fatigue and subsequent back pain [3, 4]. Surgery is usually indicated in cases with severe radiculopathy or neurodeficit, affecting daily activities. Therefore all kind of surgery requires decompression to free the nerve either foraminal or central. Decompression alone has a fear of curve progression, worsening of vertebral body subluxation and persistent back pain [4]. Therefore addition of fusion surgery is advocated. However either local or global fusion is associated with morbidity especially in elderly patients [5]

2) Patient profile
Degenerative scoliosis is usually seen in elderly .Therefore general condition of patient in view of medical complications and co morbidities should be evaluated [4]. In frail elderly, operative time, amount of blood loss and extent of surgery should be considered to prevent perioperative morbidity. Minimal short time surgery is preferred in elderly frail patients.

3) Spinal deformity
In degenerative scoliosis, the curves are stiffer and require extensive surgery for correction as compared to adolescent scoliosis. Surgery for coronal plane deformity is indicated in unbalanced curves, progression of curve and large curves and rarely for cosmetic reasons [6]. However associated sagittal plane deformity can also cause symptoms of back pain and leg pain. Inability to restore sagittal balance leads to poor surgical outcome. Sagittal decompensation due to inadequate correction can be associated with higher pelvic incidence and pelvic tilt. Therefore lumbar lordosis should be corrected in proportion to the pelvic incidence. Inadequate correction of lumbar lordosis is also seen with loss of correction of disc spaces after posterior instrumentation. Anterior column reconstruction prevents loss of correction of disc spaces and gives better restoration of lumbar lordosis [7]. Therefore the type of surgery should also aim at restoring sagittal balance.

4) Local factors
Osteoporosis is one of the major concerns in treatment of degenerative scoliosis. It is usually associated with loss of fixation and pseudoarthrosis. Use of cement with screws or additional anterior column support to augment posterior fixation helps in preventing complications [4].We believe that taking above factors in consideration and aim of restoration of coronal and sagittal imbalance with minimal surgical intervention is the key to successful outcome in degenerative scoliosis. The real answered question arises is that should the surgery be decompression alone or it should be combined with fusion (local or global) and levels of fusion

Decompression alone
Decompression alone is indicated when primary complaints is radiculopathy/claudication with minimal or no back pain. Radiographically these are typically smaller curves without any instability. This approach gives dramatic pain relief in leg symptoms and improves walking distance [8]. The concerns with decompression alone are possibility of further progression of deformity or iatrogenic spinal instability [9]. It serves as a good option in elderly patients who cannot tolerate fusion surgery. Liu et al [10] in a study of 112 patients operated for degenerative scoliosis concluded that the patients operated with decompression alone gives satisfactory results and type of surgery should be based on patient’s age, general and economic factors, severity of deformity and other coexisting lumbar degenerative disorders. Hosogane et al [11] concluded that average curve progression was 3.4 degree in mean follow up of 2.8 years in patients operated with decompression alone. In only 21.6 % patients the curve progressed to more than 5 degrees. This progression was similar to curve progression in natural history of degenerative scoliosis. Curve progression after decompression surgery alone could not be predicted in preoperative period. They concluded that fusion surgery is not always advocated to prevent curve progression when the main symptoms of patients are due to nerve compression. Matsumura et al [12] studied results of microscopic bilateral decompression via a unilateral approach (MBDU) in degenerative lumbar scoliosis. They concluded that MBDU reduces postoperative segmental instability and achieve satisfactory clinical outcome, convex approach gives good visibility of neural structures and facet joint. Figure 1 shows a 67 year old lady with multiple co morbidities and osteoporosis, complaining of severe neurogenic claudication with no back pain. Radiograph showed degenerative scoliosis and a stable spondylolisthesis at L45 level. MRI was suggestive of significant L45 level compression. Her daily functional demands were less .She was operated with decompression at L4-5 level.

Figure 1

Decompression with limited fusion
Decompression with limited fusion is usually indicated in cases having single level instability or to prevent iatrogenic instability in the decompressed area. It is a good option in moderate curve with segmental instability. The concerns with limited fusion are adjacent segment disease which is commonly seen. If the fusion stops at the apex of deformity, then deformity might increase [5].
Figure 2 shows a case of 60 year old lady with significant back pain and localized nerve symptoms; radiograph showed a degenerative scoliosis with Cobb angle of 35 degrees and L4-5 instability with significant localized compression on MRI. She was operated with decompression with L4-5 fusion.

Figure 2

Decompression with global fusion
Decompression with global fusion is indicated when there is large curve and apical vertebra subluxation. The symptoms are disabling with significant back pain with leg pain. Posterior instrumentation gives good coronal correction but poor sagittal correction. Adequate restoration of sagittal balance requires anterior column support or vertebral osteotomy procedures [5, 13, 14].

Anterior alone surgery has advantages of enhanced fusion rates due to large surface area, better global curve correction and preservation of posterior musculature. However it is associated with high complication rates and morbidity especially in elderly. Combined anterior and posterior surgery is associated with better curve correction, higher fusion rates and better restoration of sagittal and coronal imbalance. However it is associated with increase in operative time, more blood loss and morbidity [15, 16,17].
Crandall and Revella [18] compared results of anterior interbody fusion versus posterior interbody fusion in treatment of degenerative scoliosis. They found no significant difference in clinical outcomes or complication rates.
Surgical correction of sagittal deformity is described using various osteotomy procedures like Smith –Peterson osteotomy, pedicle subtraction osteotomy and vertebral column resection. When deciding on the osteotomies, advantages should be weighed against the morbidity [8].
Cho et al [5] in a comparative study between short fusion versus long fusion in degenerative scoliosis concluded that long fusion gave better correction of scoliotic curve, coronal imbalance and rotational subluxation of apical vertebra as compared to short fusion. However sagittal balance and lumbar lordosis was inadequately corrected.
Figure 3 shows a 58 year old lady with significant back pain and leg pain, radiographs shows degenerative scoliosis with Cobb angle of 45 degrees, L4 vertebra (apical vertebra) subluxated with sagittal instability. She was operated with decompression at L45 with posterior global correction.
Levels of fusion
General guidelines for fusion should be followed to prevent complications [19,20].
1) These are the fusion should not stop at apex or at spondylolisthesis.
2) Junction kyphosis should be included
3) Retrolisthesis or anterolisthesis should be included and
4) Laterally translated vertebra or level of rotatoy subluxation should be included in fixation.
5) Usually the upper instrumented vertebra should be the most horizontal vertebra.
Proximal extent
The proximal extent of fusion is debatable and there is controversy whether the fusion should stop at lumbar level, T11/T12 or T10.
Fusion stopping at L1 can cause adjacent segment disease due to high stresses in proximal junction area. Therefore it is recommended to fuse above. Some authors suggest that it does not prevent adjacent segment disease (ASD) because ASD is a part of degenerative process [21]. Extension of fusion upto T10 as against stopping at T11/T12 is favored since T10 is more stable due to true rib attachment. Fusion upto T10 is associated with high perioperative complications due to extensive surgery. Some authors suggest that T11/T12 level is acceptable if the upper instrumented vertebra is above upper end vertebra [22].
Distal extent
Fusion upto sacrum is recommended when L5-S1 segment has some pre-existing pathology. Controversy arises when L5-S1 segment is healthy [23]. Advantages of fusion upto sacrum are better correction of sagittal imbalance and no chances of subsequent degeneration. Disadvantages of fusion upto sacrum are it’s a relatively morbid procedure and high chances of pseudoarthrosis which can require subsequent extension of fusion upto ilium. Advantages of fusion upto L5 are that it is relatively less morbid and normal L5-S1 segment is spared. Disadvantage is that L5-S1 segment is prone to degeneration (ASD) [24,25].

Figure 3

Early complications include pulmonary embolism, respiratory distress, epidural hematoma, transient neurologic deficit and infection. Risk factors for perioperative complications increase with longer operative time, excess blood loss, associated medical comorbidities and medications taken prior to surgery (ecosprin or clopidogrel).This can be prevented by optimizing patient well and shorter duration surgery with less blood loss [26,27]. Cho et al concluded that longer fusion group is associated higher rate of early complications [5].
1) Adjacent segment disease
ASD presents as adjacent level stenosis and proximal junctional kyphosis. ASD can be caused due to facet joint violation, inadequate restoration of sagittal balance, stopping at junctional level (L1 or L5) and not including adjacent spondylolisthesis or apex in fixation[28,29]. ASD is common in short fusion group. ASD can be prevented by restoring sagittal balance and including high stress segments into fixation.
2) Pseudoarthrosis
Pseudoarthrosis is usually occurs at T12-L1 and L5-S1 junction. Risk factors for pseudoarthrosis are inadequate restoration of lumbar lordosis, osteoporosis and thoracolumbar kyphosis more than 20 degrees [30]. It can be prevented by including junctional area in fixation, restoring lumbar lordosis, creating larger surface area for fusion by anterior column grafting and use of artificial bone grafts or allografts.
3) Instrumentation failure
Instrumentation failure usually presents as screw loosening and screw pullout either at proximal or distal end. Risk factors for instrumentation failure are inadequate fixation, osteoporosis and inadequate sagittal balance restoration especially in long fixations [31,32]. This can be prevented by extending fusion upto ilium or using cemented screws.


Management of degenerative scoliosis is one of the most challenging issues in spine care and requires complex decision making in terms of treatment options and outcomes. Type of surgery depends on various radiological factors and clinical factors. Radiological factors affecting surgery are magnitude of curve, apical vertebra rotation or subluxation and sagittal imbalance. Clinical factors affecting surgery are amount of back pain compared to leg pain, patient willing to take risk of fusion surgery later, patient understanding of residual back pain, complications of surgery and general condition to cope with the surgery. Therefore a balance between benefits of surgery and complications should be evaluated before choosing the type of surgery.


1. Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005;30:2024-9.
2. Palmisani M, Dema E, Cervellati S. Surgical treatment of adult degenerative scoliosis. Eur Spine J. 2013 Nov;22 Suppl 6:S829-33.
3. Simmons ED. Surgical treatment of patients with lumbar spinal stenosis with associated scoliosis. Clin Orthop Relat Res 2001;(384):45-53.
4. Cho KJ, Kim YT, Shin SH, Suk SI. Surgical treatment of adult degenerative scoliosis. Asian Spine J. 2014 Jun;8(3):371-81.
5. Cho KJ, Suk SI, Park SR, Kim JH, Kim SS, Lee TJ, Lee JJ, Lee JM. Short fusion versus long fusion for degenerative lumbar scoliosis. Eur Spine J. 2008 May;17(5):650-6.
6. Palmisani M, Dema E, Cervellati S. Surgical treatment of adult degenerative scoliosis. European Spine Journal. 2013;22(Suppl 6):829-833.
7. Cho KJ, Kim KT, Kim WJ, et al. Pedicle subtraction osteotomy in elderly patients with degenerative sagittal imbalance. Spine (Phila Pa 1976) 2013;38:E1561-6.
8. Youssef JA, Orndorff DO, Patty CA, Scott MA, Price HL, Hamlin LF, Williams TL, Uribe JS, Deviren V. Current status of adult spinal deformity. Global Spine J. 2013 Mar;3(1):51-62.
9. Vaccaro AR, Ball ST. Indications for instrumentation in degenerative lumbar spinal disorders. Orthopedics 2000;23:260-71.
10. Liu W, Chen XS, Jia LS, Song DW. The clinical features and surgical treatment of degenerative lumbar scoliosis: a review of 112 patients. Orthop Surg. 2009 Aug;1(3):176-83.
11. Hosogane N, Watanabe K, Kono H, Saito M, Toyama Y, Matsumoto M. Curve progression after decompression surgery in patients with mild degenerative scoliosis. J Neurosurg Spine. 2013 Apr;18(4):321-6.
12. Matsumura A, Namikawa T, Terai H, Tsujio T, Suzuki A, Dozono S, Yasuda H, Nakamura H. The influence of approach side on facet preservation in microscopic bilateral decompression via a unilateral approach for degenerative lumbar scoliosis. Clinical article. J Neurosurg Spine. 2010 Dec;13(6):758-65.
13. Bradford DS, Tribus CB. Vertebral column resection for the treatment of rigid coronal decompensation. Spine (Phila Pa 1976) 1997;22:1590-9.
14. Daffner SD, Vaccaro AR. Adult degenerative lumbar scoliosis. Am J Orthop (Belle Mead NJ) 2003;32:77- 82.
15. Than KD,Wang AC, Rahman SU, et al. Complication avoidance and management in anterior lumbar interbody fusion. Neurosurg Focus 2011;31:E6
16. Mundis GM, Akbarnia BA, Phillips FM. Adult deformity correction through minimally invasive lateral approach techniques. Spine 2010;35(26, Suppl):S312–S321
17. Jarrett CD, Heller JG, Tsai L. Anterior exposure of the lumbar spine with and without an “access surgeon”: morbidity analysis of 265 consecutive cases. J Spinal Disord Tech 2009;22:559–564
18. Crandall DG, Revella J. Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes. Spine 2009;34:2126–2133
19. Aebi M. The adult scoliosis. Eur Spine J 2005;14:925- 48.
20. Gupta MC. Degenerative scoliosis. Options for surgical management. Orthop Clin North Am 2003;34:269-79.
21. Shufflebarger H, Suk SI, Mardjetko S. Debate: determining the upper instrumented vertebra in the management of adult degenerative scoliosis: stopping at T10 versus L1. Spine (Phila Pa 1976) 2006;31(19 Suppl):S185-94.
22. Cho KJ, Suk SI, Park SR, Kim JH, Jung JH. Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 2013;22:394-401.
23. Polly DW Jr, Hamill CL, Bridwell KH. Debate: to fuse or not to fuse to the sacrum, the fate of the L5-S1 disc. Spine (Phila Pa 1976) 2006;31(19 Suppl): S179-84.
24. Edwards CC 2nd, Bridwell KH, Patel A, et al. Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc. Spine (Phila Pa 1976) 2003; 28:2122-31.
25. Cho KJ, Suk SI, Park SR, et al. Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis. Eur Spine J 2009;18:531-7.
26. Gupta MC. Degenerative scoliosis. Options for surgical management. Orthop Clin North Am 2003;34:269–279
27. Mok JM, Cloyd JM, Bradford DS, et al. Reoperation after primary fusion for adult spinal deformity: rate, reason, and timing. Spine 2009;34:832–839
28. Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G. Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis. Spine (Phila Pa 1976) 2006;31:2359-66.
29. Cho KJ, Suk SI, Park SR, et al. Risk factors of sagittal decompensation after long posterior instrumentation and fusion for degenerative lumbar scoliosis. Spine (Phila Pa 1976) 2010;35:1595-601.
30. Kim YJ, Bridwell KH, Lenke LG, Cho KJ, Edwards CC 2nd, Rinella AS. Pseudarthrosis in adult spinal deformity following multisegmental instrumentationand arthrodesis. J Bone Joint Surg Am 2006;88:721- 8.
31. Emami A, Deviren V, Berven S, Smith JA, Hu SS, Bradford DS. Outcome and complications of long fusions to the sacrum in adult spine deformity: luquegalveston, combined iliac and sacral screws, and sacral fixation. Spine (Phila Pa 1976) 2002;27:776-86.
32. Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 2006;31:303-8.

How to Cite this Article:Shah K, Kothari M, Nene A. Decision Making in Surgical Management of Degenerative Scoliosis. International Journal of Spine Apr – June 2016;1(1):10-14 .


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Factors Influencing Sagittal Malalignment and its Effect on Clinical Implications in Adult Spinal Deformity

Volume 1 | Issue 1 | Apr – June 2016 | Page 5-9|Bassel G Diebo[1], Jeffrey J Varghese BS[1], Frank J Schwab[1].

Authors :Bassel G Diebo[1], Jeffrey J Varghese BS[1], Frank J Schwab[1].

[1]Department Spine Service, Hospital for Special Surgery, New York, NY, United States

Address of Correspondence
Dr. Bassel G. Diebo
Spine Service, Hospital for Special Surgery, New York, NY, United States.
Email: dr.basseldiebo@gmail.com


Respect for the sagittal plane has been broadly published and accessible for all surgeons. Yet, suboptimal outcomes and revision cases remain highly prevalent. In this article, the authors present a case of a pleasant lady who started with a simple lumbar decompression surgery for spinal stenosis that deteriorated and then failed revision surgery, ultimately presenting with a severely disabling flatback and a remarkable spinal deformity. Her case highlights the importance of sagittal alignment in degenerative patients. Failure to appreciate the sagittal plane has a direct impact on patient reported outcomes and serious debilitating iatrogenic deformity. The maintenance of spinal alignment is not a deformity specific exercise; therefore, all surgeons should consider optimizing the sagittal plane to reduce the incidence of not only iatrogenic deformity but the burden of any spinal pathology.
Keywords: Sagittal Malalignment, adult spinal deformity, degenerative scoliosis.

The close relationship between sagittal spinal alignment and patient reported outcomes is widely recognized [1–8]. As a result, sagittal radiographic parameters, such as the SRS-Schwab modifiers (Sagittal vertical axis: SVA, pelvic incidence minus lumber lordosis: PI-LL, and pelvic tilt: PT), have been investigated and validated in multiple spinal pathologies and patient groups. However, to date, iatrogenic causes remain an important contributor to the prevalence of adult spinal deformity. One reason for the increased incidence of iatrogenic deformity relates to the lack of correction and/or preservation of sagittal alignment when addressing focal or regional degenerative conditions. In addition to decompression and stabilization, maintenance of lumbar lordosis is crucial in avoiding the creation of deformities such as flatback syndrome [9]. The importance of the sagittal plane was originally established based on multi-center databases of spinal deformity patients; however, recent studies on patients undergoing less invasive procedures for lumbar degenerative conditions unraveled the universality of this importance. In a literature review of the last two decades, Mehta et al concluded that the sagittal parameters play a central role in the treatment of isthmic spondylolysis, spondylolisthesis, and degenerative pathologies [10]. Masevnin and Kumar et al have both demonstrated that adjacent segment pathologies are more prevalent in patients who underwent surgical correction of degenerative conditions without correcting sagittal alignment [11,12]. Finally, hypo- and hyperlordosis have been reported as risk factors for disc height reduction and facet joints arthritis, respectively [13,14]. Respect for the sagittal plane has been broadly published and accessible for all surgeons. Yet, suboptimal outcomes and revision cases remain highly prevalent [15–19]. In this article, the authors present a case of a pleasant lady who started with a simple lumbar decompression surgery and a subsequent failed revision surgery. Following a short fusion of L3-L5, the patient presented herself to the spine clinic of the senior author with a disabling flatback, an inability to walk more than 1 block, and a remarkable adult spinal deformity.

Case presentation:
History of present illness and physical examination:
This is a 70-year old Caucasian female who recently presented to the senior author’s clinic with a long history of back pain and two previous surgeries. In 2011, she had lumbar laminectomies and decompressions (L3-L5) and in 2012 she ultimately underwent a L3 to L5 instrumented fusion. Her severe (8/10) pain returned in 2013, originating in her buttock region, and traveled inferiorly through the right leg to the foot. For two years, the patient was only able to walk one block before she had to pitch forward from significant back pain and need external support. She underwent several non-operative treatments including: epidural injections, physical therapy, acupuncture, massages, and multiple nerve blocks. She is on Tramadol three times a day and one Percocet 5/325 every night. The patient stood with both sagittal and coronal malalignments (Fig. 1), was unable to toe or heel walk, and had poor tandem gait. She demonstrated right distal extremity numbness and weaknesses of both the tibialis anterior and extensor hallucis longus, but was otherwise neurovascularly intact.

Figure 1: Pre-operative anterio-posterior and lateral radiographs

Figure 1: Pre-operative anterio-posterior and lateral radiographs

Radiographic imaging:
CT scan:T12-Sacrum axial imaging revealed a mild degenerative scoliosis of the upper lumbar spine with the apex between L2-L3. Cephalad to the L3-L5 fusion, the patient had facet arthroses, a disc bulge, and central canal stenoses at T12-L1 and L1-L2. At the fusion levels, the patient had multiple degenerative discs, facet arthroses, and neural foraminal narrowings. X-Ray analysis: The patient presented with a pelvic incidence of 57°, indicating a standard pelvic morphology from a spinal perspective. Sagittal alignment analysis revealed a severe adult spinal deformity classified by the SRS-Schwab: PI-LL mismatch of 34° (++), PT of 40° (++) and SVA of 86 mm (++). Thorough analysis of the lumbar spine demonstrated a caudal (L4-S1) lordosis of 24°, L3-L5 (fused segments) lordosis of 18° and, L1-L2 (unfused segments) kyphosis of 6° (Fig. 2). The thoracic spine did not exhibit any hypokyphotic compensation (TK = 45°). Coronal x-rays revealed a 22° coronal curve (L1-L3) and a 65 mm right coronal malalignment. The full radiographic analysis is reported in Fig. 3.

Figure 2: Pre-operative sagittal radiographic analysis

Figure 2: Pre-operative sagittal radiographic analysis

Figure 3: Pre-operative segmental analysis of lumbar lordosis

Figure 3: Pre-operative segmental analysis of lumbar lordosis

Surgical planning and technique:
After discussing the treatment options, benefits, and risks, with the patient for her severe sagittal plane deformity, the decision was made to extend the fusion to T3 with pelvic fixation. The surgical strategy included a L3 pedicle subtraction osteotomy (PSO) of 35° and a L5-S1 transpedicular lumbar interbody fusion (TLIF) for an expected 10° of lordotic correction. Using dedicated software (Surgimap, Nemaris Inc, New York, NY), the surgical plan was simulated to ensure proper post-operative alignment. Patient-specific custom rods were generated and forwarded to the manufacturer to be pre-bent, ensuring an accurate execution of the surgical plan. In the OR, the reconstruction required additional T3-L2 Smith-Peterson osteotomies to afford fusion and deformity correction. At the osteotomy site, a wide laminar foraminotomy from L2 to L4 was performed and two short rods were added between these levels (Four-Rod technique), offering adequate correction and closure. Fluoroscopy confirmed that the proper correction was achieved in both planes.
Post-operative follow-up:
The patient recovered without incident, and is not only satisfied but happy with her new posture. Radiographic analysis revealed an adequate lumbar lordosis, a PI-LL within 10 degrees, a global sagittal alignment (SVA) of 36 mm, and a pelvic tilt of 28°. These are classified as (0), (0) and (+) based on SRS-Schwab classification. The lumbar coronal curve was corrected to 8 degrees and the C7PL to 16 mm to the right. (Fig 4)

Figure 4: Post-operative anterio-posterior and lateral radiographs

Figure 4: Post-operative anterio-posterior and lateral radiographs

There is a growing body of evidence in the literature regarding the clinical implications of sagittal spinal alignment. Over the last decade, scientific conferences are increasingly dedicating significant amounts of time and effort to raising awareness and spreading the sagittal message. The teaching today is: optimize or preserve the sagittal alignment of the spine in all spectrums of operations, from ‘simple’ one-level fusions to complex multi-planar deformity surgeries. For the management of spinal pathologies, it is no longer acceptable to perform only neural decompressions for stenosis and only fusions for stabilizing the spine. The sagittal plane, specifically with respect to lumbar lordosis, should be optimally aligned, if not already. This recommendation is valid almost regardless of the spinal etiology. To guide spinal realignment in adult spinal deformity, the key sagittal modifiers (PT, PI-LL, and SVA), with their clinically relevant thresholds, are already cornerstones for surgical correction. These parameters are also being investigated in patients with degenerative disc diseases, spondylolisthesis (degenerative and isthmic), as well as spinal stenosis. Moving beyond deformity: sagittal alignment in degenerative diseases:
In degenerative spondylolisthesis (DS), it is now established that higher pelvic incidences result in higher sacral slopes and shear stresses at the lumbosacral junction, making it a predisposing factor for DS. Moreover, Jeon et al took this a step further to conclude that degenerative retrolisthesis exists in two types, both of which are driven by sagittal parameters; one primarily resulting from degeneration in patients with low pelvic incidences, and the other secondarily resulting from compensatory mechanisms in patients with anterolistheses and high pelvic incidences [20]. Ultimately, sagittal alignment influences two out of the three features included in the Labelle classification of spondylolisthesis [21]. With regards to surgical treatment, Feng et al showed that the restoration of pelvic tilt and lumbar lordosis played important roles in the surgical outcomes of DS [22]. In other degenerative diseases, Bae et al demonstrated that patients with an upper lumbar disc herniation have significantly different sagittal profiles than patients with a lower disc herniation. In their studies, pelvic incidence and lumbar lordosis were significantly factors in determining the level of disc herniation [23)]. Thus, treatment of these pathologies is increasingly considering the sagittal plane.

Sagittal alignment in spinal stenosis:
Patients with lumbar stenosis adopt a forward compensatory bending posture to relieve the symptoms of neural compression [25,26].This malalignment pattern may be confused with sagittal spinal deformity and a loss of lumbar lordosis. Thus, there has been a recent debate on whether a surgeon should address the stenosis by decompression+/-fusion alone or with spinal realignment as well. Recent data demonstrated that decompression alone does indeed improve the sagittal profile of spinal stenosis patients. Jeon et al investigated 40 lumbar stenosis patients and followed them up to two years. In their study, patients who underwent decompressions alone had improvements in SVA, from 39 mm at baseline to 23 mm at 2 year follow up [24]. Buckland et al, in unpublished data, showed that while anterior truncal malalignment was similar between deformity and degenerative patients, pelvic tilt appeared to be a unique compensatory mechanism of deformity patients. Recently, Fujii et al showed that decompressions can improve global alignment in stenotic patients when malalignment is induced by a compensatory reduction in lumbar lordosis [27]. However, they also noticed that without corrective surgery, stenosis patients with higher preoperative malalignments (PI-LL > 21.5 and SVA > 69 mm) had residual malalignments postoperatively. This malalignment has proven to negatively impact patients reported outcomes in another study by Hikata et al [28)] In general, there is rising consensus that lumbar stenosis patients with severe sagittal malalignment (SRS Schwab SVA ++) should be assessed for a concomitant sagittal deformity and ultimately be considered for corrective surgery.
While more research is needed to establish treatment guidelines for sagittal realignment of spinal stenosis patients, it is crucial to understand that the maintenance of sagittal alignment is a must. The patient in this article deteriorated from being a spinal stenosis patient undergoing a two-level fusion to a flatback patient requiring realignment with osteotomy. This iatrogenic deformity is challenging and is commonly seen in daily practice of deformity surgeons. Based on the PI-LL formula, our patient needed approximately 50° of L1-S1 lordosis, of which 65% (32°) should be in the extreme caudal lumbar segments [29)]. However, when looking at the L1-S1 lordosis of this patient, she only had 21°. More importantly, the previously fused caudal segments were constructed with only 18°, which is a clear loss of lordosis.

Sagittal alignment: How to improve, What is new and How to be more patient-specific?
To improve our understanding of the sagittal plane, the gap between researchers and clinicians must be bridged. Feedback from surgeons in daily practice is crucial to improve the current guidelines of sagittal realignment. The ultimate goal is a personalized treatment that addresses the patient’s age, pathology, function, expectations, and spino-pelvic morphology.
Lafage et al investigated the impact of age on the spino-pelvic alignment and provided updated thresholds of PT, PI-LL and SVA [30]. The new targets for the radiographic parameters provide more “patient-specific” alignment thresholds. Their data revealed that age should be considered when determining the ideal sagittal alignment for a given patient, with older patients requiring less rigorous alignment objectives (Table 1).

Table 1: Age-adjusted sagittal alignment thresholds.

Table 1: Age-adjusted sagittal alignment thresholds.

Moreover, patient-specific instrumentation is a recent advancement in spine surgery. Surgeons can now plan their surgery and choose or construct certain instrumentations based on their patient’s morphology and alignment targets. Using the existing knowledge on the optimal sagittal alignment, these customized implants might help preserve the sagittal plane in degenerative patients. There are several factors that need to be acknowledged to achieve or maintain adequate sagittal alignment of the spine. The pelvis is a key component that must be considered. The measurement of pelvic incidence (PI) and the calculation of the mismatch between PI and lumbar lordosis are crucial in assessing the deformity magnitude when its main driver is the loss of LL. Any mismatch > 10° is associated with worse patient reported outcomes. Every surgeon needs to ensure that the surgical intervention does not alter this harmony between the spine and the pelvis [1,4]. Moreover, analysis of the compensatory mechanisms recruited by each patient is mandatory. Pelvic tilt, thoracic hypokyphosis, and knee flexion [31] are common mechanisms that need to be considered and delineated from the main driver of deformity. The surgery needs to be planned with the help of dedicated software and the plan needs to be simulated to confirm that post-operative alignment is ideal [32,33]. Finally, patient expectations, comorbidities, and their soft tissue profile are highly important aspects to consider. These are being investigated for their impact on how we treat our spinal pathology patients.


This article, drawing support from cases and the plethora of literature available, highlights the importance of sagittal alignment in degenerative patients. Failure to appreciate the sagittal plane has a direct impact on patient reported outcomes and serious debilitating iatrogenic deformity. The maintenance of spinal alignment is not a deformity specific exercise; therefore, all surgeons should consider optimizing the sagittal plane to reduce the incidence of not only iatrogenic deformity but the burden of any spinal pathology.


1. Schwab F, Patel A, Ungar B, Farcy J, Lafage V. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976). 2010 Dec;35(25):2224–31.
2. Schwab FJ, Lafage V, Farcy J-P, Bridwell KH, Glassman SD, Ondra S, et al. Surgical rates and operative outcome analysis in thoracolumbar and lumbar major adult scoliosis: application of the new adult deformity classification. Spine (Phila Pa 1976) [Internet]. 2007 Nov 15;32(24):2723–30.
3. Youssef J a, Orndorff DO, Patty C a, Scott M a, Price HL, Hamlin LF, et al. Current Status of Adult Spinal Deformity. Glob spine J [Internet]. 2013 Mar;3(1):51–62.
4. Schwab FJ, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D, et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976) [Internet]. 2012 May 20 [cited 2013 Aug 12];37(12):1077–82.
5. Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, et al. The SRS-schwab adult spinal deformity classification: Assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery. 2013 Jul;73(4):559–68.
6. Sengupta DK. Re: Schwab F, Ungar B, Blondel B, et al. Scoliosis research society—Schwab adult spinal deformity classification–-a validation study. Spine 2012; 37:1077—82. Spine (Phila Pa 1976) [Internet]. 2012 Sep 15 [cited 2014 Mar 24];37(20):1790.
7. Smith JS, Klineberg E, Schwab F, Shaffrey CI, Moal B, Ames CP, et al. Change in Classification Grade by the SRS-Schwab Adult Spinal Deformity Classification Predicts Impact on Health-Related Quality of Life Measures: Prospective Analysis of Operative and Non-operative Treatment. Spine (Phila Pa 1976). 2013;38:1663–71.
8. Hallager DW, Hansen LV, Dragsted CR, Peytz N, Gehrchen M, Dahl B. A comprehensive analysis of the SRS-Schwab Adult Spinal Deformity Classification and confounding variables – a prospective, non-US cross-sectional study in 292 patients. Spine (Phila Pa 1976) [Internet]. 2015 Dec 9;
9. Farcy J-P, Schwab FJ. Management of flatback and related kyphotic decompensation syndromes. Spine (Phila Pa 1976) [Internet]. 1997 Oct;22(20):2452–7.
10. Mehta V a., Amin A, Omeis I, Gokaslan ZL, Gottfried ON. Implications of spinopelvic alignment for the spine surgeon. Neurosurgery [Internet]. 2011 Mar [cited 2014 Nov 18];70(3):707–21.
11. Masevnin S, Ptashnikov D, Michaylov D, Meng H, Smekalenkov O, Zaborovskii N. Risk factors for adjacent segment disease development after lumbar fusion. Asian Spine J [Internet]. 2015 Apr;9(2):239–44.
12. Kumar M, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J [Internet]. 2001 Aug 1 [cited 2014 Nov 18];10(4):314–9.
13. Inoue G, Takaso M, Miyagi M, Kamoda H, Ishikawa T, Nakazawa T, et al. Risk Factors for L5-S1 Disk Height Reduction after Lumbar Posterolateral Floating Fusion Surgery. J Spinal Disord Tech [Internet]. 2014;27(5):187–92.
14. Jentzsch T, Geiger J, König M a, Werner CML. Hyperlordosis Is Associated With Facet Joint Pathology At The Lower Lumbar Spine. J Spinal Disord Tech [Internet]. 2013;
16. Maier SP, Lafage V, Smith JS, Obeid I, Mundis GM, Klineberg EO, et al. Revision Surgery After Three-Column Osteotomy (3CO) in 335 Adult Spinal Deformity (ASD) Patients: Intercenter Variability and Risk Factors. Spine J [Internet]. 2013 Sep [cited 2013 Dec 5];13(9):S9–10.
17. Sansur C a, Reames DL, Smith JS, Hamilton DK, Berven SH, Broadstone P a, et al. Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis. J Neurosurg Spine [Internet]. 2010 Nov [cited 2014 Jun 10];13(5):589–93.
18. Diebo BG, Henry J, Lafage V, Berjano P. Sagittal deformities of the spine: factors influencing the outcomes and complications. Eur Spine J [Internet]. 2015 Jan [cited 2015 Mar 10];24 Suppl 1:3–15.
19. Diebo BG, Passias PG, Marascalchi BJ, Jalai CM, Worley NJ, Errico TJ, et al. Primary Versus Revision Surgery in the Setting of Adult Spinal Deformity: A Nationwide Study on 10,912 Patients. Spine (Phila Pa 1976) [Internet]. 2015;
20. Jeon CH, Park JU, Chung NS, Son KH, Lee YS, Kim JJ. Degenerative retrolisthesis: Is it a compensatory mechanism for sagittal imbalance? Bone Jt J. 2013;95 B(9):1244–9.
21. Labelle H, Mac-Thiong J-M, Roussouly P. Spino-pelvic sagittal balance of spondylolisthesis: a review and classification. Eur Spine J [Internet]. 2011 Sep [cited 2013 Oct 7];20 Suppl 5:641–6.
22. Feng Y, Chen L, Gu Y, Zhang Z-M, Yang H-L, Tang T-S. Influence of the posterior lumbar interbody fusion on the sagittal spino-pelvic parameters in isthmic L5-s1 spondylolisthesis. J Spinal Disord Tech [Internet]. Elsevier Inc; 2014;27(1):E20–5.
23. Bae J, Lee S-H, Shin S-H, Seo JS, Kim KH, Jang J-S. Radiological analysis of upper lumbar disc herniation and spinopelvic sagittal alignment. Eur Spine J [Internet]. 2016;
24. Jeon C-H, Lee H-D, Lee Y-S, Seo H-S, Chung N-S. Change in Sagittal Profiles After Decompressive Laminectomy in Patients With Lumbar Spinal Canal Stenosis. Spine (Phila Pa 1976) [Internet]. 2015;40(5):E279–85.
25. Lim JK, Kim SM. Comparison of Sagittal Spinopelvic Alignment between Lumbar Degenerative Spondylolisthesis and Degenerative Spinal Stenosis. J Korean Neurosurg Soc [Internet]. 2014 Jun;55(6):331–6.
26. Suzuki H, Endo K, Kobayashi H, Tanaka H, Yamamoto K. Total sagittal spinal alignment in patients with lumbar canal stenosis accompanied by intermittent claudication. Spine (Phila Pa 1976) [Internet]. 2010 Apr 20;35(9):E344–6.
27. Fujii K, Kawamura N, Ikegami M, Niitsuma G, Kunogi J. Radiological Improvements in Global Sagittal Alignment after Lumbar Decompression without Fusion. Spine (Phila Pa 1976) [Internet]. 2015;40:703–9.
28. Hikata T, Watanabe K, Fujita N, Iwanami A, Hosogane N, Ishii K, et al. Impact of sagittal spinopelvic alignment on clinical outcomes after decompression surgery for lumbar spinal canal stenosis without coronal imbalance. J Neurosurg Spine [Internet]. 2015;23(4):451–8.
29. Been E, Barash A, Marom A, Kramer P a. Vertebral bodies or discs: which contributes more to human-like lumbar lordosis? Clin Orthop Relat Res [Internet]. 2010 Jul [cited 2014 Sep 22];468(7):1822–9.
30. Lafage R, Schwab F, Challier V, Henry JK, Gum J, Smith J, et al. Defining Spino-Pelvic Alignment Thresholds: Should Operative Goals in Adult Spinal Deformity Surgery Account for Age? Spine (Phila Pa 1976) [Internet]. 2016 Jan;41(1):62–8.
31. Diebo BG, Ferrero E, Lafage R, Challier V, Liabaud B, Liu S, et al. Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine (Phila Pa 1976) [Internet]. 2015 Feb;40(9):642–9.
32. Akbar M, Terran J, Ames CP, Lafage V, Schwab FJ. Use of Surgimap Spine in Sagittal Plane Analysis, Osteotomy Planning, and Correction Calculation. Neurosurg Clin N Am [Internet]. 2013/04/09 ed. Elsevier Inc; 2013 Apr [cited 2013 Aug 12];24(2):163–72.
33. Lafage R, Ferrero E, Henry JK, Challier V, Diebo B, Liabaud B, et al. Validation of a new computer-assisted tool to measure spino-pelvic parameters. Spine J [Internet]. 2015 Sep 4;

How to Cite this Article:Diebo BG, Varghese JJ, Schwab FJ. Factors Influencing Sagittal Malalignment and its effect on Clinical Implications in Adult Spinal Deformity. International Journal of Spine Apr – June 2016;1(1):5-9.


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Post-operative Extensively Drug Resistant Mycobacterium Tuberculous Discitis

Volume 1 | Issue 1 | Apr – June 2016 | Page 47-49|Dhiraj Vithal Sonawane[1], Eknath Pawar[2], Ajay S Chandanwale[3],Ambarish A Mathesul[3], Abhishek Salunke[4], Swapnil M Keny[1].

Authors :Dhiraj Vithal Sonawane[1], Eknath Pawar[2], Ajay S Chandanwale[3],Ambarish A Mathesul[3], Abhishek Salunke[4], Swapnil M Keny[1]

[1] Department of Orthopaedics, Grant Medical college, & Gokuldas Tejpal Hospital, Mumbai
[2] Department Of Orthopaedics, Grant medical college, Mumbai.
[3] Sasoon Hospital & BJMC, Pune
[4] Gujarat Cancer Research Institute

Address of Correspondence
Dr. Dhiraj V. Sonawane
Grant Medical college, & Gokuldas
Tejpal Hospital, Mumbai
Email: dvsortho@gmail.com


Mycobacterium tuberculosis (MTB) as a cause of postoperative discitis is extremely rare. We report a first case of extensively drug resistant mycobacterium tuberculosis (XDR-TB) as cause of early postoperative discitis, confirmed on culture and sensitivity. XDR-TB is looming threat and remains a challenge in management .Even with present day available treatment options the prognosis remains poor. Reviewing the literature we discuss possible management in XDR TB discitis.

Post-operative discitis is an uncommon but devastating complication after invasive spinal procedure [1, 2]. The incidence of post procedural discitis ranges from 0.26 to 4% [2]. Most common organisms responsible are Staph. aureus and streptococcus species. Three cases of postoperative discitis due to mycobacterium tuberculosis are reported in English literature [3, 4, 5]. XDR TB by WHO global task force on XDR TB, is defined as TB which is resistant to isoniazid and rifampin, plus resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). XDR-TB & TDR-TB (totally drug resistant tuberculosis) continues to pose challenge to control program and treating physician [6, 7, 8, 11]). We report 1st case of XDR TB discitis and discuss possible therapeutic options.

Case report:
A 61 year old male, known case of diabetes and hypertension was operated with laminectomy and discectomy for L3-4 disc prolapse in December 2010 (Fig 1a, b).

Figure 1

Pre operatively patient had left ankle dorsiflexion MRC grade 3 and depressed left knee reflex. Neurological status remained same after surgery. Three weeks after surgery, patient developed seropurulent discharge through the operated wound. Erythema and induration was present on upper end of wound. Hematological investigation showed TLC- 17,000/ cmm, ESR- 48 mm at end of one hour and CRP 4 mg/dl. Pus culture of discharge grew Pseudomonas aeruginosa. Antibiotics were given according to sensitivity for a period of 4 months, but discharge through the wound continued. Plain radiographs 4 months after surgery showed destruction of L3-4 vertebral end plates with lumbar kyphosis (Fig. 2a). MRI demonstrated altered marrow signal in L3, 4, 5 vertebral bodies with epidural soft tissue causing compression of dural sac, suggesting L3-4 infective spondylodiscitis (Fig 2b). Surgical debridement was done. Intra operative sample from disc space revealed acid fast bacilli on staining. On retrospective evaluation, patient had no past or family history of tuberculosis (TB) or TB contact. X-ray chest was normal. Patient was started on Isoniazid (H) 300mg, Rifampicin (R) 450mg, Ethambutol (E) 600mg & Pyrazinamide (Z) 750mg daily. BACTEC report at 4 weeks showed mycobacterium tuberculosis resistant to all the 1st and most of 2nd line anti tuberculosis drugs (ATT) including ciprofloxacin and kanamycin but sensitive to Amikacin and Clarithromycin. Four drug ATT was discontinued. Patient was started on PZA, Levofloxacin, cycloserine, and Amikacin as per advice of TB physician. After 2 weeks, discharging sinuses with pale granulation at the opening developed. Another surgical debridement with interbody fusion (cage and bone grafting) and posterior stabilization was done (Fig 2c). However, patient’s condition did not improve. ESR (68mm/hour) and CRP (5.8 mg/dl) remained elevated. Because of the rising serum creatinine level (2.5 mg %), Amikacin was discontinued. The follow up radiograph at 1 month post surgery showed vertebral destruction with implant loosening and progression of the kyphotic deformity (Fig. 3). Eighty eighth day postoperatively, patient status deteriorated suddenly and he developed sudden altered sensorium and neck stiffness. He was intubated and kept on vertilatory support, however his condition kept on deteriorating and he died on ninety first postoperative day. The suspected cause of death was meningitis. No Autopsy was performed.

Figure 2 and 3

The incidence of post-operative discitis is 0.7 to 0.8 % after antibiotic prophylaxis [1,2]. Discitis results due to haematogenous spread in pediatric age group and by direct inoculation in adults [2]. In TB it possibly spreads from adjacent involved urinary tract [3]. The common organisms are staph. aureus, strep. species, and anaerobic organisms. Other rare organism includes, Mycobacterium tuberculosis (MTB), Candida albicans, Mycobacterium cheloni, Propionibacterium acne [2,3]. The risk factors associated are diabetes, malnutrition, smoking, obesity, alcohol abuse and instrumentation. Early post-operative infection usually presents as wound dehiscence and discharge within 3months of surgery, while late post-operative infection may present within 7 years of surgery with milder symptoms. MRI with contrast enhancement is modality of choice with specificity (93%) and sensitivity (96%) for detection of vertebral infection. [2, 3] In recent years because of use of broad spectrum antibiotics and increased number of people with immunocompromised status there is rise in infections secondary to unusual organisms like MTB [12].On literature search, we found 3 reported cases of post-operative discitis due to M.TB [3,4,5]. Jeon DW et al [4] reported a case of post L4-5 discectomy, MTB spondylodiscitis with bizarre course. MRI showed feature of spondylodiscitis. The biopsy sample was positive for TB PCR specific for MTB. Patient was managed with curettage and interbody fusion using autologous iliac bone grafting and antituberculous therapy (ATT). Patient showed successful fusion and clinical improvement. Iraj lotfinia et al [3] reported similar case of post L4-5 discectomy due to MTB. Patient was managed conservatively with HRZE for 2 months and HR for 10 months, with good outcome. Kaplan ES [5]reported a case of post L4-5 discectomy tuberculous abscess, successfully treated with 3 drugs ATT.
The management for post-operative discitis is conservative approach with organism specific antibiotics and bracing. Those patients who fail to respond to above treatment, with continued pain, infection, spinal deformity require an operative intervention consisting of anterior debridement and interbody fusion with autologous bonegraft and posterior stabilization.
The available treatment options for XDR-TB includes use of later generation fluoroquinolone (levofloxacin, moxifloxacin, sparfloxacin) plus addition of likely active drugs (MTB strain susceptible to drugs tested and drugs to which patients had not been previously exposed) plus linezolid [10]. Surgery will help in taking specimen for diagnosis, reducing bacterial load by debridement, with advantage of fusion. In our case, because of the resistant nature of organism and limited therapeutic options the disease progressed and treatment failed. Meta analytic study using later generation cephalosporins, likely active drugs, linezolid and surgery in pulmonary XDR-TB showed a favourable outcome of 43.7% with death of 20.8% patients [10]. The newer drugs in XDR-TB are less effective, more toxic, and costlier [9, 11]. Therefore further research in development of better anti-tuberculosis drugs (ATT) is required.


1. Anthony E. Harris, Chrisanne Hennicke, Karin Byers, William C. Welch. Postoperative discitis due to Propionibacterium acnes: a case report and review of the literature . Surgical Neurology 63 2005; 538–541.
2. Jeff S. Silber, Greg Anderson, Alexander R. Vaccaro, Paul A. Anderson, Paul McCormick. Management of postprocedural discitis. The Spine Journal. 2002; 2:279–287.
3. Iraj Lotfinia , Payman Vahedi . Late-onset post-diskectomy tuberculosis at the same operated lumbar level: case report and review of literature . Eur Spine J 2010;19 (Suppl 2):226–232 .
4. Jeon do W, Chang BS, Jeung UO, Lee SJ, Lee CK, Kim MS, Nam WD. A case of postoperative tuberculous spondylitis with a bizarre course. Clin Orthop Surg. 2009 Mar;1(1):58-62..
5. Kaplan ES .Post-diskectomy tuberculous abscess. J Neurosurg 1973;38:358–361.
6. World Health Organization. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 Global report on surveillance and response. 2010. Available at: http://www.who.int/tb/publications/2010/978924599191/en/ Accessed 25 Nov 2010.
7. World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis. Emergency update 2008. 2008. Available at: http://www.who.int/tb/publications/2008/programmatic_guidelines_for_mdrtb/en/index.html Accessed 25 Nov 2010.
8. World Health Organization. Global tuberculosis control: a short update to the 2009 report. Available at: http://www.who.int/tb/publications/ global_report/2009/update/en/ Accessed 25 Nov 2010.
9. João Alves de Araújo-Filho, Arioldo Carvalho Vasconcelos-Jr, Eduardo Martins de Sousa, Colombina da Silveira, Elisangela Ribeiro, André Kipnis et al . Extensively Drug-Resistant Tuberculosis: A Case Report and Literature Review . BJID 2008; 12: 447- 452 .
10. Karen R. Jacobson, Dylan B. Tierney, Christie Y. Jeon, Carole D. Mitnick, Megan B. Murray. Treatment Outcomes among Patients with Extensively Drug-Resistant Tuberculosis:Systematic Review and Meta-Analysis . Clinical Infectious Diseases 2010; 51(1):6–14
11. Chee Kiang Phua, , Cynthia BE Chee, Angeline PG Chua, Suay Hong Gan, Aneez DB Ahmed, Yee Tang Wang . Managing a Case of Extensively Drug-Resistant (XDR) Pulmonary Tuberculosis in Singapore . Ann Acad Med Singapore 2011;40:132-5 .
12. Sapkas GS, Mavrogenis AF, Mastrokalos DS, Papadopoulos E, Papagelopoulos EC, Papagelopoulos PJ (2006) Postoperative spine infection: a retrospective analysis of 21 patients. Eur J Orthop Surg Traumatol 16(4):322–326.

How to Cite this Article: Sonawane DV, Pawar E, Chandanwale A, Mathesul AA, Salunke A, Keny SM. Post-Operative Extensively Drug Resistant Mycobacterium Tuberculous Discitis. International Journal of Spine Apr – June 2016;1(1):47-49 .

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Standalone Anchored Spacer for Anterior Cervical Decompression and Fusion-Short Term Analysis

Volume 1 | Issue 1 | Apr – June 2016 | Page 43-46|Surulivel Vignesh Jayabalan[1], V C Anil Chander[1], Ganesan G Ram[1], K Karthik Kailash[1].

Authors :Surulivel Vignesh Jayabalan[1], V C Anil Chander[1], Ganesan G Ram[1], K Karthik Kailash[1].

[1] Ortho department, Sri Ramachandra Medical Collage, Porur.Chennai.600116.

Address of Correspondence
Dr. Ganesan G Ram
B2 Ortho department, Sri Ramachandra Medical Collage,
Email: ganesangram@yahoo.com


Background: Standalone anchored spacers were aimed at reducing complications associated with traditional plating while maintaining the functionality of interbody spacer and plating. In this study, we prospectively followed up patients who underwent ACDF in single or multiple levels using the Polyetheretherketone (PEEK) Prevail cervical interbody device (Medtronic, Memphis, TN).
Method: Prospective study of 40 patients suffering from single or two level degenerative cervical disc diseases from C3-C4 to C7-T1 operated from May 2012 to May 2014. All patients underwent surgery using PEEK prevail device. Patients were evaluated using VAS neck pain and arm pain scores and disability scores. Clinical improvement was also graded by Odom’s criteria at final follow up.
Result: The mean follow-up of 37 patients continued in the study was 21.5+_2.5 months. 15 of 37 patients followed up had symptoms of mild dysphagia (40%) at immediate post op period (VAS throat pain score of 39.25+_7.2). Out of these 15, only 3(8%) had mild dysphagia at 3 months follow up (VAS throat pain score of 32.72+_6.9). The Pearson correlation coefficient for interobserver variability was 0.82, 0.84 and 0.78 for inter body height, segmental kyphotic angle, overall kyphotic angle respectively, indicating good to excellent correlation amongst the observers
Conclusion: The use of standalone cages in anterior cervical decompression and fusion provides short time clinical and radiological improvement with minimal complication rates although long terms follow up with these devices is known.
Keywords: VAS score, Standalone cages, Kyphotic angle, Odom’s criteria.

Surgical treatment has been advocated for long in patients with cervical disc disease with radiculpathy and/or myelopathy in whom conservative treatment fails. ACDF with plating and bone grafting/ interbody cages has been an effective surgery with good early and late post operative functional and radiological outcomes even in multi level procedures [1].Complication like dysphagia, tracheo esophageal injury, screw loosening with migration and soft tissue damage [2] adjacent level degeneration especially in multi level cases [3] and donor site morbidity with autologous iliac crest bone grafting were associated with this surgery. Thus in the late past decade, zero profile stand alone devices with screws were introduced for use in ACDF surgeries [4]. These were aimed at reducing complications associated with traditional plating while maintaining the functionality of interbody spacer and plating. In this study, we prospectively followed up patients who underwent ACDF in single or multiple levels using the Polyetheretherketone (PEEK) Prevail cervical interbody device (Medtronic, Memphis, TN).

Figure 1

Material and Methods
Prospective study of 40 patients suffering from single or two level degenerative cervical disc disease from C3-C4 to C7-T1 operated in Sri Ramachandra Medical university between May 2012 to May 2014. Informed consent were obtained from all the patients and ethical clearance was obtained from institutional ethical committee. Patient included in the study were skeletally mature with unilateral or bilateral radicular pain with/ without associated neck pain. All the patients had MRI done and confirmed single or two level cervical disc disease from C3-C4 to C7-T1 and had completed at least six weeks of conservative treatment without any improvement. The exclusion criteriae were previous surgery at the diseased level,congenital or iatrogenic fusion of the adjacent level, patients needing more than two levels of surgery, developmental cervical stenosis, systemic or local infection, active rheumatoid arthritis, uncontrolled diabetes and other co morbidities compromising surgical outcome,severe Osteoporosis,Known allergy to PEEK or titanium alloy and pregnancy or planning for pregnancy during the study period. 30 patients had single level disease and ten patients had two level disease. All patients underwent surgery using PEEK prevail device.Patients were evaluated using VAS neck pain and arm pain scores and disability scores (NPAD-D) . All patients were operated with a head extension in supine position. Post operatively, patients were mobilised under supervision with soft collar support in the first post operative day. No active physiotherapy of the neck was allowed for six weeks. Patients were assessed using the above mentioned scores at the time of discharge and then at six weeks, three months, three months and every six months thereafter.Three patients were lost to follow up at three months and were exclude from the study, leaving 37 patients for final analysis. Clinical improvement was also graded by Odom’s criteria [5] at final follow up. Length and Severity of Post operative dysphagia were recorded by Bazaz’s criteria at each follow up [6].Implant related and surgery related complications were documented. Pre and post operative radiographic parameters were assessed by two independent investigators. Three parameters namely Inter body height, Segmental kyphotic angle, overall kyphotic angle and inter spinous distance were assessed radio logically in the pre op, immediate post op periods and during every follow up using the lateral radiographs. Pitzen’s criteria were used to assess fusion which is defined as absence of radio lucencies and absence of bony sclerosis and evidence of bridging trabaculae within the fusion area. A decrease in more than two mm of IBH during follow up was termed segmental collapse indicating implant subsidence. An increase in interspinous distance of more than two mm in flexion extension radiographs indicated non union. CT scans were taken at one year follow up for 20 patients who consented for additional imaging (15 single level and five bi segmental patients). Statistical analysis was performed using SPSS software (version). Student’s paired t test was use to assess the significance of difference between means.

Table 1

The mean follow-up of 37 patients continued in the study was 21.5+_2.5 months. 15 of 37 patients followed up had symptoms of mild dysphagia (40%) at immediate post op period (VAS throat pain score of 39.25+_7.2). Out of these 15, only 3(8%) had mild dysphagia at 3 months follow up (VAS throat pain score of 32.72+_6.9). The mean VAS arm pain, mean VAS neck pain and mean NPAD-D scores were tabulated as per table 1 and table 2. The graph 1 represents single level and two level VAS score. According to Odom’s criteria, 27 patients (73%) had good outcome, four (10%) patients had excellent outcome and three (8.5%) had fair outcome and three (8.5%) had poor outcome. The Pearson correlation coefficient for interobserver variability was 0.82, 0.84 and 0.78 for IBH, SKA and OHA, respectively, indicating good to excellent correlation amongst the observers(Table 3).

Table 2

The mean interbody height increased significantlyafter surgery. There was significant improvement in segmental and overall kyphotic angles after surgery.Only two patients had an increase in interspinous distance of more than two mm in flexion-extension x rays. Three patients (8%) had evidence of non union at one year follow up x rays according to Pitzen’s criteria.10 (27%) patients had radiologically significant subsidence.According to CT based Bridwell’s criteria, 16 of these patients had Grade I fusion (80%), two patients had grade II fusion (10%) and one patient had grade III fusion (52 year old male with bi segmental surgery) and one patient had frank pseudoarthrosis. None of these patients showed evidence of vertebral fracture or encroachment of screws in foramen transversarium.

Table 3

The major concern in standalone devices is whether they provide biomechanical stability enough to achieve fusion. Studies using anchored spacers with 4 screw construct [7], three screw construct [8] and two screw construct[9] showed comparable biomechanical stability in flexion-extension, lateral bending and axial torsion with standard anterior plating. The “I beam” shape of the cage and Nitinol locking mechanism increases the stability of screw implant interface. PEEK material used in our implant is radio opaque allowing for better evaluation of fusion and it is more rigid than autograft. Moreover, several studies have shown PEEK to provide 100% fusion rates with good to excellent clinical outcome [10] with minimal subsidence maintaining foraminal decompression and sagittal alignment [11]. Hofstetter et al [12] evaluated post operative radiographs for pre vertebral swelling [13] and found that patients operated with plates had significant post operative prevertebral swellings that persisted for more than six months compared to patiens who had Zero profile device fixation. Decreased incidence of midterm and late dysphagia in our study and other studies with zero profile devices, clearly support the hypothesis of hardware prominence and scarring associated with plating leading to prolonged dysphagia symptoms [12,14]. More over most our patients had odynophagia rather than true dysphagia, indicated by increased VAS throat pain scores in early post operative period. Adjacent level ossification is another concern in plating. The cervical plates reaching the adjacent disc levels can induce and accelerate disc degeneration and osteophyte formation,leading to future complications. Park et alrecommend placing the plate at least five mm away from the adjacent disc space to decrease the risk of ossification. In our study, no patient had adjacent level ossification at final follow up X rays which is the case with other studies with stand alone cages [15]. Several studies have shown that fusion and clinical outcomes decrease with increasing levels of surgery, especially when three or more levels are involved [16] inspite of implant stabilisation. But, Wang et al in their review of 60 patients with two level ACDF suggested that addition of plates significantly reduced pseudoarthrosis compared to non plated group. Guiseppi et al used ‘hybrid technique’ in which multilevel surgeries were done with a combination of Zero-p device and CFRP device (Depuy, synthes). More than 90% fusion rates with significant improvement of clinical outcome scores with minimal implant related complications were seen. They also outlined several technical tips in implanting these devices in multi level patients. In our study 87% of patients had excellent to good outcomes and 13 % had fair to poor outcomes which is comparable to other studies with ACDF and plating [17] and stand alone cages [15]. Moreover, 92% and 90% of patients had x ray and CT scan proven fusion rates respectively. Two patients with CT proven pseudoarthrosis (3 and 4 Bridwell’s grading) were multilevel patients with significantly poor clinical outcome. One of the reasons for Favourable clinical and radiological outcome in our study might be due to the exclusion of patients with three or more level pathologies from the study group. There are several limitations in our study. They include absence of control group, relatively smaller number of patients with shorter follow up duration. Moreover, CT scan, one of the most accurate tools to assess the fusion is done in just over 50% of patients. Outcome studies after ACDF are usually measured using fusion rates in most of the studies although Yue et al [18] concluded that clinical outcome was not related to fusion rates, smoking, number of levels operated, collapse or subsidence. More over recent literature has suggested that radiographic results alone are not suggestive of successful clinical outcome. Quality of life measurement is an important tool to assess post operative outcome [19] which is also a draw back in our study as we did not use health status questionnaire such as SF36. Radiological outcome other than fusion is assessed with three criteria namely IBH, SKA and OKA (cervical Cobb angle) [20]. How far these measurements correlate with clinical improvement is not known. The mean IBH increased significantly after surgery from pre operative values and then decreased slightly after surgery. The mean preoperative SKA value is negative indicating relative segmental kyphosis in operated levels. The mean SKA and OKA improved significantly at final follow up compared to pre operative values. Minimal subsidence is an invariable consequence of any interbody fusion device as seen in our study. Since the implant subsidence cannot be measured due to the radiolucency of the implant, it was indirectly measured by the loss of inter body height in any of the follow ups. Keeping stringent criteria of > or = two mm for segmental collapse tend to overestimate subsidence as in our study. But the segmental collapse didn’t translate clinically, as these patients had no significant increase in neck or arm pain scores in any of the follow ups. Vaccaro et al [21] in a recent literature review reported an incidence of screwand plate loosening between 0% and 15.4%, screw breakagebetween 0% and 13.3%, plate breakage between 0% and 6.7%, plate and graft displacement (with or withoutgraft fracture) between 0% and 21.4%, and implant malposition(screws in discs, plating of unfused segments, etc) between 0% and 12.5% for long segmental anterior platefixation. None of these complications were seen in our series indicating that the implant and the surgical technique give reproducible midterm results with minimal complications in single and two level surgeries. Non operative treatment of axial neck pain with or without radiculopathy is successful in around 75% of patients [22]. In patients with failed non operative treatment, fusion and cervical disc arthroplasty remain two major surgical options [23]. Although disc arthroplasty seems to be a viable option in cervical spine compared to lumbar spine, less than 50% of patients meet the inclusion criteria for this procedure as per Auerbach et al [2]. In these patients where motion preserving surgery is contraindicated, anterior cervical decompression and fusion remains the operative treatment of choice for both axial neck pain [25] and cervical radiculopathy [26], although patients with isolated axial neck pain are excluded from our study.


The results from our prospective study indicate that use of standalone cages in anterior cervical decompression and fusion provides short time clinical and radiological improvement with minimal complication rates although long term follow up with these devices is known. Further long term studies are required to validate the usage of these devices, especially in multi level disease.


1. Song KJ, Taghavi CE, Lee KB, Song JH, Eun JP. The efficacy of plate construct augmentation versus cage alone in anterior cervical fusion. Spine (Phila Pa 1976). 2009 Dec 15;34(26):2886-92.
2. Patel NP, Wolcott WP, Johnson JP, Cambron H, Lewin M, McBride D, Batzdorf U. Esophageal injury associated with anterior cervical spine surgery. Surg Neurol. 2008 Jan;69(1):20-4
3. Park JB, Cho YS, Riew KD. Development of adjacent-level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am. 2005 Mar;87(3):558-63.
4. Barbagallo GM, Romano D, Certo F, Milone P, Albanese V. Zero-P: a new zero-profile cage-plate device for single and multilevel ACDF. A single institution series with four years maximum follow-up and review of the literature on zero-profile devices. Eur Spine J. 2013 Nov;22 Suppl 6:S868-78.
5.Björn Zoëga ,Johan Kärrholm, Bengt Lind. Outcome scores in degenerative disc disease. Eur Spine J. 2000; 9 :137–143
6. Bazaz R, Lee MJ, Yoo JU. Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine (Phila Pa 1976). 2002 Nov 15;27(22):2453-8.
7. Scholz M, Reyes PM, Schleicher P, Sawa AG, Baek S, Kandziora F, Marciano FF, Crawford NR. A new stand-alone cervical anterior interbody fusion device: biomechanical comparison with established anterior cervical fixation devices. Spine (Phila Pa 1976). 2009 Jan 15;34(2):156-60.
8. Stein MI, Nayak AN, Gaskins RB 3rd, Cabezas AF, Santoni BG, Castellvi AE. Biomechanics of an integrated interbody device versus ACDF anterior locking plate in a single-level cervical spine fusion construct. Spine J. 2014 Jan;14(1):128-36..
9. Panjabi MM, Cholewicki J, Nibu K, Grauer J, Babat LB, Dvorak J. Critical load of the human cervical spine: an in vitro experimental study. Clin Biomech (Bristol, Avon). 1998 Jan;13(1):11-17.
10. Niu CC, Liao JC, Chen WJ, Chen LH. Outcomes of interbody fusion cages used in 1 and 2-levels anterior cervical discectomy and fusion: titanium cages versus polyetheretherketone (PEEK) cages. J Spinal Disord Tech. 2010 Jul;23(5):310-6.
11.Celik SE, Kara A, Celik S: A comparison of changes over timein cervical foraminal height after tricortical iliac graft or polyetheretherketonecage placement following anterior discectomy.J Neurosurg Spine 6:10-16, 2007.
12. Hofstetter CP, Kesavabhotla K, Boockvar JA. Zero-profile Anchored Spacer Reduces Rate of Dysphagia Compared With ACDF With Anterior Plating. J Spinal Disord Tech. 2015 Jun;28(5):E284-90.
13. Kepler CK, Rihn JA, Bennett JD, Anderson DG, Vaccaro AR, Albert TJ, Hilibrand AS. Dysphagia and soft-tissue swelling after anterior cervical surgery: a radiographic analysis. Spine J. 2012 Aug;12(8):639-44.
14. Miao J, Shen Y, Kuang Y, Yang L, Wang X, Chen Y, Chen D. Early follow-up outcomes of a new zero-profile implant used in anterior cervical discectomy and fusion. J Spinal Disord Tech. 2013 Jul;26(5):E193-7.
15. Scholz M, Schnake KJ, Pingel A, Hoffmann R, Kandziora F. A new zero-profile implant for stand-alone anterior cervical interbody fusion. Clin Orthop Relat Res. 2011 Mar;469(3):666-73.
16. Sasso RC, Ruggiero RA Jr, Reilly TM, Hall PV. Early reconstruction failures after multilevel cervical corpectomy. Spine (Phila Pa 1976). 2003 Jan 15;28(2):140-2.
17.Anderson DG, Albert TJ. Bone grafting, implants, and platingoptions for anterior cervical fusions. Orthop Clin North Am.2002;33:317–328.
18.Yue WM, Brodner W, Highland TR: Long-term results afteranterior cervical discectomy and fusion with allograft andplating: A 5- to 11-year radiologic and clinical follow-up study.Spine (Phila Pa 1976) 2005;30:2138-2144.
19.Klein GR, Vaccaro AR, Albert TJ: Health outcome assessmentbefore and after anterior cervical discectomy and fusion forradiculopathy: A prospective analysis. Spine (Phila Pa 1976) 2000;25:801-803.
20.Jae Sik Shin, Sung Han Oh, Pyoung Goo Cho. Surgical Outcome of a Zero-profile Device Comparing with Stand-aloneCage and Anterior Cervical Plate with Iliac Bone Graft in the AnteriorCervical Discectomy and Fusion. Korean J Spine 2014;11(3):169-77.
21.Vaccaro AR, Falatyn SP, Scuderi GJ, Eismont FJ, McGuire RA,Singh K, Garfin SR. Early failure of a long segmentanterior cervical plate fixation. J Spinal Disord 1998;11:410–415
22. Gore DR, Sepic SB, Gardner GM, Murray MP. Neck pain: a long-term follow-up of 205 patients. Spine (Phila Pa 1976). 1987 Jan-Feb;12(1):1-5.
23. Nabhan A, Ahlhelm F, Pitzen T, Steudel WI, Jung J, Shariat K, Steimer O, Bachelier F, Pape D. Disc replacement using Pro-Disc C versus fusion: a prospective randomised and controlled radiographic and clinical study. Eur Spine J. 2007; 16:423–430.
24. Auerbach JD, Jones KJ, Fras CI, Balderston JR, Rushton SA, Chin KR. The prevalence of indications and contraindications to cervical total disc replacement.Spine J. 2008;8:711–716.
25. Riley LH 3rd, Skolasky RL, Albert TJ, Vaccaro AR, Heller JG. Dysphagia after anterior cervical decompression and fusion. Spine 2005;30(22):2564–2569.
26. Gore DR, Sepic SB: Anterior discectomy and fusion for painful cervical disc disease: A report of 50 patients with an average follow-up of 21 years. Spine (Phila Pa 1976) 1998;23:2047-2051.

How to Cite this Article: Jayabalan SV, Chander VC, Ram GG, Kailash KK. Standalone Anchored Spacer for Anterior Cervical Decompression and Fusion-short Term Analysis. International Journal of Spine Apr – June 2016;1(1):43-46 .


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