Surgical treatment analysis of 809

thoracolumbar and lumbar major adult

deformity cases by a new adult
scoliosis classification system

F Schwab, JP Farcy, K Bridwell, S Berven, S Glassman,

W Horton, M Shainline
Spinal Deformity Study Group
Zorab Symposium 2006
Background

Unlike pediatric and adolescent scoliosis, no accepted

classification system exists for adult scoliosis

 Scoliosis in the adult population

– prevalence as high as 60%
– significant pain and disability
– Quality of life issues

 Classification systems provide

– Common language for communication
– Correlation with clinical impact
 treatment algorithms
 surgical guidelines
Background
Adult deformity: Treatment approach

Curve severity
• Cobb angle
• progression

Skeletal maturity
• Risser sign

Cosmesis

PT
Pain Pain Mgmt
Bracing
Disability Surgery
Background
Multi-center prospective study

Clinical Group
Scoliosis with apex T4 to L4
Degenerative or idiopathic
809 consecutive patients

Radiographic analysis Classification System

full length, standing films Apical level
Cobb angle, Lumbar lordosis modifier
apical level of deformity, Intervertebral subluxation modifier
sagittal plane lumbar alignment Global Balance modifier

Health assessment
questionnaires
ODI / SRS-29 / SF-12
Background
Adult Scoliosis Classification

1. Type

Type I Type II Type III Type IV Type V

Thoracic Upper Thoracic Lower Thoracic Thoraco-lumbar Lumbar
only major major major major

no other Apex Apex Apex Apex

curves T9-T10 T9-T10 T11-L1 L2-L4

2. Modifiers
Lumbar Lordosis Intervertebral Subluxation Global Balance

A : marked >400 0 : none at any level N Neutrally balanced <4cm

B : moderate 0-400 + : max = 1-6mm P Positively balanced 4-9.5cm
C : no lordosis, Cobb >00 ++ : max >7mm
VP Very Positive >9.5cm
Purpose
Adult Scoliosis Classification

Reliable classification with

significant correlation to
clinical symptoms

Prediction of treatment
patterns and surgical rates
???
Materials & Methods

1. Clinical group
• Spinal Deformity Study Group database
• Prospective, consecutive 809 patients review
• Ages > 18 y.o.
• Thoracolumbar or lumbar major scoliosis
•Type IV and Type V deformities only.

2. Health questionnaires
• Oswestry Disability Index (ODI)
• Scoliosis Research Society instrument (SRS-22)
• Short From 12 (SF-12)
Materials & Methods

3. Radiographic parameters
• Full-length standing films
• Frontal Cobb angle,
• Apical level,
• Sagittal lumbar alignment (T12-S1),

Sagittal Balance
N Neutrally balanced <4cm
P Positively balanced 4-9.5cm
VP Very Positive >9.5cm

Lumbar Lordosis Intervertebral Subluxation

A : marked >40° 0 : none at any level
B : moderate 0-40 ° + : max = 1-6mm
C : no lordosis, Cobb >0° ++ : max >7mm
Materials & Methods

4. Treatment approach
• Surgical vs. non-surgical
• If Surgical:
• Anterior, Posterior, circumferential
• Use of osteotomies
• Extension of fusion to sacrum

5. Data Analysis
• Treatment Analysis regarding
• HRQOL measures
• SRS-22, ODI, SF-12
• Correlation analysis
• Classification types vs. treatment given
Results
Patients Distribution

806 thoracolumbar/lumbar major

deformities

– Type IV n=311
– Type V n=495

– Mean age 53.1 y.o. (+/- 15.3)

– 700 Females (87%)
– 106 Males (13%)
Results
Surgical rates

 Rates of operative treatment

– Lordosis modifier
 B vs. A (51% vs. 37%, p<0.05), trend for A vs. C (46%)

– Subluxation modifier
 ++ vs. 0 (52% vs. 36 %, p<0.05), trend vs. + (42 %)

– Sagittal Balance
 N vs. VP: 39% vs. 59%, p<0.05
Results
Treatment Analysis: Type IV, V curves

92% highest level of fixation above apex of major curve.

97% lowest level of fixation below apex of major curve.
10% to level of sublux, 87% at least one level beyond

Fusion to sacrum
Apical Level
Trend for type V patients more likely to have fixation to sacrum (p=.074)

Lordosis Modifier
mod B patients more likely fusion to sacrum than mod A patients (p=.041)

Sagittal Balance Modifier

increasing positive balance: more likely fixation extended to the sacrum.
(mod N: 59%, mod P: 80%, mod VP: 88%) (all p<0.05)
Results
Treatment Analysis: Type IV, V curves

Surgical Approach Use of osteotomies

 Anterior only  Lordosis modifier A vs. C

– mostly lordosis modifier A – 25% vs. 50% p=0.01
– Subluxation modifier 0
– Sagittal balance modifier N
 Sagittal balance N vs. VP
– 25% vs. 53% p=0.01
 Circumferential:
– trend most common modifier B
– Most commonly subluxation
modifier ++

 Posterior only:
– mostly lordosis modifier C
– Sagittal balance modifier VP
Results
Main findings

Treatment

• Good lordosis (modifier A) less likely to have surgery

• Most likely to require surgery:
• loss of lordosis (C),
• marked subluxation (++)
• sagittal plane imbalance (VP)

If surgery
• Cross level of subluxation
• Osteotomies to realign sagittal plane
• lordosis modifier C gets most likely to require osteotomy
• fusion to sacrum: with increasing sagittal imbalance, lost lordosis
Discussion - Conclusion
Adult scoliosis classification

 Clinical Impact established:

– HRQOL
– Treatment….non-op vs. surgical
– Surgical strategy…we’re getting there

How about results of treatment ? 2 yr

Work toward surgical guidelines
f/u
Discussion - Conclusion

Adult scoliosis
classification

Reliable
Clinical impact
• disability
• surgical rate
Surgical strategy ?

Can we broaden to a:
Comprehensive Adult Deformity
Classification
Classification of Adult Deformity

Type I thoracic-only curve (no other curves)

II upper thoracic major, apex T4-8
III lower thoracic major, apex T9-T10
IV thoracolumbar major curve, apex T11-L1
V lumbar major curve, apex L2-L4
Type K no scoli (<100), principal sagittal plane deformity

Lumbar Lordosis A marked lordosis >400

Modifier B moderate lordosis 0-400
C no lordosis present Cobb >00

Subluxation 0 no intervertebral subluxation any level

Modifier + maximal measured subluxation 1-6mm
++ maximal subluxation >7mm

Sagittal Balance N normal, <4cm positive SVA

Modifier P positive, 4-9.5cm
VP very positive, >9.5cm
Next Steps
Adult scoliosis classification

Refine Classification
• Pelvic modifier
• Co-morbidity index
• Patient expectation scale

Longitudinal follow up
• who responds well to conservative care
• who benefits (how much) from surgery
•Complications ?

Surgical analysis (2yr f/u)

• what strategies are most effective