Toward the Development of a Comprehensive Clinically Oriented Patient Profile: A Systematic Review of the Purpose, Characteristic, and Methodological Quality of Classification Systems of Adult Spinal Deformity.

BACKGROUND: Existing adult spinal deformity (ASD) classification systems are based on radiological parameters but management of ASD patients requires a holistic approach. A comprehensive clinically oriented patient profile and classification of ASD that can guide decision-making and correlate with patient outcomes is lacking. OBJECTIVE: To perform a systematic review to determine the purpose, characteristic, and methodological quality of classification systems currently used in ASD. METHODS: A systematic literature search was conducted in MEDLINE, EMBASE, CINAHL, and Web of Science for literature published between January 2000 and October 2018. From the included studies, list of classification systems, their methodological measurement properties, and correlation with treatment outcomes were analyzed. RESULTS: Out of 4470 screened references, 163 were included, and 54 different classification systems for ASD were identified. The most commonly used was the Scoliosis Research Society-Schwab classification system. A total of 35 classifications were based on radiological parameters, and no correlation was found between any classification system levels with patient-related outcomes. Limited evidence of limited quality was available on methodological quality of the classification systems. For studies that reported the data, intraobserver and interobserver reliability were good (kappa = 0.8). CONCLUSION: This systematic literature search revealed that current classification systems in clinical use neither include a comprehensive set of dimensions relevant to decision-making nor did they correlate with outcomes. A classification system comprising a core set of patient-related, radiological, and etiological characteristics relevant to the management of ASD is needed.

Clinical and radiological outcomes of hemivertebra resection for congenital scoliosis in children under age 10 years: More than 5-year follow-up.

The surgical treatment of congenital scoliosis under 10 years is difficult as it involves resecting vertebrae. Moreover, patient follow-up after surgery is extremely important because the patient is a child whose growth has not been completed. However, there are very few long-term follow-up studies after surgical treatment of congenital scoliosis. Therefore, this study is designed to evaluate surgical outcomes after posterior hemivertebra resection in children under 10 years and its long-term effects.Twenty-one patients with congenital scoliosis who were younger than 10 years at the time of the surgery and received posterior hemivertebra resection and fusion using pedicle screw fixation were included in this study.There were significant improvements in the main curve, coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis after surgery (P < .001, .021, .047, .043, .006, respectively). Coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis remained within the normal range during the follow-up period; however, main curve deteriorated significantly (P = .005). Trunk appearance of perception scale improved significantly after surgery (P = .031) and was maintained during the follow-up period (P = .078).In conclusion, posterior hemivertebra resection and fusion using pedicle screw fixation in patients under 10 years old with congenital scoliosis is a safe and effective procedure that can achieve rigid fixation and deformity correction. Complete resection of the hemivertebra is important for deformity correction and prevention of curve progression, and careful long-term follow-up is necessary.

Clinical Performance and Concurrent Validity of the Adult Spinal Deformity Surgical Decision-making Score.

STUDY DESIGN: Multicenter, retrospective study. OBJECTIVE: The aim of this study was to examine the performance and concurrent validity of the adult spinal deformity surgical decision-making (ASD-SDM) score compared to decision-making factors in the ASD population. SUMMARY OF BACKGROUND DATA: The ASD-SDM score, which has been recently proposed, is a scoring system to guide the selection of treatment modality for the ASD population. To secure the justification for its clinical use, it is necessary to verify its clinical performance and concurrent validity. METHODS: A multicenter prospective ASD database was retrospectively reviewed. The data were analyzed separately in younger (≤40 years) and older (≥41 years) age groups. The discriminating capacity of the ASD-SDM score in cases who selected surgical and nonsurgical management was compared using area under the receiver operator characteristic curves (AUROC). Concurrent validity was examined using Spearman correlation coefficients, comparing factors that are reported to be associated with the decision-making process for ASD, including baseline symptomatology, health-related quality of life measures, and the severity of radiographic spinal deformity. RESULTS: There were 338 patients (mean age: 26.6 years; 80.8% female; 129 surgical and 209 nonsurgical) in the younger age group and 750 patients (mean age: 63.5 years; 84.3% female; 410 surgical and 340 nonsurgical) in the older age group. In both younger and older patients, the ASD-SDM score showed a significantly higher performance for discriminating the surgical and nonsurgical cases (AUROC: 0.767, standard error [SE]: 0.026, P < 0.001, 95% confidence interval [CI]: 0.712-0.813; AUROC: 0.781, SE: 0.017, P < 0.001, 95% CI: 0.747-0.812, respectively) compared to the decision-making factors analyzed. In addition, the ASD-SDM showed significant correlations with multiple decision-making factors. CONCLUSION: The ASD-SDM score alone can effectively grade the indication for surgical management whilst considering multiple decision-making factors. LEVEL OF EVIDENCE: 3.

Surgical correction of Adult Spinal Deformity in accordance to the Roussouly classification: effect on postoperative mechanical complications.

STUDY DESIGN: Single-center, retrospective. OBJECTIVES: To assess the restoration of ideal sagittal spine shape in accordance to the Roussouly classification and the effect on postoperative mechanical complications. Surgical correction of Adult Spinal Deformity is both challenging and complex. The risk of postoperative complications is considerable, especially mechanical complications requiring revision surgery. Attention has been directed toward defining alignment targets in attempts to minimize these risks, and the Roussouly classification has been proposed as a potential surgical aim. METHODS: All patients undergoing ASD surgery from 2013-2016 were included at a single, quaternary institute. Successful restoration of Roussouly spine shape was retrospectively assessed, and patients were classified as either "restored" or "non-restored". Cumulative incidence of revision surgery due to mechanical failure was estimated using the Aalen-Johansen estimator, with death as the competing risk. A multivariable proportional odds model was used to estimate the effect of the Roussouly algorithm on revision surgery due to mechanical failure. RESULTS: We identified a complete and consecutive cohort of 233 patients who were followed for a mean period of 36 (± 14) months. The 2-year cumulative incidence of revision surgery was 28%. Comparing the "restored" to the "non-restored" group, the overall revision rates were high in both groups. However, when adjusting for known cofounders in a multivariable proportional odds analysis, there was an almost fivefold increased odds of revision due to mechanical failure in the "non-restored" group (p = 0.036). CONCLUSION: Surgical correction of ASD in accordance to the ideal Roussouly spine shape was correlated to a marked and significant decrease in risk of revision surgery due to mechanical failure. Nonetheless, the overall revision risk was elevated in both groups. LEVEL OF EVIDENCE: Therapeutic III.

Adult spinal deformity surgical decision-making score. Part 2: development and validation of a scoring system to guide the selection of treatment modalities for patients above 40 years with adult spinal deformity.

PURPOSE: We aimed to develop and internally validate a scoring system, the adult spinal deformity surgical decision-making (ASD-SDM) score, to guide the decision-making process for ASD patients aged above 40 years. METHODS: A multicentre prospective ASD database was retrospectively reviewed. The scoring system was developed using data from a derivation set and was internally validated in a validation set. The performance of the ASD-SDM score for predicting surgical management was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 702 patients were included for analysis in the present study. The scoring system developed based on 562 patients, ranging from 0 to 12 points, included five parameters: leg pain scored by the numerical rating scale; pain and self-image domains in the Scoliosis Research Society-22 score; coronal Cobb angle; and relative spinopelvic alignment. Surgical indication was graded as low (score 0 to 4), moderate (score 5 to 7), and high (score 8 to 12) groups. In the validation set of 140 patients, the AUC for predicting surgical management according to the ASD-SDM score was 0.797 (standard error = 0.037, P < 0.001, 95% confidence interval = 0.714 to 0.861), and in the low, moderate, and high surgical indication groups, 23.7%, 43.5%, and 80.4% of the patients, respectively, were treated surgically. CONCLUSIONS: The ASD-SDM score demonstrated reliability, with higher scores indicating a higher probability of surgery. This index could aid in the selection of surgery for ASD patients in clinical settings. These slides can be retrieved under Electronic Supplementary Material.

Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST): Development and Validation of a Prognostic Model in Untreated Adolescent Idiopathic Scoliosis Using the Simplified Skeletal Maturity System.

STUDY DESIGN: Prognostic study and validation using prospective clinical trial data. OBJECTIVE: To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. METHODS: The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). RESULTS: The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89-0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71-0.72 and NPVs of 0.85-0.93. CONCLUSIONS: This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. LEVEL OF EVIDENCE: Level 1, prognostic.

Spine Growth Modulation in Early Adolescent Idiopathic Scoliosis: Prospective US FDA IDE Pilot Study of Titanium Clip-Screw Implant at Two to Five Years.

STUDY DESIGN: Prospective longitudinal study of growth modulation system for early adolescent idiopathic scoliosis (AIS), consecutive case series from first human use to skeletal maturity, fusion, or five years postoperation. OBJECTIVES: Determine adverse events and curvature changes to end of study; examine factors most likely to explain variability in curve changes. SUMMARY OF BACKGROUND: Pilot clinical safety study was performed under US Food and Drug Administration (FDA) Investigational Device Exemption (IDE). Safety and radiographic results were previously reported to 24 months postoperation. METHODS: Subjects with early AIS underwent thoracoscopic placement of titanium clip-screw devices designed to modify growth asymmetrically. Eligibility was based on high risk of progression to 50°: single major thoracic curve 25°-40°, Risser 0, open triradiate cartilages, and premenarchal if female. Six subjects, the maximum allowed, enrolled. Adverse events (AEs), clinical outcomes, and curvatures were systematically collected. Disc heights, vertebral heights, and implant-bone contact areas were assessed. RESULTS: Consecutive subjects enrolled, aged 12.1 years (±1.7), three were female. AEs from two to five years postoperation included deformity changes leading to a second surgery in three patients: two for posterior spinal fusion, and one for thoracoscopic removal of half the implants for overcorrection. In the latter case, overcorrection appeared halted for duration of study. One patient, whose curve exceeded 50° at age 18 years, did not choose fusion. Major thoracic curves were 34° (±3°) preoperatively and 42° (±20°) at end of study. CONCLUSIONS: In a study of spine growth modulation in patients with early AIS with high risk of progression, at skeletal maturity or five years postoperation, major thoracic curves of half progressed to >50°, whereas curves of the other half remained <40°, below fusion indications. Removal of selected implants may halt overcorrection. The next, pivotal, study phase was approved by FDA. LEVEL OF EVIDENCE: Level IV, prospective case series under stringent regulatory controls.

Patient-Reported SRS-24 Outcomes Scores After Surgery for Adolescent Idiopathic Scoliosis Have Improved Since the New Millennium.

STUDY DESIGN: Observational. OBJECTIVE: To examine changes in patient-reported two-year postoperative outcomes via the Scoliosis Research Society (SRS)-24 Outcomes Instrument from 2001 through 2015. SUMMARY OF BACKGROUND DATA: Techniques for correction of adolescent idiopathic scoliosis (AIS) have evolved over the years, but it is unclear how these changes have impacted patient-reported outcomes. METHODS: AIS patients with two-year postoperative follow-up from a prospective multicenter registry were divided into three-year groups based on trends in surgical approach and construct type (2010-2014: 52% anterior, 43% posterior hybrids; 2005-2011: 3% anterior, 5% posterior hybrids; 2012-2015: 0% anterior, 0.2% posterior hybrids). Because of the ordinal scale (1-5) and bipolar nature of the response sets for the SRS-24, domain/total scores were categorized as ≤3 (predominantly negative) or 4-5 (predominantly positive). Variables were compared across the three groups. RESULTS: A total of 1,695 patients were analyzed; 172 (2010-2014), 926 (2005-2011), and 597 (2012-2015). Average age was 14.7 ± 2 years, the average primary curve was 55° ± 13°, and the group was primarily female (82%). There was a decline in the rate of positive scores for preoperative pain and self-image across the three groups (p < .05). There was an increase in the rate of positive scores for two-year postoperative self-image after surgery, function after surgery, and satisfaction (p < .05). Decreases in length of hospital stay, blood loss, surgical time, preoperative kyphosis, and postoperative trunk shift were observed (p < .05). Increases were observed in levels fused, preoperative major coronal curve, preoperative rib prominence, preoperative trunk shift, percentage correction of major curve, kyphosis restoration, and the rate of double/triple curves (p < .05). CONCLUSION: The percentage of patients with positive postoperative SRS scores has increased in the modern era, providing evidence that newer surgical techniques are resulting in improved outcomes based on the patients' perspectives. Interestingly, recent patients were more afflicted with negative pain and self-image before surgery.

Difficulties in Treating Postirradiation Kyphosis in Adults: A Series of Five Cases.

STUDY DESIGN: Clinical case series. OBJECTIVE: To assess objective outcomes of surgical correction of post-external beam radiation therapy (ERBT) kyphosis in a series of five adults. SUMMARY OF BACKGROUND DATA: EBRT is a well-established treatment for many cancers in children and adults. One complication associated with EBRT is postirradiation spine deformity. Scoliosis is the most common deformity, but kyphosis also occurs frequently. Differences in deformity patterns are likely related to the location and intensity of radiation. To our knowledge, no studies have addressed treatment of these deformities in adults, and the most recent case series (of children) was published in 2005. METHODS: We present a series of five adults who underwent surgery for postirradiation kyphosis, with a mean follow-up of 3.8 years (range, 2.5-6.2 years). RESULTS: Surgery improved the kyphotic deformity in all patients. Overall mean kyphotic deformity correction was 56° and was larger for cervical/cervicothoracic deformities (mean, 76°) than for lumbar deformities (mean, 42°) at midterm follow-up. Patients reported significant improvements in pain and self-image. Consistent with prior case series of children, we observed a high rate of complications (mean, 1.4 complications per patient) in adults. Three patients each underwent an unplanned surgical procedure because of a complication. CONCLUSION: The surgical treatment of postirradiation kyphotic spinal deformity is challenging, with common postoperative complications such as infection, instrumentation failure, and pseudarthrosis. However, with modern surgical techniques and spinal instrumentation, excellent deformity correction can be achieved and maintained. We recommend performing a two-stage procedure for cervicothoracic deformity, with anterior release followed by posterior fusion and instrumentation. In thoracolumbar deformities, correction can be achieved through single-stage posterior fusion. Rigid spinopelvic fixation with sacral-alar-iliac screws and second-stage anterior lumbar interbody fusion at L5-S1 is recommended to reduce nonunion risk. Cement augmentation of proximal and distal anchors can help prevent junctional failure. LEVEL OF EVIDENCE: Level IV.

A novel radiographic classification of severe spinal curvatures exceeding 100°: the Omega (Ω), gamma (γ) and alpha (α) deformities.

PURPOSE: For spine curvatures with Cobb angles > 100°, curve classification and characterization become more difficult with conventional radiographs. 3-D computerized axial tomography scans add relevant information to categorize and describe a new classification to aid preoperative assessment in communication and patient evaluation. The purpose of this study is to describe a radiographic classification system of curves exceeding 100°. METHODS: A consecutive series of patients with curves exceeding 100° underwent a full spine radiographic review using conventional radiographs and 3-D CT. A descriptive analysis was performed to categorize curves into 4 main types (1, 2, 3 and 4) and 6 subtypes (1C, 1S, 1CS, 2P, 2D and 2PD) based on the location of the Cobb angle of the major scoliotic and kyphotic deformity as well as the location of the upper/lower end vertebra relative to the apical vertebra. RESULTS: A total of 98 patients met the inclusion criteria. There were 51 males and 47 females with an average age of 17.8 ± 4.5 years. The diagnosis included idiopathic (48); congenital (24); neuromuscular (4); and neurofibromatosis (2). The mean major coronal and sagittal Cobb (kyphosis) were 131.2° ± 23.4° and 154 ± 45.6, respectively. The classification scheme yielded 4 main types (1, 2, 3 and 4) and 6 subtypes under types 1 and 2 (1C, 1S, 1CS, 2P, 2D and 2PD). CONCLUSIONS: Our study describes a novel method of classifying severe spinal curvatures exceeding 100° using erect AP/lateral radiographs and 3-D CT reconstructive images. We hope that the descriptive analysis and classification will expand our understanding of these complex deformities. These slides can be retrieved under Electronic Supplementary Material.

Understanding Classification Systems in Spine Deformity.

Classification systems provide organization for pathologic conditions and guide treatment for similar disease states. Spine deformity is a growing field with newer classification systems being developed as our surgical techniques and clinical understanding advances. The evolution of these classification systems reflects our current knowledge and are used to better understand the evolving field of spine surgery. Currently, classification systems in spine surgery range from describing deformity in different age groups and different regions of the spine to describing various osteotomies and the severity of proximal junctional kyphosis. This paper will describe what makes a successful classification system in spine deformity. Old classification systems will be briefly described and their limitations that necessitated the need for newer classification systems. Newer systems will also be reviewed and the importance of specific radiographic parameters. Finishing this review, clinicians will be able to pick which systems are ideal for their practice.

Sagittal Alignment After Surgical Treatment of Adolescent Idiopathic Scoliosis-Application of the Roussouly Classification.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate spinopelvic alignment and spine shape in patients surgically treated for adolescent idiopathic scoliosis (AIS) and to assess the distribution and clinical applicability of the Roussouly classification. SUMMARY OF BACKGROUND DATA: How spinopelvic alignment is affected in AIS patients is not well established. Roussouly et al. proposed a classification based on the sagittal spinal profile and spinopelvic alignment that may have clinical utility in these patients. METHODS: A consecutive cohort of 134 surgically treated AIS patients were included. Whole-spine standing lateral radiographs were analyzed preoperatively, one-week postoperatively and at two-year follow-up. Patients were categorized using the modified Roussouly classification and analyzed for sagittal alignment. RESULTS: Postoperatively, global thoracic kyphosis (TK) decreased by 2.6° and lumbar lordosis (LL) decreased by 6.2°(p ≤ .012) while Pelvic tilt (PT) increased 1.4° (p = .024). At two-year follow-up, TK and LL had returned to preoperative values (p ≥ .346) while PT had decreased from preoperative 9.7 ± 7.6° to 7.0 ± 7.5° (p > .001). Proximal junctional angle increased from 8.4 ± 5.0° preoperatively to 12.8 ± 8.9 (p < .001). Preoperatively, Roussouly curve types were distributed equally apart from a lower rate of type 1 (12%). At final follow-up, 30% were categorised as type 3 with pelvic anteversion which is considerably higher than the normal adolescent population. Only three patients were type 1 at the final follow-up. Overall, we found a high rate of proximal junctional kyphosis (16%), PI-LL mismatch (60%) and pelvic anteversion (38%). In preoperative type 1 patients, the rate was 50%, 82% and 64%, respectively. CONCLUSION: We found that immediate postoperative changes in lordosis and kyphosis were reversed at final follow-up and found evidence of proximal junctional kyphosation and pelvic anteversion as the main compensatory mechanisms. Poor sagittal alignment was frequent in type 1 curves, and surgical treatment may need to be individualized according to the sagittal profile. LEVEL OF EVIDENCE: III.

Adult cervical deformity: radiographic and osteotomy classifications.

Cervical spine deformity represents a broad spectrum of pathologies that are both complex in etiology and debilitating towards quality of life for patients. Despite advances in the understanding of drivers and outcomes of cervical spine deformity, only one classification system and one system of nomenclature for osteotomy techniques currently exist. Moreover, there is a lack of standardization regarding the indications for each technique. This article reviews the adult cervical deformity (ACD) and current classification and nomenclature for osteotomy techniques, highlighting the need for further work to develop a unified approach for each case and improve communication amongst the spine community with respect to ACD.

Characterizing Adult Cervical Deformity and Disability Based on Existing Cervical and Adult Deformity Classification Schemes at Presentation and Following Correction.

BACKGROUND: Adult cervical deformity (ACD) classifications have not been implemented in a prospective ACD population and in conjunction with adult spinal deformity (ASD) classifications. OBJECTIVE: To characterize cervical deformity type and malalignment with 2 classifications (Ames-ACD and Schwab-ASD). METHODS: Retrospective review of a prospective multicenter ACD database. Inclusion: patients ≥18 yr with pre- and postoperative radiographs. Patients were classified with Ames-ACD and Schwab-ASD schemes. Ames-ACD descriptors (C = cervical, CT = cervicothoracic, T = thoracic, S = coronal, CVJ = craniovertebral) and alignment modifiers (cervical sagittal vertical axis [cSVA], T1 slope minus cervical lordosis [TS-CL], modified Japanese Ortphopaedic Association [mJOA] score, horizontal gaze) were assigned. Schwab-ASD curve type stratification and modifier grades were also designated. Deformity and alignment group distributions were compared with Pearson χ2/ANOVA. RESULTS: Ames-ACD descriptors in 84 patients: C = 49 (58.3%), CT = 20 (23.8%), T = 9 (10.7%), S = 6 (7.1%). cSVA modifier grades differed in C, CT, and T deformities (P < .019). In C, TS-CL grade prevalence differed (P = .031). Among Ames-ACD modifiers, high (1+2) cSVA grades differed across deformities (C = 47.7%, CT = 89.5%, T = 77.8%, S = 50.0%, P = .013). Schwab-ASD curve type and presence (n = 74, T = 2, L = 6, D = 2) differed significantly in S deformities (P < .001). Higher Schwab-ASD pelvic incidence minus lumbar lordosis grades were less likely in Ames-ACD CT deformities (P = .027). Higher pelvic tilt grades were greater in high (1+2) cSVA (71.4% vs 36.0%, P = .015) and high (2+3) mJOA (24.0% vs 38.1%, P = .021) scores. Postoperatively, C and CT deformities had a trend toward lower cSVA grades, but only C deformities differed in TS-CL grade prevalence (0 = 31.3%, 1 = 12.2%, 2 = 56.1%, P = .007). CONCLUSION: Cervical deformities displayed higher TS-CL grades and different cSVA grade distributions. Preoperative associations with global alignment modifiers and Ames-ACD descriptors were observed, though only cervical modifiers showed postoperative differences.

ISYQOL: a Rasch-consistent questionnaire for measuring health-related quality of life in adolescents with spinal deformities.

BACKGROUND CONTEXT: Spinal deformities are commonly associated with poor health-related quality of life (HRQOL). Several questionnaires (eg, Scoliosis Research Society-24 [SRS-24] and Scoliosis Research Society-22 [SRS-22]) have been developed to evaluate HRQOL in these conditions. In adults as well as during growth, the HRQOL is considered one of the most relevant outcomes of both conservative and surgical treatments. Rasch analysis is a powerful statistical technique for developing high-quality and valid questionnaires. The SRS-24 and SRS-22 have been evaluated using the Rasch analysis but showed poor measurement properties. Thus, a proper measure of HRQOL in people with a spine condition is still missing. PURPOSE: This study aimed to develop a new questionnaire that is totally Rasch consistent for measuring the HRQOL in young people with a spine condition. STUDY DESIGN: This is a cross-sectional study for developing a new HRQOL measure. PATIENT SAMPLE: A total of 402 participants with adolescent idiopathic scoliosis or Scheuermann juvenile kyphosis were included in the study. OUTCOME MEASURE: The outcome measure used was the Italian Spine Youth Quality of Life (ISYQOL) questionnaire. MATERIALS AND METHODS: The study consisted of different stages: a conventional approach content analysis, an opinion poll among clinicians trained in spine deformities, and the Rasch analysis (partial credit model). RESULTS: The Rasch analysis showed that all items of the ISYQOL questionnaire had ordered thresholds and a good fit to the model. Differential item functioning was present for Item 1, with bracing only, and was solved with a conventional items splitting procedure. The ISYQOL item map spans an adequate range of HRQOL. The principal component analysis for Rasch residuals showed, in practical terms, the ISYQOL unidimensionality. The reliability of ISYQOL was high enough so that approximately three significantly different levels of HRQOL could be discerned. Two questionnaire versions were provided for patients with and without the brace, respectively. CONCLUSIONS: ISYQOL is the first HRQOL questionnaire developed according to the Rasch analysis. It was developed in a conservative treatment setting for all types of spinal deformities, including also patients with surgical curves. Validation in many languages is already under way.

Reliability assessment of a novel cervical spine deformity classification system.

OBJECT: Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification. METHODS: Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: "C," "CT," and "T" for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; "S" for primary coronal deformity with a coronal Cobb angle ≥ 15°; and "CVJ" for primary craniovertebral junction deformity. The modifiers included C2-7 sagittal vertical axis (SVA), horizontal gaze (chin-brow to vertical angle [CBVA]), T1 slope (TS) minus C2-7 lordosis (TS-CL), myelopathy (modified Japanese Orthopaedic Association [mJOA] scale score), and the Scoliosis Research Society (SRS)-Schwab classification for thoracolumbar deformity. Application of the classification system requires the following: 1) full-length standing posteroanterior (PA) and lateral spine radiographs that include the cervical spine and femoral heads; 2) standing PA and lateral cervical spine radiographs; 3) completed and scored mJOA questionnaire; and 4) a clinical photograph or radiograph that includes the skull for measurement of the CBVA. A series of 10 CSD cases, broadly representative of the classification system, were selected and sufficient radiographic and clinical history to enable classification were assembled. A panel of spinal deformity surgeons was queried to classify each case twice, with a minimum of 1 intervening week. Inter- and intrarater reliability measures were based on calculations of Fleiss k coefficient values. RESULTS: Twenty spinal deformity surgeons participated in this study. Interrater reliability (Fleiss k coefficients) for the deformity descriptor rounds 1 and 2 were 0.489 and 0.280, respectively, and mean intrarater reliability was 0.584. For the modifiers, including the SRS-Schwab components, the interrater (round 1/round 2) and intrarater reliabilities (Fleiss k coefficients) were: C2-7 SVA (0.338/0.412, 0.584), horizontal gaze (0.779/0.430, 0.768), TS-CL (0.721/0.567, 0.720), myelopathy (0.602/0.477, 0.746), SRS-Schwab curve type (0.590/0.433, 0.564), pelvic incidence-lumbar lordosis (0.554/0.386, 0.826), pelvic tilt (0.714/0.627, 0.633), and C7-S1 SVA (0.071/0.064, 0.233), respectively. The parameter with the poorest reliability was the C7-S1 SVA, which may have resulted from differences in interpretation of positive and negative measurements. CONCLUSIONS: The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.

Iphone app use to Cobb angle in adolescent idiopathic scoliosis: Does this apply? / Uso de aplicativo de iphone para ângulo de Cobb na escoliose idiopática do adolescente: É aplicável? / Uso de aplicaciones móviles para Iphone para el ángulo de Cobb en la escoliosis idiopática del adolescente: ¿es aplicable?

To validate a new method of measuring the Cobb angle for scoliosis from the mobile app CobbMeter to facilitate the evaluation and measurement in clinical practice.

Validar um novo método de medida do ângulo de Cobb para escoliose a partir do aplicativo para aparelho telefônico celular CobbMeter para facilitar a avaliação e medição na prática clínica.

Validar un nuevo método de medición del ángulo de Cobb para la escoliosis a partir de la aplicación móvil CobbMeter, para facilitar la evaluación y la medición en la práctica clínica.

Incidence of spinal deformity in adults and its distribution according SRS-Schwab classification / Incidência da deformidade vertebral no adulto e sua distribuição quanto à classificação SRS-Schwab / Incidencia de la deformidad espinal en adultos y su distribución según la clasificación SRS-Schwab

To evaluate the incidence of spinal deformity in adults, as well as its distribution according the curve type and the occurrence of sagittal modifiers of the SRS-Schwab classification..

Evaluar la incidencia de la deformidad de la columna en adultos, así como su distribución en los tipos de curva y la aparición de modificadores sagitales de la clasificación SRS-Schwab.

Avaliar a incidência da deformidade vertebral do adulto, além de sua distribuição quanto aos tipos de curva e ocorrência de modificadores sagitais da classificação SRS-Schwab.