Selection of fusion levels in adults with spinal deformity: an update.

BACKGROUND CONTEXT: Adult spinal deformity (ASD) is commonly associated with disability and represents a challenging condition for physicians. Although surgical management has been reported as superior to conservative care, the choice of patient-specific optimal strategy has been poorly defined. A key question remains selection of fusion levels as this implies careful balance of risks and benefits. PURPOSE: The aim of this review is to propose an update on current knowledge related to optimal fusion levels in the surgical treatment of ASD. STUDY DESIGN: Literature review. METHODS: Based on a comprehensive literature search, recent studies focusing on the management of ASD were reviewed to establish current concepts on fusion levels in the management of symptomatic ASD. RESULTS: Despite numerous published studies, the management of ASD and specifically optimal fusion levels is incompletely defined. Described approaches carry benefits and risks. However, the need for detailed analysis and preoperative planning is confirmed as a prerequisite to obtaining realignment objectives and good outcomes. CONCLUSIONS: The treatment of ASD is emerging as an important health-care issue of the 21st century because of prevalence and cost. Despite technical advances related to ASD surgery, complication rates remain elevated, particularly in the older population. Recent research, mostly driven by outcome measures, has improved our understanding of optimal treatment approaches to ASD. The development of a widely accepted classification system will help to share knowledge and improve our ability to treat these complex patients.

Validity of Cobb angle measurements using digitally photographed radiographs.

BACKGROUND CONTEXT: Advances in technology are influencing the way that medical information is archived and shared. Considering that an estimated two-thirds of the world has little or no orthopedic care, high demand exists for adequate consultation regarding diagnostic images in orthopedic specialties. PURPOSE: To validate the use of photographed scoliosis films for the accurate interpretation of Cobb angles. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Thirty scoliosis radiographs. OUTCOME MEASURE: Cobb angle. METHODS: Thirty scoliosis radiographs were photographed using a digital camera from a straight and a 45° angle position. Cobb angles were then measured on the digital images using standard measurement software. Comparison was made between two types of curves: convex and concave, relative to the left side (side for the angled position). RESULTS: There was excellent reproducibility between the measurements of the conventional radiographs and the photographs taken from a straight on position, p value of .97 for convex curves and p value of .98 for concave curves. Photographs taken from a 45° angle significantly increased the magnitude of the curve convex to the angle (p=.001). CONCLUSION: Sharing photographs of scoliosis radiographs can be done with reliability if the image is taken directly in front of the viewbox rather than at an oblique angle; pictures taken at oblique angles are prone to misinterpretation of curve magnitude.

The prevalence of transitional vertebrae in the lumbar spine.

BACKGROUND CONTEXT: Lumbosacral transitional vertebrae (LSTVs) are a congenital vertebral anomaly of the L5-S1 junction in the spine. This alteration may contribute to incorrect identification of a vertebral segment, leading to wrong-level spine surgery and poor correlation with clinical symptoms. Although several studies describe the occurrence of this anomaly in back pain populations, investigation of the prevalence in the American general population is lacking. PURPOSE: To establish the prevalence rates for LSTVs in the general population. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: Consecutive kidney-urinary bladder (KUB) radiographs of subjects from the past 2 years (2008-2009). OUTCOME MEASURES: Clinical demographics, number of lumbar vertebrae, L5-S1 transverse process (TP) height, and rib length. METHODS: Consecutive adult KUB studies of adult subjects were queried with clear visibility of the last rib's vertebral body articulation, all lumbar TPs, and complete sacral wings. Exclusion criteria consisted of any radiologic evidence of previous lumbosacral surgery that would obstruct our measurements. A total of 1,100 abdominal films were reviewed, and 211 were identified as being adequate for the measurement of the desired parameters. RESULTS: Two hundred eleven subjects were identified as eligible for the study, and 75 (35.6%) were classified as positive for a transitional lumbosacral vertebra. The most common anatomical variant was the Castellvi Type IA (14.7%). The average age at the time of the KUB study was 59.8 years (18-95 years). One hundred ninety-seven subjects (93.4%) presented five lumbar (nonribbed) vertebrae, and only 14 (6.6%) had six lumbar vertebrae. CONCLUSIONS: The significance of lumbosacral transitional level changes to the establishment of pain, degenerative changes, stenosis, and disc disease have been well documented in symptomatic patients. Although LSTV's role in low back pain remains controversial, our study has shown that, when the same criteria are used for classification, prevalence among the general population and symptomatic patients may be similar.

Comparison of intraoperative supine and postoperative standing radiographs after posterior instrumentation for adolescent idiopathic scoliosis.

The utility of intraoperative radiographs after posterior spinal segmental instrumentation for adolescent idiopathic scoliosis (AIS) is debatable. A retrospective review of 74 patients with moderately severe AIS revealed the main thoracic Cobb measurements of 57° preoperatively, 17° intraoperatively, 18° on initial postoperative, and 20° on final postoperative radiographs. On the basis of the extent and type of instrumentation (pedicle screws vs. hybrid construct), there was no clinically significant difference in curve magnitude between intraoperative and postoperative radiographs. After posterior segmental instrumentation for moderate AIS, frontal plane correction measured on intraoperative supine radiographs are comparable with similar measurements made on full-length postoperative standing radiographs.