Faculty Bibliography

STUDY DESIGN/METHODS:Consensus-building using the Delphi and nominal group technique. OBJECTIVE:To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS:The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS:Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION/CONCLUSIONS:We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE/METHODS:Level V.

PURPOSE/OBJECTIVE:Sagittal spinal deformity (SSD) patients utilize pelvic tilt (PT) and their lower extremities in order to compensate for malalignment. This study examines the effect of hip osteoarthritis (OA) on compensatory mechanisms in SSD patients. METHODS:Patients ≥ 18 years with SSD were included for analysis. Spinopelvic, lower extremity, and cervical alignment were assessed on standing full-body stereoradiographs. Hip OA severity was graded by Kellgren-Lawrence scale (0-4). Patients were categorized as limited osteoarthritis (LOA: grade 0-2) and severe osteoarthritis (SOA: grade 3-4). Patients were matched for age and T1-pelvic angle (TPA). Spinopelvic [sagittal vertical axis (SVA), T1-pelvic angle, thoracic kyphosis (TK), pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence minus lumbar lordosis (PI-LL), T1-spinopelvic inclination (T1SPi)] and lower extremity parameters [sacrofemoral angle, knee angle, ankle angle, posterior pelvic shift (P. Shift), global sagittal axis (GSA)] were compared between groups using independent sample t test. RESULTS:136 patients (LOA = 68, SOA = 68) were included in the study. SOA had less pelvic tilt (p = 0.011), thoracic kyphosis (p = 0.007), and higher SVA and T1Spi (p < 0.001) than LOA. SOA had lower sacrofemoral angle (p < 0.001) and ankle angle (p = 0.043), increased P. Shift (p < 0.001) and increased GSA (p < 0.001) compared to LOA. There were no differences in PI-LL, LL, knee angle, or cervical alignment (p > 0.05). CONCLUSIONS:Patients with coexisting spinal malalignment and SOA compensate by pelvic shift and thoracic hypokyphosis rather than PT, likely as a result of limited hip extension secondary to SOA. As a result, SOA had worse global sagittal alignment than their LOA counterparts. These slides can be retrieved under Electronic Supplementary Material.

PURPOSE: While there is a consensus that pelvic incidence (PI) remains constant after skeletal maturity, recent reports argue that PI increases after 60 years. This study aims to investigate whether PI increases with age and to determine potential associated factors. METHODS: 1510 patients with various spinal degenerative and deformity pathologies were enrolled, along with an additional 115 asymptomatic volunteers. Subjects were divided into six age subgroups with 10-year intervals. RESULTS: PI averaged 54.1 degrees in all patients. PI was significantly higher in the 45-54-year age group than 35-44-year age group (55.8 degrees vs. 49.7 degrees ). There were significant PI differences between genders after age 45. Linear regression revealed age, gender and malalignment as associated factors for increased PI with R 2 of 0.22 (p < 0.001). CONCLUSIONS: PI is higher in female patients and in older patients, especially those over 45 years old. Spinal malalignment also may have a role in increased PI due to increased L5-S1 bending moment.

PURPOSE: A comprehensive understanding of normative sagittal profile is necessary for adult spinal deformity. Roussouly described four sagittal alignment types based on sacral slope, lumbar lordosis, and location of lumbar apex. However, the lower limb, a newly described component of spinal malalignment compensation, is missing from this classification. This study aims to propose a full-body sagittal profile classification in an asymptomatic population based on full-body imaging. METHODS: This is a retrospective analysis of a prospective single-center study of 116 asymptomatic volunteers. Cluster analysis including all sagittal parameters was first performed, and then ANOVA was performed between sub-clusters to eliminate the non-significantly different parameters. This loop was repeated until all parameters were significantly different between each sub-cluster. RESULTS: Three types of full-body sagittal profiles were finalized according to cluster analysis with ten radiographic parameters: hyperlordosis type (77 subjects), neutral type (28 subjects), and compensated type (11 subjects). Radiographic parameters included knee angle, pelvic shift, pelvic angle, PT, PI-LL, C7-S1 SVA, TPA, T1 slope, C2-C7 angle, and C2-C7 SVA. Age was significantly different across compensation types, while BMI and gender were comparable. Age-matched subjects were randomly selected with 11 subjects in each type. ANOVA analysis revealed that all parameters but PT and C2-C7 angle remained significantly different. CONCLUSIONS: The current three compensation types of full-body sagittal profiles in asymptomatic adults included significant changes from cervical region to knee, indicating that subjects should be evaluated with full-length imaging. All three types exist regardless of age, but the distribution may vary.

Objectives: Hip arthroscopy for femoroacetabular impingement (FAI) and related hip pathology is increasing in volume. Variable presentations of hip pain often lead to confusion with lumbar spine pathology however. We sought to define the relationship between the lumbar spine and the hip joint. Our hypothesis is that patients with concurrent lumbar spine pathology will experience inferior outcomes after hip arthroscopy when compared to patients without lumbar spine pathology. Methods: Prospectively-collected data from a single-surgeon database from 2010 to 2014 was used to identify patients who had undergone hip arthroscopy and had documented concurrent lumbar spine pathology. Patients with spine pathology were matched by age, gender, and BMI in a 3:1 fashion to patients without spine pathology. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to scores at two-year follow-up. "Poor outcome" of initial hip arthroscopy was defined as any combination of: requiring a revision procedure, conversion to THA, or mHHS below 70. Results: 167 patients met inclusion criteria: 72.5% were "normal" while 27.5% had spine pathology. Baseline demographics were appropriately matched between cohorts (Table I). Preoperative and two-year mHHS scores were significantly different between cohorts (Figure 1). Both cohorts demonstrated significant within-group improvement at two-year follow-up, however normal patients had greater improvements than those with spine pathology (34.0 vs 31.76, p<0.001). Overall revision/THA conversion rate for entire cohort was 14.97%, with nearly twice as many spine co-pathology patients requiring additional surgery than those in the normal cohort (23.91% vs 11.57%, p=0.045). Patients with spine pathology were significantly more likely to have "poor outcomes" than those without spine pathology (36.96% vs 21.49%, p=0.048). Conclusion: Our results demonstrate that patients undergoing hip arthroscopy with concomitant lumbar spine pathology demonstrate significantly lower total improvement, significantly higher revision/THA conversion rates and significantly higher rates of suboptimal outcomes after hip arthroscopy than patients without spine pathology. (Table Presented) (Figure Presented)

Pelvic tilt is an essential parameter in spinal deformity surgery and in acetabular positioning for total hip arthroplasty. However, the measurement of tilt varies between the hip and spine literature. Hip surgeons measure the anterior pelvic plane tilt, whereas spine surgeons measure the spinopelvic tilt. This study uses stereoradiography (EOS imaging SA, Paris, France) to assess the relationship and the inter-observer and intra-observer reliability of measuring these two common references for pelvic tilt. Retrospective analysis of full-body, standing stereoradiographic studies of 100 patients with varying degrees of spinal deformity was performed at a single institution. Assessment of anterior pelvic plane and spinopelvic tilt were undertaken by two orthopaedic surgeons and two orthopaedic residents using validated software. The pelvic incidence and sacral slope were also measured. The mean difference between anterior pelvic plane and spinopelvic tilt was 13.98° ± 7.04°, and the values were linearly inversely related. Both measures of tilt were strongly correlated with each other. Spinopelvic tilt has greater inter- and intra-user reliability and was a more precise measurement than anterior pelvic plane. Spinopelvic tilt is a more precise and reliable measurement than the anterior pelvic plane tilt; however, both measurements are strongly correlated. The clinical implications of this are not completely understood; however, it may be important for hip surgeons when placing acetabular components with precision. Further investigation is needed to assess which is a more accurate reference for the placement of acetabular components in hip arthroplasty.

BACKGROUND CONTEXT: Patients with degenerative lumbar stenosis (DLS) adopt a forward flexed posture in an attempt to decompress neural elements. The relationship between sagittal alignment and severity of lumbar stenosis has not previously been studied. PURPOSE: We hypothesized that patients with increasing radiological severity of lumbar stenosis will exhibit worsening sagittal alignment. STUDY DESIGN: This is a cross-sectional study. PATIENT SAMPLE: Our sample consists of patients who have DLS. OUTCOME MEASURES: Standing pelvic, regional, lower extremity and global sagittal alignment, and health-related quality of life (HRQoL) were the outcome measures. METHODS: Patients with DLS were identified from a retrospective clinical database with corresponding full-body stereoradiographs. Exclusion criteria included coronal malalignment, prior spine surgery, spondylolisthesis>Grade 1, non-degenerative spinal pathology, or skeletal immaturity. Central stenosis severity was graded on axial T2-weighted magnetic resonance imaging (MRI) from L1-S1. Foraminal stenosis and supine lordosis was graded on sagittal T1-weighted images. Standing pelvic, regional, lower extremity, and global sagittal alignment were measured using validated software. The HRQoL measures were also analyzed in relation to severity of stenosis. RESULTS: A total of 125 patients were identified with DLS on appropriate imaging. As central stenosis grade increased, patients displayed significantly increasing standing T1 pelvic angle, pelvic tilt, sagittal vertical axis, and pelvic incidence-lumbar lordosis (p<.05). No significant difference wasfound in pelvic incidence, supine lordosis, thoracic kyphosis, or T1 spinopelvic inclination between central stenosis groups. Despite similar supine lordosis between stenosis groups, patients with Grades 2 and 3 stenosis had less standing lordosis, suggesting antalgic posturing. Upper lumbar (L1-L3) stenosis predicted worse alignment than lower lumbar (L4-S1) stenosis. Increasing severity of foraminal stenosis was associated with reduced lumbar lordosis; however, no significant postural difference in lordosis, thoracolumbar, or lower extremity compensatory mechanisms were noted between foraminal stenosis groups. Stenosis grading did not predict worsening HRQoLs in central or foraminal stenosis. CONCLUSIONS: Severity of central lumbar stenosis as graded on MRI correlates with severity of sagittal malalignment. These findings support theories of sagittal malalignment as a compensatory mechanism for central lumbar stenosis.

Study Design: Retrospective analysis. Purpose: Our hypothesis is that the surgical correction of adolescent idiopathic scoliosis (AIS) maintains normal sagittal alignment as compared to age-matched normative adolescent population. Overview of Literature: Sagittal spino-pelvic alignment in AIS has been reported, however, whether corrective spinal fusion surgery re-establishes normal alignment remains unverified. Methods: Sagittal profiles and spino-pelvic parameters of thirty-eight postsurgical correction AIS patients