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Under Correction of Sagittal Deformities Based on Age-adjusted Alignment Thresholds Leads to Worse Health-related Quality of Life Whereas Over Correction Provides No Additional Benefit

Scheer, Justin K., MD; Lafage, Renaud, MS; Schwab, Frank J., MD; Liabaud, Barthelemy, MD; Smith, Justin S., MD, PhD; Mundis, Gregory M., MD§; Hostin, Richard, MD; Shaffrey, Christopher I., MD; Burton, Douglas C., MD||; Hart, Robert A., MD∗∗; Kim, Han J., MD; Bess, Shay, MD††; Gupta, Munish, MD‡‡; Lafage, Virginie, PhD; Ames, Christopher P., MD§§; International Spine Study Group

doi: 10.1097/BRS.0000000000002435
DEFORMITY
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Study Design. Retrospective review of prospectively-collected database.

Objective. This study aims to compare 2-year clinical outcomes of patients who underwent surgical reconstructions based on their achievement to age-adjusted alignment ideals.

Summary of Background Data. Recent research in sagittal plane has proposed age-adjusted alignment thresholds. However, the impact of these thresholds on postoperative health-related quality of life (HRQOL) is yet to be investigated.

Methods. Patients were included if they were more than 18-years old and underwent surgical correction of adult spinal deformity with a complete 2-year follow-up. Patients were stratified into three groups based on achievement of age-adjusted thresholds in pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), and sagittal vertical axis (SVA). First group included patients who reached the exact age-adjusted threshold ± 10 years (MATCHED), other two groups included patients who were over corrected (OVER), and under corrected (UNDER). Clinical outcomes including actual value and offset from age-adjusted Oswestry Disability Index, Short-Form-36 (SF-36) -physical component summary, and Scoliosis Research Society-22r (SRS-22r) were compared between groups at 2 years follow-up.

Results. A total of 343 patients (mean, 57 yrs and 83% females) were included. Sagittal profile of the population was: PT = 23.6°, SVA = 65.8 mm, and PI-LL = 15.6°. At 2-year follow-up, there was significant improvement in all sagittal modifiers with 25.7%, 24.3%, and 33.1% of the patients matching their age alignment targets in terms of PT, PI-LL, and SVA, respectively. For PT and PI-LL, the three groups (MATCHED, OVER, and UNDER) had comparable values and offsets from age-adjusted patient reported outcome. However, for SVA groups, patients in UNDER had significantly worse HRQOL than the two other groups. Patients in PT, PI-LL, and SVA UNDER groups were significantly younger than the other groups, P < 0.05.

Conclusion. At 2 years after adult spinal deformity surgical treatment, only 24.3% to 33.1% of the patients reached age-adjusted alignment thresholds. Those under corrected in SVA demonstrated worse clinical outcomes. No significant improvements were found between matched and overcorrected patients, with overcorrection being an established risk for proximal junctional kyphosis. These results further emphasize the need for patient specific operative planning.

Level of Evidence: 3

Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL

Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, NY

Department of Neurosurgery, University of Virginia, Charlottesville, VA

§San Diego Center for Spinal Disorders, La Jolla, CA

Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, TX

||Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS

∗∗Swedish Neuroscience Institute, Seattle, WA

††Denver international spine clinic, Presbyterian St. Luke's Medical Center, Rocky Mountain hospital for children, Denver, CO

‡‡Department of Orthopedic Surgery, Washington University, St Louis, MO

§§Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA.

Address correspondence and reprint requests to Virginie Lafage, PhD, Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 523 East 72nd Street, New York, NY 10021; E-mail: virginie.lafage@gmail.com

Received 28 November, 2016

Revised 7 June, 2017

Accepted 26 June, 2017

J.K.S. and R.L. contributed equally to this work.

The manuscript submitted does not contain information about medical device(s)/drug(s).

DePuy Spine grant funds and individual donations for the International Spine Study Group Foundation were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants, royalties, stocks, and patents.

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