F Schwab 1,2, JP Farcy 1,2, K Bridwell 2, S Berven 2, S Glassman 2,

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Presentation transcript:

F Schwab 1,2, JP Farcy 1,2, K Bridwell 2, S Berven 2, S Glassman 2, A clinical impact classification of scoliosis in the adult. A multi-center clinical and radiographic analysis F Schwab 1,2, JP Farcy 1,2, K Bridwell 2, S Berven 2, S Glassman 2, J Harrast 2, W Horton 2 1 Maimonides Medical Center, Orthopaedic Surgery, Division of Spinal Surgery 2 Spinal Deformity Study Group SRS 2005

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

Purpose Develop a reliable classification system for adult scoliosis validated through a large database Use radiographic criteria with significant correlation to clinical symptoms to develop a classification system for adult scoliosis

Materials and Methods Multi-center prospective study Inclusion Criteria scoliosis with apex T4 to L4 thoracic thoracolumbar, lumbar spine degenerative or idiopathic 947 consecutive patients Spinal Deformity Study Group Radiographic analysis full length, standing films Cobb angle, apical level of deformity, sagittal plane lumbar alignment Health assessment questionnaires ODI / SRS-29 Classification System Apical level Lumbar lordosis score Intervertebral subluxation score

1. Type 2. Modifiers Adult Scoliosis Classification Type I Type II Thoracic only Type II Upper Thoracic major Type III Lower Thoracic Type IV Thoraco-lumbar Type V Lumbar no other curves Apex T9-T10 T11-L1 L2-L4 2. Modifiers Intervertebral Subluxation 0 : none at any level + : max = 1-6mm ++ : max >7mm Lumbar Lordosis A : marked >400 B : moderate 0-400 C : no lordosis, Cobb >00

Classification Reliability ? Data Processing Classification Reliability ? Inter- and intra-observer analysis Excellent reliability : Type : k > 0.6 / 0.8 Lordosis & subluxation : k > 0.9 / 0.9 Xray parameters vs health scores ? Grouped by apical level, lumbar lordosis, subluxation t-test amongst subgroups in terms of ODI and SRS Xray parameters vs treatment ? Same radiological groups Surgical vs conservative rate ?

Results 1/2 T12-S1 lordosis Mean 46° (SD 25) Mean Age (±SD) and Mean Cobb Angle (±SD) amongst Curve type for 947 Patients T12-S1 lordosis Mean 46° (SD 25) Not obtainable in 85 cases 17 48 260 343 279 947 No lordosis Cobb >0 Moderate lordosis Cobb 0-40 Marked lordosis Cobb>40 n=44 n=261 n=557 Mean Max Intervertebral Subluxation Frontal plane : 4.2mm (SD 6.2) Sagittal plane : 1.2mm (SD 3.1) Division into categories No subluxation (n=526, Moderate subluxation/1-6mm (n=109) Marked subluxation/>7mm (n=299) Not obtainable in 13 cases

Results 2/2 Correlation between function / Curve Type / XRay parameter / Treatment Thoracic curves (Type I, II, III) Lower apical level & loss of lumbar lordosis (modifier A vs. C) Higher subluxation score (modifier ++ vs. O) => lead to significantly higher SRS pain scores Thoracolumbar (type IV) and lumbar major (type V) curves Loss of lumbar lordosis (modifier A vs. C) Higher subluxation score (modifier ++ vs. O) => significantly greater disability by ODI/SRS instruments ( p<0.01) Surgical rate vs Major curve Apical level upper thoracic (T4-T7) 37% lower thoracic (T8-T10) 39% thoracolumbar (T11-L1) 48% lumbar (L2-L4) 37%

Unique multi-center analysis of adult scoliosis Discussion Conclusion Unique multi-center analysis of adult scoliosis Xray parameters (lower curve apex and loss of thoracolumbar lordosis, loss of lumbar lordosis, frontal and sagittal intervertebral subluxation) correlated with health measures (ODI, SRS), Cobb angle did not [Schwab & al 2004-2005]. Previous study + updated findings of the SDSG database => Attempt at classification of scoliosis

References [Schwab & al 2004] [Schwab & al 2005] Deformity apex, thoracolumbar alignment, but not Cobb angle, determine disability in adult major thoracic scoliosis. IMAST2004 [Schwab & al 2005] Deformity apex, lordosis and olisthesis in Adult Scoliosis: correlation with disability. A multi-center radiographic and health status analysis. ISSLS 2005 [Spinal Deformity Study Group] Annual meetings : Chicago 2002, Arizona 2003, Chicago 2003, Miami 2004, San Diego 2005 [Book] O’Brien, M.F.; Kuklo, T.R.; Blanke, K.M.; Lenke, L.G.: Spinal Deformity Study Group – Radiographic Measurement Manual. Medtronic Sofamor Danek USA, Inc