When to operate on

Adult Scoliosis patients

and when to say No

Frank Schwab, MD
Jean-Pierre Farcy, MD
New York University School of Medicine

What is Adult Scoliosis?

What is Adult Scoliosis?

Coronal plane deformity
Sagittal plane deformity
Imbalance/malalignment
Focal
Regional
Global

Adolescent deformity in an adult

AISA
De-novo deformityof aging
DDS

Scoliosis
Prevalence
AIS

2-4% of screened pediatric population

Adult >60% of screened elderly population#

Demographics :
Life expectancy, birth rates.
Significant growth of aging population segment
# Schwab et al. SPINE 2005 May 1;30(9):1082-5

Adolescent Idiopathic Scoliosis:

surgical treatment
Curve severity
Cobb angle
progression

Classification
Lenke
King

Skeletal maturity
Risser sign

Curve pattern
apex
distribution
sagittal
overhang

Surgical
strategy

Adult Scoliosis Scoliosis:

treatment approach
Curve severity
Cobb angle
progression

Skeletal maturity
Risser sign

Classification
?

Cosmesis

Pain
Disability

PT
Pain Mgmt
Bracing
Surgery

The aging spine

Spine
skeletal
maturity

30s
disc degen.
MRI changes

50s
facet DJD
disc collapse

Stable spine
ankylosis

Unfavorable degeneration
stenosis

spondylo deformity

Adult Scoliosis

Progressive
collapse

Stable ankylosis

Adult Scoliosis / Deformity

What are the disability / pain generators ?
98 patients (Schwab,Farcy. SPINE 2004)
adult scoliosis, all levels
SF-36
radiographic-clinical analysis

325 patients (Schwab, Farcy. SDSG. SRS 2004)

thoracolumbar/lumbar scoliosis
SRS instrument, ODI
radiographic-clinical correlation

Adult Scoliosis : Clinical impact

Significant

Spondylolisthesis
Lateral Subluxation
Lumbar lordosis
Thoracolumbar
alignment
Apical level
Sagittal Balance (SVA)

Not significant
Coronal Cobb
Age
Adolescent vs. de-novo
degenerative scoliosis

Statistically significant: SRS-22, ODI, SF-12/36

Adult Scoliosis: the disability / pain generators

plain radiographs

Apical level of deformity (lumbar dominant)

Lumbar lordosis T12-S1
Maximal intervertebral subluxation (frontal/sagittal)
Sagittal balance (PlC7-S1 offset)

Selected for high clinical impact: SRS, ODI, SF-36

(excluding fractures or other
pathologies)

Classification of Adult Deformity

Schwab et al. SPINE 2006
Type

I
II
III
IV
V
Type K

thoracic-only curve (no other curves)

upper thoracic major, apex T4-8
lower thoracic major, apex T9-T10
thoracolumbar major curve, apex T11-L1
lumbar major curve, apex L2-L4
no scoli (<100), principal sagittal plane deformity

Lumbar Lordosis
Modifier

A
B
C

marked lordosis >400

moderate lordosis 0-400
no lordosis present Cobb >00

Subluxation
Modifier

0
+
++

no intervertebral subluxation any level

maximal measured subluxation 1-6mm
maximal subluxation >7mm

Sagittal Balance
Modifier

N
P
VP

normal, <4cm positive SVA

positive, 4-9.5cm
very positive, >9.5cm

Adult Scoliosis
947 patients: (86% female, 14% male)
Average age 48 years (SD 18)
Coronal Cobb mean 460 (SD 19)

ODI
Lordosis

Lordosis modifier A (< -40)

Lordosis modifier C ( >= 0)

Subluxation

Subluxation Modifier 0
Subluxation Modifier ++

Global
Balance

Oswestry
Mean
SD
p = 0.002
27
19
37

16

Oswestry
Mean
SD
p < 0.001
27
20
34

18

SRS
SRS Function
Mean
SD
p < 0.001
69
17
57

15

SRS Function
Mean
SD
p < 0.001
68
18
63

16

SRS Pain
Mean
SD
p = 0.007
65
20
56

17

SRS Pain
Mean
SD
p < 0.001
64
20
58

19

Adult Scoliosis / Deformity

Thus.deformity = disability ?

Yes, certain aspects

Focal: subluxation
Regional: loss of lordosis
Global: sagittal imbalance

Not coronal Cobb angle

Coronal/Sagittal

Sagittal plane

Adult Scoliosis / Deformity: Why surgery ?

Young adult: AISA

>500 thoracic
>300 lumbar (progressive)

Curve progression likely

Disability later (potential)
More difficult to treat later
Depending upon age

Surgical risks greater later

Progression with disability

Cosmetic concerns

Weinstein S,. Spine 24(24), 1999

Adult Scoliosis / Deformity: Why surgery ?

Older Adult:
AISA = DDS
Pain/disability
failed conservative care

Pain unacceptable
Disability unacceptable
Risk/Benefit ratio
- favorable

Adult Scoliosis / Deformity

If the justification for surgery is acceptable.

..when is it really reasonable to operate

?
Dont do it

Sure success

Adult Scoliosis / Deformity

Not a candidate for surgery:

young AISAno disability, mild/mod curve, happy

patient who does not want surgery
patient is unlikely to survive surgery
patient does not understand risk/benefit
unrealistic expectations

planned operation is not reasonable

experience, team, environment

Adult Scoliosis / Deformity

Possibly Excellent candidate for surgery:
young AISAprogressive, severe curve (>700)
DDS or AISA older adult:
Perfectly isolated pain generator, failed extensive non-operative care
Well informed, wishes to pursue operative care
Excellent health
Realistic expectations, highly motivated

team has abundant experience only excellent results with planned

intervention

Adult Scoliosis / Deformity

The common cases:

Patient might consider surgery with certain assurances

Health is acceptable (not ideal),
Pain generators present (there are several),
Non-operative care tried (variable participation and response),
Expectations are overall rather realistic.
The surgeon comfortable with intervention

When to operate on Adult Scoliosis patients and when to say No

How can we select the best patients for surgery ?

(and how to optimize the chances of a successful outcome)

non-operative care vs. surgery

If surgerywhich strategy/approach
Specific treatment algorithms lacking
few studies to guide us.where is the data ?

Adult Scoliosis: Thoracolumbar / Lumbar Deformity

Who gets surgeryand what type ?
Operative rates
Lordosis
Lost lordosis vs. good lordosis (B vs. A) 51% vs 37%, p<0.05

Subluxation modifier
Marked subluxation vs. none (++ vs. 0) 52% vs. 36 %, p<0.05

Sagittal Balance
Well balanced versus marked imbalance (N vs. VP) 39% vs.59%, p<0.05

(n=809)

Adult Scoliosis: Thoracolumbar / Lumbar Deformity

Who gets surgeryand what type ?

Use of osteotomies
Lordosis >400 lordo vs. no lordo : 25% vs. 50% p=0.01
Sagittal balance no imbalance vs. >9.5cm : 25% vs. 53% p=0.01
Surgical Approach
Anterior only: no lost lordosis, no subluxation
Circumferential: some lost lordosis, marked subluxation
Posterior only: marked loss of lordosis, marked sagittal imbalance

Fusion to sacrum
Lordosis
Sagittal Balance

Loss of lordosis more likely fusion to sacrum (p = .041)

increasing positive balance: more fixation to sacrum.
(<4cm: 59%, 4-9.5cm: 80%, >9.5cm: 88%) (all p<0.05)

Adult Scoliosis: Thoracolumbar / Lumbar Deformity

How about surgical outcomes ?

111patients 1-year follow up

45 patients 2-year follow up
Adult Thoracolumbar / Lumbar major curves
Surgical treatment, complete data
Full-length standing x-rays (0,12,24 months)
SRS, ODI, SF-12

2-year Surgical outcome: Lordosis modifier

Lumbar Lordosis
Modifier

A
B
C

marked lordosis >400

moderate lordosis 0-400
no lordosis present Cobb >00

Mean SRS Total Score at Baseline and Two Years by Lordosis

Modifier
80

70

60

Mean Score

50
Marked Lordosis
Moderate Lordosis
No Lordosis

40

30

20

10

0
Baseline

Two Year
Measurement Period

Lordosis modifier Cmost improved

2-year Surgical outcome: sagittal balance (surgical approach)

Sagittal Balance
Modifier

N
P
VP

normal, <4cm positive SVA

positive, 4-9.5cm
very positive, >9.5cm

Mean Oswestry Disability Index at Baseline and Two Years by Sagittal

Balance Modifier and Surgical Approach
60

50

Mean Score

40
<40 Anterior
<40 Circum
<40 Posterior
40 to 95 Circum
40 to 95 Circum
96+ Circum
posterior
96+ Circum

30

20

10

0
Baseline

Two Year
Measurement Period

N with anterior approach did worst (VP posterior-only also not so good)
P, VP did best with circumferential fusion

2-year Surgical outcome: sagittal balance (fixation to sacrum)

Mean SRS Total Score at Baseline and Two Years by Sagittal Balance
Modifier and Fixation to the Sacrum
90

80

70

Mean Score

60
<40 Without
<40 With
40 to 95 Without
40 to 95 With
96+ Without
96+ With

50

40

30

20

10

0
Baseline

Two Year
Measurement Period

VP without fixation to sacrum got worse

P and VP did best with fixation to sacrum (no difference for N)

2-year Surgical outcome: osteotomy or not ?

Mean SF-12v2 PCS at Baseline and Two Years by Osteotomy
50
45
40
35

Mean Score

30
No Osteotomy
Osteotomy

25
20
15
10
5
0
Baseline

Two Year
Measurement Period

Patients who had osteotomy did better !

Baseline to Two-Year Changes: Significant Interaction

ODI / SRS Total Score by lordosis
patients with no lordosis (C) greatest improvement,
Patients with marked lordosis (A) little or no improvement

ODI / SRS Total Score by sagittal balance by surgical approach

well balanced least disabled, fused short of sacrum did best

very imbalance (VP) most disabled and worse off if not fused to sacrum

SF-12v2 / SRS Total Score by Subluxation

significant subluxation (++,+) more improvement than no subluxation

SF-12v2 PCS / SRS Total score by Osteotomy Status

patients with osteotomy had lower baseline scores
At 2 years f/u, patients with an osteotomy had higher scores

Adult Scoliosis: Thoracolumbar / Lumbar Deformity

Follow-up data
When is improvement clinically significant ?
Set a bar of 10-point increase in SRS score
From 100pt. Scale

Assumption of patient perceived improvement

Minimal Clinically Important Difference
Berven et al.

Minimum 10 point SRS instrument improvement

Met Ten-Point SRS Improvement Criterion by Year and Gender
100%

100%

100%

90%

Percent Meeting Criterion

80%
69%

70%
62%
60%

One Year
Two Year

50%
40%
30%
20%
10%
0%
Female

Male

Gender

Minimum 10 point SRS instrument improvement

Met Ten-Point SRS Improvement Criterion by Year and Lordosis
Modifier
100%

100%

100%

90%
78%

Percent Meeting Criterion

80%
70%

67%
61%

60%

57%
One Year
Two Year

50%
40%
30%
20%
10%
0%
A - marked lordosis

B - moderate lordosis

C - No lordosis present

Lordosis Modifier

Loss of lumbar lordosisgreater likelihood of clinical success

Minimum 10 point SRS instrument improvement

Met Ten-Point SRS Improvement Criterion by Year and Sagittal
Balance Modifier
100%
88%

90%
80%

Percent Meeting Criterion

73%
70%
60%

73%

64%

63%

60%

One Year
Two Year

50%
40%
30%
20%
10%
0%
Under 40

40 to 95

96 and Greater

Sagittal Balance Modifier

At 2-yr follow up:

greater imbalance patients more likely to have successful outcome

Minimum 10 point SRS instrument improvement

Met Ten-Point SRS Improvement Criterion by Year and Osteotomy
100%
90%
80%

80%

Percent Meeting Criterion

73%
70%
60%

66%
59%
One Year
Two Year

50%
40%
30%
20%
10%
0%
No Osteotomy Performed

Osteotomy Performed

Osteotomy

Patients having osteotomies more likely to have successful outcome

Minimum 10 point SRS instrument improvement

Met Ten-Point SRS Improvement Criterion by Year and Baseline SF-12
PCS
100%
92%
90%
83%
78%

Percent Meeting Criterion

80%
70%

67%
58%

60%

58%

50%

44%

44%

One Year
Two Year

40%
30%
20%
10%
0%
Under 25

25 to Under 35

35 to Under 45

45 and Higher

Baseline SF-12 PCS

Patients with lower baseline scores more likely to achieve significant improvement

When to operate on Adult Scoliosis patients and when to say No

How can we select the best patients for surgery ?

(and how to optimize the chances of a successful outcome)

Can we predict who will have successful surgery ?

Predictive Models

Gender
Age
Apical Modifier
Lordosis Modifier
Subluxation Modifier
Sagittal Balance

Surgical Approach
Osteotomy
Fixation to Sacrum
SF-12v2 Physical Component Summary
SF-12v2 Mental Component Summary
SRS Total Score
Oswestry Disability Index

Outcome ?

Models to predict Clinical Improvement with Surgery

Strength of Predictive Models
Outcome Score
(meeting the
MCID threshold)

% Correct
Classification by
Model

Area Under ROC

Curve (.80 and above
is considered good
discrimination)

% of Surgical Cases
Failing to Meet
Criterion

SRS Pain

81.1%

.864

39.5%

SRS Appearance

75.4%

.838

33.3%

SRS
Pain and Appearance

78.1%

.845

53.5%

SF-12v2 PCS

77.9%

.862

47.6%

Follow-up data: Conclusions

The winners

Greater disability at start (SRS, ODI, SF-12)

Male
Subluxation >6mm
Lost lumbar lordosis <400
Osteotomy

Who benefits least

minimal baseline disability (SRS, ODI, SF-12)
No subluxation, no marked sagittal imbalance
Good lordosis, >400
Lack of osteotomy

When to operate on Adult Scoliosis patients and when to say No

How can we select the best patients for surgery ?

(and how to optimize the chances of a successful outcome)

Regional deformity

Global sagittal balance

SRS, ODI, SF-12

Surgical approach
gender

apex

Focal deformity

osteotomy

Adult Scoliosis / Deformity: next steps

Refine Classification

+
SRS
ODI
SF-12/36

Predictive outcomes model

Treatment Algorithm

Thank you.