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A clinical impact classification of scoliosis in the adult. A multi-center clinical and radiographic analysis

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

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A clinical impact classification of scoliosis in the adult. A multi-center clinical and radiographic analysis

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  1. 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 Surgery2 Spinal Deformity Study Group SRS 2005

  2. Unlike pediatric and adolescent scoliosis, no acceptedclassification systemexists for adult scoliosis Background • Scoliosis in the adult population • prevalence as high as60% • significant pain and disability • Quality of life issues • Classification systems provide • Commonlanguagefor communication • Correlation withclinicalimpact • treatment algorithms • surgical guidelines

  3. Develop a reliable classification system for adult scoliosis validated through a large database Purpose Use radiographic criteria withsignificant correlation to clinical symptomsto develop a classification system for adult scoliosis

  4. Materials and Methods • Classification System • Apical level • Lumbar lordosis score • Intervertebral subluxation score 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

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

  6. 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 byapical level, lumbar lordosis, subluxation • t-testamongst subgroups in terms ofODIandSRS • Xray parameters vs treatment ? • Same radiological groups • Surgicalvsconservativerate ?

  7. Results 1/2 No lordosis Cobb >0 Moderate lordosis Cobb 0-40 Marked lordosis Cobb>40 n=44 n=261 n=557 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 • 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

  8. 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 ratevs Major curveApical level • upper thoracic (T4-T7) 37% • lower thoracic (T8-T10) 39% • thoracolumbar (T11-L1) 48% • lumbar (L2-L4) 37%

  9. 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

  10. References • [Schwab & al 2004] • 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

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