Classifications for Adult Spinal Deformity and Use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classification

Departments of Orthopedics, Rocky Mountain Hospital for Children, Presbyterian/St Lukes Medical Center, Rocky Mountain Scoliosis and Spine, 2055 High Street, Suite 130, Denver, CO 80205, USA. Electronic address: .
Neurosurgery clinics of North America (Impact Factor: 1.44). 04/2013; 24(2):185-93. DOI: 10.1016/
Source: PubMed


Adult spinal deformity (ASD) is a complex disease state that pathologically alters standing upright posture and is associated with substantial pain and disability. This article provides an overview of classification systems for spinal deformity, clarifies the need to differentiate between pediatric and adult classifications, and provides an explanation on the use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classification (SRS-Schwab ASD Classification). This information allows surgeons, researchers, and health care providers to (1) identify sources of pain and disability in patients with ASD and (2) accurately use the SRSeSchwab ASD Classification to evaluate patients with ASD.

Download full-text


Available from: Virginie Lafage, Oct 05, 2015
323 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose The alignment of the cervical spine is of primary importance to maintain horizontal gaze and contributes to the functional outcome of patients. Cervical spine alignment after correction of major sagittal imbalance has rarely been reported in the literature. Methods Retrospective review of 31 consecutive patients with sagittal plane deformities operated by lumbar pedicle subtraction osteotomy. Pre-operative and 3 months post-operative full-length radiographies were analyzed for spinopelvic and cervical-specific parameters. Results There was a significant increase in lumbar lordosis (LL), thoracic kyphosis, and sacral slope. There was also a significant decrease in pelvic tilt, pelvic incidence minus LL, knee flexion and sagittal vertical axis. The cervical analysis revealed that there was no significant difference between pre- and post-operative global cervical lordosis (CL) angle and external auditory meatus (EAM) tilt. There was a significant decrease of C7 slope and distal CL, while a significant increase in occipito-C2 (OC2) angle was observed. Conclusion LL restoration decreased the need of compensation at the pelvis and thoracic spine. The distal CL and C7 slope decreased because there was no need for compensation at this level after the surgery, but the proximal cervical spine takes a slightly flexed position to maintain horizontal sight. EAM tilt measures the head position toward C7, and is close to 0° even in severe cases. Changes of this parameter after surgery are insignificant, probably due to the balance between upper and lower cervical segments; when one of these segments shifts backward the other shifts forward and the result is a balanced head over C7.
    European Spine Journal 01/2015; 24(6). DOI:10.1007/s00586-014-3738-4 · 2.07 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Cervical Deformity (CD) is prevalent among patients with adult spinal deformity (ASD). The effect of baseline cervical alignment on achieving optimal thoracolumbar alignment in ASD surgery is unclear. This study assesses the relationship between pre-operative cervical spinal parameters and global alignment following thoracolumbar ASD surgery at 2-year follow up. A retrospective review of a multi-center, prospective database. Surgical ASD patients with 2-year follow-up and cervical x-rays. The outcome measure was radiographic parameters and self-reported HRQL measures (SF-36, ODI and SRS-22). Surgical ASD patients over the age of 18 with scoliosis ≥20° and one of the following radiographic parameters were included: SVA ≥5cm, pelvic tilt ≥25° or thoracic kyphosis >60°. SRS-Schwab sagittal modifiers (PT, GA, PI-LL) were assessed at 2-year post-op as either normal ("0") or abnormal ("+" or "++"). Patients were classified in the Aligned Group (AG) or Malaligned Group (MG) at 2-year follow-up if all 3 sagittal modifiers were normal or abnormal, respectively. Patients were assessed for CD based on the following criteria: C2-C7 SVA >4cm, C2-C7 SVA <4cm, cervical kyphosis (CL >0), cervical lordosis (CL <0), any deformity (C2-C7 SVA >4cm OR CL >0), and both CD (C2-C7 SVA >4cm AND CL >0). Univariate testing was performed using t-tests or chi square, looking at the following pre-op parameters: CD, C2-C7 SVA, C2-T3 SVA, CL, T1S, T1S-CL, C2-T3 angle, LL, TK, PT, C7-S1 SVA, and PI-LL. No study funding sources are related to this clinical study. The International Spine Study Group (ISSG) is funded through research grants from DePuy-Synthes and individual donations. 104 patients met initial inclusion criteria with 70 in the AG group and 34 in MG. Pre-op, patients in the MG group had a higher cervical lordosis (11.7 vs 4.9, p=0.03), higher C2-T3 angle (13.59 vs 4.9 p=0.01), higher PT (p<0.0001), higher SVA (p<0.0001), and higher PI-LL (p<0.0001) compared to the AG group. Interestingly, the prevalence of CD at baseline was similar for both groups. There was no statistically significant difference among groups in the amount of improvement over 2 years on the ODI or the SF-36 PCS. Patients with sagittal spinal mal-alignment associated with significant cervical compensatory lordosis are at increased risk of realignment failure at 2 year follow up. Assessment of the degree of cervical compensation may be helpful in preoperative evaluation to assist in realignment outcome prediction. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 04/2015; 15(8). DOI:10.1016/j.spinee.2015.04.007 · 2.43 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT Three-column osteotomies (3COs) are technically challenging techniques for correcting severe rigid spinal deformities. The impact of these interventions on outcomes reaching minimum clinically important difference (MCID) or substantial clinical benefit (SCB) is unclear. The objective of this study was to determine the rates of MCID and SCB in standard health-related quality of life (HRQOL) measures after 3COs in patients with adult spinal deformity (ASD). The impacts of location of the uppermost instrumented vertebra (UIV) on clinical outcomes and of maintenance on sagittal correction at 2 years postoperatively were also examined. METHODS The authors conducted a retrospective multicenter analysis of the records from adult patients who underwent 3CO with complete 2-year radiographic and clinical follow-ups. Cases were categorized according to established radiographic thresholds for pelvic tilt (> 22°), sagittal vertical axis (> 4.7 cm), and the mismatch between pelvic incidence and lumbar lordosis (> 11°). The cases were also analyzed on the basis of a UIV in the upper thoracic (T1-6) or thoracolumbar (T9-L1) region. Patient-reported outcome measures evaluated preoperatively and 2 years postoperatively included Oswestry Disability Index (ODI) scores, the Physical Component Summary and Mental Component Summary (MCS) scores of the 36-Item Short Form Health Survey, and Scoliosis Research Society-22 questionnaire (SRS-22) scores. The percentages of patients whose outcomes for these measures met MCID and SCB were compared among the groups. RESULTS Data from 140 patients (101 women and 39 men) were included in the analysis; the average patient age was 57.3 ± 12.4 years (range 20-82 years). Of these patients, 94 had undergone only pedicle subtraction osteotomy (PSO) and 42 only vertebral column resection (VCR); 113 patients had a UIV in the upper thoracic (n = 63) orthoracolumbar region (n = 50). On average, 2 years postoperatively the patients had significantly improved in all HRQOL measures except the MCS score. For the entire patient cohort, the improvements ranged from 57.6% for the SRS-22 pain score MCID to 24.4% for the ODI score SCB. For patients undergoing PSO or VCR, the likelihood of their outcomes reaching MCID or SCB ranged from 24.3% to 62.3% and from 16.2% to 47.8%, respectively. The SRS-22 self-image score of patients who had a UIV in the upper thoracic region reached MCID significantly more than that of patients who had a UIV in the thoracolumbar region (70.6% vs 41.9%, p = 0.0281). All other outcomes were similar for UIVs of upper thoracic and thoracolumbar regions. Comparison of patients whose spines were above or below the radiographic thresholds associated with disability indicated similar rates of meeting MCID and SCB for HRQOL at the 2-year follow-up. CONCLUSIONS Outcomes for patients having UIVs in the upper thoracic region were no more likely to meet MCID or SCB than for those having UIVs in the thoracolumbar region, except for the MCID in the SRS-22 self-image measure. The HRQOL outcomes in patients who had optimal sagittal correction according to radiographic thresholds determined preoperatively were not significantly more likely to reach MCID or SCB at the 2-year follow-up. Future work needs to determine whether the Schwab preoperative radiographic thresholds for severe disability apply in postoperative settings.
    Journal of neurosurgery. Spine 06/2015; 23(3):1-9. DOI:10.3171/2014.12.SPINE141031 · 2.38 Impact Factor