Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S28S

STUDY DESIGN/SETTING: Retrospective study design. Predictor vari-ables include patient demographics, curve characteristics (end vertebra,magnitude), and surgical strategy (fusion levels, approach (A/P vs Poste-rior only)).PATIENT SAMPLE: Consecutive patients undergoing surgery for themanagement of degenerative scoliosis in the lumbar spine.OUTCOME MEASURES: Outcome variables include radiographic pa-rameters and self-assessment of outcome using SF-36 and SRS instruments.METHODS: Correlation analysis to determine relationship between surgi-cal strategy and outcomes including self-assessment scores and compli-cations.RESULTS: 27 patients, 21 females, 6 males, average age 63.6 (range40–81). Clinical follow-up averaged 54.9 months (range 24–129), andradiographic follow-up averaged 34.9 months (range 1–97). Pre-operativelumbar lordosis improved to –42 degrees in the combined surgery group,and was unchanged with posterior only surgery. Lumbar curves averaged28 degrees (range 10–58) preoperatively, and 20 degrees (8–40) at mostrecent follow-up. Kyphosis at the thoracolumbar junction (T12-L2) was5.2 degrees preoperatively and did not change significantly at most recentfollow-up. 8/27 patients required revision surgery (3/7 combined A/P,5/20 PSF only). 7 patients underwent revision surgery for proximal exten-sion of arthrodesis, and one patient had a hardware removal. 5/10 (50%)patients fused to a cephalad level below the measured Cobb required revisionsurgery for proximal extension of arthrodesis, and one patient had progres-sive sagittal decompensation not requiring revision surgery. 2/6 (33%)patients fused to L4 have radiographic changes and symptoms consistentwith subjacent segment degeneration and stenosis. Post-op SF-36 and SRS-29 scores were available on 15 patients. Bodily pain and physical functionscores were lower than age-adjusted norms, while general health was equal.The SRS-29 outcomes instrument demonstrates average post-operativescores of: Pain�3,3, Function�3.5, Mental Health�4.1, Self-image�

3.5, overall satisfaction�3.8. 89% of patients felt that surgery improvedtheir pain, and 67% of patients felt that surgery improved their function. Thisstudy was unable to demonstrate a significant relationship between surgicalstrategy and clinical outcome score.CONCLUSIONS: Fusion of the measured Cobb levels is the most reliablestrategy for the operative management of degenerative scoliosis. Leavingmobile segments above L5 may result in symptomatic subjacent stenosis.Combined anterior/posterior surgery led to a more significant increase inlumbar lordosis than posterior only surgery. No difference in outcome wasdemonstrated for posterior only compared with combined surgery.DISCLOSURES: No disclosures.CONFLICT OF INTEREST: No Conflicts.

doi: 10.1016/j.spinee.2004.05.051

8:3651. Fusions to the sacrum and pelvis in adult spinal deformityMatthew Mermer, MD1, Oheneba Boachie-Adjei, MD2, BernardRawlins, MD2, Melissa Peskin, BA3, Ramil Bhatnagar, MD4; 1CornellUniversity, New York, NY, USA; 2Hospital for Special Surgery, NewYork, NY, USA; 3NY, USA; 4Hospital for Special Surgery, New York,NJ, USA

BACKGROUND CONTEXT: The treatment of adults with scoliosis hasbeen the source of much debate over the last three decades. Pain associatedwith curve progression and decompensation is the most common presentingscenario and surgical management is often indicated. Correction of thesedeformities may involve long segment fusions to the sacrum and pelvis.Although the literature evaluating long fusions to the pelvis in adultscoliosis is relatively sparse, most authors have reported high rates ofcomplications associated with this procedure. There remains little consensuswith regard to the treatment of this challenging condition.PURPOSE: The purpose of this study was to evaluate one surgeon’sexperience at one institution with long fusions to the sacropelvis.STUDY DESIGN/SETTING: This study was a retrospective chart andradiographic review which included 97 consecutive adult patients who

underwent elective surgical reconstruction for nonparalytic spine deformityover the period between August 1994 through December 2000. The patientswere treated by a single surgeon at a single institution with one primarymethod of reconstruction. Patient outcome data was also measured.PATIENT SAMPLE: The inclusion criteria for this study required patientsolder than 21 years at the time of surgery, a continuous fusion from T11 orproximal to the sacropelvis, a diagnosis of nonparalytic adult deformity, andat least two years of follow-up. Posterior Isola segmental instrumentation tothe sacrum and at least one ilium was used in all but two patients.OUTCOME MEASURES: Each patient was asked to complete a self-perceived outcome questionnaire created by the National Spine Network(NSN).METHODS: Inpatient and outpatient charts were reviewed for 97 patients.The information reviewed included patient age, gender, comorbidities, intra-operative and postoperative parameters. The questionnaire is a one-page,10-question form used for long-term follow-up evaluation of patients afterspine surgery. This form is a part of a patient outcomes questionnairecreated by the National Spine Network (NSN). Standing radiographic coro-nal and sagittal measurments were recorded preoperatively, immediatelypostoperatively, and at the most recent follow-up visit (minimum two yearspost-operatively).RESULTS: Between August 1994 and December 2000, 97 patients under-went surgery from T11 or higher to the sacropelvis by a single surgeon atone institution. Two patients had fixation to the sacrum without extensioninto the ilium. There were 89 women and 8 men enrolled in the study.There were 103 complications in 67 patients. Fifteen of these patients hadmultiple complications. Structural curves averaged 53 degrees preopera-tively, 32 degrees postoperatively, and 33 degrees at follow-up. Coronalimbalance averaged 2.9 cm preoperatively, 2.4 cm postoperatively, and 2.3cm at follow-up. Sagittal imbalance averaged 6.8 cm preoperatively, 2.9cm postoperatively, and 3.6 cm at follow-up. Fifty-four patients (73%of respondants) would choose to have the same treatment if placed backin time.CONCLUSIONS: Treatment of adult spinal deformity carries a significantcomplication rate even amongst the most experienced surgeons. There doesnot appear to be an increased complication rate in revision surgery. Themost common complication was related to the pelvic instrumentation. Coro-nal and sagittal balance appear to play a pivitol role with respect to eventualclinical outcome. Favorable objective results and patient derived outcomemeasures are common in spite of an inherently high complication rate.DISCLOSURES: Device or drug: Isola Segmental Spinal Intrumentation.Status: Approved for this indication.CONFLICT OF INTEREST: Author (OB) Consultant: Depuy Spine, Inc.

doi: 10.1016/j.spinee.2004.05.052

Thursday, October 28, 20043:50–4:20 PM

Concurrent Focused Reviews 1A: Diagnostics

3:5052. Usefulness of the anterior-posterior cervical spine radiograph inthe initial trauma evaluationGordon Li1, Jon Hald2, Jonathan Hartman2, Kee Kim2*; 1Universityof California, Davis, Sacramento, CA, USA; 2University of California,Davis, CA, USA

BACKGROUND CONTEXT: Acute traumatic spinal cord injury affects12,000 to 14,000 people in North America each year and can cause devasta-ting consequences. Appropriate clinical and radiographic assessment isvital to the proper management of these patients. Currently the “three-wayview” (lateral, open-mouth odontoid, and AP radiographs) is recommended

Proceedings of the NASS 19th Annual Meeting / The Spine Journal 4 (2004) 3S–119S 29S

functional lateral radiographs of the lumbar spine in the standing position,if range of motion for intervertebral space is 15 �or over or slipping degreeof vertebral body is 3mm or over, the patient should be diagnosed as havinginstability. According to the criteria, 28 of 67 patients were diagnosed ashaving instability and 39 were diagnosed as not having instability.METHODS: Regarding the PLE Test, the authors instructed patients lieon the bed in the prone position and lifted both legs concurrently to the heightof about 30cm from the bed while maintaining the knees extended andgently pulling the legs and thus those who developed severe lumbarand gluteal pain were diagnosed as positive in PLE Test. The location andcondition of pain complained by the patient, pain of hip joint or related painof femoral nerve were cautiously differentiated. We investigate the sensitiv-ity and specificity of the PLE Test.RESULTS: Of the 28 patients diagnosed as having instability based onthe X-ray findings, 26 patients were tested positive in PLE Test. Of the39 patients diagnosed as not having instability based on the X-ray findings, 33patients were tested negative in PLE Test. The data suggest the sensitivityand specificity of the PLE Test is 92.3% and 84.6%, respectively.CONCLUSIONS: The Passive Lumbar Extension Test, a new diagnostictool is considered to be a convenient method that enables orthopaedists toassess lumbar spinal instability easily.DISCLOSURES: No disclosures.CONFLICT OF INTEREST: No Conflicts.

doi: 10.1016/j.spinee.2004.05.054

3:5854. Importance of deformity apex in adult lumbar scoliosis: amulticenter radiographic and health status analysisFrank Schwab1, Jean-Pierre Farcy2, Sigurd Berven3, Steven Glassman4,Keith Bridwell5, William Horton6; 1Maimonides Medical Center,Brooklyn, NY, USA; 2New York University, New York, NY, USA;3University of California, San Francisco, San Francisco, CA, USA;4University of Louisville, Louisville, KY, USA; 5Washington Universityin St. Louis, Saint Louis, MO, USA; 6Emory University, Atlanta, GA,USA

BACKGROUND CONTEXT: Classification systems and prognostic pa-rameters based on radiographic parameters have been outlined for adoles-cent idiopathic scoliosis. Such information is lacking for adult scolioticdeformities although recent studies have reported radiographic criteria with

for radiographic evaluation of the cervical spine in patients who are symp-tomatic after traumatic injury (Neurosurgery, March 2002 Supplement).However, it has been suggested that the AP view can be dropped from theinitial screening of cervical spinal injury because of low sensitivity (Holli-man et al, 1991). Others have claimed that lateral radiograph alone will misscervical spine injuries detected on a three way series (Cohn et al, 1991and Shaffer and Doris, 1981) and therefore the AP view necessary.PURPOSE: The purpose of this study is to evaluate the usefulness of theAP view as part of the initial radiographic evaluation of the cervical spinetrauma patient. The elimination of the AP radiograph in the acute traumascreening could save time in the initial assessment of the patient, wouldreduce radiation and could lead to significant cost savings.STUDY DESIGN/SETTING: This was a retrospective study.PATIENT SAMPLE: Trauma patients with cervical spine fracture, dislo-cation, or cord injury treated at University of California, Davis MedicalCenter (UCDMC), a level 1 trauma center, from January 2003 throughSeptember 2003 were reviewed.OUTCOME MEASURES: Whether the diagnosis was changed after re-viewing the AP view was the outcome measure.METHODS: Original radiographs from the initial trauma screening wereobtained from these cases and sequentially presented to two board certifiedneuroradiologists at UCDMC. Three way views in which there were noabnormalities were added randomly to serve as controls. The radiologistsfirst reviewed the lateral cervical spine and odontoid views and made adiagnosis based on these two films together. Swimmer’s and Fuch’s viewswere reviewed if needed. Finally the AP view was viewed and any changein diagnosis was noted.RESULTS: 49 cervical spine injuries and 9 control cases were reviewed.In 3/49 cases, a fracture was seen on the AP view that was not detected onthe other views. False positives were present on the AP radiograph in 6/49 cases, determined after review of the cervical spine CT of the patient.All nine of the control cases were read as negative after lateral and odontoidviews and one of the nine cases had a false positive reading of the AP view.CONCLUSIONS: In 6% of cases, fracture was detected on AP view only.Thus, caution should be exercised in considering removal of this view fromradiographic series used in the initial evaluation of cervical spine traumapatients. However the cost paid is that of a 12% false positive rate.DISCLOSURES: No disclosures.CONFLICT OF INTEREST: No Conflicts.

doi: 10.1016/j.spinee.2004.05.053

3:5453. A new evaluation method for lumbar spinal instability: passivelumbar extension testYuichi Kasai, Koichiro Morishita, Atsumasa Uchida; Mie University,Tsu, Mie prefecture, Japan

BACKGROUND CONTEXT: There is no clear definition about clinicalsymptoms associated with lumbar spinal instability and few researchershave discussed lumbar spinal instability based on physical findings. Noresearcher has assessed sensitivity or specificity of the physical findings.PURPOSE: The authors contrived Passive Lumbar Extension Test (PLETest) for assessing lumbar spinal instability by passively extending thelumbar spine and inducing pain. We discuss the usefulness.STUDY DESIGN/SETTING: A prospective clinical and radiographicstudy conducted by an independent observer was performed on 67 patientswith lumbar degenerative diseases.PATIENT SAMPLE: The study was conducted in 67 patients who under-went surgery for the diagnosis of lumbar spinal canal stenosis, lumbarspondylolisthesis and lumbar spinal degenerative scoliosis at the age ofbetween 39 and 76 years old (mean: 63.9 years old) at the author’s hospitalduring the period from 1998 to 2000 (male: 34, female: 33). They werefollowed for 2 years and 9 months in the average (2 year to 3 years and4 months).OUTCOME MEASURES: The authors made a diagnosis of lumbarspinal instability according to the following assessment criteria: In the

significant correlation to clinical symptoms.PURPOSE: To analyze correlation between lumbar scoliosis apex/endlevel and intervertebral subluxation with outcomes measures. This may laythe groundwork to a clinically useful classification.STUDY DESIGN/SETTING: Multi-center database review.PATIENT SAMPLE: All consecutively enrolled Spinal Deformity StudyGroup (SDSG) adult patients with scoliosis of the lumbar spine and apexL1, L2 or L3 (of degenerative or idiopathic origin). Apical levels below L3were excluded, as these were likely to represent fractional curves or focalrotatory subluxation.OUTCOME MEASURES: Oswestry Disability Index, Scoliosis ResearchSociety (SRS-29) instrument.METHODS: The study included 209 patients. For all subjects radiographicanalysis (from full-length standing films) included: apical level and lowerend level of the lumbar deformity, sagittal plane lumbar lordosis (L1–S1), spondylolisthesis (in mm.), frontal plane intervertebral olisthesis (inmm.). Subjects were divided into groups by apical level of the lumbarscoliosis and further subdivided by degree of lumbar lordosis, frontaland sagittal plane intervertebral subluxations. Statistical comparison (t-test) amongst subgroups in terms of ODI and SRS function/pain scoreswas made.RESULTS: For the 209 patients, distribution by apical level was as follows:L1�26, L2�113, L3�70. Significant differences between apex L1 andapex L3 subjects were found (L1: ODI mean 18, L3 ODI mean 28 p�0.015,L1 SRS pain 79, L3 SRS pain 64, p�0.006). Lumbar lordosis was signifi-cantly correlated with SRS function score (100 patients without lordosis