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Adult Spinal Deformity Classifi Cation: Frank Schwab Sigurd Berven Keith H. Bridwell
Adult Spinal Deformity Classifi Cation: Frank Schwab Sigurd Berven Keith H. Bridwell
Adult Spinal Deformity Classifi Cation: Frank Schwab Sigurd Berven Keith H. Bridwell
Frank Schwab
88 Sigurd Berven
Keith H. Bridwell
measures: Oswestry Disability Index (ODI), SRS, Short Form-12 CLASSIFICATION AND TREATMENT
(SF-12) instruments2:
Type I: thoracic-only scoliosis (no thoracolumbar or lumbar In an effort to analyze treatment by classification group, a pro-
component) spective study including 784 adult patients (18 years) with
Type II: upper thoracic major curve, apex T4-8 (with a thora- thoracolumbar (type IV) or lumbar deformity (type V) of the
columbar or lumbar curve) spine was pursued.11 Subjects were drawn from the SDSG
Type III: lower thoracic major curve, apex T9-T10 (with thora- database. The inclusion criteria included scoliotic curvature
columbar/lumbar curve) with minimal Cobb angle of 30 and apex of the major curva-
Type IV: thoracolumbar major curve, apex T11-L1 (with any ture in the thoracolumbar spine (type IV) or lumbar spine
other minor curve) (type V). Of the 784 patients, 339 were treated surgically
Type V: lumbar major curve, apex L2-L4 (with any other minor (43%). An analysis by gender revealed no significant differ-
curve) ences. Further analysis (Fig. 88.1) by Lordosis Modifier
Type K: deformity in the sagittal plane only revealed greater surgical rates for patients with moderate (B,
rate 37%) or no lordosis (C, rate 46%) than for patients
The type I in the SDSG database are the least symptomatic with marked lordosis (A, rate 51%). Analysis by Sublux-
while the type K are the most disabled. ation Modifier revealed greater surgical rates for patients with
Modifiers of the classification were established through pre- large subluxation (, rate 52%) than for patients with
liminary studies by Schwab et al and repeated database correla- moderate (, rate 42%) or no subluxation (0, rate 36);
tions. A parallel analysis by Glassman et al3,4 underlined the differences were significant between and 0 patients
primary importance of global sagittal balance in the setting of (p .05). Finally, patients with greater Sagittal Malalignment
adult deformity. In order to condense key parameters into a (VP, rate 58%) were more likely to receive surgical treat-
clinically useful approach, the modifiers integrated in the clas- ment than did patients with moderate (P, rate 46%) or
sification have been reduced to the following: neutral (N, rate 39%) sagittal alignment; differences were
significant (N vs. VP, p .002).
Global Balance Modifier: Sagittal plane offset; C7-posterosuperior
The data furthermore revealed significant association between
corner S1
modifiers and surgical technique/strategy (Table 88.3):
N (Normal): 0 to 4 cm
P (Positive): 4 to 9.5 cm Role of curve Type (apex):
VP (Very Positive): 9.5 cm Thoracolumbar deformities (type IV) were more likely to
Lordosis Modifier: T12-S1 sagittal Cobb angle have circumferential procedure than lumbar deformities
A: Marked lordosis 40 (type V) (64% compared with 47%, p .007).
B: Moderate lordosis 0 to 40 Lordosis modifier:
C: No lordosis present Cobb 0 (Kyphosis) In terms of operative intervention, loss of lumbar lordosis
Subluxation Modifier: Frontal/sagittal plane; maximal value (modifier B and C) lead to increased osteotomy rates (A
0: No subluxation 26%, B 40%, C 57%, p .005). Modifier B and C
: Subluxation 1 to 6 mm patients also were treated more frequently by a posterior or
: Subluxation 7 mm circumferential surgical approach than anterior.
The cutoffs between groups within each modifier were deter- Subluxation modifier:
mined by the HRQOL measures, splitting the population Marked subluxation (modifier ) was associated with
into discreet groups by clinical impact of each modifier more circumferential surgery (65% compared with 46% for
parameter. 0 and combined, p .002)
60
50
40
30
20
10
0
Lordosis Subluxation Global Balance
Type
Sagittal balance modifier: Patients with no lordosis (modifier C) had the greatest dis-
Greater sagittal imbalance (modifiers P and VP) was associ- ability before surgery and the least disability 1 year following
ated with a higher rate of posterior-only surgery. Rates of surgery. In contrast, patients with marked lordosis (modifier
osteotomies also increased with increasingly positive sagittal A) had the least disability before surgery and the greatest
alignment (N 25%, P 41%, VP 55%, p .001). Fixa- disability 1 year following surgery.
tion to the sacrum was more likely to occur as sagittal align- Greater subluxation was associated with greater baseline dis-
ment became increasingly positive (N 61%, P 78%, ability and greater improvement in ODI score at 1 year.
VP 89%, p .001). Patients without subluxation (modifier 0) had higher base-
line scores and less improvement in score than patients with
marked subluxation (modifier ). These differences were
SURGICAL OUTCOME AND THE significant (p .003).
CLASSIFICATION Greater imbalance (P, VP vs. N) was associated with greater
baseline disability, and there was a trend toward greater
The classification was designed initially to categorize nonopera- improvement in ODI score at 1 year (p .09). This differ-
tively treated patients as well as preoperative patients. It is ence was significant in terms of improved SF-12 Physical
important, however, that postoperative patients can also be cat- Component Score (PCS) (p 02).
egorized into clinical groups based upon classification. Thus a Patients who had osteotomies had significantly lower scores
set of patients with 1- and 2-year postoperative follow-up were prior to surgery, but higher scores at 1 and 2 years. The inter-
analyzed. The clinical follow-up included 111 patients at 1 year action between SF-12v2 PCS scores and osteotomy status was
and 45 patients who had reached a minimum 2-year postopera- also significant, with patients who had osteotomies showing
tive follow-up and had complete radiographic and outcomes worse health status before surgery, but better health status at
questionnaires at the 1- and 2-year milestones. Analysis revealed 1 and 2 years following surgery (p .035).
that the classification modifiers were correlated with HRQOL Patients with sagittal balance of less than 40 mm (modifier N)
in the follow-up population. without fixation to the sacrum showed less disability preop-
In the outcomes analysis of the 1- and 2-year follow-up no eratively and continued to have the lowest ranking disability
significant difference was noted in outcome between the 1- and postoperatively. Patients with sagittal balance greater than
2-year mark. However, outcome was linked to surgical strategy, 95 mm (modifier VP) whose fixation stopped above the
and there was variation in improvement by classification sacrum showed the greatest disability before surgery, and
category: had worse postoperative versus preoperative scores.
A B
Figure 88.2. Case 1. (A) A 54-year-old woman with iatrogenic adult spinal deformity [K, B, 0, VP] (curve
type K: sagittal plane deformity, lordosis B, subluxation 0, sagittal alignment VP). SVA 159 mm,
L1-S 37, no sacropelvic fixation. (B) Improvement in classification modifiers; lordosis B A, sagittal
alignment VP N via L3 pedicle subtraction osteotomy. SVA 45 mm, L1-S 61, with pelvic fixation.
A B
Figure 88.5. Case 4: (A) A 54-year-old female patient [IV, C, 0, VP] (curve type IV: TL curve,
lordosis C, subluxation , sagittal alignment VP). SVA 245 mm, L1-S1 2, pelvic tilt 48.
(B) Improvement in classification modifiers; lordosis C A, sagittal alignment VP P via L4 pedicle
subtraction osteotomy. SVA 51 mm, L1-S 37, pelvic tilt 31, long fusion with pelvic fixation.
8. Lowe T, Berven S, Schwab F, Bridwell K. The SRS classification for adult spinal deformity:
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