Basically, this is sort of the last of the different lectures, and what I'm going to try to do is try to wrap up and amalgamate all the different things that you've heard during the course of the week. As neurosurgeons, I think many of you get encouraged to come to these different courses. And it's funny, in our own program, the number of people that, quote, had no interest in spine who I get a call two months or six months or a year or continuously get called from some of these people who didn't pay as much attention during the course of their residency, who suddenly went out thinking that they were going to do nothing but brain tumors or do nothing but pediatric cases or, on the other hand, think that everybody, like some of their attendings, has a practice where everybody walks through the door with giant cervical disc herniations and lumbar disc herniations are what they see day in and day out. The fact is, they have kind of a rude awakening, and they suddenly realize that most people that you're going to see have something wrong with them that's more complicated than that. Now, 82% of all surgical procedures performed by neurosurgeons in 2011 were spine operations. The fact is, there's just not that many brain tumors, and there's just not that many aneurysms to clip or coil, and actually, the coiling, most of your neurology colleagues who do about half your training are out and about. They're the ones who are scooping them all up right now anyway. Almost 60% of all spine procedures in the United States are done by neurosurgeons. Who do you think did that? One's from AANS, and one is from analysis of a Medicare database that one of the companies had done to go and determine how much resources they wanted to give for neurosurgery education versus orthopedic education. That's from a white paper they put together. Basically, what's happening is, is that if you're going to do spine, and most of you are going to at least do some of it, there's some deformity in almost any spine surgery that you do. At least having an understanding of the deformity principles, I think, will help you from screwing things up. This number continues to grow and grow and grow. This goes out through 2007, but this was the number of adult scoliosis surgeries that were done compared to primary brain tumors treated versus aneurysms clipped. I think that aneurysm clip now has almost disappeared off the screen. What happens, these are all deformity cases. You look at it, some of them are extremely simple. At least in my training, when I was a resident, we essentially never got a plain x-ray. Somebody had to have a grade four spinal ascesis to get a plain x-ray. For many of these things, if you don't stand somebody up and take the x-ray, you don't know to the degree of deformity is there. One of the things which you always have to do is, we look at a patient like this, when this patient is someone in her mid-70s who's fairly debilitated, doing back pain. The question is, is it worth putting her through doing something like this in somebody that's in their 70s? That's what we're going to talk about. Typically in deformity, it used to be thought it was sort of a singular condition. In fact, there are a lot of subtypes, and each of these subtypes have distinctly different natural histories. The surgical strategies for them are different, and it's really important to go and separate between these. The first of one is the people that you heard about Pete talking about, about kids with untreated scoliosis, kids who are untreated as adolescents who have scoliosis as adults. The fact is that most of these people who have idiopathic scoliosis, the biggest thing until they get at least into the late 50s and 60s, is really a cosmetic issue. Some people just don't like the way that they look. There's a type of scoliosis that people have no deformity until they're in their 40s or 50s. That kind of scoliosis is the most common one. And then there are scoliosis that are present that are due to previous treatment. Someone removes portions of the facet joints or does something else to destabilize the spine and results in deformity. So this here is someone who's in her late 20s, was unhappy with her appearance. She had some breast asymmetry, other problems that went on, and it really was, if you talk to people and you say, well, we really shouldn't do surgery unless you're having pain, if it's just cosmetic, they'll eventually come back and say, I've got pain, I've got pain, I've got pain, until you eventually operate on them. And you treat these people like that you would an idiopathic case. And you can see, as Bob had mentioned earlier, these are kind of satisfying cases to do. They're much more flexible. It's kind of an easy surgery. There's not the same work in it. The people are healthier. And it leads to some of the attractiveness of this type of surgery. But on the other hand, if you don't make them look better, if you do not do an operation that goes and levels the shoulders and makes the ribs, the rib hump go away and whatnot, they're not going to be very happy with what you've done for them. Now what happens is, and this is used by a lot of the insurance carriers, is if you look at people who had scoliosis, just much like Dan's study that looked at the long-term results of Sherman's kyphosis, the fact is people with untreated idiopathic scoliosis actually do pretty well for their lives. They have a little bit more back pain. Their back pain's a little bit more severe. But most of these people have had thoracic curvatures. And the fact is, the impact on life is relatively minimal. And this is why a lot of people say, hey, you really shouldn't be treating adults with scoliosis. Because in fact, they do pretty well. Well, like everything, there's always sort of extremes. And for example, this lady here, whose parents, she was a Mennonite, and her parents really weren't much for medical treatment. And you looked at this lady here, who was in her 50s, who was severely debilitated by the scoliosis. She didn't have treated as a child, and it resulted in a pretty big operation to be able to go and to fix that. Now the most common scoliosis is a degenerative scoliosis. This is a consequence of disdegeneration. It's the same cascade of events that leads to degenerative spondylolisthesis and other conditions. And there's a very heavy interaction between them. For example, for people with degenerative scoliosis, about half of them will have at least one level of degenerative spondylolisthesis. A lot of people will develop some rotatory translation of the spine that occurs. And these degenerative changes really make it common that they have neurological symptoms. That's why it's really frequent that these people come to the neurosurgery clinic because they're complaining of, in addition to back pain, leg pain, and other symptoms. What happens is, is if you look, as people in their 30s begin to get disdegeneration in their 50s, they begin to develop facet joint changes. More commonly in men, they just go on and develop a stable ankylosis. But more commonly in women, they develop things where they develop spondylolisthesis and deformity that occurs. And again, this is sort of a typical picture, and this is a person in their late 60s who had had a straight spine, at least as well as she knew, until she was about 50 years old and began to notice some changes. And you can see the extensive amount of arthritic changes that are present, and again, a relatively bigger operation needed to go in to correct that condition. What happens, and why is it going to impact you even more than it's impacting someone like me or with Bob, is that the population is aging. And so what's happening is, is that over the next 25 years, the number of people that are 65 or older are going to increase by 125%. And even people older than 80 is going to markedly increase. And one of the things which is so funny is so many medical conditions that years ago people would have ignored. For example, if you were 55 years old and you tore your anterior cruciate ligament, you know, 20 years ago, no one would operate on that. And that's actually the fastest growing procedure in the United States is ACL repair in patients older than 50. Because people want to be able to play tennis, they want to be functional, they're not happy to lay around in bed, and there's going to be an increasing demand, right or wrong, for people who want to be treated for conditions like degenerative scoliosis. Now what happens is this is an extremely common condition. It used to be thought to be uncommon because most of the population studies that were done years ago were done in people who, young adults, for example, who got things like abdominal x-rays in the emergency room or other things, and they looked at a big series of them. And what happened is they thought the scoliosis was present somewhere around 4 or 5% of the population. The reason why, these were younger people who had untreated idiopathic scoliosis and didn't take into account the people who had these degenerative changes later in life. A recent study by Frank Schwab looked at it, and he had asymptomatic adults who got standing x-rays, and those people older than 70, 70% of them had some component of scoliosis defined as a curve greater than 10 degrees. What happens is the natural history between untreated idiopathic scoliosis and degenerative scoliosis is markedly different. Untreated idiopathic scoliosis for low-level curves, curves under 40 degrees, almost never progress. It can't happen, but it's usually, it's very unusual. On the other hand, people who go and have degenerative scoliosis as adults, developing in adults, actually will develop relatively rapid progression. And one study showed that it's somewhere between 3 and 5 degrees a year. This is a patient that I followed over the time of my career from about my first day in practice out till she's still alive and I'm still seeing her. But this is a lady who was seen in her late 50s really with back pain, and it actually didn't even have the definition of scoliosis at that point. I saw her about five years later and she had a bit worse of a curve and here we are after a little bit more time, but you can see by the time she was 70, she had a pretty substantial curve and also had some spinal stenosis and had complaints of severe back pain and neurogenic claudication. So I initially did kind of a limited operation and three years later, her pain increased and she developed a junctional problem and I extended her up. And now this lady is in her late 80s and still clicking along. So what's the impact of adult scoliosis is pretty significant. There was just a, we just presented at NASS this last year, that people who have scoliosis and sagittal imbalance more than 10 centimeters are the single most disabled group of adults. It's having greater disability than having bilateral above knee amputations. It's the single greatest thing that's present and that's why these patients do come to your office because they are having severe problems due to this condition. Basically this was a study that we looked at people, younger people with scoliosis and older people with scoliosis, and the bottom line from this thing was that the younger people came because they didn't like the way they looked and the older people came because they were so disabled due to their condition and they're really distinctly different groups of patients. One of the other things which we found is that there's a really high incidence of neurological compromise with people with degenerative scoliosis. This was a study that we did looking at patients of changed of mind and Justin and Kai Ming Fu really did this. What they did is they had a radiologist independently go and look at patients with degenerative scoliosis that were coming to be seen by me and the radiologist went and graded each level to the degree of central canal stenosis and neural foraminal stenosis. What we found was that patients with at least one level of severe stenosis was present 97% of the patients and almost half of them had at least one level of severe central canal stenosis and this leads to a pretty significant degree of symptoms. This is again going through there and there are really 25% of the people have a significant weakness grade four or worse and the number of patients with neurogenic claudication is relatively high. What's happening is that we used all of these different things to have a basic understanding that it's kind of a bad condition but who's going to do well and who's not going to do well took a little bit more refinement. For you guys if you ever want just sort of a nice overview you've gotten some of the different lectures but this is an article review article was put together by Chris Ames. It was e-published initially in March of 2012 it's now it's actually the JNS website is June of 2012. It's a free article and there's lots of different videos on it and I'm going to show a couple of those videos in the course of course of my talk. So what's happening was if you went in 15 or 20 years ago if you went to a meeting about orthopedic deformity surgeons they would they would be also all over the board as far as who how you would treat them and what kids needed treatment and which kids didn't need treatment. And there was recognized that there were certain factors that were important you know the curve severity how skeletally mature all the things that Pete talked about talked about this morning. But what happened was Larry Linke and a group of people went and looked at it as systematically to go and try to figure out how to go and operate on these people what signs were the most worrisome. And if you go to a meeting now there's usually a relatively uniform approach to treating most of these different most of these different kids. You know there are a few you know out there examples sometimes people will do a little bit of a shorter fusion and not get as successful a correction to spare motion segments. But most people you know over 85 percent of people operate in the same manner. Now what's happening in adults over a long time it was thought you could treat them treat them like like they did kids. And what happens is all the things that are so important in decision making in children and adolescents mean absolutely nothing in as far as adult decision making is concerned. And so what is recognized is it doesn't almost matter what the curve looks like at least the coronal curve. It doesn't matter a lot of different factors are really it comes down to how much pain someone has and how much disability they're having. You know whether they can't you know walk to the out to the car to their mailbox is really important. And there were some initial attempts to go and try to classify adult scoliosis. They really failed miserably because they kept on looking at factors that were really important in adolescence but not important in adults. So this began to change when there was a realization that why people did poorly was directly related to how much energy they were expending. What happens is if you're standing in a normal comfortable position you're a young person you know you can go and stand for hours literally and do it relatively comfortable. All of us in the operating room it's not like we all have to sit down if we have a big case we'll sit there for six or seven hours and usually do it do it pretty well. And the reason why is the human body is really uniquely configured to allow people to stand with with with using almost no calories. And what's happening it was it's been it's begun to be realized over time that that that that that if you go and you put yourself in a position where you begin to stand in a less efficient position less efficient posture that it really goes and creates a tremendous amount of energy expenditure. In this particular study they actually used an oxygen utilization if someone stands out perfectly upright they use minimal oxygen but the amount of calorie expenditure it does to stand up in a bent posture is quite high. And there were several studies sort of the most famous one was by Steve Glassman who looked and saw almost a direct linear correlation between the amount of pain someone had and how imbalanced they were. This is a paper a patient of mine that I treated now over 10 years ago but this lady at that time had an ODI of 72 and she was relatively young and and I went and did an operation and I remember this is when I first came to UVA and people said oh my god you're truly you're going to do a fusion with somebody that's 48 years old and do this kind of a fusion on them. They thought it was insane. But if you look her ODI at 24 months was 13 okay and just by getting her up in a good position she's certainly not flexible, she's not going to be a ballerina, but the fact is, by getting her in a normal position, it makes it so that her pain level was markedly reduced. This has been shown by a variety of different things that this is important. What's happening is a group called the Spine Deformity Study Group that I was involved in, and subsequently something called the International Spine Study Group. We wanted to do an evaluation to do some predictive modeling to go and try to predict how well people are going to do either before or after surgery, depending upon a variety of different clinical factors. We actually looked at over 36 different factors and put them into our models and did some initial pilot studies, then bigger and bigger studies, and we went and began to realize that sagittal imbalance was important, but that wasn't the total amalgamation of how well people did. In our predictive modeling, the best we could get is into the low 70s as far as predicting how symptomatic they were. So basically what we realized is that we were missing some vital component, and that vital component was the interplay between the spine and the pelvis. If you look at the scatter plot here, this is the correlation that's present between what your lumbar lordosis is and your pelvic incidence is if you're a young person. It's almost perfect, and those two lines are the 10-degree lines above and below. So basically it was recognized that if you knew what somebody's pelvic incidence was, you knew what their lumbar lordosis was as a young person. Well basically to this same thing, what we realized that for a lot of people, the initial reaction to be able to go and try to compensate for a loss of lumbar lordosis and becoming sagittal imbalanced was to rotate your pelvis to get up in an upright posture. So we knew that there was interplay between what's called the pelvic tilt and between overall alignment. So basically you've heard all this over the last couple days. We recognize that pelvic incidence is a fixed parameter and basically dictates what someone's lumbar lordosis is going to be. What happens is that those people who inherently have a more vertically placed sacrum or people who have less need for lumbar lordosis and less thoracic kyphosis, those people who have a more horizontal placement of their sacrum in their pelvis need more lumbar lordosis to be able to compensate for that. This just shows the different kind of morphotypes that are present, and again, depending upon what that relationship is between the sacrum and within the pelvis. You can see how the spine configuration changes due to those different factors. Here's someone with a very horizontal pelvis, and you can see the much greater lumbar lordosis. The second thing is something called the pelvic tilt, and you guys, Justin, had you draw that the other day, and the fact is what happens is you can retrovert your pelvis to be able to stand upright, but it does result in some energy expenditure. You can see here, here's this patient here, and what they're doing is they're retroverting their pelvis to stand upright, and again, this is something that results in significant energy expenditure. Here's a person here that I operated on a few years ago, and you look and you see the person's not horrifically saggily imbalanced, but is doing a significant degree of pelvic retroversion. Anytime you see somebody on their x-ray and their sacrum is completely straight up and down, that's not a normal situation. Someone's putting a lot of energy into doing it, and again, this is the operation I did with a subtraction osteotomy to be able to go do it, and you can see now with a pelvic tilt of 18 degrees within the normal range, that patient's putting a lot less energy to go and stand upright, and this sort of demonstrates these principles here, so basically, the patient's going and retroverting their pelvis to be able to get into an upright position and making some other changes in the thoracic spine and in their necks to try to be able to get upright by losing their thoracic kyphosis and hyperextending their neck, and you see the patient bending their knees and their hips to try to be upright, and this is why these people have sort of global overall pain. So what's happening is that the Scoliosis Research Society is part of a group that went and tried to systematize this, and what we found looking at this was that basically by looking at the factors of how much the mismatch is between their pelvic incidence and their lumbar lordosis, what their global spinal alignment is, how much they're retroverting their pelvis by measuring their pelvic tilt, that we can really go and now predict very accurately greater than 92% how much symptoms someone's going to have with deformity. On the other hand, if we restore these to normative values, how well someone's going to do after the surgery. So what we know now is that we can go and get their sagittal vertical axis near their sacrum, if we can go and reduce their pelvic tilt to under 25, maybe even under 20, and we can go and make their lumbar lordosis proportional to their pelvic incidence, that these people are going to do well. And again, this is sort of a typical adult deformity patient that I've operated on and with my goals and achieved that, and the patient did pretty well. And this is, again, just sort of study after study, saying this is not theoretical. This is, in fact, in truth, real. Now the next thing that comes into play is to say, okay, maybe you've convinced me that you can help people with this, but is it cost-effective? Now everybody in society is looking at these different treatments and saying, hey, is it worth it? So we did a pilot study for something for an NIH grant that we eventually ended up getting, and what we did is we looked at the cost of non-operative treatment, and what we found in this is that for those people who elected not to go undergo surgery, we followed them over a two-year period of time, and what we found was, for people who had symptoms of an ODI of 40 or greater, that it cost $14,000 over a two-year period to do non-operative treatment. And unfortunately, these people, despite maximum non-operative treatment, continued to deteriorate as far as their pain and function was concerned. Again, this is a study that looked, comparing operative to non-operative. This is another sub-analysis, the same group of patients. What you saw was people that ended up electing for surgery at the end of two years were markedly improved, whereas the non-operative patients continued to deteriorate, despite it being relatively costly for them. And again, here's just another patient with adult deformity. So basically, just going through here, these are looking at best and worst outcomes. This is probably the most important slide of the whole talk. So this is Justin's work, looking at some study group patients, and what happened is we looked at patients that were young, that were middle-aged, and who were elderly, and our big thing was, is it worth doing this in this older group of patients? And if you look at the literature, the complications for elderly patients can be pretty extreme. And our hypothesis was it might not be worth it to do these big surgeries on these old people. So what we ended up finding, what we ended up finding was that, as been previously reported, the number of complications, particularly in the elderly, were pretty sobering. We had a 71% complication rate if you took minor and major complications together. But we found, which we suspected, that the patients who were the oldest were also the ones who were the most symptomatic. And these patients had pretty severe disability due to their condition. And the fact was, despite having all these complications at two years, the outcomes for all three groups, young, middle-aged, and elderly, were exactly the same. So despite them having complications, they were people who did just as well as their younger counterparts. If you wanted to go and ask which group had the highest patient satisfaction, it was this group here, because you did such a big change in their condition. So despite them being really, really, really, really bothered by this, that it was a pretty substantial improvement in their lives. So basically, how does this all come together? I'm just going to show this one last case, just another part of the talk, but I'm going to end it after this last case. But this was a 67-year-old executive. This was kind of the epiphany for me back some years ago about all of these different concepts. So this 67-year-old had a little hemilaminectomy years ago. But he was the former CEO of a Fortune 50 company that came to Charlottesville to retire. And he said, look, I just can't stand up. He goes, I'm fine. If I'm sitting at my desk, I'm OK. But I basically came to retire to play some golf and to do some other things. And he goes, I can't even stand up for five minutes at a cocktail party. As soon as I stand for a couple of minutes, my back starts hurting, my legs start quivering, and I am just absolutely, absolutely miserable. So he went and was coming to me, actually, for a fourth opinion. So he saw a couple of other guys in town, and he went up to Northern Virginia and got an opinion. And this is what a CT myelogram was. And so he was told by one surgeon that he needed a three-level intraspinous process device for his spinal stenosis. He saw another person and said that he needed a three-level laminectomy and facetectomy. His pain was all due to neurogenic claudication. That's why when he stood up, he had trouble. And he said, look, if I go and I, he did say, if I lean on something, bend all the way forward, like lean on a shopping cart, I can walk a little bit better if I support myself on the cart. And then he went to another person who wanted to do a two-level trans-psoas fusion on the patient. So what happened is I looked at this guy, and at that time, I wasn't quite as sophisticated. But if you look here, if you look at this patient here, he's got a little bit of scoliosis, and that's why he was sent to me. And the person actually was going to do the three-level laminectomy, sent him to me saying, hey, does he need to be fused if I do the laminectomy or not? But if you look here, if you look here, and I'll do the gentleman in the front in the white shirt. So his lumbar lordosis is six degrees, and his pelvic incidence is 58 degrees. What should his lumbar lordosis be? Within 10. Pardon me? Within 10. Within 10 degrees of that, right. So his lumbar lordosis should be at least 48 degrees. So you can see there's a huge mismatch. Now if you look, his sagittal vertical axis is 5.4 centimeters. What's that? Is that, what's that? That's pretty close to normal, right? So but if you look at his pelvic tilt, that's 36. What should that be? Less than 20. Less than 20. Okay. So what's happening is this guy here, if you took, we took this x-ray, you know, he got up out of the chair and went over and got his x-ray, but what would have happened to this guy if you made him stand for 20 minutes is he would have gradually leaned forward like that because everything would have tired out and he would have gone forward. So the fact is, is just this x-ray without taking a look at the hips really markedly underestimates this guy's deformity. And so what happens is for each of your practices, you know, most of the people you work with, the guys who are just going to go look at the CT myelogram, if you just saw this and you didn't see his upright x-rays and I've got, I've got, my legs get tired when I stand or walk too long, what would you do for him? You might be prompted to do a laminectomy as well, okay? So what happened was is that, you know, using all these different things that we talked about and using this SRF classification, you can see even though that he's pretty significantly symptomatic in his classification, he's pretty high up on all the different parameters. So I know in my mind if I'm going to treat him for deformity, okay, and he may have a component of neurological symptoms, but if I'm going to treat him for deformity, what I need to know is I have to achieve these alignment objectives. So what happens if I do a decompression alone, that three-level laminectomy, what do you think that's going to do to his overall alignment? Probably make it worse, okay? If I put three interspinous spacers in, which each gives five degrees more kyphosis at each level, how do you think that's going to do for him? Probably not really very, very well. Now the fact is is that there are some people who can get some good lordosis restored with a trans-PSOAS procedure, but if you look at the literature, for those people who do only stand-alone trans-PSOAS procedures, none of them get any additional lordosis. So for me, at least, and I went and told them, I said, well, look, you need to have this big fusion done, and this is what I ended up doing, this is about, again, this is about nine years ago. And basically, when I did this operation on him, I suggested this to him, he just looked at me and said, like I was crazy, he goes, one guy said, I'll be back playing golf in four days, and you're telling me you're going to do an operation where I'm going to spend 10 days in the hospital and all this different stuff, but eventually, I sort of, you know, for whatever reason, he eventually sort of trusted what I said, and we did this, and I think, I forget what his ODI is, it's pretty little, eight was his ODI upon the completion of the procedure. So what I want to do is just have you guys keep this in mind when you go back. You know, we don't want to have it too over the top, you know, if you go back and tell every single one of your patients, got a disc herniation, telling your attendings that you need a 36-inch film and you won't do the operation, and your attendings are criminals, then I'll get a bunch of nasty emails, so we don't want to do that. But what I would suggest to you, whenever you're seeing clinic and somebody's just doing terribly, okay, terribly, so for whatever operation they did, for example, this guy here, if he had a three-level laminectomy, he'd have come back, you know, four months or six months later, and it would have been doing terribly, okay, and if you go and suggest for those people to get a long cassette x-ray and draw out all the measurements that you've learned over the last couple days, you're going to see many, many of those people, the reason why they're doing so terribly is because they're really profoundly mild-lined, and there is, you know, at times, the solutions for, you know, what's been done. So hopefully, during the course of this, this last couple days, it's given you a taste, at least, of some of the procedures and some concepts that, you know, even if you don't want to do it, you can certainly do some things to try to prevent, you know, disasters from happening. And as a general rule, you know, the belief that when you're doing a fusion operation that you should get things back to a physiological level of lumbar lordosis, if nothing else, for lumbar procedures is really something that is important and that you guys should take back to your decision-making. And the last thing is, you know, if you're going to do a fusion, you may not even need to get a 36-inch film, but you do need to get an upright x-ray that has their hips on it so you can see what their lumbar lordosis is and what their pelvic incidence is. What happens is, you know, if you have somebody that's got an 18 or 20-degree mismatch between the two of them, that doesn't mean you have to do a great big deformity operation, but you sure as heck don't want to do an operation that gives them less lumbar lordosis when you complete the procedure than before. You want to move them closer to what's ideal. If you do that and you take this back, I think you're going to find that your outcomes from surgical procedures are much better. And I'm going to tell you my own practice, you know, 10 years ago, I probably had a third of my patients that didn't really do that well, and probably when Charlie came through, it may have been 20% of my patients, and it's probably 10% of them now. And it's just because learning to see these factors and adding these different concepts to your practice and continually refining this continues to make things better and better. So hopefully this has given you guys a bit of an overview, and if you have any questions, let me know.

adult scoliosis

neurosurgeons

spine surgeries

deformity

types of scoliosis

sagittal imbalance

SRF classification system