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Optimizing Outcomes in Scoliosis and Complex Spinal Surgery

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 25 October 2025 | Viewed by 2022

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Dr. Francis C. Lovecchio

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Guest Editor

Department of Spine Surgery, Hospital for Special Surgery, New York, NY 10021, USA
Interests: spine surgery; adult degenerative scoliosis; degenerative disc disease; herniated discs; kyphosis

Special Issue Information

Dear Colleagues,

Correction of adult spine deformity (ASD) often requires a substantial surgical insult, subjecting patients to an arduous, prolonged, and uncertain recovery that can compromise the value of the procedure. The first step of recovery is to avoid medical complications, which occur in 30-50% of patients undergoing ASD reconstruction. Once out of the hospital, randomized trials have shown that it takes patients 6 months to reach 50% of their expected improvement, and only half of patients reach the minimal clinically important difference in many patient reported outcomes. Reoperations for mechanical failures (approximately 20-30% at two-year follow-up) and neurologic complications (up to 10%) are two major reasons that patient outcomes may remain unsatisfactory. If these outcome and complication rates continue, third-party payors will inevitably begin limiting who can perform and who can receive complex spine surgery.

We may tackle this problem in several ways. First, understanding why complications occur is crucial. There remain critical knowledge gaps in how we understand spinal alignment, patient-level risk factors, and modes of instrumentation failure. Second, we must come to a consensus on surgical technique. There are infinite strategies available to the modern spine surgeon, and we must determine which techniques are worthwhile. Finally, we must embrace a systems-based approach. Multidisciplinary pre-, intra-, and post-operative care protocols may have a greater impact on patient outcomes than the execution of the surgery itself.

In this issue, you will find several original works and literature reviews that fit into one of the three approaches listed above, but all with the same goal—helping to optimize outcomes in scoliosis and complex spine surgery.

Dr. Francis Lovecchio
Guest Editor

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Keywords

outcomes
complications
scoliosis
adult spinal deformity
proximal junctional kyphosis
complex spine
pseudarthrosis

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10 pages, 506 KiB

Open AccessArticle

How Much Variance Exists Among Published Definitions of Proximal Junctional Kyphosis? A Retrospective Cohort Study of Adult Spinal Deformity

by Tim T. Bui, Karan Joseph, Alexander T. Yahanda, Samuel Vogl, Miguel Ruiz-Cardozo and Camilo A. Molina

J. Clin. Med. 2025, 14(15), 5469; https://doi.org/10.3390/jcm14155469 - 4 Aug 2025

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Abstract

Background/Objectives: We sought to characterize the variance and overlap among definitions of Proximal Junctional Kyphosis (PJK) used in the adult spinal deformity (ASD) literature. PJK is defined as excess in PJK angle, a Cobb angle between the upper-instrumented vertebra (UIV) and a supra-adjacent vertebra (SAV), either one (UIV+1) or two (UIV+2) levels rostral of the UIV. No expert consensus exists for threshold angle or which SAV to use. Methods: A total of 116 thoracolumbar fusion patients ≥ 65 years old were reviewed. The UIV+1 and UIV+2 angles were measured. Six definitions of PJK from the literature were evaluated. These definitions were selected based on citation frequency, historical relevance, and accessibility through commonly used databases. Pearson’s Chi-squared and pairwise comparisons were performed to evaluate the distinctness and agreement rates among these definitions. Results: The six definitions of PJK were as follows: [PJK20] PJK angle ≥ 20° with UIV+2 as the (SAV), [PJK10] PJK angle ≥ 10° with a >10° change from pre-op with UIV+2 as the SAV, [PJK2SD] PJK angle > 2 standard deviations from average with UIV+1 as the SAV, [PJK10+10] PJK angle ≥ 10° with a >10° change from pre-op with UIV+1 as the SAV, [PJK15] PJK angle > 15° with UIV+1 as the SAV, and [PJK30] PJK angle > 30° with UIV+2 as the SAV, or displaced rod fracture, or reoperation within 2 years for junctional failure, pseudoarthrosis, or rod fracture. [PJK10] and [PJK2SD] were the most distinct definitions while [PJK20], [PJK10+10], [PJK15], and [PJK30] showed no significant pairwise differences. [PJK2SD] was stringent, while definition [PJK30] included unique diagnostic information not captured by other definitions. Conclusions: The use of [PJK20], [PJK10+10], [PJK15], or [PJK30] is recommended for consistency, with [PJK15] presenting the best balance. Stringent [PJK2SD] may be beneficial for identifying severe PJK, though with low sensitivity. Overall, PJK definitions must be standardized for the consistent reporting of clinical outcomes and research comparability. Full article

(This article belongs to the Special Issue Optimizing Outcomes in Scoliosis and Complex Spinal Surgery)

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14 pages, 2334 KiB

Open AccessArticle

Balance or Strength? Reconsidering Muscle Metrics in Sagittal Malalignment in Adult Sagittal Deformity Patients

by Donghua Huang, Zhan Wang, Mihir Dekhne, Atahan Durbas, Tejas Subramanian, Gabrielle Dykhouse, Robert N. Uzzo, Luis Felipe Colón, Stephane Owusu-Sarpong, Han Jo Kim and Francis Lovecchio

J. Clin. Med. 2025, 14(10), 3293; https://doi.org/10.3390/jcm14103293 - 9 May 2025

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Background/Objectives: Atrophy of the paraspinal and psoas major muscles is closely linked to sagittal malalignment in adult spinal deformity (ASD). However, most studies overlook the balance between these muscle groups. This study investigates the relationship between trunk muscle balance and sagittal alignment in ASD patients. Methods: A single-institution database was reviewed for patients with sagittal malalignment (PT > 20° and PI–LL > 10°). Standard sagittal parameters were measured based on standing X-rays. The cross-section area (CSA) of trunk posterior muscles (CSA^P: erector spinae and multifidus) and anterior muscles (CSA^A: psoas) at L4 were measured based on a T2-weighted MRI. Patients with prior lateral fusions were excluded. Muscle balance was evaluated by the CSA ratio of trunk posterior to anterior muscles (CSA^P/A). The relationship between sagittal alignment parameters and CSA^P, CSA^A, as well as CSA^P/A were analyzed using linear and quadratic regressions. Akaike information criteria (AIC) compared model fit. Subgroup analyses examined the relationship between sagittal alignment changes and different CSA^P/A levels. Results: A total of 112 patients met inclusion and exclusion criteria. CSA^P correlated linearly with SS (r² = 0.057, p = 0.011), PT (r² = 0.043, p = 0.028), and T4–L1PA mismatch (r² = 0.044, p = 0.027). CSA^A showed no significant linear or quadratic relationships with sagittal spinal alignment parameters. In contrast, CSA^P/A was quadratically associated with LL (r² = 0.056, p = 0.044), SS (r² = 0.134, p < 0.001), PI (r² = 0.096, p = 0.004), L1PA (r² = 0.114, p = 0.001), and T4–L1PA mismatch (r² = 0.094, p = 0.005). Quadratic models of CSA^P/A consistently had higher r² and lower AIC values compared to the linear models of CSA^P for most sagittal alignment parameters, especially in SS, PI, L1PA, and T4–L1PA mismatch (AIC difference ≥4). Higher CSA^P/A is correlated to larger PI (and consequently, larger LL, SS, and L1PA). Conclusions: Trunk posterior–anterior muscle balance (CSA^P/A) demonstrates a stronger relationship with sagittal alignment than individual muscle metrics. Quantitative MRI-based definitions of sarcopenia may need to be adjusted for PI. Full article

(This article belongs to the Special Issue Optimizing Outcomes in Scoliosis and Complex Spinal Surgery)

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12 pages, 1901 KiB

Open AccessArticle

A Feasibility Study of a Controlled Standing Fulcrum Side-Bending Test in Adolescent Idiopathic Scoliosis

by Christian Wong, Christos Koutras, Hamed Shayestehpour, Benny Dahl, Miguel A. Otaduya and John Rasmussen

J. Clin. Med. 2024, 13(24), 7809; https://doi.org/10.3390/jcm13247809 - 20 Dec 2024

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Abstract

Background/Objectives: Spinal flexibility radiographs are important in adolescent idiopathic scoliosis (AIS) for clinical decision-making. In this study, we introduce a new method, the ‘quantitatively controlled standing fulcrum side-bending’ test (CSFS test). This is a feasibility study; we aimed to quantify the applied force and track the temporospatial changes in the spine specifically by measuring the continuous change in the Cobb angle (in degrees) during lateral bending. Methods: In this cross-sectional study, we included patients with AIS. Using a low-dose cinematic fluoroscopic technique, we captured the lateral bending of the thoracolumbar vertebral spine while inducing quantified lateral force on the ribs by a force gauge in a three-point fixation setup of controlled lateral bending. Trial registration number: H-1703423. Results: Twenty-one patients with small-curve AIS were included as subjects. All subjects performed the CSFS test adequately. They had small curves with a mean Cobb angle of 12.0 (range: 0.0–26.0, SD: 7.1). The measured median stiffness was 3.66 N/degrees (°) of the Cobb angle (range: 0.02–11.81) with a median coefficient of determination R² of 0.58 (range: 0.002–0.92) by regression analyses. When analysed concerning the median-term clinical outcome of either progression/regression or stationary curves, various Cobb angle measurements and the other experimental parameters, there were no significant relationships. Conclusions: The CSFS test is feasible to quantify the force applied and the temporospatial changes in the spine during lateral bending. The CSFS test has been utilised in basic research for mechanical characterisation of the scoliotic spine and has the potential of being implemented directly in patient-specific bracing to estimate the forces needed for brace correction and adjustment so as not to supersede the allowed skin pressure. Full article

(This article belongs to the Special Issue Optimizing Outcomes in Scoliosis and Complex Spinal Surgery)

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19 pages, 2246 KiB

Open AccessSystematic Review

The Association of Poor Preoperative Mental Health and Outcomes After Surgical Correction of Adult Spinal Deformity: A Systematic Review and Meta Analysis

by Yifei Sun, Hariteja Ramapuram, Riyaz Razi, Mohammad Hamo, Sasha Howell, Nicholas M. B. Laskay, Jovanna Tracz, Anil Mahavadi, James Mooney and Jakub Godzik

J. Clin. Med. 2025, 14(15), 5516; https://doi.org/10.3390/jcm14155516 - 5 Aug 2025

Abstract

Background/Objectives: Adult Spinal Deformity (ASD) is a pathologic malalignment of the spine that can lead to significant reductions in quality of life, functional limitations, and increased morbidity. While poor mental health is commonly observed among patients undergoing ASD surgery, its impact on surgical outcomes remains poorly understood. We conducted a systematic review and meta-analysis to examine the association between preoperative mental health and outcomes following surgical correction for ASD. Methods: A comprehensive search of MEDLINE, Embase, Web of Science, and Scopus was performed from inception to April 2025 to identify studies investigating the relationship between preoperative mental health and postoperative health-related quality of life outcomes or complications. Data was pooled using a restricted maximum likelihood (REML) random-effects model. Heterogeneity was assessed using Cochran’s Q statistic, and between-study variance was reported as τ². Study quality was assessed with the Newcastle–Ottawa Scale, and risk of bias was evaluated using the ROBINS-I tool. Results: Twenty-four studies comprising a total of 248,427 patients met inclusion criteria. In pooled analyses, patients with poor preoperative mental health showed comparable improvements in health-related quality of life measures after surgery (standardized mean difference [SMD] −0.04, 95% CI −0.30 to 0.22; I² = 91.5%, τ² = 0.42) and in pain scores (SMD −0.15, 95% CI −0.42 to 0.11; I² = 71.8%, τ² = 0.09). However, patients with poor mental health had significantly higher odds of postoperative complications (odds ratio [OR] 1.44, 95% CI 1.23 to 1.67; I² = 97.4%, τ² = 0.08). These patients also demonstrated worse preoperative disease severity (SMD –0.94, 95% CI −1.41 to −0.47; I² = 95.5%, τ² = 1.64) and worse postoperative disease severity (SMD –0.34, 95% CI −0.44 to −0.25; I² = 48.9%, τ² = 0.03). Conclusions: While patients with poor preoperative mental health have a greater disease severity both before and after ASD surgery, they appear to experience comparable benefits from surgical intervention compared to those without. Recognizing and managing mental health may be useful in preoperative management of ASD patients. Further prospective studies to further elucidate these associations are necessary. Full article

(This article belongs to the Special Issue Optimizing Outcomes in Scoliosis and Complex Spinal Surgery)

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