Evaluation and Treatment of Adult Scoliosis and Sagittal Plane Deformity
Adult spinal deformity (ASD) is a broad diagnostic classification encompassing a wide spectrum of pathology ranging from stable, asymptomatic scoliosis to more complex, progressive deformity. Although age-related degeneration likely contributes, the pathophysiology of ASD is complex and multifactorial. The prevalence of ASD may be higher than previous estimates, which may reflect demographic trends and an expanding elderly population. The negative health burden of spinal deformity on adults can exceed that of commonly recognized chronic diseases. As such, it is increasingly important for health care providers to recognize ASD and understand management options. Patients with ASD typically present with pain and disability, which have correlation to spinopelvic parameters and positive global sagittal malalignment. Therefore in addition to a detailed medical history and physical examination, appropriate assessment of patients with ASD should include analysis of spinopelvic radiographic parameters in both sagittal and coronal planes. For patients with progressive deformity, worsening pain, and/or neurological deficit, surgery can be offered if appropriate conservative measures have failed. Surgery includes various techniques ranging from Smith-Petersen osteotomies to three-column osteotomies, with more aggressive bony resection generally needed for severe, rigid deformity. Although surgery has potential for significant clinical benefits, it is associated with high complication rates. In addition to minimally invasive approaches with theoretical advantages related to less adjacent tissue disruption, other strategies for avoiding complications will be reviewed in this chapter including junctional tethers to reduce proximal junction kyphosis/failure, tranexamic acid to reduce surgical blood loss and transfusions, and multirod techniques to reduce primary rod fracture and/or pseudarthrosis. Predictive analytics is emerging in ASD outcomes research as a potentially powerful modeling tool for risk stratification and preoperative decision making. As research continues and patient selection improves, surgeons may have more opportunities in the future to limit the substantial health burden of ASD and improve surgical outcomes.
