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Factors Elucidated for Good Outcomes From Nonoperative Treatment of Adult Spinal Deformity

A new study provides some answers to the long-standing question of why some individuals with adult spinal deformity improve significantly without surgery.

Members of the International Spine Study Group (ISSG) reviewed the records of 215 consecutive patients. They found that patients who had significantly more baseline pain and significantly less deformity—particularly coronal deformities in the thoracolumbar region—were more likely to reach a minimum clinically important difference (rMCID) in their Activity or Pain Sclerosis Research Society-22R Patient Questionnaire scores (SRS-22R). These patients also had significantly decreased pain at a two-year follow-up compared with individuals who did not reach or “missed” the MCID (mMCID). MCID was defined using the external anchor methodology with the Short Form-36 health transition item.

A univariate analysis revealed the members of the two groups had similar average ages, body mass indices and sagittal spino-pelvic alignment at baseline. Of the patients in this study, 40% were in the rMCID group.

A multivariate analysis confirmed that baseline pain was worse in rMCID patients, with an average SRS-22R pain subscale score of 3. The average thoracolumbar coronal Cobb angle in the rMCID group was significantly smaller than in the mMCID group: 29.6 versus 36.5 degrees (P=0.007).

The team discovered that although the overall mean pain level of the 215 patients did not change over time, the rMCID group’s SRS-22R pain scores decreased significantly from 3.7 to 3 at the two-year follow-up. The mean SRS-22R pain scores of the mMCID patients changed from 3.6 to 3.3 (P<0.001).

The researchers said more research is needed, with an emphasis on nonoperative care.

“We are starting a dedicated study on the analysis of nonoperative care in the setting of adult spinal deformity. It will include information on specific types of nonoperative treatment,” said lead investigator Virginie Lafage, PhD, director, spine research, New York University Hospital for Joint Diseases, New York City.

Charles H. Crawford III, MD, adult and pediatric spine surgeon, Norton Leatherman Spine Center, Louisville, Ky., who was not part of the study, agreed that key information is missing. He said the ISSG is very well respected and used a large and thoroughly evaluated patient population.

“What we’re lacking in the literature—and what we need nonoperative specialists to clarify for us—is what nonoperative treatments really work and which patients they work for,” said Dr. Crawford, assistant professor of orthopedic surgery at the University of Louisville. “What are the indications for nonoperative treatment?”

The findings were presented at the North American Spine Society’s 2014 annual meeting (abstract 41).

Article by: Rosemary Frei, MSc