Abstract
Introduction
Scoliosis is defined as 3-dimensional deformity of the spine with lateral deviation more than 10° and rotation of the vertebrae. Adolescence idiopathic scoliosis (AIS) is scoliosis that affect children between the age of 11–18 years old without any identifiable cause or underlying disease.
Presentation of case
This study will compare the pelvic parameters and functional score of the patients before and after the procedure. Pelvic parameters are represented by 3 angles: pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) of 5 adolescence idiopathic scoliosis patients. Functional outcomes were evaluated using Indonesian SF-36 questionnaire and also pain scale of preoperative and postoperative.
Discussion
An important outcome of this study was a statistically significant improvement in coronal alignment, functional capacity, pain, and role of limitation due to physical health. Coronal angle deformity correction of AIS patients is correlated with sagittal improvement which caused by compensatory alteration of pelvic parameter.
Conclusion
This finding correlates with the improvement of functional outcome of the patients.
Keywords: Scoliosis, Pelvic parameter, Deformity correction, Adolescence idiopathic scoliosis, SF-36, Pelvic tilt, Pelvic incidence, Sacral slope
Highlights
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Coronal angle deformity correction of AIS patients is correlated with sagittal improvement which caused by compensatory alteration of pelvic parameter
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Sagittal improvement is correlated to coronal angle deformity correction in AIS patients which caused by compensatory alteration of pelvic parameter
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Compensatory alteration of pelvic parameter that caused by sagittal improvement correlated to coronal angle deformity correction in AIS patients
1. Introduction
Scoliosis is defined as 3-dimensional deformity of the spine with lateral deviation more than 10° and rotation of the vertebrae. Scoliosis can be classified into idiopathic, neuromuscular, congenital, and developmental. Idiopathic scoliosis itself can be further classified as infantile (0–3 years), juvenile (4–10 years), and adolescence (11–18 years) based on the onset of the scoliosis [1], [2].
Adolescence idiopathic scoliosis (AIS) is scoliosis that affect children between the age of 11–18 years old without any identifiable caused or underlying disease. AIS is the most common form of scoliosis, encompassing 80% of all idiopathic scoliosis with the prevalence of 2%–4% of adolescents. AIS more common in girls with a female to male ratio of 1.5:1 to 3:1, and almost 90% of them will show right-sided thoracic curve [1], [3], [4], [5].
The indications for surgery treatment in AIS are curves >45°–50° or rapidly progressing curves. The goals of the surgery are to correct deformity and stabilize the spinal curve while also considering for overall spinal balance, including sagittal balance. Sagittal balance can be maintained through 3 compensatory mechanisms, which may happen in the spine, pelvic, and lower limb [3].
The deformity correction surgery in scoliosis will mainly focus on coronal alignment correction. However, in scoliosis there was 3-dimensional deformity which are identified in coronal, sagittal, and axial plane. For this case the deformity of all planes is related to each other, it means that correction of coronal alignment will also alter the spinal sagittal balance including pelvic parameter.
In this study the coronal alignment based on Lenke classification, which is proximal thoracic, main thoracic, and thoracolumbar/lumbar curvature and sagittal balance with spine parameter (TK and LL) and pelvic parameter (PI, PT, SS) of the spine along with sagittal vertebral axis (SVA) of AIS patients who underwent deformity correction surgery, pre and post operatively were measured. We also correlate this finding with clinical symptoms using Indonesian SF-36 questionnaire of the patient after the surgery.
This case report is presented and written in line with the SCARE 2018 criteria.
2. Material and methods
This is a cross sectional study with five cases included that were diagnosed with Adolescent Idiopathic Scoliosis and treated operatively in Dr. Sardjito General Hospital. The patients were admitted at Dr. Sardjito General Hospital in Yogyakarta from February 2016 until June 2021. Ethical approval was done through the Gadjah Mada University Ethical committee. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
The same attending senior spinal surgeon performed all surgical procedure. Segmental pedicle screws with titanium rod were used in all patients. All patients received posterior surgery.
Standing full length anteroposterior (AP) and lateral radiographs before surgery and at the last follow up of minimum 16 weeks after surgery (after the patients free of orthoses) were measured. In the AP standing radiograph, 3 coronal Cobb's angle based on Lenke classification were measured: proximal thoracic (PT), main thoracic (MT), Thoracolumbar curvature (TL/L). In the lateral standing radiographs, five sagittal parameters were measured: thoracic kyphosis, (TK), lumbar lordosis (LL), Sagittal vertical axis (SVA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) [6].
Thoracic parameter is represented in thoracic kyphosis that is measured between the upper T1 and the lower endplate of T12. The theoretical value of thoracic kyphosis is 0.75 times the global lumbar lordosis angle, usually range between 20° – 50°. However, many articles measure thoracic kyphosis between T4 – T12 due to structures superposition in normal radiographs made it difficult to identify the T1 vertebrae. Lumbar lordosis is measured between the upper endplate of L1 and upper endplate of S1 with normal value range between 20° – 80°, average 60°. Almost 70% of the global lordosis is happen in the level of L4 – S1. The sagittal vertical axis is measured as the horizontal distance between a plumb line drawn from center of C7 and a line drawn from center of C7 to posterior superior corner of S1 [7], [8].
Pelvic parameters are represented by 3 angles: pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). PI is an angle between the perpendicular to the upper S1 endplate passing through its center and the line connecting this point to the center of femoral head. This angle is constant in each person and independent to the spatial orientation of the pelvis. SS is defined by an angle between a line tangent to the upper S1 endplate and horizontal line, the more vertical the sacrum, the lower the SS angle. While PT is an angle between the vertical line and the line connecting the center S1 upper endplate to the center of femoral head. PT angle will increase during retroversion of the pelvis. SS and PT are positional and related to the pelvic orientation. PI, SS, and PT has a correlation between each other with formula of PI = SS + PT [7], [8], [9], [10], [11].
Functional outcomes were evaluated using SF-36 questionnaire and also pain scale of preoperative and postoperative.
3. Case series
3.1. Case 1
A female, 16 years old was diagnosed with Adolescent idiopathic scoliosis Lenke 2A. She had no response to conservative treatment and planned for operative procedure.
In this patient we performed deformity correction and stabilization with long segment fusion with pedicle screw at the level of 3rd thoracal – 1st lumbar spine (Fig. 1).
Fig. 1.
Case 1 radiograph presentation.
Post-operative sagittal parameters were measured and compared with pre-operative radiologic (Table 1). From coronal alignment, we found decrease of proximal thoracic of 230, main thoracic of 310, thoracolumbar curve of 60. From sagittal alignment, we found there is increase of thoracal kyphotic of 80, lumbar lordotic of 90. From pelvic parameters, there is increase of sacral slope of 100, and there is decrease of pelvic tilt of 100. Pain scale improved from 4 to 1 compared with preoperative.
Table 1.
Case 1 radiograph parameter.
| Pre-operative | Post-operative |
|---|---|
| Coronal: | Coronal: |
| Proximal thoracic: 650 (secondary structural) | Proximal thoracic: 420 (secondary structural) |
| Main thoracic: 700 (primary). Apex T6 | Main thoracic: 390 (primary). Apex T6 |
| Thoracolumbar curve: 170 (secondary non-structural) | Thoracolumbar curve: 110 (secondary non-structural) |
| Sagittal: | Sagittal: |
| Thoracic kyphotic: 130 (20–40) | Thoracic kyphotic: 90 (20–40) |
| Lumbar lordotic: 400 (40–60) | Lumbar lordotic: 490 (40–60) |
| SS: 36° (30–50) | SS: 36° (30–50) |
| PT: 22° (10–25) | PT: 12° (10–25) |
| PI: 58° (40–65) | PI: 58° (40–65) |
| SVA: +2 | SVA: +2 |
3.2. Case 2
A female, 17 years old was diagnosed with Adolescent idiopathic scoliosis Lenke 2A. She had no response to conservative treatment and planned for operative procedure.
In this patient we performed deformity correction and stabilization with long segment fusion with pedicle screw at the level of 4th thoracal – 1st lumbar spine (Fig. 2).
Fig. 2.
Case 2 radiograph presentation.
Post-operative sagittal parameters were measured and compared with pre-operative radiologic (Table 2). From coronal alignment, we found decrease of proximal thoracic of 320, main thoracic of 360, thoracolumbar curve of 30. From sagittal alignment, we found that there is increase of thoracal kyphotic of 70, lumbar lordotic of 190. From pelvic parameters, there is decrease of sacral slope of 120, and there is increase of pelvic tilt of 120. Pain scale improved from 4 to 1 compared with preoperative.
Table 2.
Case 2 radiograph parameter.
| Pre-operative | Post-operative |
|---|---|
| Coronal: | Coronal: |
| Proximal thoracic: 560 (secondary structural) | Proximal thoracic: 240 (secondary structural) |
| Main thoracic: 630 (primary). Apex T7 | Main thoracic: 270 (primary). Apex T7 |
| Thoracolumbar curve: 190 (secondary non-structural) | Thoracolumbar curve: 160 (secondary non-structural) |
| Sagittal: | Sagittal: |
| Thoracic kyphotic: 70 (20–40) | Thoracic kyphotic: 80 (20–40) |
| Lumbar lordotic: 310 (40–60) | Lumbar lordotic: 500 (40–60) |
| SS: 48° (30–50) | SS: 36° (30–50) |
| PT: 10° (10–25) | PT: 22° (10–25) |
| PI: 58° (40–65) | PI: 58° (40–65) |
| SVA: −1 | SVA: Neutral |
3.3. Case 3
A female, 16 years old was diagnosed with Adolescent idiopathic scoliosis Lenke I BN. She had no response to conservative treatment and planned for operative procedure.
In this patient we performed deformity correction and stabilization with long segment fusion with pedicle screw at the level of 5th thoracal – 3rd lumbar spine (Fig. 3).
Fig. 3.
Case 3 radiograph presentation.
Post-operative sagittal parameters were measured and compared with pre-operative radiologic (Table 3). From coronal alignment, we found decrease of proximal thoracic of 20, main thoracic of 430, thoracolumbar curve of 170. From sagittal alignment, we found there is increase of thoracal kyphotic of 70, lumbar lordotic of 250. From pelvic parameters, there is decrease of sacral slope of 70, and there is increase of pelvic tilt of 70. Pain scale improved from 3 to 1 compared with preoperative.
Table 3.
Case 3 radiograph parameter.
| Pre-operative | Post-operative |
|---|---|
| Coronal: | Coronal: |
| Proximal thoracic: 240 (secondary non-structural) | Proximal thoracic: 220 (secondary non-structural) |
| Main thoracic: 590 (primary). Apex T9 | Main thoracic: 160 (primary). Apex T9 |
| Thoracolumbar curve: 240 (secondary non-structural) | Thoracolumbar curve: 70 (secondary non-structural) |
| Sagittal: | Sagittal: |
| Thoracic kyphotic: 160 (20–40) | Thoracic kyphotic: 230 (20–40) |
| Lumbar lordotic: 250 (40–60) | Lumbar lordotic: 500 (40–60) |
| SS: 44° (30–50) | SS: 37° (30–50) |
| PT: 11° (10–25) | PT: 18° (10–25) |
| PI: 55° (40–65) | PI: 55° (40–65) |
| SVA: +1 | SVA: +0.5 |
3.4. Case 4
A female, 16 years old was diagnosed with Adolescent idiopathic scoliosis Lenke 3 BN. She had no response to conservative treatment and planned for operative procedure (Fig. 4).
Fig. 4.
Case 4 radiograph presentation.
In this patient we performed deformity correction and stabilization with long segment fusion with pedicle screw at the level of 2nd thoracal – 3rd lumbar spine.
Post-operative sagittal parameters were measured and compared with pre-operative radiologic (Table 4). From coronal alignment, we found decrease of proximal thoracic of 30, main thoracic of 470, thoracolumbar curve of 270. From sagittal alignment, we found there is increase of thoracal kyphotic of 120, lumbar lordotic of 120. From pelvic parameters, there is decrease of sacral slope of 80, and there is increase of pelvic tilt of 80. Pain scale improved from 2 to 2 compared with preoperative.
Table 4.
Case 4 radiograph parameter.
| Pre-operative | Post-operative |
|---|---|
| Coronal: | Coronal: |
| Proximal thoracic: 130 (secondary non-structural) | Proximal thoracic: 100 (secondary non-structural) |
| Main thoracic: 900 (primary). Apex T6 | Main thoracic: 430 (primary). Apex T6 |
| Thoracolumbar curve: 470 (secondary structural) | Thoracolumbar curve: 200 (secondary structural) |
| Sagittal: | Sagittal: |
| Thoracic kyphotic: 100 (20–40) | Thoracic kyphotic: 220 (20–40) |
| Lumbar lordotic: 430 (40–60) | Lumbar lordotic: 550 (40–60) |
| SS: 53° (30–50) | SS: 45° (30–50) |
| PT: 12° (10–25) | PT: 20° (10–25) |
| PI: 65° (40–65) | PI: 65° (40–65) |
| SVA: Neutral | SVA: +2 |
3.5. Case 5
A male, 17 years old was diagnosed with Adolescent Idiopathic Scoliosis Lenke 6CN Risser 5 Sanders 8. He had no response to conservative treatment and planned for operative procedure.
In this patient we performed deformity correction and stabilization with long segment fusion with pedicle screw at the level of 5th thoracal – 2nd lumbar spine (Fig. 5).
Fig. 5.
Case 5 radiograph presentation.
Post-operative sagittal parameters were measured and compared with pre-operative radiologic (Table 5). From coronal alignment, we found decrease of proximal thoracic of 100, main thoracic of 360, thoracolumbar curve of 80. From sagittal alignment, we found there is increase of thoracal kyphotic of 290, lumbar lordotic of 60. From pelvic parameters, there is increase of sacral slope of 130, and there is decrease of pelvic tilt of 130. Pain scale improved from 2 to 2 compared with preoperative.
Table 5.
Case 5 radiograph parameter.
| Pro-operative | Post-operative |
|---|---|
| Coronal: | Coronal: |
| Proximal thoracic: 120 (secondary non-structural) | Proximal thoracic: 220 (secondary non-structural) |
| Main thoracic: 110 (primary). Apex T12 | Main thoracic: 470 (primary). Apex T12 |
| Thoracolumbar curve: 220 (secondary structural) | Thoraolumbar curve: 300 (secondary structural) |
| Sagittal: | Sagittal: |
| Thoracic kyphotic: 380 (20–40) | Thoracic kyphotic: 90 (20–40) |
| Lumbar lordotic: 550 (40–60) | Lumbar lordotic: 490 (40–60) |
| SS: 53° (30–50) | SS: 40° (30–50) |
| PT: 12° (10–25) | PT: 56° (10–25) |
| PI: 65° (40–65) | PI: 40 (40–65) |
| SVA: +1.5 | SVA: −1 |
Functional outcomes were evaluated using Indonesian SF-36 questionnaire and found there is improvement in 3 out of 8 domains which is the domains physical function, pain and role limitation due to physical health compared with preoperative (Table 6, Table 7).
Table 6.
SF-36 questionnaire score.
Table 7.
SF-36 questionnaire score improvement.
4. Discussion
The spine is a complex structure balanced by multiple forces that implement structural changes in attempt to compensate the sagittal and coronal vertical axis, so that the human being can maintain as balanced a movement as possible. Sagittal balance can be maintained through three main compensatory mechanisms, which may occur in the spine, pelvis and/or lower limb areas, including reduction of TK/hyperextension of adjacent segments, pelvis retroversion (increase of PT and rotation of the pelvis), knee flexion and ankle extension [12], [13].
Many studies investigated the sagittal spinopelvic parameter in adults, but little research has been devoted to examining this relationship on patients with Adolescent Idiopathic Scoliosis. Very little studies focused on the spinal balance in Adolescent Idiopathic Scoliosis (AIS) [14], [15], but its relation to pelvic configuration is not define detailed in the literature.
In our studies, we found from the mean of coronal alignment based on Lenke classification there is decrease of 39.40 of main thoracic, 17.40 of thoracolumbar/lumbar curvature, and 14.40 of proximal thoracic compared with preoperative. Also, from mean of sagittal alignment there is increase 2.80 of thoracal kyphosis and 12.80 of lumbar lordosis. And from mean of pelvic parameter showed there is decrease 2.80 of sacral slope and increase 0.80 of pelvic tilt. This is similar with the recent literature regarding variances relevant to some spinopelvic parameters in patients with AIS following surgical management. La Maida et al. reported a statistically increase in pelvic tilt (PT) [16], similarly Tanguay et al. acquired significant relationship between lumbar lordosis (LL) and pelvic parameter below and within the fusion from the analysis of 60 patients with AIS following posterior spinal instrumentation and fusion surgery [17].
In the present sample, we found mean of PI is 60.20, and there is relatively difference of LL and PI for ±100. This is similar to studies conducted by Le Huec et al. that reported when the incidence is over 50°, the lordosis tends to be less ±100 than the PI [18]. Thereby, it was possible to confirm a strong connection between the pelvic geometry and lumbar lordosis.
In this study, we used the SF-36 questionnaire to evaluate the quality of life of the patients with AIS, due to convenience. This questionnaire can be applied to more than 130 conditions, including spinal-related problems, which may considerably affect the quality of life related to health [19]. An important outcome of this study was a statistically significant improvement in functional capacity, pain, and role of limitation due to physical health, a result similar to that found by Cabral et al. [20]
There are several limitations in our study. First the number of patients is relatively small. Second, this study was cross sectional and some of the patients had a relatively short follow up period. However, the major strength of this study is the detailed description between the coronal alignment, sagittal balance and pelvic parameter before and after surgery. Moreover, pedicle screws were the only instrumentation method in every case, and all surgical procedures were performed by 1 senior surgeon. Nonetheless, a larger, longer follow-up study is necessary to further validate our findings.
5. Conclusion
Sagittal spinopelvic parameters are important in treating adolescent idiopathic scoliosis and must be taken into account before and after the surgery. Coronal angle deformity correction of AIS patients is correlated with sagittal improvement which caused by compensatory alteration of pelvic parameter. This finding correlates with the improvement of functional outcome of the patients.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Funding
This study is funded by the authors.
Sources of funding
There's no particular sponsor for this research.
Ethical approval
Ethical approval was done by the Gadjah Mada University Ethical comitee.
Consent
Consent was given before the study.
CRediT authorship contribution statement
Sakti, Y.M: Conceptualization, Supervision.
Magetsari, R: Conceptualization, Supervision.
Pratama, B.Y: Conceptualization. Reviewing, Editing.
Cein, C.R: Writing, Reviewing, Editing.
Tampubolon, Y.O: Writing, Reviewing, Editing.
Mafaza, A: Writing, Reviewing, Editing.
Declaration of competing interest
There is no conflict of interest in this study.
Appendix 1. Lenke classification
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