Adult Spinal Deformity Focus Issue: Summary Statement

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Deformity in the adult has a significant and measurable impact on health-related quality of life. Reconstructive surgery for spinal deformity is challenging for the patient and the physician. Medical complications of reconstructive surgery are an important risk and limitation of spinal deformity surgery. In the adult population, age and comorbidities, including osteoporosis and systemic disease, are important considerations in the preparation of patients before surgery, and in anticipating perioperative complications. Hu as well as Baron and Albert address how to prepare the patient for major reconstructive surgery, and how to reduce the prevalence of complications of surgery, emphasizing the importance of consideration of systemic health in the evaluation of patients in the perioperative period. In a debate format, Akbarnia, Oglivie, and Hammerberg identify specific considerations of when to operate and when to avoid surgery in a patient with significant comorbidities.
There is significant variability in the clinical presentation of patients with adult deformity and in the strategies for surgical care. Lowe et al propose a classification for adult scoliosis that is useful in categorizing deformity patterns and will improve the ability of future surgeries to identify and compare similar cases. Surgical strategies for adult deformity encompass a broad spectrum of approaches and options. Kuklo describes principles for decision-making on the choice of levels for surgery. In specific debates, Polly, Hammill, and Bridwell address considerations on when to fuse to L5 versus S1, and Suk, Mardjetko, and Shufflebarger debate considerations at the thoracolumbar junction. Surgical techniques for the management of kyphotic deformity and of combined coronal and sagittal imbalance are discussed by Bridwell and Macagno. DeWald identifies the limitations of fixation in the older patient and strategies to avoid complications of fixation in patients with compromised bone quality.
Surgical approaches to adult deformity continue to evolve, and the role of new techniques and technologies is included in this issue. Weidenbaum discusses limited surgical intervention in adult deformity and addresses the advantages and limitations of decompression only and short instrumented fusion procedures. McAfee presents biomechanical data that demonstrates rotational destabilization of the lumbar spine resulting from disc arthroplasty, and concludes that existing arthroplasty devices may exacerbate rotational deformity in the adult lumbar scoliosis.
This Focus Issue on Adult Spinal Deformity is intended to identify and discuss important considerations in preoperative planning, perioperative complications, surgical decision-making, and new approaches in surgical reconstruction. The debates included demonstrate that, in many cases, a single right answer does exist and variability in approaches is valid. It should be noted by the reader that the debaters were required to support their assigned position even if it would not be their preferred choice. The articles included review data that have been presented in the literature on adult deformity to date. There remains a significant need for future research to provide compelling data to develop an evidence-based approach specific deformity patterns and treatment strategies. It is important to recognize that the surgical management of spinal deformity and degenerative disease is not often accomplished in a solitary moment in time by a single surgical procedure. Rather, this management occurs along a continuum that may necessitate involving the patient in multiple surgical episodes. The utility of an improvement of health status with limited duration, and of delaying the progression of degenerative pathology will require valuation in determining where surgery for spinal deformity lies on the spectrum of medical and surgical interventions that compete for our healthcare dollars.

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