Session 11: Spine
Fredag den 24. oktober
09:00 – 10:30
Lokale: Stockholm/Copenhagen
Chairmen: Mikkel Østerheden Andersen / Søren Eiskjær
109. A modification of the Tokuhashi Revised score improves prognostic precision in patients with metastatic spinal cord compression.
Søren Schmidt Morgen, Martin Gehrchen, Sebastian Bjørck, Claus Falck Larsen, Svend Aage Engelholm, Benny Dahl
Spine Section, Department of Orthopedic Surgery , Copenhagen University Hospital, Rigshospitalet ; Trauma Center, Copenhagen University Hospital, Rigshospitalet ; Department of Radiation and Oncology, Copenhagen University Hospital, Rigshospitalet
Background: Patients suffering from metastatic spinal
cord compression (MSCC) are routinely
evaluated with pre-operative prognostic
scoring systems. The most well known
scoring system is the Tokuhashi Revised
score (TR), but recent studies have
proposed a modification of the TR due to
lack of precision.
Purpose / Aim of Study: To modify the TR in order to improve the
prognostic precision.
Materials and Methods: In 2011 and 2012 a total of 1143
consecutive patients admitted with MSCC
were prospectively included and variables
for the TR score were collected. In the 2011
cohort each component of the TR including
primary cancer diagnosis was analyzed
regarding prognostic ability by Cox
regression analysis. Based on these
findings a modified TR score (MTR) was
defined. New prognostic groups were
determined using Receiver Operating
Characteristics (ROC) analysis for survival
< 6 months, >= 6 months, and >= 12
months. These prognostic groups were
used to compare the TR and the MTR in the
2012 cohort based on Kaplan-Meier (KM)
survival curves and ROC analysis.
Findings / Results: There were no significant differences
between the 2011 and the 2012 cohort
regarding age and gender distribution. The
mean age was 66 years (range 20-97) and
the most common primary tumor sites were
prostate (21%) and lung (20%).
In the 2012 cohort the KM curves showed
that the actual survival for each prognostic
group was separated more accurate with
the MTR compared to the TR. The areas
under the ROC curves were significant
larger for the MTR compared with the TR.
The ROC area were for < 6 months survival,
MTR = 0.71 and TR = 0.65; p = 0.003, for
>= 6 months survival, MTR = 0.71 and TR =
0.65; p = 0.003, for >= 12 months survival
MTR = 0.72 and TR= 0.67; p = 0.0015.
Conclusions: A modification of the TR can improve the
precision in the estimation of survival
among patients with MSCC.
110. Reliability and validity of the Danish version of SRS 22r
Ane Simony, Karen Højmark Hansen, Leah Carreon, Mikkel Østerheden Andersen
Rygkirurgisk Afdeling, Middelfart Sygehus; Research Department for Spine Surgery, Norton Spine Center
Background: Adolescent idiopathic scoliosis (AIS) is a
three dimensional disease of the spine,
with a Cobb angel greater than 10º. AIS
affects children in the age of 12-16, and
develops during the growth spurt.
Treatment of AIS is correction of the
spine by either brace treatment or
surgery. Haher et al created the SRS 22
questionnaire as a tool to monitor health
related quality of life in scoliosis patients,
but no previous Danish version has
been validated.
Purpose / Aim of Study: To evaluate the validity and reliability, of
the Danish adapted version of SRS 22.
Materials and Methods: The SRS 22 were translated and cross
cultural adapted, according to the
guidelines from WHO. The SRS22 Danish
version was distributed to 262 patients
with scoliosis and 50 age matched
controls, together with SF12. All data
where analyzed by a independent
statistician.
Findings / Results: A total of 207 questionnaires (79.2%
response rate) were retrieved.165
questionnaires from scoliosis patients
and 42 from healthy controls. No floor
effects was noted. In the scoliosis
patients, moderate ceiling effects were
observed on the Satisfaction with
Management domain.
Reliability of the SRS-22 seemed good
with a Cronbach á of 0.93 in scoliosis
patients, 0.90 in healthy controls. In
patients, good reliability was found for
all domains: Pain, 0.88; Self-image, 0.87;
Function, 0.89; Mental Health, 0.90;
Satisfaction with Management, 0.68.
The concurrent validity showed good
reliability with an overall á of 0.88. The
results were statistically significant at P
<0.05.
The discriminant validity was tested with
a t-test. All domains differed significantly
and reveal scoliosis patients have lower
scores compared with the controls.
Conclusions: The Danish translated version of SRS 22
is valid, and can detect difference
between patient with scoliosis and a
age matched healthy control group.
111. Self-reported scoliosis is not a valid method for estimating concordance rates of Adolescent Idiopathic Scoliosis in a Danish twin population
Mikkel Andersen, Kirsten O. Kyvik , Karsten Thomsen , Ane Simony
Sector of Spine Surgery and Research, Region of Southern Denmark, Sygehus Lillebælt; Institute of Public Health, University of Southern Denmark; Sector of Spine Surgery, , Aleris
Background: The aetiology of adolescent idiopathic
scoliosis is still unclear and the true
mode of inheritance has yet to be
established. From the Danish twin cohort
concordance rates in monozygotic twins
have previously been reported to be
0.13¬ and in dizygotic twins 0. Studies
on concordance in twin pairs provide a
basis for analysing the influence of
genetic versus environmental factors.
Purpose / Aim of Study: To validate if self-reported scoliosis is a
valid method to establish incidence and
concordance rates in a twin population
Materials and Methods: All 46,418 twins registered in the Danish
Twin Registry born from 1931 to 1982
were sent a questionnaire, which
included questions about scoliosis.
A sub group of 344 individuals with self-
reported scoliosis were invited to a
clinical and a radiologic examination
together with their twin, in total 644
individuals/ 322 twin pairs. Zygosity
was established by genetic testing.
Findings / Results: 203 individuals (31.5% of the cohort)
participated. The total number of
participants consisted of 95 twin pairs,
where one or both twins had scoliosis
and 13 individuals.
35 individuals (32.4%) of the 108
participants with self-reported scoliosis
presented a clinical and radiological
confirmed curve. Of these were 5 twin
pairs (4 monozygotic pairs and 1
dizygotic pair) with scoliosis in both
twins and 11 twin pairs with scoliosis in
only one twin and 3 individuals where
only one twin participated.
Calculating concordance in twins with
curves greater than 15 degrees, we
found that the pairwise concordance
rate was 0.4 (0.12-0.74) for
monozygotic and 0.05 (0.01 -0.25) for
dizygotic twin pairs, probandwise
concordance was 0.45 for monozygotic
and 0.1 for dizygotic pairs.
Conclusions: Self-reported scoliosis in a Danish twin
population is not a valid method to
establish the true concordance rates.
112. Investigating human VANGL1, as a candidate gene for adolescent idiopathic scoliosis
Malene Rask Andersen, Ane Simony, Lars Allan Larsen
Wilhelm Johannesen Centre for Functional Genome Research, Department of Cellular and Molecular Medic, Københavns Universitet; Rygkirurgisk afdeling, Middelfart Sygehus
Background: The human VANGL1 genes has been
predicted to be associated with
idiopathic scoliosis, as a mutation
(c.676C>T, L226F) was identified in a
family with dominant inheritance of the
disease. Previous investigation of the
gene revealed the candidate to
segregate, with all but one family
member. Adolescent idiopathic scoliosis
(AIS) is generally considered multi-genic,
but the determining genes remain yet to
be characterised.
Purpose / Aim of Study: In this study we have examined
VANGL1 as a contributor to the
phenotype of AIS.
Materials and Methods: We have conducted automated Sanger
sequencing of the seven coding exons
of VANGL1 gene in a disease cohort of
170 AIS patients (n=340) and 177
controls (n=354). Localization of mutated
VANGL1 proteins were investigeted in
cell systems.
Findings / Results: Two novel mutations, each in separate
individuals within the considered
disease cohort, were identified. One
mutation is situated in the third coding
exon, which encodes the
transmembrane parts of the VANGL
protein. This mutation is a c.407T>A
(L136N) conversion, for which the
patient is heterozygotes. This mutation
was also identified in the dizygotic
unaffected twin of the patient.
The second mutation was found in the
seventh coding exon, which encode the
C-terminal of the VANGL1 protein. This
mutation is a c.1318T>G (F440V)
conversion, for which the patient is also
heterozygotes. Neither of the identified
mutations was present in the sequenced
controls or in 2000 Danish exomes.
Currently, the cellular localization of wt
and mutant VANGL1 protein are being
investigated using immunofluorescence
microscopy.
Conclusions: On behalf of the current results of this
study we conclude that mutations in the
VANGL1 gene may be a rare cause of
AIS. Examination of the expression of
VANGL1 in teenage-adult stages of life
is wanted as well as examinations of
effects.
113. Does obesity delay time of surgery for Lumbar Disc Herniation, and does it influence surgical outcome in 832 patients treated with discectomy.
Rikke Rousing, Ane Simony, Henrik Grønvall, Karen Højmark, Stefan Hummel, Mikkel Østerheden Andersen
Rygkirurgisk afdeling, Middelfart sygehus, Vejle sygehus
Background: Lumbar disc herniation (LDH) is
associated with great morbidity and
significant socioeconomics impact.
Studies have shown that most LDH can
be treated effective conservatively.
However for the group of patients
where pain and disability is
unacceptable, surgical intervention
provides effective clinical relief in many
cases. Several factors may influence
the outcome of surgery for LDH,
including obesity and prolonged time of
symptoms. Data from the Danish National
Healthprofile 2010 state that 47% of the
danish population is overweight (BMI ≥
25) and about 13% is classified as
obese (BMI ≥ 30).
Purpose / Aim of Study: To investigate if obesity is correlated
with surgical outcome and whether
overweight patients has a delayed time
of surgery compared with non-obese
patients.
Materials and Methods: 832 patients with first-time LDH were
included in a Single-Center Study. Data
were prospectively collected in
DaneSpine, the Danish National Spine
Register. The patient reported outcome
measures (PROMs) EQ5D, SF36, ODI,
VAS-leg and -back were correlated with
duration of symptoms. A comparison
between subgroups of BMI and 1-year
follow-up PROMs were performed. Data
was analysed with STATA.
Findings / Results: Overweight and obese patients have
symptoms-relieve following LDH
surgery, but the outcome is inferior to
patients of normal weight. Patients with
BMI ≥ 35 are treated conservatively for a
longer time and have an inferior outcome.
Conclusions: Severe obesity delays time of surgery
and influences the surgical outcome.
114. Moderate Precision of the Tokuhashi Revised Score and the Bauer Modified Score in Patients with Metastatic Spinal Cord Compression.
Søren Schmidt Morgen, Martin Gehrchen, Dennis Hallager Nielsen, Claus Falck Larsen, Svend Aage Engelholm, Benny Dahl
Spine Section, Department of Orthopedic Surgery, Copenhagen University Hospital, Rigshospitalet ; Trauma Center, Copenhagen University Hospital, Rigshospitalet ; Department of Radiation and Oncology, Copenhagen University Hospital, Rigshospitalet
Background: Estimated survival is an important element
in the evaluation of patients with metastatic
spinal cord compression (MSCC). The
Tokuhashi Revised score (TR) has been
recommended as a prognostic score in
many studies, but two recent studies have
showed that the Bauer Modified Score (BM)
was the more accurate.
Purpose / Aim of Study: To compare the TR and the BM in the
prediction of survival among patients
surgically treated for MSCC.
Materials and Methods: From January 1st 2009 to December 31st
2011, a total of 246 MSCC patients were
treated surgically for MSCC in one center.
These patients were included in a cohort
with a minimum of two years follow-up. The
patients were scored with the TR and the
BM scoring systems.
Findings / Results: The mean age on admission was 63 years
(range 27-94) and 54% of the patients were
men. The most common primary tumor-sites
were lungs (24%) and breast (15%). The
logrank test showed that each prognostic
group in both scoring system were
significantly different (p < 0.001). The
Kaplan Meyer survival curves showed good
prognostic value in each prognostic group
for both of the scoring systems, but the
specificity and sensitivity was moderate. In
both scoring systems the prognostic groups
with a short predicted survival had “longtime
survivors” who lived longer than one-year
(20% in the TR-group and 19% in the BM-
group). For the prognostic groups with long
estimated survival, a considerable
proportion of the patients were dead within
6 months (27% in the BM and 31% in the
TR).
Conclusions: This study showed that the TR and the BM
ability to predict survival were almost equal.
Both scoring systems performed well in
categorizing patients in prognostic groups,
but the moderate precision in predicting
survival emphasizes that a modification may
be necessary.
115. Morbidity and mortality of complex spine surgery: a prospective cohort study in 679 patients validating the SAVES system in a European population
Sven Karstensen, Tanvir Bari, Martin Gehrchen, John Street, Benny Dahl
SpineUnit, Department of Orthopaedic Surgery, Rigshospitalet and University of Copenhagen ; ICORD, University of British Columbia
Background: The Spine AdVerse Events Severity system
(SAVES) has been found reliable and valid
in two North American spine centers,
providing precise information regarding all
adverse events after complex spine surgery.
Purpose / Aim of Study: The purpose of the present study was to
assess the generalizability of the SAVES
system in a European population of
patients, including pediatric patients,
undergoing complex spine surgery.
Materials and Methods: All patients undergoing spinal surgery in the
period January 1, 2013 through December
31, 2013 were prospectively included. A
modified SAVES form was used, and a
research coordinator collected all data
prospectively. Once a week all patients
were reviewed for additional events,
validation of the data and clarification of any
questions. The survival status was
registered on January 31, 2014 to obtain
30-day survival.
Findings / Results: A total of 679 consecutive patients were included
with 100% SAVES data completed. The in-hospital
mortality was 1.3% and the 30-day mortality was
2.7 %; all occurring after emergency procedures.
There was no significant difference between
lengths of stay after elective or emergency
surgery. The number of intraoperative AE’s was
162 and the number of postoperative AE’s was
1415; the most frequent event being postoperative
electrolyte imbalance. 2.2% of the patients had
postoperative infections requiring surgical revision.
The frequency of postoperative AE’s was
significantly higher in patients 65 years or older
compared to young individuals (P=0.002).
Conclusions: The results confirm that a rigorous
prospective system improves adverse event
recognition, confirming the generalizability
of the SAVES system to a non-Canadian
populations including pediatric patients.
116. Clinical correlation of the SRS-Schwab Classification with HRQOL measures in a prospective non-US cohort of ASD patients
Dennis Hallager Nielsen, Lars Valentin Hansen, Casper Rokkjær Dragsted, Martin Gehrchen, Benny Dahl
Dept. of Orthopaedic Surgery, Rigshospitalet
Background: The SRS-Schwab adult spinal deformity
(ASD) classification system is
considered an important communication
tool for spine surgeons as it summarizes
the complex pathology of ASD in four
coronal curve types with three sagittal
modifiers (PI-LL, PT and SVA). The
cut-off values separating level 0 from +
have been proposed to predict severe
disability defined by an Oswestry
Disability Index (ODI) of more than 40.
The clinical correlations of the
classification system have only been
evaluated using US ASD patients.
Purpose / Aim of Study: The aim of the present study was to
assess the clinical correlations of the
sagittal modifiers with various HRQOL
measures in a prospective, consecutive
non-US cohort of ASD patients.
Materials and Methods: Between March and August 2013 a total of
112 ASD patients aged >18 years having
sufficient long standing X-rays taken at
our out-patient clinic completed VAS
scores for back pain, ODI, SRS22r, EQ5D
and SF36 questionnaires. 14 patients
were excluded due to predefined
criteria. For each sagittal modifier the
variation of score means/ranks across
levels 0, + and ++ was assessed with
one-way ANOVA/Kruskal-Wallis test.
Findings / Results: 98 patients were included with a median
age of 64 years (range 18-85). 64% were
female, and 49% had a history of
previous deformity surgery. We found a
significant variation for SF36 physical
component summary (PCS) scores across
the levels of all modifiers. Significant
variation was also found for SRS22r
total score across PI-LL and PT levels,
EQ5D and VAS for back pain across PI-LL
and SVA levels and ODI across SVA levels.
Conclusions: We showed that the SRS-Schwab
classification modifiers are able to
classify patients according to the SF36
PCS and various other HRQOL measures in
a non-US cohort of ASD patients.
117. Providence Nighttime Bracing in adolescent idiopathic scoliosis
Ane Simony, Inge Beuschau , Lena Quisth , Mikkel Østerheden Andersen, Stig Mindedahl Jespersen
Rygkirurgisk Afdeling, Middelfart Sygehus; , Ortos, Odense; Rygkirurgisk sektor, Odense Universitets Hospital
Background: 6 years ago the primary conservative
treatment of adolescent idiopathic
scoliosis (AIS) in the southern part of
Denmark, went from full time bracing to
nighttime bracing.
Purpose / Aim of Study: To evaluate the effectiveness of
nighttime bracing in AIS.
Materials and Methods: Patients diagnosed with AIS and skeletal
immature. With an apex of the primary
curve from TH7 and below and with a
cobb angel between 20- 45 degrees.
The patients were asked to wear the
brace at least 7-8 hours pr. night.
No other previous treatments were
accepted and a follow up at least 6
months out of brace. The brace
treatment was continued until two years
post menarche or for male at the
expected adult height.
Cross-measured x-rays was used to
compare the primary cobb angel, the in-
brace correction and the outcome cobb
angel. A decreased outcome cobb
angle as well as the overcorrection of
the curve measured in brace was
recorded as zero.
The brace treatment was considered
failed if progression more than 5
degrees occurred and if surgery were
performed.
Findings / Results: A total of 55 patients, 8 male and 47
female, with the mean age at 14 years
(11-16.5) and the mean primary cobb at
31 degrees (20-41) were included in this
study. The mean time of treatment was
18 month (5-59).
After ended treatment the mean cob
angle was 28 degrees (7-50), an
average of no progression. The end
results were 11 failures (6-15 degrees);
equal 20 % and out of these 11 patients,
3 had surgery performed (5%).
Conclusions: The results show a good curve control
and an acceptable 20 % failure rate,
which is equal to other studies. The
providens brace is an excellent
alternative to standard conservative
treatment. Larger studies are needed to
establish the relationship between
inbrace correction and curve
progression.
118. Is the surgical outcome for lumbar disc herniations related to the duration of symptoms?
Christian Støttrup, Carsten Ernst, Dorte Clemmensen, Alexander Isenberg-Jørgensen, Randi Holm, Mikkel Østerheden Andersen
Rygkirurgisk sektor, Middelfart Sygehus, Vejle Sygehus
Background: Lumbar disc herniation (LDH) is
associated with great morbidity and
significant socio-economic impact in
many parts of the world. Studies have
shown that most LDH can be treated
effectively with conservative
management and the passage of time.
However for the group of patients
where pain and disability is
unacceptable, surgical intervention
provides effective clinical relief in many
cases. Currently there is little consensus
in the medical community on the timing of
surgery for patients suffering from
radicular pain due to LDH. Reports
based on the SPORT database indicate
that prolonged symptom-duration
correlates with inferior outcome.
Purpose / Aim of Study: The aim of this study is to evaluate if
prolonged symptom-duration is
correlated with less favorable outcome
following surgery for LDH in a Single-
Center Study.
Materials and Methods: 832 patients with first-time LDH were
included in a Single-Center Study. Data
were prospectively collected in
DaneSpine, the Danish National Spine
Register. The patient reported outcome
measures (PROM) EQ5D, SF36, ODI,
VAS-leg and -back were correlated with
duration of symptoms.
Findings / Results: 832 patients were included in the study,
with complete one-year follow-up on
664 patients (80%) and a reoperation
rate of 6%.
The duration of symptoms have a
negative correlation on all patient related
outcome measures.
Conclusions: Delayed surgical intervention results in
inferior patient related outcome. Our
results indicate that patients operated
within the first 3 months of leg-pain
achieve best outcome.
119. Does loss of follow-up bias patient-related outcome measures of spine surgery performed at the Sector for Spine Surgery and Research, Region of Southern Denmark.
Karen Højmark , Christian Støttrup, Mikkel Østerheden Andersen
Rygkirugisk sektor, Ortopædkirurgisk afdeling Vejle, Sygehus Lillebælt
Background: DaneSpine, the Danish National Spine
Register, collects patient-based pre- and
postoperative questionnaires, completed
before surgery and at 1, 2, 5 and 10
years postoperatively. The preoperative
data entered into DaneSpine are entirely
patient-based, and include age, sex,
height, weight, duration of back and leg
pain on the VAS-scale, SF-36, ODI and
EQ-5D.
The database was implemented at the
Sector for Spine Surgery and Research
on June 1st 2010. So far preoperative
data has been collected on 99.3% of
surgical patients, with a subsequent 1-
year follow-up of more than 80%.
Loss of follow-up may bias the outcome
assessment of clinical registries.
Purpose / Aim of Study: To determine whether patient related
outcome measures (PROMs) differed
between responders and none-responders.
Materials and Methods: In order to validate DaneSpine data, we
have performed 1-year follow-up on
non-responding patients for a 3 months
consecutive period between 1st of
August 2013 until 31st of October 2013.
Of the 262 patients operated in the same
period 1-year prior, 217 (82,8%) had
responded, 3 had died and 10 had
received other primary spine surgery and
therefore restarted in their registration
period.
During spring 2014 a structured
interview was performed by telephone
on the remaining 32 patients, 2 of which
could not be reached and 2 did not want
to participate.
Findings / Results: We found no difference in PROMs between
responders and non-responders at the
Sector for Spine Surgery and Research.
Conclusions: A 17% loss of 1-year follow-up does not
bias conclusions drawn from PROMs at the
Sector for Spine Surgery and Research.