title: Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: an international survey of spine surgeons.
abstract: OBJECT The associations among global spinal alignment, patient-reported disability, and surgical outcomes have increasingly gained attention. The assessment of global spinal alignment requires standing long-cassette anteroposterior and lateral radiographs; however, spine surgeons routinely rely only on short-segment imaging when evaluating seemingly isolated lumbar pathology. This may prohibit adequate surgical planning and may predispose surgeons to not recognize associated pathology in the thoracic spine and sagittal spinopelvic malalignment. The authors used a case-based survey questionnaire to evaluate if including long-cassette radiographs led to changes to respondents' operative plans as compared with their chosen plan when cases contained standard imaging of the involved lumbar spine only. METHODS A case-based survey was distributed to AOSpine International members that consisted of 15 cases of lumbar spine pathology and lumbar imaging only. The same 15 cases were then shuffled and presented a second time with additional long-cassette radiographs. Each case required participants to select a single operative plan with 5 choices ranging from least to most extensive. The cases included 5 "control" cases with normal global spinal alignment and 10 "test" cases with significant sagittal and/or coronal malalignment. Mean scores were determined for each question with higher scores representing more invasive and/or extensive operative plans. RESULTS Of 712 spine surgeons who started the survey, 316 (44%) completed the entire series, including 68% of surgeons with spine fellowship training and representation from more than 40 countries. For test cases, but not for control cases, there were significantly higher average surgical invasiveness scores for cases presented with long-cassette radiographs (4.2) as compared with those cases with lumbar imaging only (3.4; p = 0.002). The addition of long-cassette radiographs resulted in 82.1% of respondents recommending instrumentation up to the thoracic spine, a 23.2% increase as compared with the same cases presented with lumbar imaging only (p = 0.008). CONCLUSIONS This study demonstrates the importance of maintaining a low threshold for performing standing long-cassette imaging when assessing seemingly isolated lumbar pathology. Such imaging is necessary for the assessment of spinopelvic and global spinal alignment, which can be important in operative planning. Deformity, particularly positive sagittal malalignment, may go undetected unless one maintains a high index of suspicion and obtains long-cassette radiographs. It is recommended that spine surgeons recognize the prevalence and importance of such deformity when contemplating operative intervention.
authors.affiliation: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors.forename: Dominic
authors.initials: D
authors.lastname: Maggio
authors.affiliation: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors.forename: Tamir T
authors.initials: TT
authors.lastname: Ailon
authors.affiliation: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors.forename: Justin S
authors.initials: JS
authors.lastname: Smith
authors.affiliation: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Shaffrey
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.
authors.forename: Virginie
authors.initials: V
authors.lastname: Lafage
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.
authors.forename: Frank
authors.initials: F
authors.lastname: Schwab
authors.affiliation: Atlanta Brain and Spine Care, Atlanta, Georgia.
authors.forename: Regis W
authors.initials: RW
authors.lastname: Haid
authors.affiliation: Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.
authors.forename: Themistocles
authors.initials: T
authors.lastname: Protopsaltis
authors.affiliation: Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California.
authors.forename: Eric
authors.initials: E
authors.lastname: Klineberg
authors.affiliation: Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Justin K
authors.initials: JK
authors.lastname: Scheer
authors.affiliation: Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado.
authors.forename: Shay
authors.initials: S
authors.lastname: Bess
authors.affiliation: Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Arnold
authors.affiliation: Department of Orthopaedic Surgery, University of Washington, Seattle, Washington.
authors.forename: Jens
authors.initials: J
authors.lastname: Chapman
authors.affiliation: Division of Neurosurgery, University of Toronto, Ontario, Canada; and.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Fehlings
authors.affiliation: Department of Neurosurgery, University of California, San Francisco, California.
authors.forename: Christopher
authors.initials: C
authors.lastname: Ames
keywords: ASP = adjacent segment pathology; HRQOL = health-related quality of life; PA = posteroanterior; PJF = proximal junctional failure; PJK = proximal junctional kyphosis; PT = pelvic tilt; SVA = sagittal vertical axis; UIV = uppermost instrumented vertebra; deformity; long-cassette imaging; lumbar; radiographs; spine alignment; surgery