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From Static Spinal Alignment to Dynamic Body Balance: Utilizing Motion Analysis in Spinal Deformity Surgery Abstract » Three-dimensional motion analysis is necessary to bridge the gap between static spinal radiographic alignment and dynamic body balance in the setting of pediatric and adult spinal deformities.
Bassel G. Diebo, MD Neil V. Shah, MD, MS Robert Pivec, MD Qais Naziri, MD, MBA Ashish Patel, MD Nicholas H. Post, MD Ayman Assi, PhD Ellen M. Godwin, PT, PhD, PCS Virginie Lafage, PhD
» Lessons learned from gait analysis in patients with adolescent idiopathic scoliosis may be applicable to patients with adult spinal deformity, with the potential to improve our understanding of dynamic compensatory mechanisms, the hip-spine complex, and proximal junctional kyphosis. » Dynamic and functional assessments such as gait analysis are expected to be the future of pediatric and adult spinal deformity research, with potential clinical and surgical applications.
Frank J. Schwab, MD Carl B. Paulino, MD
Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
COPYRIGHT © 2018 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
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pinal alignment is a postural radiographic concept, currently evaluated on static standing radiographs, that serves as the basis for the preoperative and postoperative assessment of patients with spinal deformity. Maintaining proper spinal alignment is crucial for enabling horizontal gaze as well as ensuring that the gravity line of the human body falls between the feet without the need to recruit excessive compensatory mechanisms1,2. Over the past few decades, our understanding of the biomechanical principles needed to maintain optimal spinal alignment has grown3-7. Spinal balance and body balance are active processes that require a thorough understanding of the harmony between posture and motion and are thus imperfectly represented by static radiographs alone. At present, our understanding of how surgical correction of spinal deformity impacts the functional mobility and daily activities of our patients is incomplete, as it is only assessed through quality-of-life
questionnaires without having a more objective and quantified tool8-10. Three-dimensional gait analysis (3DGA) is a tool used for the quantification of kinematics (angles) and kinetics (forces) developed in the joints during motion activities such as walking11-14. These parameters are usually described bilaterally during the gait cycle, which starts by the heel-strike and ends by the next heel-strike of the same limb (Fig. 1). It is widely used in patients with musculoskeletal disorders, such as spastic cerebral palsy15, Parkinson disease16, and spina bifida17. Quantifying motion via 3DGA enables a better understanding of how each joint or skeletal segment is performing in the 3 planes and during motion as well as how this is altered when compared with normal subjects18-21. Moreover, this tool has been used for tracking of spinal motion during static posture22, dynamic posture23, gait21, and other functional activities, including sit-tostand24. More recently, 3DGA has also
Disclosure: There was no source of external funding for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A354).
· http://dx.doi.org/10.2106/JBJS.RVW.17.00189
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Fig. 1 Tracking the phases of the normal gait cycle and percent completion, utilizing 3DGA. The gait cycle comprises initial contact (0%), opposite toe-off (10%), heel-rise (single-limb stance, 30%), opposite initial contact (50%), toe-off (60%), mid-swing (feet adjacent, 73%), terminal swing (vertical tibia, 87%), and next initial contact (100%). The right limb is green; the left limb is red.
been used to assess subjects with adolescent idiopathic scoliosis25-28. Therefore, 3DGA could be an efficient tool in the objectivation of spinal alignment during ambulation and other activities of daily living25,29-32. This review aims to update readers on the applications and the current state of the utility of motion analysis for the evaluation and management of adolescent idiopathic scoliosis and its potential role in enhancing the treatment of adult spinal deformity. Gait in Adolescent Idiopathic Scoliosis Adolescent idiopathic scoliosis is a well-recognized and thoroughly studied pathology of the spine30. The simplification of adolescent idiopathic scoliosis as a lateral curvature in the coronal plane of .10° understates the
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complexity of the deformity, which remains difficult to quantify accurately and to describe completely30,33,34. With a cutoff measure of 10°, the prevalence rates of adolescent idiopathic scoliosis in the general population are approximately 2.0% to 2.5%; however, rates as high as 9.2% have been reported35,36. Given that nearly 80% of idiopathic scoliosis cases are among adolescents, adolescent idiopathic scoliosis represents an important clinical entity that calls for rigorous and patient-specific management37. Standing radiography offers a practical method of measurement for most surgeons30. Various classifications have been developed for adolescent idiopathic scoliosis, all of which assess the deformity utilizing static radiographs in the coronal plane38-40. In 2001, Lenke et al.41 devised the
current classification system that guides selection of fusion levels. However, sole reliance on static biplanar (coronal and sagittal) measurements limits the utility of these classification methods, as they fail to account for the dynamic, rotational, and horizontal aspects of the deformity42. Evolution of Gait Analysis in Adolescent Idiopathic Scoliosis Prior to the advent of dynamic assessment of motion, standing force plate analysis of spinal balance and spinopelvic offsets offered information beyond radiographic assessment. Force plates with distributed pressure sensors allowed for analysis of both foot positioning and ground reaction forces in the standing posture43. To maintain their center of mass within their base of support, patients with spinal deformity
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develop compensatory mechanisms that can be detected via force plate analysis44. However, within the literature, force plate analysis has provided mixed results. Kramers-de Quervain et al.45 and Schizas et al.46 reported that the magnitude of asymmetries in the vertical component of the ground reaction force in adolescent idiopathic scoliosis was close to 4%, which was comparable with the normative population reported by Herzog et al.47. However, Chen et al.48 observed poorer postural stability in patients with idiopathic scoliosis when compared with normal subjects, with larger sway areas and lateral and sagittal sway magnitudes. Although force plate analysis improved the understanding of balance and reductions in center-ofmass deviations in the coronal plane49-51, an indication of a tighter cone of economy44, it offered limited insight into dynamic balance during ambulation52. The application of motion analysis in adolescent idiopathic scoliosis has increased over the past 2 decades. Most investigations have focused on several sets of data that are collected by motion analysis systems, including those related to gait efficiency (time-distance or temporal-spatial), range of motion (kinematic), and force-related (kinetic) parameters of gait. The results of the previous studies can be broken down into 2 components: (1) the impact of adolescent idiopathic scoliosis on gait
efficiency, force, and range-of-motion parameters of gait; and (2) the analysis of patients with adolescent idiopathic scoliosis by plane (sagittal, coronal, and axial). Impact of Adolescent Idiopathic Scoliosis on Gait Efficiency Among studies analyzing gait patterns in patients with adolescent idiopathic scoliosis, the most commonly collected gait efficiency parameters are walking speed (reportedly 1.04 to 1.24 m/s in healthy subjects), cadence (steps per minute), length and width of stride and step (in mm), and the side-to-side asymmetry of these parameters11. Multiple studies have found reduced walking speed53-55, cadence48, and stride length31,45,53-56 in patients with adolescent idiopathic scoliosis compared with controls; yet other authors have reported no such changes for walking speed28,45,56-61, stride length28,48,59,62, or cadence28,31,45,55,56,59,61,62. These disparities may be attributable to differences in the degree of spinal deformity, curve location, and postural stability control among the patients selected for each of the studies. Moreover, gait efficiency parameters were observed to decrease with the increasing magnitude of coronal deformity11,63,64. Vertebral segmental rotation in the axial plane is considered to be the primary deformity in adolescent idiopathic scoliosis and may be the
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cause of asymmetric right-left gait patterns in patients45,65,66. Within the sagittal plane, gait performance has been demonstrated to rely on underlying sagittal spinopelvic radiographic parameters (sacral slope, pelvic incidence, pelvic tilt, and sagittal vertical axis)67. These findings underlie the importance of dynamic, multiplanar evaluation of gait performance, especially in the context of a 3-dimensional deformity such as adolescent idiopathic scoliosis. Impact of Adolescent Idiopathic Scoliosis on Walking Forces Measurements of kinetics, which refer to the forces that drive bodily movement, have also been collected by studies evaluating gait within the patient population with adolescent idiopathic scoliosis68. These measurements include joint moments of force and power peaks at the hips, knees, and ankles via ground reaction forces during gait and stepping patterns (Table I)11. Ground reaction force data in several studies depict asymmetric gait in relation to mediolateral28,69 and vertical ground reaction forces46,70, as well as lateral and forward stepping patterns in patients with adolescent idiopathic scoliosis when compared with control subjects71-73. This may be due to altered global postural control secondary to deformity28, as well as changes in sensory input systems37,38,62-64. Moreover,
TABLE I Walking Force (Kinetics) Parameters Related to Gait Typically Collected in the Study of Patients with Spinal Pathologies Parameter
Definition and Notes
Planes Measured
Ground reaction force
A positive ground reaction force value indicates a vertical (upward), anterior, and/or lateral force; the ground reaction force is normalized to body weight
Anterior-posterior, medial-lateral, vertical
Joint moments
A positive external joint moment indicates adduction of the hip or abduction of the knee or ankles
Coronal, sagittal, transverse
Power peak
Product of the internal joint moment and joint angular velocity
Coronal, sagittal, transverse
Work
Joint power integrated over time; a negative value indicates energy absorption (via eccentric muscular contractions)
Coronal, sagittal, transverse
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reduced efficiency of the lumbar and pelvic musculature yields decreased mediolateral forces at the hip, which might contribute to the development of spinal deformity in patients with adolescent idiopathic scoliosis74. Additionally, motion analysis has been used to identify subtle variations in centerof-mass excursion in the coronal plane in patients with adolescent idiopathic scoliosis; Paul et al.67 demonstrated that correction of thoracic kyphosis paradoxically impacted the center-ofmass excursion, revealing changes that were not previously identifiable, possibly because of de-rotation of the curve. Motion analysis has expanded the capability of force plate analysis beyond the center of mass, ground reaction forces, and sway to provide investigators with a comprehensive understanding of the forces at play during gait52. Impact of Adolescent Idiopathic Scoliosis on Joint Range of Motion Kinematic parameters include range of motion of the pelvis, hip, knee, and ankle (Table II and Fig. 2)68. These parameters are compared between the right and left sides in an effort to identify any asymmetries in motion across the lower extremities in the coronal, sagittal, and axial planes in comparison with normal subjects11. When compared with healthy control subjects, patients with adolescent idiopathic scoliosis demonstrated reduced motion in the axial and coronal pelvic planes31,54,66, coronal and axial hip planes31,48, and sagittal hip66,75 and knee31 planes. Several factors may explain these findings, including delayed activation of pelvic and lumbar musculature bilaterally31, rigidity of the spinal deformity, and misaligned spinal musculature48. Patients with adolescent idiopathic scoliosis were observed to employ compensatory mechanisms, including asymmetric knee flexion during stance, early heel rise of the functionally longer limb during stance, and reduced pelvic range of motion to compensate for reduced triplanar pelvic motion and leg-
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length discrepancy31,66. Varghese et al.76 demonstrated how patients with adolescent idiopathic scoliosis with large coronal offsets (C7 plumb line [C7PL], .30 mm) to the right employed compensatory mechanisms of the lower limbs during gait, resulting in significantly limited ipsilateral hip abduction and reduced hip and knee flexion range of motion in these patients (all p , 0.05). Kinematic analysis of motion also evaluates the range of motion of the trunk. Movement of the shoulder with respect to the pelvis (thoracopelvic coordination) is often a proxy for truncal rotation; it can be categorized as inphase, if the 2 segments rotate together in the same direction, or anti-phase, if there is simultaneous rotation of the 2 segments in opposite directions77. Typically, healthy subjects have higher anti-phase coordination patterns and superior consistency of thoracopelvic coordination78,79. By comparing thoracopelvic rotation in the axial plane throughout the gait cycle, evaluating differences in range of motion, and studying in-phase or anti-phase coordination, Park et al.54 found that patients with adolescent idiopathic scoliosis demonstrated significantly higher inphase and lower anti-phase coordination (p , 0.05), resulting in decreased truncal instability during gait when compared with healthy controls. In coronal and axial plane analyses of patients with adolescent idiopathic scoliosis with single lumbar curves (Lenke type 5), Nishida et al.80 reported similar asymmetries, findings that are supported by several other studies45,54,81. Range-of-motion disparities of the spine, pelvis, and lower extremities during gait should be assessed and accounted for as potential markers for deformity progression in patients with adolescent idiopathic scoliosis11,28,31,45,48. Moreover, studies that evaluate spinal motion in patients with adolescent idiopathic scoliosis at baseline are lacking; the majority have studied patients following surgical correction82-84. Such investigation may be beneficial to incorporate
into the evaluation and management of adolescent idiopathic scoliosis. Investigators have specifically compared patients’ preoperative and postoperative dynamic function by analyzing gait efficiency, joint range of motion, and walking force parameters during gait in the sagittal, coronal, and axial planes; yet the literature is lacking in studies with larger sample sizes and long-term follow-up85-87. Clinical Relevance of Gait Analysis in Adolescent Idiopathic Scoliosis and Impact on Decision-Making Motion analysis provides an in-depth view into a patient’s dynamic performance in various planes of motion. Skalli et al.88 were among the earliest to employ motion analysis to identify dynamic compensatory changes in patients with adolescent idiopathic scoliosis; their findings demonstrated the central role of the pelvis in maintaining both balance and motion preoperatively and postoperatively in patients with adolescent idiopathic scoliosis. Similarly, Patel et al.89 evaluated the role of pelvic morphology, by way of pelvic incidence, in analyzing sagittal alignment in adolescent idiopathic scoliosis. They suggested that after accounting for global coronal alignment (C7PLmatched patients), pelvic incidence may play a role in hip dynamics during the overall gait cycle. Specifically, patients with pelvic incidence greater than the 60th percentile (i.e., patients with a pelvic incidence in the top 40% of the study population) had a greater hip range of motion in the sagittal and coronal planes. Identification of such parameters as key contributors to postural alignment and motion will enable clinicians to better prepare for individualized planning for these 3-dimensional dynamic pathologies. These studies strengthen the call for surgeons to be more cognizant of the importance of patient-specific gait analysis to complement radiographic studies to highlight pelvic morphology and compensation profiles for each patient prior to surgical intervention.
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TABLE II Joint Motion-Related (Kinematic) Parameters Related to Gait, Organized by Involved Joint, Typically Collected in the Study of Patients with Spinal Pathologies* Joint
Parameters
Plane
Pelvic range of motion Pelvic tilt
Sagittal
Mean range of motion Pelvic obliquity
Coronal
Mean range of motion Pelvic rotation
Transverse
Mean range of motion Hip range of motion Flexion and extension
Sagittal
Mean flexion and extension in the stance phase and throughout the gait cycle Range of motion in the stance phase and throughout the gait cycle Peak flexion and extension in the swing phase Maximum extension time in the stance phase Maximum flexion time in the swing phase Abduction and adduction
Coronal
Mean abduction and adduction in the stance phase and throughout the gait cycle Range of motion in the stance phase and throughout the gait cycle Internal and external rotation
Transverse
Mean internal and external rotation in the stance phase and throughout the gait cycle Range of motion in the stance phase and throughout the gait cycle Hip rotation
Sagittal
At initial contact Knee range of motion Flexion and extension
Sagittal
Maximum flexion and extension in the stance and swing phases Range of motion in the stance phase and throughout the gait cycle Mean flexion and extension in the stance phase and throughout the gait cycle Value at initial contact Maximum extension time in the stance phase Maximum flexion time in the swing phase Ankle range of motion Dorsiflexion and plantar flexion
Sagittal
Maximum dorsiflexion and plantar flexion in the stance and swing phases Range of motion in the stance phase and throughout the gait cycle Mean dorsiflexion and plantar flexion in the stance phase and throughout the gait cycle Maximum plantar flexion time in the stance phase Maximum dorsiflexion time in the swing phase *These include mean joint motion (in degrees), range of motion (in degrees), and time of joint motion (in milliseconds).
Motion analysis might be capable of quantifying outcomes of surgical intervention in a faster time frame than long-term follow-up, while producing results comparable with those in previous studies. For example, Lander et al.90
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reported that patient-reported outcomes from patients with adolescent idiopathic scoliosis followed over at least 40 years showed that patients in whom a caudal lowest instrumented vertebra (L4 or below) was selected had greater rates
of additional surgical procedures and lower functional outcomes scores than patients in whom a cephalad lowest instrumented vertebra (L3 or above) was selected. Similarly, Nakashima et al.91 reported that patients with adolescent
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Fig. 2 Several markers placed to capture thoracic, pelvic, hip (not depicted), knee, ankle, and foot motion during 3DGA.
idiopathic scoliosis with 20-year imaging (radiography, magnetic resonance imaging [MRI]) and patient-reported follow-up as well as caudal lowest instrumented vertebra placement (L3 to S1) had higher rates of disc degeneration when compared with control patients or those with more proximal lowest instrumented vertebra selection. On the contrary, with short-term follow-up, motion analysis is capable of highlighting patterns of motion and preoperativeto-postoperative changes in gait, serving as a powerful tool both to help to guide surgical decision-making and to assess outcomes. In a cohort study by Diebo et al.92, 36 patients with adolescent idiopathic scoliosis were observed over a 1year period with preoperative and 1-year postoperative radiographic and gait assessments. In comparison with patients with a caudal lowest instrumented vertebra (L3 to L4), those with a cephalad lowest instrumented vertebra (T12 to L2) were shown to demonstrate greater pelvic range of motion in the horizontal plane (10.6° compared with 7.0°), knee flexion and extension range of motion throughout the gait cycle (56.9° compared with 46.6°), and walking speed (1.2
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compared with 1.1 m/s) than did patients with a caudal lowest instrumented vertebra. These results highlight the ability of functional assessments through gait analysis to detect subtle, yet important, differences between patients who underwent comparable spinal deformity surgical procedures. These data show that gait parameters may differ on the basis of the lowest instrumented vertebra selection alone, which may serve to alter the natural history of adjacent joints. An additional implication of gait analysis is the correlation of the magnitude of intraoperative vertebral derotation with postoperative functional performance. Patel et al.81 demonstrated improvement of postoperative axial plane motion in patients undergoing spinal fusion for adolescent idiopathic scoliosis. The authors showed that abnormal preoperative in-phase pelvic and thoracic rotation during gait improved postoperatively, with normal counterrotation of the pelvis and thorax occurring at 38% and 65% completion of the gait cycle. These studies emphasized the utility of gait analysis for providing data on the impact of adolescent idiopathic scoliosis surgery and its potential use in the prediction of long-term functional outcomes. Gait in Adult Spinal Deformity Adult spinal deformity represents a clinical entity that parallels adolescent idiopathic scoliosis when considering the utility of motion analysis. Several studies have validated force plate analysis in quantifying static postural movement patterns about the gravity line5,43,44. Lafage et al.43 and Schwab et al.44 assessed the influence of the sagittal vertical axis offset on spinopelvic parameters and positioning in relation to the gravity line in standing subjects of varying sagittal alignment. They found most offset values to differ between groups and yet noted that the gravity line remained relatively constant with relation to the feet regardless of changes in the sagittal vertical axis.
Motion analysis has been used to evaluate the differences between standing and walking posture (Fig. 3). Studies have shown an association between the magnitude of sagittal spinal deformity, as measured by the pelvic incidencelumbar lordosis mismatch, and underlying differences in posture between standing and walking93. Specifically, Engsberg et al.94 reported on gait differences between patients with adult spinal deformity receiving a primary or revision long fusion surgical procedure. The authors investigated truncal motion during gait, as assessed by thoracopelvic rotation, at 1 year and 2 years postoperatively. With respect to thoracopelvic range of motion, patients demonstrated similar trends at 1 year and 2 years postoperatively when compared with healthy subjects; for the primary procedure, the thoracopelvic range of motion was 7° at 1 year postoperatively and 5° at 2 years postoperatively for patients with degenerative changes superimposed on idiopathic scoliosis and 14° for healthy subjects, and for the revision procedure, it was 6° at 1 year postoperatively and 4° at 2 years postoperatively for patients with previous long fusion to L4, L5, or the sacrum and 14° for healthy subjects (p , 0.05). Additionally, they reported that for patients undergoing a revision adult spinal deformity surgical procedure, significant decreases in preoperative dynamic hip and knee flexion range of motion, compared with healthy subjects, were no longer observed at 1 and 2 years postoperatively. The hip flexion range of motion was 24° at both 1 year and 2 years postoperatively for patients undergoing a revision procedure, compared with 25° for healthy subjects (p . 0.05). The knee flexion range of motion was 10° at 1 year postoperatively and 7° at 2 years postoperatively for patients undergoing a revision procedure, compared with 4° for healthy subjects (p . 0.05). This emphasized the ability of gait analysis to highlight changes that cannot be assessed on static radiography or clinical examination.
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Fig. 3 Utilizing 3DGA to depict the vertical ground reaction forces (yellow arrows) of the right (green) and left (blue) lower extremities during ambulation represents a dynamic upgrade from force (kinetic) analysis, which was limited to analysis of standing posture by a force plate.
However, despite recent advances, motion analysis as a tool for thorough assessment of the effects of a corrective surgical procedure on gait mechanics in patients with adult spinal deformity has seen limited use. Yagi et al.95 showed that patients with adult spinal deformity had asymmetric gait patterns and decreased gait efficiency when compared with healthy subjects. Although a spinopelvic realignment surgical procedure, in conjunction with strength-improving exercises, was found to improve the walking ability of patients with adult spinal deformity95, the moderate association found between patient-reported satisfaction and improvements in gait velocity highlights the necessity of more data pertaining to forces and range of motion during gait for adult spinal deformity evaluation and management. Future Implications of Gait Analysis and Global Functional Assessment in Adult Spinal Deformity Determining Ideal Dynamic Profile Although gait analysis can provide insight into disturbances of dynamic motion in patients with spinal pathology96, it has the potential to utilize walking patterns to identify ideal alignment and resolve this knowledge gap regarding it. Building on the classification
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of normal static sagittal alignment of Roussouly et al.97, Bakouny et al.18 found that each of the sagittal morphotypes (characterized by pelvic incidence, sacral slope, and lumbar lordosis) classified by Roussouly et al. had a gait pattern that was distinctly different from the other morphotypes, although all of them were within the range of normal. This may be an indication that a patient’s normal dynamic profile could be different on the basis of his or her radiographic sagittal alignment profile. Further investigation in this area may benefit patients with spinal pathology, for whom dynamic alignment data may allow for more individualized and appropriate correction of their specific dynamic profile. Yet, without future correlation to patient-reported outcomes pertaining to quality of life, the objective measures obtained with 3DGA may be limited in utility. Energy Expenditure and Standardized Tests as Objective Measures of Function Among patients with adult idiopathic scoliosis, energy expenditure during gait, typically evaluated by O2 consumption (or VO2 [mL/kg/min]) and peripheral oxygen saturation (SpO2), has been demonstrated to be increased when compared with
healthy subjects 11,58,98-101 . Such evaluations are limited with respect to patients with adult spinal deformity. Current efforts are under way to investigate the impact of different treatment modalities and alignment targets on optimizing energy expenditure of patients with adult spinal deformity. Challier et al. 102 tested a novel, standardized global functional assessment, conceptually proposed by Jean Dubousset. The Dubousset functional test is a 4-component test that attempts to quantify a patient’s functional capacity by recording the time taken for each and all tests (Fig. 4)102. The components of the Dubousset functional test are the (1) up-andwalking test: rising from a seated position unassisted, walking 5 m forward to a stop, walking backward for 5 m, and returning to a seated position; (2) steps test: climbing up 3 stairs, turning around on the top step, and then going down 3 stairs; (3) down-and-sitting test: sitting down on the ground from a standing position and returning to a standing position; and (4) dual-tasking test: walking 5 m back and forth while conducting a working memory test (counting down from 50 by 2). Challier et al.102 performed a pilot study on 10 patients and found the Dubousset
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Fig. 4 The Dubousset functional test is a 4-component test that attempts to quantify a patient’s functional capacity by recording the time taken for each and all tests. The components of the Dubousset functional test are the (1) up-and-walking test: rising from a seated position unassisted, walking 5 m forward to a stop, walking backward for 5 m, and returning to a seated position; (2) steps test: climbing up 3 stairs, turning around on the top step, and then going down 3 stairs; (3) down-and-sitting test: sitting down on the ground from a standing position and returning to a standing position; and (4) dual-tasking test: walking 5 m back and forth while conducting a memory test (counting down from 50 by 2).
functional test to be safe and useful in providing insights into a patient’s global functional capacities. The Dubousset functional test is an attempt at quantification of quiet motor and sensory function and overall balance during motion, such as gait; coupling this test and 3DGA may increase our capacity to identify drivers of functional disability and may obtain a better overall picture of a patient’s dynamic functionality. Current multicenter efforts are under way to utilize and examine the ability of the Dubousset functional test to predict surgical success of adult spinal deformity realignment procedures. Utilizing objective measures of functionality such as energy expenditure and the Dubousset functional test may help in understanding the patient’s preoperative state and may highlight certain comorbidities that could be optimized prior to surgical treatment. Dynamic Compensatory Mechanisms Full-body compensatory mechanisms are known to be triggered throughout the musculoskeletal system in the setting of adult spinal deformity29,103-106. Parallel investigations of how these mechanisms are recruited by patients with adult spinal deformity during motion are important to better understand the impact of adult spinal deformity on
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patients’ daily activities and how a surgical procedure can improve their quality of life. Although investigations by Lazennec et al.107,108 have compared static full-body imaging in sitting and standing positions to identify dynamic and compensatory changes in global alignment, motion analysis may have the potential to bolster the validity and clinical applicability of such findings. Such studies will identify the compensatory mechanisms adapted by patients from preoperative to postoperative time points and might increase the likelihood of achieving a more optimal postoperative correction for the global alignment profile in both static and dynamic fashions. The Hip-Spine Complex Radiographically, there is an established interplay between spinal alignment and the hip joints in both patients with native joints and those undergoing arthroplasty107,109. The study of forces and motion along the spine-hip continuum may substantiate our understanding of this complex interplay. Several studies have demonstrated how hip and lumbar spinal forces may be altered during motion in patients with symptomatic back pain110,111. Motion analysis has also been utilized to identify gait parameters that assist in clinical
decision-making by distinguishing patients with L4 radiculopathy from patients with hip osteoarthritis85. Another possible application of motion analysis is its potential to identify the dynamic safe zone in which patients with concomitant spine-hip disease have lower risk of hip dislocation. Widmer112 utilized computer modeling to identify a combined safe zone to guide optimal component placement and positioning; in doing so, he showed how the safe zone is dynamic and varies with each prosthesis system. Gait analysis can provide surgeons with a tool to identify this zone in real time. Understanding Proximal Junctional Kyphosis Following Deformity Correction Proximal junctional kyphosis presents a substantial challenge for adult spinal deformity surgeons, as it represents an adjacent segment disease that is usually encountered following spinal fusion and deformity correction surgery113,114. Proximal junctional kyphosis typically is defined as a .10° kyphotic change in the sagittal Cobb angle between the upper end plate of the vertebra 2 levels above the uppermost instrumented vertebra and the lower end plate of the uppermost instrumented vertebra. With several etiologies, proximal junctional kyphosis
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is driven by substantial motion disturbances between the fused and unfused segments of the spine. Investigations focused on the development of proximal junctional kyphosis in patients with adult spinal deformity are all currently lacking in dynamic assessment. Elys´ee et al.115 assessed the relationship between the center of gravity and development of proximal junctional kyphosis at the junction of the uppermost instrumented vertebra and the adjacent noninstrumented segment and reported a moderate correlation between bending moment at the uppermost instrumented vertebra and proximal junctional kyphosis severity. That study revealed an important relationship, and it also served to demonstrate how motion analysis could enhance our knowledge by exploring the joint forces and range-of-motion parameters during motion at the transitional junction where proximal junctional kyphosis typically occurs. Limitations and Future Directions The motion analysis laboratory is an invaluable tool for orthopaedic surgeons, providing the opportunity to obtain a wealth of patient-specific clinical information during motion. However, these laboratories would function best in a multidisciplinary environment, with thorough patient assessment in collaboration between the physician and other staff, including physical therapists and biomechanical engineers, to glean maximal knowledge about patients’ dynamic functional status. Often, such laboratories are underutilized beyond research purposes116,117. Moreover, there is a high cost associated with establishing and maintaining equipment within a motion analysis laboratory116. At this time, highly customized wearable sensor systems, which offer the potential for convenient and continuous data capture away from the clinical setting, are limited by their inaccuracy and errors, largely because of their reliance on double integration118 as well as drifting of measurements from their true values because of building signal noise118,119.
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Three-dimensional gait analysis may help to address the current lack of a classification system to categorize patients’ gait patterns into distinct clinical entities, which can then be correlated with known spinal pathologies. Currently, involvement of experienced clinicians is required to identify some otherwise subtle pathological gait patterns. The development of a computational, standardized classification system may extend the utility of gait analysis to a broader group of providers with varying levels of experience120. Additionally, while preoperative static and dynamic assessment may assist in formulating goals for correction, these may be difficult to achieve intraoperatively. Conclusion Motion analysis is a powerful tool that has granted researchers a vastly improved understanding of the dynamic nature of the pediatric spinal deformity previously assessed by static radiography alone. Objective dynamic and functional assessments such as gait analysis are expected to be part of the future of pediatric and adult spinal deformity research and offer a variety of clinical and surgical applications and a previously unobtainable wealth of data. NOTE: The authors thank Frank Fasano for his assistance in image production. MD1,
Bassel G. Diebo, Neil V. Shah, MD, MS1, Robert Pivec, MD1, Qais Naziri, MD, MBA1, Ashish Patel, MD2, Nicholas H. Post, MD3, Ayman Assi, PhD4,5, Ellen M. Godwin, PT, PhD, PCS6, Virginie Lafage, PhD7, Frank J. Schwab, MD7, Carl B. Paulino, MD1 1Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York 2Orthopaedic and Spine Center, Methodist
Hospitals, Merrillville, Indiana
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3Division of Neurosurgery, Brookdale University Hospital Medical Center, Brooklyn, New York 4Laboratory of Biomechanics and Medical Imaging, University of Saint-Joseph, Beirut, Lebanon 5Gait and Motion Analysis Lab, SESOBEL, Beirut, Lebanon 6Department of Physical Therapy, Long Island University, Brooklyn, New York 7Spine Service, Hospital for Special Surgery, New York, NY
E-mail address for B.G. Diebo:
[email protected] ORCID iD for B.G. Diebo: 0000-00027835-2263
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JULY 2018
· VOLUME 6, ISSUE 7 · e3
