December 2018

Full Article

SRS Core Curriculum

Laurel C. Blakemore, MD
Core Curriculum Task Force Chair

Under the leadership of the SRS Education Task Force, the Core Curriculum Task Force was charged with the task of defining a comprehensive competency-based core curriculum for use in spinal deformity training. This work would serve as the basis for SRS educational efforts including worldwide courses, and ensure consistency in post-training societal education.

A Delphi process which included 139 spinal deformity educators and experts from throughout the world completed multiple rounds with a remarkable retention rate of 89%. The participants defined the body of knowledge in the practice of spinal deformity into ten comprehensive Knowledge Domains (KDs). Within each Knowledge Domain are included an average of fourteen Learning Objectives (LOs). Each LO is a brief, clear statement of what the learner will be able to perform at the conclusion of the learning experience. LOs define the expected goal of a curriculum, course, lesson or activity in terms of demonstrable skills or knowledge that will be acquired by a student as a result of instruction.

The Core Curriculum Task Force has reviewed the content of the 2018 Annual Meeting and highlighted presentations based on the ten Knowledge Domains. The Core Curriculum is available on the SRS website. Future directions include the development of Assessment Tools which can be to assess learning outcomes for SRS educational efforts as well as development of content based on the curriculum structure which can be utilized by educators for development of spinal deformity courses and curricula.

Domain I: Foundation Knowledge – Alpaslan Senkoylu, MD

Foundation Knowledge (Domain I) was a component of nearly all sessions of the Annual Meeting in Bologna. One example was the Half-Day Course entitled “Achieving Excellence in the Management of Severe Pediatric Spinal Deformity” which was moderated by Drs. Cahill and Yaszay. Part 1 was about “Understanding the Development of Severe Scoliosis” including three impressive lectures. Dr. James Sanders gave first two lectures about all aspect of growth in early years and peri-pubertal period. These two presentations demonstrated learning objectives concerning development and anatomy of Foundation Knowledge Domain (I.1.1. Learner will be able to describe the normal embryologic development and growth of the spine and neural axis and their relation to function). The third topic was “Looking at Growth in 3D”. Dr. Stefan Parent’s discussions highlighted learning objective I.1.3. (Learner will be able to identify basic anatomy, biomechanics and alignment (including 3-dimensional alignment) of the spine.)

Domain II: Early Onset Scoliosis – Suken A Shah, MD

The Lunchtime Symposium on Early Onset Scoliosis – Expert Roundtable, chaired by James Sanders, MD and Ron El-Hawary, MD was a hybrid of presentations, panel solicitations and vibrant discussion involving the audience and falls into Core Curriculum Domain II. Topics included proximal junctional kyphosis (prevention strategies and treatment options), sagittal alignment (what is “optimal” for young children and what is acceptable?) and when should strategies other than growth modification be employed in EOS (Learning Objective II.3.3: Learner will be able to list the risk, benefits and complications of various growth friendly implant and correction strategies (e.g. distraction based, compression based, growth guided.)) These treatment challenges of EOS were outlined by cases, backed by evidence and further developed by lively academic debate.

Domain III: Adolescent Idiopathic Scoliosis – Stefan Parent, MD, PhD

The Hibbs Award session was the theater of a contrast between new innovative methods vs. long-term outcome of uninstrumented curves in selectively fused AIS patients. These two papers are part of knowledge domain III – Adolescent Idiopathic Scoliosis. Dr Firoz Miyanji first reported on a prospective multicenter consecutive series of 28 patients having undergone anterior vertebral body tethering with a minimum of 2 years of follow-up. The authors reported good outcome in reaching clinical success they also reported an 18% reoperation rate which demonstrates a need to further study these innovative techniques. Burt Yaszay then presented the results of 51 patients with 10 years of follow-up who underwent selective spinal fusion. At ten years, most compensatory curve matched the instrumented Cobb while only 10% of patients showed significant progression over the same period. Both papers generated significant discussion and will certainly be the focus of further work over the years to come. Of note, Dr Yaszay won the Hibbs Award for Best Clinical paper. Congratulations!

Domain IV: Neuromuscular Scoliosis – Suken A. Shah, MD

The Lunchtime Symposium on Neuromuscular Spine Deformities: The Spine is Only a Small Piece of the Big Puzzle, chaired by Olavo Letaif, MD and Muharrem Yazici, MD, was a collection of experts who highlighted the importance of a multidisciplinary approach to the care of these medically complex patients and falls into Core Curriculum Domain IV. Topics took a global view of the NM patient and included preoperative workup, specific principles to ensure success in these patients, effects of co-morbidities on decision-making, and innovations of disease modifying treatment and rapid recovery pathways. (Learning Objective IV.1.3 Learner will be able to discuss the impact of medical comorbidities associated with the most common etiologies of NMS. Learning Objective IV.2.2 Learner will be able to describe the role of preoperative optimization including interdisciplinary care teams. Learning Objective IV.3.7 Learner will describe use of measures to improve safety in NMS surgery and minimize perioperative complications.) These guidelines will help us optimize care of patients with neuromuscular patients and prevent complications.

Domain V: Cervical Deformity – Lindsay Andras, MD

In the free paper session on Saturday morning, there was an informative session on cervical deformity. Much of this work focused on predicting outcomes and risk stratification. In Paper 132 Hyun et. al. investigated a cervical spine deformity classification focused on T1 slope minus cervical lordosis and C2-C7 sagittal vertical axis. Using regression models, they predicted that a threshold C2-C7 SVA (value
of 40.8 mm and 70.6 mm) and TS-CL (value of 20° and 25°) correlated with moderate and severe disability following posterior cervical fusion with a mean of 7 years follow up. Paper 133 by the ISSG compared outcomes of primary vs revision procedures for cervical deformity. Interestingly, they found that while both groups had significant improvement in disability scores and neurologic symptoms, the recovery of myelopathy was worse in the revision group at 1 year but similar by 2 years. Additional work from the ISSG described a surgical invasiveness index for cervical deformity. This newly developed CD invasiveness index was strongly predictive of high blood loss, operative time and extended length of stay. Sciubba et. al. then looked at risk factors for identifying patients requiring discharge to inpatient rehab or skilled nursing facilities and found that severe preoperative cervical malalignment, age >59, fusions >8 levels and EBL >900cc were all predictive factors of inability to be discharged directly home. (Learning Objective V.3.2 Learner will be able to describe indications, risks and benefits of surgical treatment options.

In addition to looking at outcomes and risk stratification, there were also discussions on surgical techniques for managing complex problems. In Paper 136, Zhang et al presented the management of cervical kyphosis in neurofibromatosis with halo gravity traction and posterior only approach. They reported 92% correction and no loss of correction with stable neurologic function at mean follow up of nearly 4 years. Additionally, in the half day course Dr. Bangping Qian presented a case of ear on shoulder deformity and management with C7 PSO that is nicely outlined in the program. (Learning Objective V.3.3 Learner will be able to describe age-based correction strategies including approaches, fixation and bone grafting options)

Domain VI: Adult Spinal Deformity and Domain VII: Degenerative Spinal Deformity – Praveen V. Mummaneni, MD

The Thursday afternoon Half-Day course entitled “Adult Spinal Deformity: an International Exchange on the Safety and Efficiency of Current Techniques” was directed by Dr. Munish Gupta and Dr. Yan Wang.  The two knowledge domains covered in this session included Adult Spinal Deformity (Domain VI) and  Degenerative Spinal Deformity (Domain VII). Two platform talks from this session particularly captured the essence of the learning objectives for these knowledge domains. 

Dr. Stephen Lewis gave a talk entitled “Intraop Positioning and Neuromonitoring to Avoid Complications”. This talk gave succinct pearls focused on two learning objectives in Domain IV. Specifically, Dr. Lewis addressed patient positioning to optimize spinal alignment and minimize complications from patient positioning (like nerve palsy) as well as intraop techniques for neuromonitoring to improve safety (Learning Objective VI.3.4 Learner will describe use of measures to improve safety in ASD surgery and minimize perioperative complications). The talk gave pearls to the audience on how to deal with neuromonitoring alerts. 

A second talk in this session by Dr. Juan Uribe entitled “Lateral approach can avoid 3 column osteotomies” was also well recieved. This talk focussed on objectives in Domain VII (Degenerative Deformity). Dr. Uribe discussed anterior and posterior treatment options to restore spinal balance. He also discussed how to select fusion levels and when to stage the procedures (Learning Objective VII.3.5 Learner will be able to discuss anterior and posterior treatment options including different types of osteotomies). The concepts in this talk were novel and Dr. Uribe demonstrated with case examples the restoration of sagittal balance with anterior column release as an alternative to PSO. 

Domain VII: Kyphotic Deformities – Saumyajit Basu, MD

An abstract which attracted a lot of attention during the SRS Annual Meeting which fits in extremely well with the currently proposed Knowledge Domain VIII: on Kyphotic Deformities was Paper 115: A New Classification for Scheuermann’s Kyphosis, presented by David Bumpass, et al. This is the first time that a new classification system for Scheuermann’s Kyphosis was introduced keeping in mind 3 variables including the apex of the deformity (thoracic or thoracolumbar), the last-touched sagittal vertebra (LTSV), which might be any of T12 to L4), and pelvic incidence (PI). Cluster analysis was done and excellent inter-observer reliability was noted. The importance of the abstract lies in the fact that this would help in dictating a treatment especially regarding choosing the lower end of fusion. Thus clear guidelines of the knowledge domain of kyphotic deformities can be well established.

Domain IX: Spondylolisthesis – Stefan Parent, MD, PhD

The Annual Meeting scientific program kicked-off Wednesday afternoon with a session on both adult and pediatric deformities. Two papers discussed a controversial topic namely in situ fusion vs. reduction for spondylolisthesis (Domain IX). In Paper 16 by Anders Joelson et al. the authors presented the results of long-term outcome 30 years following in situ fusion for spondylolisthesis with good quality of life for patients operated with this technique. Although they did not have pre-operative radiographs and quality of life for all of these patients, they concluded that long-term outcome of in situ fusion was good. Paper 17 by Hubert Labelle reported on a single center consecutive series of 30 patients with high-grade spondylolisthesis that underwent reduction and circumferential fusion. Their results showed a significant improvement in both radiographic features and sagittal balance as well as a significant improvement in HRQoL with minimal complications.

Domain X: Acquired Deformities – Ferran Pellisé, MD

With the exception of Paper 93 presented by Kai Cao et al, who nicely reported on surgical treatment outcomes of fixed post-traumatic kyphosis, most papers and presentations dealing with “Acquired Deformities” (Domain X) were not included in the general abstract sessions. Different aspects of ankylosing spondylitis (AS) and spinal tuberculosis (TB) were covered in half-day courses and poster presentations.

Yong Qiu (Nanjing, China) defined the indications, advantages and outcomes of asymmetrical pedicle subtraction osteotomy in AS patients with thoracolumbar kyphoscoliotic deformity during the Half-Day Course focused on An International Exchange on Safety and Efficacy. Poster 245 from the same institution (Drum Tower Hospital, Nanjing) showed that in AS patients osteotomies located closer to or at the preoperative apex of the deformity have highest chances of achieving ideal postoperative apex re-location. Poster 248 by Samir Dalvie et al showed that posterior pedicular spinal stabilization is sufficient to achieve circumferential fusion in AS patients suffering 3-column spinal pseudoarthrosis.

Poster 284 presented by Arjun Dhawale et al, suggested an algorithmic approach with consideration of neurology, spinal stability and cord compression to manage TB spondylitis with myelopathy. The study confirmed that multiple vertebral involvement and MDR TB are risk factors for complications. Poster 159 by Saumyajit Basu et al, analyzed 24 patients and concluded that craniovertebral junction TB with atlantoaxial instability but without major neurodeficit has excellent results with conservative management (transoral biopsy/aspiration and halo-vest immobilization).

Overall these papers nicely covered different learning objectives concerning prediction of outcomes and complications as well as guidance in the treatment decision making process for acquired spinal deformities.