Pedicle subtraction osteotomy in adult spinal deformity correction: Clinical and radiographic risk factors for early instrumentation failure

Background: Instrumentation failure (IF) such proximal junctional kyphosis/failure or distal junctional failure (PJK/PJF/DJF), rod fracture and screw-loosening can cause morbidity in patients with spinal deformity correction. Factors such as bone mineral density (BMD) or region of deformity correction may play a role in postoperative IF. Methods: We reviewed the relationship between IF and BMD or extent of spinal deformity. IF includes PJK/PJF/DJF, fractured rod, screw-looseing, radiculopathy, and non-union. BMD groups included Normal, osteopenia/osteoporosis, and Unknown. The extent of correction included Lumbar, Short Thoracolumbar (5-8 levels), Long Thoracolumbar (8 to 12 levels), and Cervical-thoracic. Results: 60 patients (41:19 F:M) were included, with average age of 65. Total IF=29 patients (48.3%). Normal BMD in N=14, with half of them (50.0%) developing IF; Low BMD in N=15, with one-third of them (33.3%) developing IF. Lumbar correction was performed in N=19, with IF in 36.8%; Short Thoracolumbar correction was performed in N=28, with IF in 46.4%; Long Thoracolumbar correction was performed in N=11, with IF in 81.8%; and Cervical correction in N=2, with no postoperative IF. Conclusions: Patients that received long-segment thoracolumbar had the highest rates of postoperative morbidity. We did not demonstrate an association between abnormal BMD and postoperative IF. A larger study would be needed for further investigations.

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Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis

Journal of Neurosurgery Spine ◽

10.3171/2018.11.spine18927 ◽

2019 ◽

Vol 30 (6) ◽

pp. 822-832

Author(s):

Cecilia L. Dalle Ore ◽

Christopher P. Ames ◽

Vedat Deviren ◽

Darryl Lau

Keyword(s):

Rheumatoid Arthritis ◽

Spinal Deformity ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Vena Cava ◽

Deformity Correction ◽

Perioperative Outcomes ◽

Medical Complications ◽

Filter Placement ◽

Estimated Blood Loss

OBJECTIVESpinal deformity causing spinal imbalance is directly correlated to pain and disability. Prior studies suggest adult spinal deformity (ASD) patients with rheumatoid arthritis (RA) have more complex deformities and are at higher risk for complications. In this study the authors compared outcomes of ASD patients with RA following thoracolumbar 3-column osteotomies to outcomes of a matched control cohort.METHODSAll patients with RA who underwent 3-column osteotomy for thoracolumbar deformity correction performed by the senior author from 2006 to 2016 were identified retrospectively. A cohort of patients without RA who underwent 3-column osteotomies for deformity correction was matched based on multiple clinical factors. Data regarding demographics and surgical approach, along with endpoints including perioperative outcomes, reoperations, and incidence of proximal junctional kyphosis (PJK) were reviewed. Univariate analyses were used to compare patients with RA to matched controls.RESULTSEighteen ASD patients with RA were identified, and a matched cohort of 217 patients was generated. With regard to patients with RA, 11.1% were male and the mean age was 68.1 years. Vertebral column resection (VCR) was performed in 22.2% and pedicle subtraction osteotomy (PSO) in 77.8% of patients. Mean case length was 324.4 minutes and estimated blood loss (EBL) was 2053.6 ml. Complications were observed in 38.9% of patients with RA and 29.0% of patients without RA (p = 0.380), with a trend toward increased medical complications (38.9% vs 21.2%, p = 0.084). Patients with RA had a significantly higher incidence of deep vein thrombosis (DVT)/pulmonary embolism (PE) (11.1% vs 1.8%, p = 0.017) and wound infections (16.7% vs 5.1%, p = 0.046). PJK occurred in 16.7% of patients with RA, and 33.3% of RA patients underwent reoperation. Incidence rates of PJK and reoperation in matched controls were 12.9% and 25.3%, respectively (p = 0.373, p = 0.458). At follow-up, mean sagittal vertical axis (SVA) was 6.1 cm in patients with RA and 4.5 cm in matched controls (p = 0.206).CONCLUSIONSFindings from this study suggest that RA patients experience a higher incidence of medical complications, specifically DVT/PE. Preoperative lower-extremity ultrasounds, inferior vena cava (IVC) filter placement, and/or early initiation of DVT prophylaxis in RA patients may be indicated. Perioperative complications, morbidity, and long-term outcomes are otherwise similar to non-RA patients.

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Instrumentation techniques to prevent proximal junctional kyphosis and proximal junctional failure in adult spinal deformity correction—a systematic review of biomechanical studies

The Spine Journal ◽

10.1016/j.spinee.2021.01.011 ◽

2021 ◽

Author(s):

Remco J.P. Doodkorte ◽

Timon F.G. Vercoulen ◽

Alex K. Roth ◽

Rob A. de Bie ◽

Paul C. Willems

Keyword(s):

Systematic Review ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Proximal Junctional Kyphosis ◽

Proximal Junctional Failure ◽

Junctional Kyphosis

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Recurrence of proximal junctional kyphosis after revision surgery for symptomatic proximal junctional kyphosis in patients with adult spinal deformity: incidence, risk factors, and outcomes

European Spine Journal ◽

10.1007/s00586-020-06669-0 ◽

2021 ◽

Author(s):

Haruki Funao ◽

Floreana N. Kebaish ◽

Richard L. Skolasky ◽

Khaled M. Kebaish

Keyword(s):

Risk Factors ◽

Spinal Deformity ◽

Revision Surgery ◽

Adult Spinal Deformity ◽

Proximal Junctional Kyphosis ◽

Incidence Risk ◽

Junctional Kyphosis

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Sagittal Deformity Correction in a Patient Suffering From Diffuse Idiopathic Skeletal Hyperostosis Who Previously Underwent a Total Hip and Bilateral Knee Replacement

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321992745 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199274

Author(s):

Victor Garcia-Martin ◽

Ana Verdejo-González ◽

David Ruiz-Picazo ◽

José Ramírez-Villaescusa

Keyword(s):

Knee Replacement ◽

Spinal Deformity ◽

Diffuse Idiopathic Skeletal Hyperostosis ◽

Deformity Correction ◽

Pedicle Subtraction Osteotomy ◽

Lower Limbs ◽

Sagittal Imbalance ◽

Total Hip ◽

Correction Technique ◽

Compensation Mechanisms

Introduction: Physiological aging frequently leads to degenerative changes and spinal deformity. In patients with hypolordotic fusions or ankylosing illnesses such as diffuse idiopathic skeletal hyperostosis or ankylosing spondylitis, compensation mechanisms can be altered causing severe pain and disability. In addition, if a total hip replacement and/or knee replacement is performed, both pelvic and lower limbs compensation mechanisms could be damaged and prosthetic dislocation or impingement syndrome could be present. Pedicle subtraction osteotomy has proven to be the optimal correction technique for spinal deformation in patients suffering from a rigid spine. Case Presentation: A 70-year-old male patient with diffuse idiopathic skeletal hyperostosis criteria and a rigid lumbar kyphosis, who previously underwent a total hip and knee replacement, had severe disability. We then performed corrective surgery by doing a pedicle subtraction osteotomy. The procedure and outcomes are presented here. Conclusion: In symptomatic patients with sagittal imbalance and a rigid spine, pedicle subtraction osteotomy can indeed correct spinal deformity and re-establish sagittal balance.

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Failure Types and Related Factors of Spinopelvic Fixation After Long Construct Fusion for Adult Spinal Deformity

Neurosurgery ◽

10.1093/neuros/nyaa469 ◽

2020 ◽

Author(s):

Se-Jun Park ◽

Jin-Sung Park ◽

Yunjin Nam ◽

Tae-Hoon Yum ◽

Youn-Taek Choi ◽

...

Keyword(s):

Risk Factors ◽

Ct Scan ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Study Cohort ◽

Related Factors ◽

Fixation Failure ◽

Failure Group ◽

Pelvic Fixation ◽

Spinopelvic Fixation

Abstract BACKGROUND Rigid internal fixation of the spine is an essential part of adult spinal deformity (ASD) surgery. Despite the use of pelvic fixation and anterior column support, spinopelvic fixation failure (SPFF) still remains an issue. Few studies have evaluated the types of such failure or its related factors. OBJECTIVE To classify the types of SPFF and investigate its risk factors, including the fusion status at L5-S1 on CT scan. METHODS The study cohort consisted of ninety-eight ASD patients who underwent more than 4-level fusions to the sacrum with interbody fusion at L5-S1. Patients with SPFF were divided into the two groups: above-S1 and below-S1 failure groups. The patient, surgical, and radiographic variables in each group were compared to those of the no-failure group. The L5-S1 fusion status was assessed using 2-yr computed tomography (CT) scan. Univariate and multivariate analyses were performed to determine the risk factors for each failure group. RESULTS The mean age was 68.5 yr. Follow-up duration was 55.7 mo. The SPFF developed in 46 (46.9%) patients at 32.7 mo postoperatively. There were 15 patients in the above-S1 failure group and 31 patients in the below-S1 failure group. Multivariate analysis revealed that nonunion at L5-S1 was a single risk factor for above-S1 failure. In contrast, the risk factors for below-S1 failure included a greater number of fused segments and postoperative less thoracic kyphosis. CONCLUSION SPFF develops in different patterns with different risk factors. Above-S1 SPFF was associated with nonunion at L5-S1, while below-S1 SPFF was associated with mechanical stress.

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