232. Optimal lumbar lordosis correction for adult spinal deformity with severe sagittal imbalance in patients over age 65: role of pelvic tilt and pelvic tilt ratio

Abstract BACKGROUND: Sagittal balance in adult spinal deformity is a major predictor of quality of life. A temporary loss of paraspinal muscle force and somatic pain following spine surgery may limit a patient's ability to maintain posture. OBJECTIVE: To assess the evolution of sagittal balance and clinical outcomes during recovery from adult spinal deformity surgery. METHODS: Retrospective review of a prospective observational database identified a consecutive series of patients with sagittal vertical axis (SVA) > 40 mm undergoing adult deformity surgery. Radiographic parameters and clinical outcomes were measured out to 2 yr after surgery. RESULTS: A total of 113 consecutive patients met inclusion criteria. Mean preoperative SVA was 90.3 mm, increased to 104.6 mm in the first week, then gradually reduced at each follow-up interval to 59.2 mm at 6 wk, 45.0 mm at 3 mo, 38.6 mm at 6 mo, and 34.1 mm at 1 yr (all P < .05). SVA did not change between 1 and 2 yr. Pelvic incidence-lumbar lordosis (PI-LL) corrected immediately from 25.3° to 8.5° (16.8° change; P < .01) and a decreased pelvic tilt from 27.6° to 17.6° (10° change; P < .01). No further change was noted in PI-LL. Pelvic tilt increased to 20.2° (P = .01) at 6 wk and held steady through 2 yr. Mean Visual Analog Scale, Oswestry Disability Index, and Short Form-36 scores all improved; pain rapidly improved, whereas disability measures improved as SVA improved. CONCLUSION: Radiographic assessment of global sagittal alignment did not fully reflect surgical correction of sagittal balance until 6 mo after adult deformity surgery. Sagittal balance initially worsened then steadily improved at each interval over the first year postoperatively. At 1 yr, all clinical and radiographic measures outcomes were significantly improved.

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Toward understanding the underlying mechanisms of pelvic tilt reserve in adult spinal deformity: the role of the 3D hip orientation

European Spine Journal ◽

10.1007/s00586-021-06778-4 ◽

2021 ◽

Author(s):

Mario Mekhael ◽

Georges Kawkabani ◽

Renée Maria Saliby ◽

Wafa Skalli ◽

Eddy Saad ◽

...

Keyword(s):

Spinal Deformity ◽

Pelvic Tilt ◽

Adult Spinal Deformity ◽

Underlying Mechanisms

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Overcorrection of lumbar lordosis for adult spinal deformity with sagittal imbalance: comparison of radiographic outcomes between overcorrection and undercorrection

European Spine Journal ◽

10.1007/s00586-016-4441-4 ◽

2016 ◽

Vol 25 (8) ◽

pp. 2668-2675 ◽

Cited By ~ 15

Author(s):

Jung-Hee Lee ◽

Ki-Tack Kim ◽

Sang-Hun Lee ◽

Kyung-Chung Kang ◽

Hyun-Seok Oh ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Sagittal Imbalance ◽

Radiographic Outcomes

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Long fusion from sacrum to thoracic spine for adult spinal deformity with sagittal imbalance: upper versus lower thoracic spine as site of upper instrumented vertebra

Neurosurgical FOCUS ◽

10.3171/2014.3.focus13541 ◽

2014 ◽

Vol 36 (5) ◽

pp. E9 ◽

Cited By ~ 28

Author(s):

Takahito Fujimori ◽

Shinichi Inoue ◽

Hai Le ◽

William W. Schairer ◽

Sigurd H. Berven ◽

...

Keyword(s):

Thoracic Spine ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Thoracic Kyphosis ◽

Adult Spinal Deformity ◽

Sagittal Imbalance ◽

Fusion Surgery ◽

Significant Difference ◽

Upper Instrumented Vertebra

Object Despite increasing numbers of patients with adult spinal deformity, it is unclear how to select the optimal upper instrumented vertebra (UIV) in long fusion surgery for these patients. The purpose of this study was to compare the use of vertebrae in the upper thoracic (UT) versus lower thoracic (LT) spine as the upper instrumented vertebra in long fusion surgery for adult spinal deformity. Methods Patients who underwent fusion from the sacrum to the thoracic spine for adult spinal deformity with sagittal imbalance at a single medical center were studied. The patients with a sagittal vertical axis (SVA) ≥ 40 mm who had radiographs and completed the 12-item Short-Form Health Survey (SF-12) preoperatively and at final follow-up (≥ 2 years postoperatively) were included. Results Eighty patients (mean age of 61.1 ± 10.9 years; 69 women and 11 men) met the inclusion criteria. There were 31 patients in the UT group and 49 patients in the LT group. The mean follow-up period was 3.6 ± 1.6 years. The physical component summary (PCS) score of the SF-12 significantly improved from the preoperative assessment to final follow-up in each group (UT, 34 to 41; LT, 29 to 37; p = 0.001). This improvement reached the minimum clinically important difference in both groups. There was no significant difference in PCS score improvement between the 2 groups (p = 0.8). The UT group had significantly greater preoperative lumbar lordosis (28° vs 18°, p = 0.03) and greater thoracic kyphosis (36° vs 18°, p = 0.001). After surgery, there was no significant difference in lumbar lordosis or thoracic kyphosis. The UT group had significantly greater postoperative cervicothoracic kyphosis (20° vs 11°, p = 0.009). The UT group tended to maintain a smaller positive SVA (51 vs 73 mm, p = 0.08) and smaller T-1 spinopelvic inclination (−2.6° vs 0.6°, p = 0.06). The LT group tended to have more proximal junctional kyphosis (PJK), although the difference did not reach statistical significance. Radiographic PJK was 32% in the UT group and 41% in the LT group (p = 0.4). Surgical PJK was 6.4% in the UT group and 10% in the LT group (p = 0.6). Conclusions Both the UT and LT groups demonstrated significant improvement in clinical and radiographic outcomes. A significant difference was not observed in improvement of clinical outcomes between the 2 groups.

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Optimal Lumbar Lordosis Correction for Adult Spinal Deformity with Severe Sagittal Imbalance in Patients over Age 60

Spine ◽

10.1097/brs.0000000000004068 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Ki Young Lee ◽

Jung-Hee Lee ◽

Sang-Kyu Im

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Sagittal Imbalance

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Early Outcomes of Minimally Invasive Anterior Longitudinal Ligament Release for Correction of Sagittal Imbalance in Patients with Adult Spinal Deformity

The Scientific World JOURNAL ◽

10.1100/2012/789698 ◽

2012 ◽

Vol 2012 ◽

pp. 1-7 ◽

Cited By ~ 71

Author(s):

Armen R. Deukmedjian ◽

Elias Dakwar ◽

Amir Ahmadian ◽

Donald A. Smith ◽

Juan S. Uribe

Keyword(s):

Minimally Invasive ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Early Experience ◽

Sagittal Imbalance ◽

X Rays ◽

Anterior Longitudinal Ligament ◽

Average Hospital ◽

Estimated Blood Loss

The object of this study was to evaluate a novel surgical technique in the treatment of adult degenerative scoliosis and present our early experience with the minimally invasive lateral approach for anterior longitudinal ligament release to provide lumbar lordosis and examine its impact on sagittal balance.Methods. All patients with adult spinal deformity (ASD) treated with the minimally invasive lateral retroperitoneal transpsoas interbody fusion (MIS LIF) for release of the anterior longitudinal ligament were examined. Patient demographics, clinical data, spinopelvic parameters, and outcome measures were recorded.Results. Seven patients underwent release of the anterior longitudinal ligament (ALR) to improve sagittal imbalance. All cases were split into anterior and posterior stages, with mean estimated blood loss of 125 cc and 530 cc, respectively. Average hospital stay was 8.3 days, and mean follow-up time was 9.1 months. Comparing pre- and postoperative 36′′ standing X-rays, the authors discovered a mean increase in global lumbar lordosis of 24 degrees, increase in segmental lumbar lordosis of 17 degrees per level of ALL released, decrease in pelvic tilt of 7 degrees, and decrease in sagittal vertical axis of 4.9 cm. At the last followup, there was a mean improvement in VAS and ODI scores of 26.2% and 18.3%.Conclusions. In the authors’ early experience, release of the anterior longitudinal ligament using the minimally invasive lateral retroperitoneal transpsoas approach may be a feasible alternative in correcting sagittal deformity.

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Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study

Journal of Neurosurgery Spine ◽

10.3171/2014.2.spine1347 ◽

2014 ◽

Vol 20 (5) ◽

pp. 515-522 ◽

Cited By ~ 55

Author(s):

Jotham C. Manwaring ◽

Konrad Bach ◽

Amir A. Ahmadian ◽

Armen R. Deukmedjian ◽

Donald A. Smith ◽

...

Keyword(s):

Minimally Invasive ◽

Cobb Angle ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Interbody Fusion ◽

Adult Spinal Deformity ◽

Spinal Instrumentation ◽

Sagittal Imbalance ◽

Lumbar Interbody Fusion ◽

Spinopelvic Parameters

Object Minimally invasive (MI) fusion and instrumentation techniques are playing a new role in the treatment of adult spinal deformity. The open pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO) are proven segmental methods for improving regional lordosis and global sagittal parameters. Recently the MI anterior column release (ACR) was introduced as a segmental method for treating sagittal imbalance. There is a paucity of data in the literature evaluating the alternatives to PSO and SPO for sagittal balance correction. Thus, the authors conducted a preliminary retrospective radiographic review of prospectively collected data from 2009 to 2012 at a single institution. The objectives of this study were to: 1) investigate the radiographic effect of MI-ACR on spinopelvic parameters, 2) compare the radiographic effect of MI-ACR with PSO and SPO for treatment of adult spinal deformity, and 3) investigate the radiographic effect of percutaneous posterior spinal instrumentation on spinopelvic parameters when combined with MI transpsoas lateral interbody fusion (LIF) for adult spinal deformity. Methods: Patient demographics and radiographic data were collected for 36 patients (9 patients who underwent MI-ACR and 27 patients who did not undergo MI-ACR). Patients included in the study were those who had undergone at least a 2-level MI-LIF procedure; adequate preoperative and postoperative 36-inch radiographs of the scoliotic curvature; a separate second-stage procedure for the placement of posterior spinal instrumentation; and a diagnosis of degenerative scoliosis (coronal Cobb angle > 10° and/or sagittal vertebral axis > 5 cm). Statistical analysis was performed for normality and significance testing. Results Percutaneous transpedicular spinal instrumentation did not significantly alter any of the spinopelvic parameters in either the ACR group or the non-ACR group. Lateral MI-LIF alone significantly improved coronal Cobb angle by 16°, and the fractional curve significantly improved in a subgroup treated with L5–S1 transforaminal lumbar interbody fusion. Fifteen ACRs were performed in 9 patients and resulted in significant coronal Cobb angle correction, lumbar lordosis correction of 16.5°, and sagittal vertebral axis correction of 4.8 cm per patient. Segmental analysis revealed a 12° gain in segmental lumbar lordosis and a 3.1-cm correction of the sagittal vertebral axis per ACR level treated. Conclusions The lateral MI-LIF with ACR has the ability to powerfully restore lumbar lordosis and correct sagittal imbalance. This segmental MI surgical technique boasts equivalence to SPO correction of these global radiographic parameters while simultaneously creating additional disc height and correcting coronal imbalance. Addition of posterior percutaneous instrumentation without in situ manipulation or overcorrection does not alter radiographic parameters when combined with the lateral MI-LIF.

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