Outcomes of Surgical Treatment for One Hundred and Thirty-Eight Patients With Severe Sagittal Deformity at a Minimum 2-Year Follow-Up

Abstract INTRODUCTION Operative treatment of ASD can be very challenging with high complication rates. It's well established that pts benefit from such treatment. However, the surgical outcomes for pts with severe sagittal deformity have not been reported. METHODS Retrospective review of a prospective, multicenter adult spinal deformity (ASD) database. Inclusion criteria: operative patients age = 18, SVA = 15 cm, PI-LL = 30 degrees, and/or lumbar kyphosis = 5 degrees with a minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores: Oswestry Disability Index (ODI), Short form-36 (SF36), Scoliosis Research Society (SRS22), back/leg pain numerical rating scale (NRS) and min clinically important difference (MCID)/substantial clinical benefit (SCB) for patients eligible to meet it. Radiographic values: max coronal cobb angle, coronal C7 plumb line, pelvic tilt, mismatch between pelvic incidence and lumbar lordosis, thoracic kyphosis, C7 sagittal vertical axis. Demographic, frailty, surgical, and complication data were also collected. Comparisons between 2 yr postop and baseline HRQOL/radiographic data were made. P < .05 was significant. RESULTS About 138 patients were included from 502 operative patients (54.3% females, average age 63.3 ± 11.5 yr). Averege baseline frailty score was 4.1 ± 1.4, indicating that patients were frail. A total of 71 (51.4%) of the patients had a prior fusion. A total of 89.9% patients had posterior fusion only, with an average 11.5 ± 4.1 post levels fused. About 44.9% had 3-column osteotomy. Two standard deviations was considered for for SVA = 14.8 cm. All 2-yr postop radiographic parameters were significantly improved compared to baseline (P < .05) except coronal C7 plumb line (P > .05). All 2-yr HRQOL measures were significantly improved compared to baseline (P < .004). About 46.6% to 73.8% of patients met either MCID or SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had a minimum 1 major complication, and 42 (30.4%) had a postop revision. CONCLUSION Patients with a severe sagittal malalignment benefit from surgical correction at 2 yr postop both radiographically and clinically despite having a high complication rate.

Download Full-text

Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions

Journal of Neurosurgery Spine ◽

10.3171/2021.2.spine201938 ◽

2021 ◽

pp. 1-13

Author(s):

Thomas J. Buell ◽

Christopher I. Shaffrey ◽

Han Jo Kim ◽

Eric O. Klineberg ◽

Virginie Lafage ◽

...

Keyword(s):

Thoracic Spine ◽

Spinal Deformity ◽

Rating Scale ◽

Numerical Rating Scale ◽

Adult Spinal Deformity ◽

Leg Pain ◽

Sagittal Vertical Axis ◽

Upper Thoracic ◽

The Impact

OBJECTIVE Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors’ objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm. METHODS This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up. RESULTS Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society–22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810). CONCLUSIONS In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.

Download Full-text

Outcomes of Surgical Treatment for One Hundred Thirty-Eight Patients With Severe Sagittal Deformity at a Minimum 2-Year Follow-up: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opab153 ◽

2021 ◽

Author(s):

Justin K Scheer ◽

Lawrence G Lenke ◽

Justin S Smith ◽

Darryl Lau ◽

Peter G Passias ◽

...

Keyword(s):

Adult Spinal Deformity ◽

Case Series ◽

Major Complication ◽

Vertical Axis ◽

Surgical Correction ◽

Complication Rates ◽

Sagittal Vertical Axis ◽

Estimated Blood Loss ◽

Sagittal Deformity

Abstract BACKGROUND Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported. OBJECTIVE To report the outcomes of patients undergoing surgical correction for severe sagittal deformity. METHODS Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age ≥18, sagittal vertical axis (SVA) ≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL) ≥30°, and/or lumbar kyphosis ≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P < .05 was significant. RESULTS A total of 138 patients were included from 502 operative patients (54.3% Female, Average (Avg) age 63.3 ± 11.5 yr). Avg operating room (OR) time 386.2 ± 136.5 min, estimated blood loss (EBL) 1829.8 ± 1474.6 cc. A total of 71(51.4%) had prior fusion. A total of 89.9% were posterior fusion only. Mean posterior levels fused 11.5 ± 4.1. A total of 44.9% had a 3-column osteotomy. All 2 yr postoperative radiographic parameters were significantly improved compared to baseline (P < .001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P < .004 for all). A total of 46.6% to 73.8% of patients met either MCID/SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had minimum 1 major complication, and 42(30.4%) had a postop revision. CONCLUSION Patients with severe sagittal malalignment benefit from surgical correction at 2 yr postoperative both radiographically and clinically despite having a high complication rate.

Download Full-text

Coronal Correction Using Kickstand Rods for Adult Thoracolumbar/Lumbar Scoliosis: Case Series With Analysis of Early Outcomes and Complications

Operative Neurosurgery ◽

10.1093/ons/opaa073 ◽

2020 ◽

Vol 19 (4) ◽

pp. 403-413 ◽

Cited By ~ 1

Author(s):

Thomas J Buell ◽

Peter A Christiansen ◽

James H Nguyen ◽

Ching-Jen Chen ◽

Chun-Po Yen ◽

...

Keyword(s):

Rating Scale ◽

Numerical Rating Scale ◽

Adult Spinal Deformity ◽

Case Series ◽

Wound Dehiscence ◽

Transforaminal Lumbar Interbody Fusion ◽

Leg Pain ◽

Complication Rates ◽

Iliac Screw ◽

Coronal Correction

Abstract BACKGROUND The “kickstand rod technique” has been recently described for achieving and maintaining coronal correction in adult spinal deformity (ASD). Kickstand rods span scoliotic lumbar spine from the thoracolumbar junction proximally to a “kickstand iliac screw” distally. Using the iliac wing as a base, kickstand distraction produces powerful corrective forces. Limited literature exists for this technique, and its associated outcomes and complications are unknown. OBJECTIVE To assess alignment changes, early outcomes, and complications associated with kickstand rod distraction for ASD. METHODS Consecutive ASD patients treated with kickstand distraction at our institution were retrospectively analyzed. RESULTS The cohort comprised 19 patients (mean age: 67 yr; 79% women; 63% prior fusion) with mean follow-up 21 wk (range: 2-72 wk). All patients had posterior-only approach surgery with tri-iliac fixation (third iliac screw for the kickstand) for mean fusion length 12 levels. Three-column osteotomy and lumbar transforaminal lumbar interbody fusion were performed in 5 (26%) and 15 (79%) patients, respectively. Postoperative alignment improved significantly (coronal balance: 8 to 1 cm [P < .001]; major curve: 37° to 12° [P < .001]; fractional curve: 20° to 10° [P < .001]; sagittal balance: 11 to 4 cm [P < .001]; pelvic incidence to lumbar lordosis mismatch: 38° to 9° [P < .001]). Pain Numerical Rating Scale scores improved significantly (back: 7.2 to 4.2 [P = .001]; leg: 5.9 to 1.7 [P = .001]). No instrumentation complications occurred. Motor weakness persisted in 1 patient. There were 3 reoperations (1-PJK, 1-wound dehiscence, and 1-overcorrection). CONCLUSION Among 19 ASD patients treated with kickstand rod distraction, alignment, and back/leg pain improved significantly following surgery. Complication rates were reasonable.

Download Full-text

Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature

Global Spine Journal ◽

10.1177/2192568217699182 ◽

2017 ◽

Vol 7 (2) ◽

pp. 170-178 ◽

Cited By ~ 16

Author(s):

Alisson R. Teles ◽

Tobias A. Mattei ◽

Orlando Righesso ◽

Asdrubal Falavigna

Keyword(s):

Quality Of Life ◽

Systematic Review ◽

Rating Scale ◽

Numerical Rating Scale ◽

Short Form ◽

Adult Spinal Deformity ◽

Numerical Rating ◽

Short Form Health

Study Design: Systematic review. Objective: There is a need for synthesizing data on effectiveness of treatments for patients with adult spinal deformity (ASD) due to its increasing prevalence and health care costs for these patients. The objective of this review was to estimate the effectiveness of surgery versus nonoperative care in patients with ASD. Methods: A systematic review of articles in published in English using PubMed between 2005 and 2015. Surgical and nonsurgical series that reported baseline and follow-up health-related quality of life measures of patients with ASD with a minimum 2 years of follow-up were selected. Independent extraction of articles by 2 authors using predefined data fields, including risk of bias assessment. Results: Surgery significantly reduces disability, pain, and improves patients’ quality of life. The average postoperative improvement in Oswestry Disability Index was −19.1 (±9.0), Numerical Rating Scale back pain −4.14 (±1.38), Numerical Rating Scale leg pain −3.36 (±1.33), Short-Form Health Survey 36-SF36-Physical Component score 11.2 (±5.07), and Short-Form Health Survey 36-Mental Component score 9.93 (±4.96). The complication rate ranged from 9.52% to 81.52% (mean = 39.62%), and the need for revision surgery ranged from 1.72% to 40.0% (mean = 15.71%). The best existing evidence about nonoperative care of ASD is provided from observational studies with very high risk of bias. Quantitative analyses of nonsurgical cohorts did not demonstrate significant changes in quality of life of patients after 2 years of observation. Conclusions: This data may assist clinicians to counsel patients, as well as to inform health care providers and policymakers about what to expect from the treatment for ASD.

Download Full-text

Addition of Fusion to Decompression for Grade I Degenerative Lumbar Spondylolisthesis is Associated With Greater Patient-Reported Outcome Improvements at Twenty-Four-Month Follow-Up: A Multicenter Study Using the Quality Outcomes Database

Neurosurgery ◽

10.1093/neuros/nyz310_112 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Jian Guan ◽

Erica F Bisson ◽

Mohamad Bydon ◽

Mohammed A Alvi ◽

Steven D Glassman ◽

...

Keyword(s):

Rating Scale ◽

Numerical Rating Scale ◽

Primary Outcome Measure ◽

Patient Reported Outcome ◽

Leg Pain ◽

Quality Outcomes ◽

Degenerative Lumbar Spondylolisthesis ◽

Patient Reported ◽

Lumbar Spondylolisthesis

Abstract INTRODUCTION Extensive investigation has not ascertained the ideal surgical management of grade 1 lumbar spondylolisthesis. Using the large, multicenter, prospectively collected Quality Outcomes Database (QOD), we compared 24-mo outcomes for patients undergoing decompression alone vs decompression and fusion. METHODS Patients undergoing single-level surgery from 7/1/2014 to 6/30/2016 were identified. The primary outcome measure, 24-mo Oswestry Disability Index (ODI) change, was analyzed with univariate and multivariable linear regression. EQ-5D scores, numerical rating scale (NRS) back and leg pain scores, and North American Spine Society patient satisfaction scores were also analyzed. RESULTS Of the 608 patients (85.5% with at least 24-mo follow-up) who met the inclusion criteria, 140 (23.0%) underwent decompression alone and 468 (77.0%) underwent decompression and fusion. The 24-mo change in ODI was significantly greater in the fusion group than the decompression-only group (−25.8 ± 20.0 vs −15.2 ± 19.8, P < .001). Fusion remained independently associated with 24-mo ODI change in our multivariable model (B = −7.05, 95% CI 10.70-3.39, P = < .001). Patients in the fusion group were significantly more likely to reach minimal clinically important difference (MCID, 12.8 points) in ODI at 24 mo (73.3% vs 56.0%, P = < .001), and to experience significantly greater NRS back pain improvement at 24-mo follow-up (3.8 ± 3.1 vs −1.8 ± 3.9, P < .001). Fusion was also independently associated with achieving MCID for ODI at 24 mo in our logistic regression model (OR 1.767, 95% CI 1.058-2.944, P = .029). CONCLUSION The results of our study suggest that decompression plus fusion may offer superior outcomes to decompression alone in patients with grade 1 lumbar spondylolisthesis at 24 mo. Longer-term follow-up is warranted to assess whether this effect is sustained.

Download Full-text

Clinical, Radiographic, and Genetic Analyses in a Population-Based Cohort of Adult Spinal Deformity in the Older Population

Neurospine ◽

10.14245/ns.2142544.272 ◽

2021 ◽

Vol 18 (3) ◽

pp. 608-617

Author(s):

Jun Jae Shin ◽

Byeongwoo Kim ◽

Juwon Kang ◽

Junjeong Choi ◽

Bong Ju Moon ◽

...

Keyword(s):

Spinal Deformity ◽

Short Form ◽

Adult Spinal Deformity ◽

Fatty Infiltration ◽

Leg Pain ◽

Sagittal Imbalance ◽

Sagittal Vertical Axis ◽

Multifidus Muscle ◽

Sf 36 ◽

Goutallier Classification

Objective: This study aimed to identify the sagittal parameters associated with health-related quality of life and genetic variations that increase the risk of adult spinal deformity (ASD) onset in the older population.Methods: We recruited 120 participants who had a sagittal vertical axis > 50 mm in a sagittal imbalance study. Sagittal radiographic parameters, cross-sectional area, and intramuscular fatty infiltration using the Goutallier classification in the paraspinal lumbar muscles were evaluated. Functional scales included the self-reported Oswestry Disability Index (ODI), 36-item Short Form Health Survey (SF-36), and visual analogue scales (VAS) for back and leg pain. We performed whole-exome sequencing and an exome-wide association study using the 100 control subjects and 63 individuals with severe phenotypes of sagittal imbalance.Results: Pelvic incidence minus lumbar lordosis (PI–LL) mismatch was negatively associated with the SF-36 and positively correlated with ODI and VAS for back and leg pain. PI–LL was related to the quality and size of the paraspinal muscles, especially the multifidus muscle. We identified common individual variants that reached exome-wide significance using single-variant analysis. The most significant single-nucleotide polymorphism was rs78773460, situated in an exon of the SVIL gene (odds ratio, 9.61; p = 1.15 × 10-9).Conclusion: Older age, higher body mass index, and a more significant PI–LL mismatch were associated with unfavorable results on functional scales. We found a genetic variation in the SVIL gene, which has been associated with the integrity of the cytoskeleton and the development of skeletal muscles, in severe ASD phenotypes. Our results help to elucidate the pathogenesis of ASD.

Download Full-text

Thoracolumbar Slope Is Useful Parameter for Evaluating HealthRelated Quality of Life and Sagittal Imbalance Aggravation in Adult Spinal Deformity: A Prospective Observational Cohort Study

Neurospine ◽

10.14245/ns.2142408.204 ◽

2021 ◽

Vol 18 (3) ◽

pp. 467-474

Author(s):

Bong Ju Moon ◽

Moon-Soo Han ◽

Jae-Young Kim ◽

Jung-Kil Lee

Keyword(s):

Quality Of Life ◽

Short Form ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Clinical Situation ◽

Sagittal Imbalance ◽

Sagittal Vertical Axis ◽

Highly Correlated

Objective: The purpose of the present study was to evaluate the natural course of primary degenerative sagittal imbalance (PDSI), its aggravating factors, and health-related quality of life (HRQoL) associated with various spinal alignment parameters (SAPs) in patients with PDSI who have not undergone surgery.Methods: One hundred three participants volunteered to participate. The SAPs, including T1 pelvic angle (T1PA), thoracolumbar tilt, and thoracolumbar slope (TLS), were measured on whole-spine standing radiographs. The back and lumbar muscle volumes were measured. To determine HRQoL at baseline and at 2-year follow-up, face-to-face questionnaires were administered, which included visual analogue scale of the back and leg, physical component summary/mental component summary of 36-item Short Form Health Survey, Oswestry Disability Index (ODI), and Mini-Mental State Examination.Results: Overall HRQoL measures had improved after 2 years of follow-up compared to baseline. PDSI aggravation was observed in 18 participants (26.1%). TLS, sagittal vertical axis (SVA), and T1PA were strongly correlated with each other. TLS, SVA, and T1PA were correlated with ODI score. Among them, TLS was most highly correlated with ODI score. TLS greater than -3.5° was a predicting factor for PDSI aggravation (p = 0.034; 95% confidence interval, 1.173–63.61; odds ratio, 8.636).Conclusion: The present study implied that PDSI does not necessarily worsen with aging. TLS is an appropriate parameter for assessing the clinical situation in patients with PDSI. Furthermore, a TLS greater than -3.5° predicts PDSI aggravation; thus, TLS may be a useful parameter for predicting prognosis in PDSI.

Download Full-text

Asymmetrical pedicle subtraction osteotomy for correction of concurrent sagittal-coronal imbalance in adult spinal deformity: a comparative analysis

Journal of Neurosurgery Spine ◽

10.3171/2020.5.spine20445 ◽

2020 ◽

Vol 33 (6) ◽

pp. 822-829

Author(s):

Darryl Lau ◽

Alexander F. Haddad ◽

Vedat Deviren ◽

Christopher P. Ames

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Pedicle Subtraction Osteotomy ◽

Sagittal Imbalance ◽

Sagittal Vertical Axis ◽

Coronal Imbalance ◽

Significant Correction ◽

Sagittal Deformity

OBJECTIVERigid multiplanar thoracolumbar adult spinal deformity (ASD) cases are challenging and many require a 3-column osteotomy (3CO), specifically asymmetrical pedicle subtraction osteotomy (APSO). The outcomes and additional risks of performing APSO for the correction of concurrent sagittal-coronal deformity have yet to be adequately studied.METHODSThe authors performed a retrospective review of all ASD patients who underwent 3CO during the period from 2006 to 2019. All cases involved either isolated sagittal deformity (patients underwent standard PSO) or concurrent sagittal-coronal deformity (coronal vertical axis [CVA] ≥ 4.0 cm; patients underwent APSO). Perioperative and 2-year follow-up outcomes were compared between patients with isolated sagittal imbalance who underwent PSO and those with concurrent sagittal-coronal imbalance who underwent APSO.RESULTSA total of 390 patients were included: 338 who underwent PSO and 52 who underwent APSO. The mean patient age was 64.6 years, and 65.1% of patients were female. APSO patients required significantly more fusions with upper instrumented vertebrae (UIV) in the upper thoracic spine (63.5% vs 43.3%, p = 0.007). Radiographically, APSO patients had greater deformity with more severe preoperative sagittal and coronal imbalance: sagittal vertical axis (SVA) 13.0 versus 10.7 cm (p = 0.042) and CVA 6.1 versus 1.2 cm (p < 0.001). In APSO cases, significant correction and normalization were achieved (SVA 13.0–3.1 cm, CVA 6.1–2.0 cm, lumbar lordosis [LL] 26.3°–49.4°, pelvic tilt [PT] 38.0°–20.4°, and scoliosis 25.0°–10.4°, p < 0.001). The overall perioperative complication rate was 34.9%. There were no significant differences between PSO and APSO patients in rates of complications (overall 33.7% vs 42.3%, p = 0.227; neurological 5.9% vs 3.9%, p = 0.547; medical 20.7% vs 25.0%, p = 0.482; and surgical 6.5% vs 11.5%, p = 0.191, respectively). However, the APSO group required significantly longer stays in the ICU (3.1 vs 2.3 days, p = 0.047) and hospital (10.8 vs 8.3 days, p = 0.002). At the 2-year follow-up, there were no significant differences in mechanical complications, including proximal junctional kyphosis (p = 0.352), pseudarthrosis (p = 0.980), rod fracture (p = 0.852), and reoperation (p = 0.600).CONCLUSIONSASD patients with significant coronal imbalance often have severe concurrent sagittal deformity. APSO is a powerful and effective technique to achieve multiplanar correction without higher risk of morbidity and complications compared with PSO for sagittal imbalance. However, APSO is associated with slightly longer ICU and hospital stays.

Download Full-text

Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction

Journal of Neurosurgery Spine ◽

10.3171/2020.11.spine201915 ◽

2021 ◽

pp. 1-14

Author(s):

Thomas J. Buell ◽

Christopher I. Shaffrey ◽

Shay Bess ◽

Han Jo Kim ◽

Eric O. Klineberg ◽

...

Keyword(s):

Operative Treatment ◽

Interbody Fusion ◽

Short Form ◽

Adult Spinal Deformity ◽

Anterior Lumbar Interbody Fusion ◽

Lumbar Interbody Fusion ◽

Curve Correction ◽

Sagittal Vertical Axis ◽

Operative Duration

OBJECTIVE Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4–S1 TLIF versus those of ALIF as an operative treatment of ASLS. METHODS The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4–5 and/or L5–S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4–S1. RESULTS Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4–5, and 84.0% underwent TLIF/ALIF at L5–S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (−13.6° ± 6.7° for TLIF patients vs −13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society–22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4–5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5–S1 ALIF cage lordosis led to a 0.4° increase in L5–S1 segmental lordosis (p = 0.045). CONCLUSIONS Operative treatment of ASLS with L4–S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.

Download Full-text

Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity

Neurosurgery ◽

10.1227/neu.0000000000001116 ◽

2016 ◽

Vol 78 (6) ◽

pp. 851-861 ◽

Cited By ~ 92

Author(s):

◽

Justin S. Smith ◽

Virginie Lafage ◽

Christopher I. Shaffrey ◽

Frank Schwab ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Short Form ◽

Adult Spinal Deformity ◽

Research Society ◽

Nonoperative Treatment ◽

Leg Pain ◽

Scoliosis Research Society

Abstract BACKGROUND: High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed. OBJECTIVE: To compare outcomes of operative and nonoperative treatment for ASD. METHODS: This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence–to–lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up. RESULTS: Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence–to–lumbar lordosis mismatch, and sagittal vertical axis (P ⩽ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications. CONCLUSION: Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability.

Download Full-text