Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

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Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2020.8.spine201037 ◽

2021 ◽

pp. 1-10

Author(s):

Ki Young Lee ◽

Jung-Hee Lee ◽

Kyung-Chung Kang ◽

Sang-Kyu Im ◽

Hae Seong Lim ◽

...

Keyword(s):

Spinal Deformity ◽

Interbody Fusion ◽

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Lumbar Interbody Fusion ◽

Patient Factors ◽

Rod Fracture ◽

Cobalt Chrome

OBJECTIVERestoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD.METHODSThe authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed.RESULTSThe overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF.CONCLUSIONSGreater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

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Changes in Spinal Alignment following eXtreme Lateral Interbody Fusion Alone in Patients with Adult Spinal Deformity using Computed Tomography

Scientific Reports ◽

10.1038/s41598-019-48539-w ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 1

Author(s):

Akihiko Hiyama ◽

Hiroyuki Katoh ◽

Daisuke Sakai ◽

Masato Sato ◽

Masahiro Tanaka ◽

...

Keyword(s):

Computed Tomography ◽

Spinal Deformity ◽

Interbody Fusion ◽

Adult Spinal Deformity ◽

Spinal Alignment ◽

Lateral Interbody Fusion ◽

Extreme Lateral Interbody Fusion ◽

Lateral Interbody

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Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance

Journal of Neurosurgery Spine ◽

10.3171/2017.5.spine161370 ◽

2018 ◽

Vol 28 (1) ◽

pp. 40-49 ◽

Cited By ~ 19

Author(s):

Junseok Bae ◽

Alexander A. Theologis ◽

Russell Strom ◽

Bobby Tay ◽

Shane Burch ◽

...

Keyword(s):

Spinal Deformity ◽

Interbody Fusion ◽

Adult Spinal Deformity ◽

Leg Pain ◽

Surgical Strategies ◽

Self Image ◽

Hrqol Outcome ◽

Sf 36 ◽

Outcome Scores

OBJECTIVESurgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)–only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF).METHODSThe medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years’ follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were −1.2 (VAS back pain), −1.6 (VAS leg pain), −15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary).RESULTSA total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence–lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence–LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score.CONCLUSIONSSatisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

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Efficacy and radiographic analysis of oblique lumbar interbody fusion in treating adult spinal deformity

PLoS ONE ◽

10.1371/journal.pone.0257316 ◽

2021 ◽

Vol 16 (9) ◽

pp. e0257316

Author(s):

Dae-Jean Jo ◽

Eun-Min Seo

Keyword(s):

Spinal Deformity ◽

Interbody Fusion ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Lumbar Interbody Fusion ◽

Spinal Fixation ◽

Invasive Approach ◽

Radiographic Parameters ◽

Oblique Lumbar Interbody Fusion

Adult spinal deformity (ASD) is usually rigid and requires a combined anterior–posterior approach for deformity correction. Anterior lumbar interbody fusion (ALIF) allows direct access to the disc space and placement of a large interbody graft. A larger interbody graft facilitates correction of ASD. However, an anterior approach carries significant risks. Lateral lumbar interbody fusion (LLIF) through a minimally invasive approach has recently been used for ASD. The present study was performed to evaluate the effectiveness of oblique lumbar interbody fusion (OLIF) in the treatment of ASD. We performed a retrospective study utilizing the data of 74 patients with ASD. The inclusion criteria were lumbar coronal Cobb angle > 20°, pelvic incidence (PI)–lumbar lordosis (LL) mismatch > 10°, and minimum follow–up of 2 years. Patients were divided into two groups: ALIF combined with posterior spinal fixation (ALIF+PSF) (n = 38) and OLIF combined with posterior spinal fixation (OLIF+PSF) (n = 36). The perioperative spinal deformity radiographic parameters, complications, and health-related quality of life (HRQoL) outcomes were assessed and compared between the two groups. The preoperative sagittal vertical axis (SVA), LL, PI–LL mismatch, and lumbar Cobb angles were similar between the two groups. Patients in the OLIF+PSF group had a slightly higher mean number of interbody fusion levels than those in the ALIF+PSF group. At the final follow–up, all radiographic parameters and HRQoL scores were similar between the two groups. However, the rates of perioperative complications were higher in the ALIF+PSF than OLIF+PSF group. The ALIF+PSF and OLIF+PSF groups showed similar radiographic and HRQoL outcomes. These observations suggest that OLIF is a safe and reliable surgical treatment option for ASD.

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Transiency of postoperative cervical kyphosis seen after surgical correction of sagittal malalignment in adult spinal deformity patients

PLoS ONE ◽

10.1371/journal.pone.0254381 ◽

2021 ◽

Vol 16 (7) ◽

pp. e0254381

Author(s):

Ki Young Lee ◽

Jung-Hee Lee ◽

Sang Kyu Im ◽

Hae Sung Lim ◽

Gil Han

Keyword(s):

Regression Analysis ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Sagittal Imbalance ◽

Cervical Lordosis ◽

Multilinear Regression ◽

Factors Affecting ◽

Multilinear Regression Analysis

Objective In this study, we evaluated factors affecting changes in cervical lordosis after deformity correction and during follow-up period in adult spinal deformity (ASD) patients with severe sagittal imbalance. Methods Seventy-nine patients, with an average age of 71.6 years, who underwent long-segment fixation from T10 to S1 with sacropelvic fixation were included. We performed a comparative analysis of the radiographic parameters after surgery (Post) and at the last follow-up (Last). We calculated the Pearson’s correlation coefficient and performed multilinear regression analysis to predict independent parameters for Post and Last cervical lordosis (CL), T1 slope (T1S), and thoracic kyphosis (TK). Results Hyperlordotic changes of -23.3° in CL before surgery was reduced to -7° after surgery, and Last CL had increased to -15.3°. T1S was reduced from 27° before surgery to 14.4° after surgery and had increased to 18.8° at the last follow-up. Through multilinear regression analysis, we found that Post CL and T1S were more significantly affected by the amount of LL correction (p = .045 and .049). The effect of Last T1S was significantly associated with the Last CL; the effect of Last TK, with the Last T1S; and the effect of Post PI-LL, with the Last TK (p < .05). Conclusion The postoperative kyphotic change in CL in ASD patients with preoperative cervical hyperlordosis is not permanent and is affected by drastic LL correction and SVA restoration. To achieve spinopelvic harmony proportional to the difference in LL relative to PI, TK becomes modified over time to increase T1S and CL, in an effort to achieve optimal spine curvature.

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Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity

Journal of Neurosurgery Spine ◽

10.3171/2021.7.spine21138 ◽

2021 ◽

pp. 1-14

Author(s):

Andrew K. Chan ◽

Robert K. Eastlack ◽

Richard G. Fessler ◽

Khoi D. Than ◽

Dean Chou ◽

...

Keyword(s):

Back Pain ◽

Minimally Invasive ◽

Spinal Deformity ◽

Interbody Fusion ◽

Adult Spinal Deformity ◽

Leg Pain ◽

Hybrid Procedures ◽

Hybrid Surgery ◽

Hybrid Techniques

OBJECTIVE Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD. METHODS A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence–lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5–S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level. RESULTS Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22–74 months) and hybrid correction (39.9 ± 16.8 months, range 22–94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039). CONCLUSIONS In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis.

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