scholarly journals Upper-thoracic versus lower-thoracic upper instrumented vertebra in adult spinal deformity patients undergoing fusion to the pelvis: surgical decision-making and patient outcomes

2020 ◽  
Vol 32 (4) ◽  
pp. 600-606 ◽  
Author(s):  
Alan H. Daniels ◽  
Daniel B. C. Reid ◽  
Wesley M. Durand ◽  
D. Kojo Hamilton ◽  
Peter G. Passias ◽  
...  
Keyword(s):  
Decision Making ◽  
Blood Loss ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Complication Rates ◽  
Sagittal Vertical Axis ◽  
Surgical Decision ◽  
Estimated Blood Loss ◽  
Upper Thoracic ◽  
Surgical Decision Making

OBJECTIVEOptimal patient selection for upper-thoracic (UT) versus lower-thoracic (LT) fusion during adult spinal deformity (ASD) correction is challenging. Radiographic and clinical outcomes following UT versus LT fusion remain incompletely understood. The purposes of this study were: 1) to evaluate demographic, radiographic, and surgical characteristics associated with choice of UT versus LT fusion endpoint; and 2) to evaluate differences in radiographic, clinical, and health-related quality of life (HRQOL) outcomes following UT versus LT fusion for ASD.METHODSRetrospective review of a prospectively collected multicenter ASD database was performed. Patients with ASD who underwent fusion from the sacrum/ilium to the LT (T9–L1) or UT (T1–6) spine were compared for demographic, radiographic, and surgical characteristics. Outcomes including proximal junctional kyphosis (PJK), reoperation, rod fracture, pseudarthrosis, overall complications, 2-year change in alignment parameters, and 2-year HRQOL metrics (Lumbar Stiffness Disability Index, Scoliosis Research Society-22r questionnaire, Oswestry Disability Index) were compared after controlling for confounding factors via multivariate analysis.RESULTSThree hundred three patients (169 LT, 134 UT) were evaluated. Independent predictors of UT fusion included greater thoracic kyphosis (odds ratio [OR] 0.97 per degree, p = 0.0098), greater coronal Cobb angle (OR 1.06 per degree, p < 0.0001), and performance of a 3-column osteotomy (3-CO; OR 2.39, p = 0.0351). While associated with longer operative times (ratio 1.13, p < 0.0001) and greater estimated blood loss (ratio 1.31, p = 0.0018), UT fusions resulted in greater sagittal vertical axis improvement (−59.5 vs −41.0 mm, p = 0.0035) and lower PJK rates (OR 0.49, p = 0.0457). No significant differences in postoperative HRQOL measures, reoperation, or overall complication rates were detected between groups (all p > 0.1).CONCLUSIONSGreater deformity and need for 3-CO increased the likelihood of UT fusion. Despite longer operative times and greater blood loss, UT fusions resulted in better sagittal correction and lower 2-year PJK rates following surgery for ASD. While continued surveillance is necessary, this information may inform patient counseling and surgical decision-making.

Adult spinal deformity surgical decision-making score

2019 ◽  
Vol 28 (7) ◽  
pp. 1652-1660 ◽  
Author(s):  
Takashi Fujishiro ◽  
◽  
Louis Boissière ◽  
Derek Thomas Cawley ◽  
Daniel Larrieu ◽  
...  
Keyword(s):  
Decision Making ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Surgical Decision ◽  
Surgical Decision Making

Clinical Performance and Concurrent Validity of the Adult Spinal Deformity Surgical Decision-making Score

Spine ◽  
2020 ◽  
Vol 45 (14) ◽  
pp. E847-E855
Author(s):  
Takashi Fujishiro ◽  
Louis Boissière ◽  
Derek Thomas Cawley ◽  
Daniel Larrieu ◽  
Olivier Gille ◽  
...  
Keyword(s):  
Decision Making ◽  
Spinal Deformity ◽  
Concurrent Validity ◽  
Clinical Performance ◽  
Adult Spinal Deformity ◽  
Surgical Decision ◽  
Surgical Decision Making

scholarly journals P.089 A comparison of perioperative complication rates in adult spinal deformity correction with one versus two surgeons

2017 ◽  
Vol 44 (S2) ◽  
pp. S36-S36
Author(s):  
K Parvez ◽  
J Hsu ◽  
Z Ivanishvilli ◽  
S Boisvert ◽  
M Warren ◽  
...  
Keyword(s):  
Blood Loss ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Deformity Correction ◽  
Radicular Pain ◽  
Complication Rates ◽  
Perioperative Morbidity ◽  
Hardware Failure ◽  
Estimated Blood Loss ◽  
One Year

Background: Morbidity can be high in the management of adult spinal deformity patients. Complications include blood loss (EBL), durotomy, radicular pain, and postoperative hardware failure. Utilization of one versus two spinal surgeons in spinal deformity correction reduces overall perioperative morbidity is unclear. Methods: All procedures were performed by surgeons at a single institution between January 2012-2015. Patients were followed for a minimum of one year and maximum of four years. We retrospectively reviewed 60 cases of adult spinal deformity. Our cohort was divided into 1 versus 2 surgeons (12 vs 48 cases). We analyzed these cases for estimated blood loss and peri-operative complications. Results: Cases involving long thoracic to pelvis correction (T3-T6) was 20.8% in the 2 surgeons group and 8.3% in the 1 surgeon group. The EBL >3.0 L for 1 versus 2 surgeon groups were 25% and 41.6% respectively. Major complications in the 1 versus 2 surgeon group were 25% and 47.9% and the revision rates were 25% versus 37.5%. The percentage of minor complications in the 1 versus 2 surgeon group was 33.3% versus 14.6%. Conclusions: Utilizing two surgeons did not reduce complication rates. Procedures performed by two surgeons were more extensive deformity corrections. The extent of correction is the likely explanation for differing complication rates.

Does MIS Surgery Allow for Shorter Constructs in the Surgical Treatment of Adult Spinal Deformity?

Neurosurgery ◽  
2017 ◽  
Vol 80 (3) ◽  
pp. 489-497 ◽  
Author(s):  
Juan S. Uribe ◽  
Joshua Beckman ◽  
Praveen V. Mummaneni ◽  
David Okonkwo ◽  
Pierce Nunley ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Blood Loss ◽  
Clinical Outcomes ◽  
Spinal Deformity ◽  
Lumbar Lordosis ◽  
Adult Spinal Deformity ◽  
Radiographic Parameters ◽  
Estimated Blood Loss ◽  
Significant Difference ◽  
The Impact

Abstract BACKGROUND: The length of construct can potentially influence perioperative risks in adult spinal deformity (ASD) surgery. A head-to-head comparison between open and minimally invasive surgery (MIS) techniques for treatment of ASD has yet to be performed. OBJECTIVE: To examine the impact of MIS approaches on construct length and clinical outcomes in comparison to traditional open approaches when treating similar ASD profiles. METHODS: Two multicenter databases for ASD, 1 involving MIS procedures and the other open procedures, were propensity matched for clinical and radiographic parameters in this observational study. Inclusion criteria were ASD and minimum 2-year follow-up. Independent t-test and chi-square test were used to evaluate and compare outcomes. RESULTS: A total of 1215 patients were identified, with 84 patients matched in each group. Statistical significance was found for mean levels fused (4.8 for circumferential MIS [cMIS] and 10.1 for open), mean interbody fusion levels (3.6 cMIS and 2.4 open), blood loss (estimated blood loss 488 mL cMIS and 1762 mL open), and hospital length of stay (6.7 days cMIS and 9.7 days open). There was no significant difference in preoperative radiographic parameters or postoperative clinical outcomes (Owestry Disability Index and visual analog scale) between groups. There was a significant difference in postoperative lumbar lordosis (43.3° cMIS and 49.8° open) and pelvic incidence-lumbar lordosis correction (10.6° cMIS and 5.2° open) in the open group. There was no significant difference in reoperation rate between the 2 groups. CONCLUSION: MIS techniques for ASD may reduce construct length, reoperation rates, blood loss, and length of stay without affecting clinical and radiographic outcomes when compared to a similar group of patients treated with open techniques.

The impact of preoperative supine radiographs on surgical strategy in adult spinal deformity

2021 ◽  
pp. 1-7
Author(s):  
Francis Lovecchio ◽  
Jonathan Charles Elysee ◽  
Renaud Lafage ◽  
Jeff Varghese ◽  
Mathieu Bannwarth ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Lumbar Lordosis ◽  
Adult Spinal Deformity ◽  
Surgical Decision ◽  
Spinal Flexibility ◽  
Grade 3 ◽  
Upper Instrumented Vertebra ◽  
Invasive Techniques ◽  
The Impact ◽  
Surgical Decision Making

OBJECTIVE Preoperative planning for adult spinal deformity (ASD) surgery is essential to prepare the surgical team and consistently obtain postoperative alignment goals. Positional imaging may allow the surgeon to evaluate spinal flexibility and anticipate the need for more invasive techniques. The purpose of this study was to determine whether spine flexibility, defined by the change in alignment between supine and standing imaging, is associated with the need for an osteotomy in ASD surgery. METHODS A single-center, dual-surgeon retrospective analysis was performed of adult patients with ASD who underwent correction of a thoracolumbar deformity between 2014 and 2018 (pelvis to upper instrumented vertebra between L1 and T9). Patients were stratified into osteotomy (Ost) and no-osteotomy (NOst) cohorts according to whether an osteotomy was performed (Schwab grade 2 or higher). Demographic, surgical, and radiographic parameters were compared. The sagittal correction from intraoperative prone positioning alone (sagittal flexibility percentage [Sflex%]) was assessed by comparing the change in lumbar lordosis (LL) between preoperative supine to standing radiographs and preoperative to postoperative alignment. RESULTS Demographics and preoperative and postoperative sagittal alignment were similar between the Ost (n = 60, 65.9%) and NOst (n = 31, 34.1%) cohorts (p > 0.05). Of all Ost patients, 71.7% had a grade 2 osteotomy (mean 3 per patient), 21.7% had a grade 3 osteotomy, and 12.5% underwent both grade 3 and grade 2 osteotomies. Postoperatively, the NOst and Ost cohorts had similar pelvic incidence minus lumbar lordosis (PI-LL) mismatch (mean PI-LL 5.2° vs 1.2°; p = 0.205). Correction obtained through positioning (Sflex%) was significantly lower for in the osteotomy cohort (38.0% vs 76.3%, p = 0.004). A threshold of Sflex% < 70% predicted the need for osteotomy at a sensitivity of 78%, specificity of 56%, and positive predictive value of 77%. CONCLUSIONS The flexibility of the spine is quantitatively related to the use of an osteotomy. Prospective studies are needed to determine thresholds that may be used to standardize surgical decision-making in ASD surgery.

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

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.

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

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 &lt; .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 &lt; .001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P &lt; .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.

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