Safety of lateral access to the concave side for adult spinal deformity

OBJECTIVE Minimally invasive surgery (MIS) techniques, particularly lateral lumbar interbody fusion (LLIF), have become increasingly popular for adult spinal deformity (ASD) correction. Much discussion has been had regarding theoretical and clinical advantages to addressing coronal curvature from the convex versus concave side of the curve. In this study, the authors aimed to broadly evaluate the clinical outcomes of addressing ASD with circumferential MIS (cMIS) techniques while accessing the lumbar coronal curvature from the concave side. METHODS A multi-institution, retrospective chart and radiographic review was performed for all ASD patients with at least a 10° curvature, as defined by the Scoliosis Research Society, who underwent cMIS correction. The data collected included convex versus concave access to the coronal curve, durable or sensory femoral nerve injury lasting longer than 6 weeks, vascular injury, visceral injury, and any additional major complication, with at least a 2-year follow-up. Neither health-related quality-of-life metrics nor spinopelvic parameters were included within the scope of this study. RESULTS A total of 152 patients with ASD treated with cMIS correction via lateral access were identified and analyzed. Of these, 126 (82.9%) were approached from the concave side and 26 (17.1%) were approached from the convex side. In the concave group, 1 (0.8%) motor and 4 (3.2%) sensory deficit cases remained at 6 weeks after the operation. No vascular, visceral, or catastrophic intraoperative injuries were encountered in the concave group. Of the 26 patients in the convex group, 2 (7.7%) experienced motor deficits lasting longer than 6 weeks and 5 (19.2%) had lower-extremity sensory deficits. CONCLUSIONS It has been reported that lateral access to the convex side is associated with similar clinical and radiographic outcomes with fewer complications when compared with access to the concave side. Advantages to approaching the lumbar spine from the concave side include using one incision to access multiple levels, breaking the operative table to assist with curvature correction, easier access to the L4–5 disc space, the ability to release the contracted side, and, often, avoidance of the need to access or traverse the thoracic cavity. This study illustrates the largest reported cohort of concave access for cMIS scoliosis correction; few postoperative sensory and motor deficits were found.

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Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Global Spine Journal ◽

10.1177/2192568220960753 ◽

2020 ◽

pp. 219256822096075

Author(s):

Jonathan Charles Elysee ◽

Francis Lovecchio ◽

Renaud Lafage ◽

Bryan Ang ◽

Alex Huang ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Pelvic Incidence ◽

Lumbar Fusion ◽

Adult Spinal Deformity ◽

Multilinear Regression ◽

Sagittal Vertical Axis ◽

Type Curve ◽

Scoliosis Research Society ◽

Correlation Analyses

Study Design: Retrospective cohort study. Objective: To investigate correlations between preoperative supine imaging and postoperative alignment. Methods: A retrospective review was conducted of a single-institution database of patients with adult spinal deformity (ASD). Patients were stratified by fusion location in the lumbar or thoracic spine. Outcomes of interest were postoperative lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal alignment parameters were compared and correlation analyses were performed. Multilinear stepwise regression was conducted to identify independent predictors of postoperative LL or TK. Regression analyses were repeated within the lumbar and thoracic fusion cohorts. Results: A total of 99 patients were included (mean age 63.2 years, 83.1% female, mean body mass index 27.3 kg/m2). Scoliosis Research Society classification demonstrated moderate to severe sagittal and/or coronal deformity (pelvic tile modifier, 18.2% ++; sagittal vertical axis, 27.3% ++, pelvic incidence minus lumbar lordosis mismatch, 29.3% ++, SRS type, 29.3% N type curve and 68.7% L or D type curve). A total of 73 patients (73.7%) underwent lumbar fusion and 50 (50.5%) underwent thoracic fusion. Correlation analyses demonstrated a significant association between pre- and postoperative LL and TK. Multilinear regression demonstrated that LL supine and pelvic incidence were significant predictors of postoperative LL ( r 2 = 0.568, P < .001). LL supine, TK supine, and age were significant predictors of postoperative TK ( r 2 = 0.490, P < .001). Conclusion: Preoperative supine films are superior to standing in predicting postoperative alignment at 1-year follow-up. Anticipation of undesired alignment changes through supine imaging may be useful in mitigating the risk of iatrogenic malalignment.

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The Scoliosis Research Society Classification for Adult Spinal Deformity

Neurosurgery Clinics of North America ◽

10.1016/j.nec.2007.03.002 ◽

2007 ◽

Vol 18 (2) ◽

pp. 207-213 ◽

Cited By ~ 24

Author(s):

Sigurd H. Berven ◽

Thomas Lowe

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Research Society ◽

Scoliosis Research Society

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Health insurance policy on surgical treatment of adult spinal deformity

Journal of Korean Medical Association ◽

10.5124/jkma.2021.64.11.722 ◽

2021 ◽

Vol 64 (11) ◽

pp. 722-726

Author(s):

Ho-Joong Kim

Keyword(s):

Health Insurance ◽

Surgical Treatment ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Surgical Indication ◽

Surgical Results ◽

Proximal Junctional Kyphosis ◽

Scoliosis Research Society ◽

Spinal Sagittal Alignment ◽

Junctional Kyphosis

Background: Recent burgeoning research on adult spinal deformity (ASD) has unveiled the benefits of surgical treatment and how to gain the benefits although these have only been around for 10 years.Current Concepts: During the last decade, the significance of pelvic incidence in the global spinal sagittal alignment and introductions of the Scoliosis Research Society-Schwab classification for ASD have been the guidelines of surgical treatment for ASD and the milestones for promising surgical results. However, one of the unsolved problems for the surgical treatment of ASD is the proximal junctional kyphosis, for which multifactorial causative factors have been suggested. Recent studies have focused on dynamic natures in patients with ASD during daily activities, which might be a clue for both prevention of proximal junctional kyphosis and a better level of surgical results. Even though a recent remarkable advancement for surgical treatment for ASD is present, the national guideline for reimbursement is still following the surgical indication for lumbar degenerative kyphosis published in 1988.Discussion and Conclusion: A significant gap exists between the national reimbursement guideline and generally held surgical indication for ASD surgery. Consequently, this huge gap raises trouble in both patients and surgeons. The patients with ASD cannot take an appropriate surgery for ASD, while the spine surgeons experience unreasonable adjustment of the cost by the Health Insurance Review and Assessment Service.

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Relationship between Displacement of the Psoas Major Muscle and Spinal Alignment in Patients with Adult Spinal Deformity

Asian Spine Journal ◽

10.4184/asj.2018.12.2.335 ◽

2018 ◽

Vol 12 (2) ◽

pp. 335-342

Author(s):

Yoshiaki Oda ◽

Tomoyuki Takigawa ◽

Ryo Ugawa ◽

Yasuyuki Shiozaki ◽

Haruo Misawa ◽

...

Keyword(s):

Cobb Angle ◽

Spinal Deformity ◽

Lateral Displacement ◽

Adult Spinal Deformity ◽

Convex Side ◽

Spinal Alignment ◽

Radiographic Parameters ◽

Psoas Major Muscle ◽

The Difference ◽

Psoas Major

<sec><title>Study Design</title>Cross sectional study.</sec><sec><title>Purpose</title>To clarify the difference in position of the psoas muscle between adult spinal deformity (ASD) and lumbar spinal stenosis (LSS).</sec><sec><title>Overview of Literature</title>Although it is known that the psoas major muscle deviates in ASD patients, no report is available regarding the difference in comparison with LSS patients.</sec><sec><title>Methods</title>This study investigates 39 patients. For evaluating spinal alignment, pelvic tilt (PT), pelvic incidence (PI), sacral slope, lumbar lordosis (LL), PI–LL, Cobb angle, and the convex side, the lumbar curves were measured. For measuring the position of the psoas major at the L4/5 disk level, magnetic resonance imaging was used. The displacements of psoas major muscle were measured separately in the anterior–posterior and lateral directions. We examined the relationship between the radiographic parameters and anterior displacement (AD) and lateral displacement (LD) of the psoas major muscle.</sec><sec><title>Results</title>AD was demonstrated in 15 cases with ASD and nine cases with LSS (<italic>p</italic>>0.05). LD was observed in 13 cases with ASD and no cases with LSS (<italic>p</italic><0.01). The Cobb angle was significantly greater in cases with AD than in those without AD (<italic>p</italic>=0.04). PT, LL, PI–LL, and Cobb angle were significantly greater in cases with LD (<italic>p</italic><0.05). All cases with LD had AD, but no case without AD had LD (<italic>p</italic><0.001). The side of greater displacement at L4/5 and the convex side of the lumbar curve were consistent in all cases.</sec><sec><title>Conclusions</title>Despite AD being observed in LSS as well, LD was observed only in the ASD group. Radiographic parameters were worse when LD was seen, rather than AD.</sec>

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Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

Journal of Neurosurgery Spine ◽

10.3171/2021.3.spine202140 ◽

2021 ◽

pp. 1-9

Author(s):

Ferran Pellisé ◽

Miquel Serra-Burriel ◽

Alba Vila-Casademunt ◽

Jeffrey L. Gum ◽

Ibrahim Obeid ◽

...

Keyword(s):

Quality Of Life ◽

Spinal Deformity ◽

Oswestry Disability Index ◽

Adult Spinal Deformity ◽

Research Society ◽

Data Sets ◽

Scoliosis Research Society ◽

Sagittal Deformity

OBJECTIVE The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010. METHODS This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR). RESULTS Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01). CONCLUSIONS The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

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Long-term clinical and radiographic outcomes and patient satisfaction after adult spinal deformity correction

Scandinavian Journal of Surgery ◽

10.1177/1457496918812201 ◽

2018 ◽

Vol 108 (4) ◽

pp. 343-351 ◽

Cited By ~ 4

Author(s):

K. Kyrölä ◽

H. Kautiainen ◽

L. Pekkanen ◽

P. Mäkelä ◽

I. Kiviranta ◽

...

Keyword(s):

Patient Satisfaction ◽

Spinal Deformity ◽

Oswestry Disability Index ◽

Patient Reported Outcomes ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Research Society ◽

Scoliosis Research Society ◽

Patient Reported ◽

Poor Outcomes

Background and Aims: Adult spinal deformity surgery has increased with the aging population and modern surgical approaches, although it has high complication and reoperation rates. The permanence of radiographic correction, mechanical complications, predictive factors for poor patient-reported outcomes, and patient satisfaction were analyzed. Material and Methods: A total of 79 adult patients were retrospectively analyzed at baseline and 1–9 years after adult spinal deformity correction between 2007 and 2016. Patient-reported outcomes (Oswestry Disability Index, visual analog scale, and Scoliosis Research Society–30 scores), changes in radiographic alignment, indications for reoperation, predictors of poor outcomes according to the Oswestry Disability Index and Scoliosis Research Society–30 scores, and patient satisfaction with management were studied. Results: Oswestry Disability Index and visual analog scale scores (p = 0.001), radiographic correction of thoracic kyphosis, lumbar lordosis, and pelvic retroversion (p ⩽ 0.001) and sagittal vertical axis (p = 0.043) were significantly better at 4–5 years of follow-up than at baseline. The risk for the first reoperation owing to mechanical failure of instrumentation or bone was highest within the first year, at 13.9% (95% confidence interval = 8.0%–23.7%), and 29.8% (95% confidence interval = 19.4%–43.9%) at the 5-year follow-up. Oswestry Disability Index and Scoliosis Research Society–30 total scores had a good correlation (r = −0.78; 95% CI = −0.86 to –0.68; p < 0.001). Satisfaction with management was correlated with patient-reported outcomes. Male sex and depression (p = 0.021 and 0.018, respectively) predicted poor outcomes according to the Oswestry Disability Index and/or Scoliosis Research Society–30 score. Conclusion: The achieved significant radiographic correction was maintained 5 years postoperatively. Despite reoperations, patient satisfaction and clinical outcomes were good. Depression and male sex predicted poor clinical outcomes.

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The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016

Spine Deformity ◽

10.1016/j.jspd.2018.08.014 ◽

2019 ◽

Vol 7 (2) ◽

pp. 319-324 ◽

Cited By ~ 3

Author(s):

Neel Anand ◽

Aniruddh Agrawal ◽

Evalina L. Burger ◽

Emmanuelle Ferrero ◽

Jeremy L. Fogelson ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Research Society ◽

Scoliosis Research Society

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Reaching minimal clinically important difference in adult spinal deformity surgery: a comparison of patients from North America and Japan

Journal of Neurosurgery Spine ◽

10.3171/2019.12.spine19593 ◽

2020 ◽

Vol 32 (6) ◽

pp. 859-864

Author(s):

Hideyuki Arima ◽

Steven D. Glassman ◽

Keith Bridwell ◽

Yu Yamato ◽

Mitsuru Yagi ◽

...

Keyword(s):

North America ◽

Spinal Deformity ◽

Minimal Clinically Important Difference ◽

Adult Spinal Deformity ◽

Clinical Status ◽

Scoliosis Research Society ◽

Self Image ◽

Clinically Important Difference ◽

Significant Difference ◽

Domain Scores

OBJECTIVEThe Scoliosis Research Society-22r questionnaire (SRS-22r) has been shown to be reliable, valid, and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimal clinically important difference (MCID) is the smallest difference in a health-related quality of life score that is considered to be worthwhile or clinically important to the individual. The authors hypothesized that the proportion of patients with ASD achieving an MCID in the SRS-22r score would be different between two culturally different cohorts. The purpose of this study was to compare the proportion of patients with ASD achieving MCID for the SRS-22r domains in North American (NA) and Japanese cohorts.METHODSA total of 137 patients from North America (123 women, mean age 60.0 years) and 60 patients from Japan (56 women, mean age 65.5 years) with at least 2 years of follow-up after corrective spine surgery for ASD were included. Except for self-image, published Japanese MCID values of SRS-22r for ASD were higher (function = 0.90, pain = 0.85, self-image = 1.05, subtotal = 1.05) than the published NA MCID values (function = 0.60, pain = 0.40, self-image = 1.23, subtotal = 0.43).RESULTSThere was a statistically significant improvement in all SRS-22r domain scores at 2 years compared to baseline in both cohorts. Except for mental health (NA = 0.32, Japanese = 0.72, p = 0.005), the mean improvement from baseline to 2 years was similar between the NA and Japanese cohorts. The proportion of patients achieving MCID was higher in North America for function (NA = 51%, Japanese = 30%, p = 0.006), pain (NA = 80%, Japanese = 47%, p < 0.001), and subtotal (NA = 72%, Japanese = 35%, p < 0.001), while there was no significant difference for self-image (NA = 53%, Japanese = 58%, p = 0.454).CONCLUSIONSDespite similar improvements in SRS-22r domain scores from baseline to 2 years postoperatively, the proportion of patients reaching SRS-22r MCID for function, pain, and subtotal after ASD surgery was higher in the NA cohort than in the Japanese cohort. This may imply that patients in North America and Japan may value observed changes in clinical status differently.

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Impact of preoperative depression on 2-year clinical outcomes following adult spinal deformity surgery: the importance of risk stratification based on type of psychological distress

Journal of Neurosurgery Spine ◽

10.3171/2016.2.spine15980 ◽

2016 ◽

Vol 25 (4) ◽

pp. 477-485 ◽

Cited By ~ 20

Author(s):

Alexander A. Theologis ◽

Tamir Ailon ◽

Justin K. Scheer ◽

Justin S. Smith ◽

Christopher I. Shaffrey ◽

...

Keyword(s):

Risk Stratification ◽

Clinical Outcomes ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Clinical History ◽

Assessment Method ◽

Scoliosis Research Society ◽

Sf 36 ◽

History Of ◽

History Of Depression

OBJECTIVE The objective of this study was to isolate whether the effect of a baseline clinical history of depression on outcome is independent of associated physical disability and to evaluate which mental health screening tool has the most utility in determining 2-year clinical outcomes after adult spinal deformity (ASD) surgery. METHODS Consecutively enrolled patients with ASD in a prospective, multicenter ASD database who underwent surgical intervention with a minimum 2-year follow-up were retrospectively reviewed. A subset of patients who completed the Distress and Risk Assessment Method (DRAM) was also analyzed. The effects of categorical baseline depression and DRAM classification on the Oswestry Disability Index (ODI), SF-36, and Scoliosis Research Society questionnaire (SRS-22r) were assessed using univariate and multivariate linear regression analyses. The probability of achieving ≥ 1 minimal clinically important difference (MCID) on the ODI based on the DRAM’s Modified Somatic Perceptions Questionnaire (MSPQ) score was estimated. RESULTS Of 267 patients, 66 (24.7%) had self-reported preoperative depression. Patients with baseline depression had significantly more preoperative back pain, greater BMI and Charlson Comorbidity Indices, higher ODIs, and lower SRS-22r and SF-36 Physical/Mental Component Summary (PCS/MCS) scores compared with those without self-reported baseline depression. They also had more severe regional and global sagittal malalignment. After adjusting for these differences, preoperative depression did not impact 2-year ODI, PCS/MCS, or SRS-22r totals (p > 0.05). Compared with those in the “normal” DRAM category, “distressed somatics” (n = 11) had higher ODI (+23.5 points), lower PCS (−10.9), SRS-22r activity (−0.9), and SRS-22r total (−0.8) scores (p ≤ 0.01), while “distressed depressives” (n = 25) had lower PCS (−8.4) and SRS-22r total (−0.5) scores (p < 0.05). After adjusting for important covariates, each additional point on the baseline MSPQ was associated with a 0.8-point increase in 2-year ODI (p = 0.03). The probability of improving by at least 1 MCID in 2-year ODI ranged from 77% to 21% for MSPQ scores 0–20, respectively. CONCLUSIONS A baseline clinical history of depression does not correlate with worse 2-year outcomes after ASD surgery after adjusting for baseline differences in comorbidities, health-related quality of life, and spinal deformity severity. Conversely, DRAM improved risk stratification of patient subgroups predisposed to achieving suboptimal surgical outcomes. The DRAM’s MSPQ was more predictive than MCS and SRS mental domain for 2-year outcomes and may be a valuable tool for surgical screening.

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