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

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.

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

Neurosurgery ◽

10.1093/neuros/nyw072 ◽

2017 ◽

Vol 80 (3) ◽

pp. 489-497 ◽

Cited By ~ 18

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.

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Upper instrumented vertebra–femoral angle and correlation with proximal junctional kyphosis in adult spinal deformity

Spine Deformity ◽

10.1007/s43390-021-00408-1 ◽

2021 ◽

Author(s):

Hao-Hua Wu ◽

Dean Chou ◽

Kevork Hindoyan ◽

Jeremy Guinn ◽

Joshua Rivera ◽

...

Keyword(s):

Femoral Head ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Surgical Correction ◽

Proximal Junctional Kyphosis ◽

Upper Instrumented Vertebra ◽

Femoral Head Center ◽

Junctional Kyphosis

Abstract Introduction Although matching lumbar lordosis (LL) with pelvic incidence (PI) is an important surgical goal for adult spinal deformity (ASD), there is concern that overcorrection may lead to proximal junctional kyphosis (PJK). We introduce the upper instrumented vertebra–femoral angle (UIVFA) as a measure of appropriate postoperative position in the setting of lower thoracic to pelvis surgical correction for patients with sagittal imbalance. We hypothesize that a more posterior UIV position in relation to the center of the femoral head is associated with an increased risk of PJK given compensatory hyperkyphosis above the UIV. Methods In this retrospective cohort study, adult patients undergoing lower thoracic (T9–T12) to pelvis correction of ASD with a minimum of 2-year follow-up were included. UIVFA was measured as the angle subtended by a line from the UIV centroid to the femoral head center to the vertical axis. Patients who developed PJK and those who did not were compared with preoperative and postoperative UIVFA as well as change between postoperative and preoperative UIVFA (deltaUIVFA). Results Of 119 patients included with an average 3.6-year follow-up, 51 (42.9%) had PJK and 24 (20.2%) had PJF. Patients with PJK had significantly higher postoperative UIVFA (12.6 ± 4.8° vs. 9.4 ± 6.6°, p = 0.04), deltaUIVFA (6.1 ± 7.6° vs. 2.1 ± 5.6°, p < 0.01), postoperative pelvic tilt (27.3 ± 9.2 vs. 23.3 ± 11, p = 0.04), postoperative lumbar lordosis (47.7 ± 13.9° vs. 42.4 ± 13.1, p = 0.04) and postoperative thoracic kyphosis (44.9 ± 13.2 vs. 31.6 ± 18.8) than patients without PJK. With multivariate logistic regression, postoperative UIVFA and deltaUIVFA were found to be independent risk factors for PJK (p < 0.05). DeltaUIVFA was found to be an independent risk factor for PJF (p < 0.05). A receiver operating characteristic (ROC) curve for UIVFA as a predictor for PJK was established with an area under the curve of 0.67 (95% CI 0.59–0.76). Per the Youden index, the optimal UIVFA cut-off value is 11.5 degrees. Conclusion The more posterior the UIV is from the femoral head center after lower thoracic to pelvis surgical correction for ASD, the more patients are at risk for PJK. The greater the magnitude of posterior translation of the UIV from the femoral head center from preop to postop, the greater the likelihood for PJF.

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Adult spinal deformity surgical decision-making score

European Spine Journal ◽

10.1007/s00586-019-05932-3 ◽

2019 ◽

Vol 28 (7) ◽

pp. 1652-1660 ◽

Cited By ~ 3

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

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The Impact of Global Alignment and Proportion Score and Bracing on Proximal Junctional Kyphosis in Adult Spinal Deformity

Global Spine Journal ◽

10.1177/21925682211001812 ◽

2021 ◽

pp. 219256822110018

Author(s):

Elizabeth L. Lord ◽

Ethan Ayres ◽

Dainn Woo ◽

Dennis Vasquez-Montes ◽

Yesha Parekh ◽

...

Keyword(s):

Spinal Deformity ◽

Chart Review ◽

Adult Spinal Deformity ◽

Retrospective Chart Review ◽

Global Alignment ◽

X Rays ◽

Proximal Junctional Kyphosis ◽

Upper Instrumented Vertebra ◽

The Impact ◽

Junctional Kyphosis

Study Design: Retrospective chart review. Objective: The goal of this study is to examine the relationship between global alignment and proportion (GAP) score and postoperative orthoses with likelihood of developing proximal junctional kyphosis (PJK). Methods: Patients who underwent thoracic or lumbar fusions of ≥4 levels for adult spinal deformity (ASD) with 1-year post-operative alignment x-rays were included. Chart review was conducted to determine spinopelvic alignment parameters, PJK, and reoperation. Results: A total of 81 patients were included; baseline and 1-year postoperative alignment did not differ between patients with and without PJK. There was no PJK in 53.1%, 29.6% had PJK from 10-20°, and 17.3% had severe PJK over 20° (sPJK). At baseline, 80% of patients had severely disproportioned GAP, 13.75% moderate, 6.25% proportioned. GAP improved across the population, but improved GAP was not associated with sPJK. Greater correction of the upper instrumented vertebra to pelvic angle (UIV-PA) was associated with a larger PJK angle (PJKA) change (R = -0.28) as was the 1 year T1-upper instrumented vertebra (T1-UIV) angle (R = 0.30), both P < .05. GAP change was not correlated with PJKA change. Postoperative orthoses were used in 46% of patients and did not impact sPJK. Conclusions: There was no correlation between PJK and GAP or change in GAP. Greater correction of UIV-PA and larger postop T1-UIV was associated with greater PJKA change; suggesting that the greater alignment correction led to greater likelihood of failure. Postoperative orthoses had no impact on PJK.

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Biomechanical Analysis of Acute Proximal Junctional Failure After Surgical Instrumentation of Adult Spinal Deformity: The Impact of Proximal Implant Type, Osteotomy Procedures, and Lumbar Lordosis Restoration*

Spine Deformity ◽

10.1016/j.jspd.2018.02.007 ◽

2018 ◽

Vol 6 (5) ◽

pp. 483-491 ◽

Cited By ~ 2

Author(s):

Leo Fradet ◽

Xiaoyu Wang ◽

Dennis Crandall ◽

Carl-Eric Aubin

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Biomechanical Analysis ◽

Surgical Instrumentation ◽

Proximal Junctional Failure ◽

The Impact

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Adult spinal deformity surgical decision-making score. Part 2: development and validation of a scoring system to guide the selection of treatment modalities for patients above 40 years with adult spinal deformity

European Spine Journal ◽

10.1007/s00586-019-06068-0 ◽

2019 ◽

Vol 29 (1) ◽

pp. 45-53 ◽

Cited By ~ 2

Author(s):

Takashi Fujishiro ◽

◽

Louis Boissière ◽

Derek Thomas Cawley ◽

Daniel Larrieu ◽

...

Keyword(s):

Decision Making ◽

Spinal Deformity ◽

Scoring System ◽

Adult Spinal Deformity ◽

Treatment Modalities ◽

Surgical Decision ◽

Development And Validation ◽

Surgical Decision Making ◽

Selection Of

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A Spine in Limbo: Does the Difference between Standing and Supine Spino-Pelvic Measurements of Patients with Adult Spinal Deformity Correlate with Surgical Decision-Making?

The Spine Journal ◽

10.1016/j.spinee.2017.08.208 ◽

2017 ◽

Vol 17 (10) ◽

pp. S268

Author(s):

Awais K. Hussain ◽

Khushdeep S. Vig ◽

Robert Merrill ◽

Jun Kim ◽

Byron W. Mui ◽

...

Keyword(s):

Decision Making ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Surgical Decision ◽

The Difference ◽

Surgical Decision Making

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

Journal of Neurosurgery Spine ◽

10.3171/2019.9.spine19557 ◽

2020 ◽

Vol 32 (4) ◽

pp. 600-606 ◽

Cited By ~ 1

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.

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