Useful and innovative methods for the treatment of postoperative coronal malalignment in adult scoliosis: the "kickstand rod" and "tie rod" procedures

Placement of a Kickstand Rod in Adult Spinal Deformity Surgery: A Simple 8-Step Process With Intraoperative Images and Video

BACKGROUND AND OBJECTIVES

In adult spinal deformity (ASD) surgery, operative correction of coronal malalignment remains a challenging surgical task. Given the proven effectiveness and longevity of the kickstand rod (KSR) technique and its powerful ability to correct coronal malalignment, this technique is an important tool to have available. Therefore, we sought to provide a simple 8-step description of the KSR technique using intraoperative images and video in a patient undergoing combined sagittal and coronal malalignment correction.

METHODS

A 68-year-old female with a previous history of T11-S1 posterior spinal fusion presented with mid thoracic back pain, leg paresthesias, and a right-leaning posture. The patient underwent a T4-pelvis extension of fusion, T8-11 posterior column osteotomies, and placement of a right-sided KSR to address her coronal malalignment.

RESULTS

The KSR technique is summarized in the following steps: (1) place kickstand screw, (2) place contralateral main rod and tighten all set plugs, (3) place ipsilateral main rod and keep rod long distally, (4) place a domino in the lower/mid thoracic area, (5) place the KSR and leave the rod long proximally, (6) tighten the ipsilateral main rod above the domino, (7) loosen the ipsilateral main rod below the domino, and (8) place a rod gripper below the domino and distract. Postoperatively, the coronal vertical axis improved from 4.8 to 0.6 cm, and the sagittal vertical axis improved from 9.5 to 3.9 cm.

CONCLUSION

The current case report provides a simple 8-step description of the KSR technique to improve coronal malalignment accompanied by intraoperative images and video.

The iliac kickstand screw: anatomic CT analysis of screw trajectory and osseous corridor for screw placement

INTRODUCTION

The 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium.

OBJECTIVE

Using a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw.

METHODS

50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured.

RESULTS

50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes.

CONCLUSIONS

The novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.

Adherence to the Obeid coronal malalignment classification and a residual malalignment below 20 mm can improve surgical outcomes in adult spine deformity surgery

PURPOSE

Coronal balance is a major factor impacting the surgical outcomes in adult spinal deformity (ASD). The Obeid coronal malalignment (O-CM) classification has been proposed to improve the coronal alignment in ASD surgery. Aim of this study was to investigate whether a postoperative CM < 20 mm and adherence to the O-CM classification could improve surgical outcomes and decrease the rate of mechanical failure in a cohort of ASD patients.

METHODS

Multicenter retrospective analysis of prospectively collected data on all ASD patients who underwent surgical management and had a preoperative CM > 20 mm and a 2-year follow-up. Patients were divided in two groups according to whether or not surgery had been performed in adherence to the guidelines of the O-CM classification and according to whether or not the residual CM was < 20 mm. The outcomes of interest were radiographic data, rate of mechanical complications and Patient-Reported Outcome Measures.

RESULTS

At 2 years, adherence to the O-CM classification led to a lower rate of mechanical complications (40 vs. 60%). A coronal correction of the CM < 20 mm allowed for a significant improvement in SRS-22 and SF-36 scores and was associated with a 3.5 times greater odd of achieving the minimal clinical important difference for the SRS-22.

CONCLUSION

Adherence to the O-CM classification could reduce the risk of mechanic complications 2 years after ASD surgery. Patients with a residual CM < 20 mm showed better functional outcomes and a 3.5 times greater odd of achieving the MCID for the SRS-22 score.

New Effective Intraoperative Techniques for the Prevention of Coronal Imbalance after Circumferential Minimally Invasive Correction Surgery for Adult Spinal Deformity

This study aimed to devise measures and investigate their effect on coronal imbalance (CI) after circumferential minimally invasive correction surgery (CMIS) with lateral lumbar interbody fusion and percutaneous pedicle screw for adult spinal deformity (ASD). A total of 115 patients with ASD who underwent CMIS from the lower thoracic spine to the ilium were included. Patients were stratified based on the distance between the spinous process of the upper instrumented vertebra and central sacrum vertical line (UIV-CSVL) after the first intraoperative rod application into groups P (UIV-CSVL > 10 mm, n = 50) and G (UIV-CSVL < 10 mm, n = 65). Measures to correct postoperative CI introduced during surgery, preoperative and postoperative UIV-CSVL, and changes in UIV-CSVL after various measures (ΔUIV-CSVL) were investigated in group P. Rod rotation (RR), S2 alar-iliac screw distraction (SD), and kickstand-rod (KR) technique were performed in group P. Group P was further divided into group RR (n = 38), group SD (RR and SD) (n = 7), and group KR (RR and KR) (n = 5); the ΔUIV-CSVLs were 13.9 mm, 20.1 mm, and 24.4 mm in these three groups, respectively. Postoperative C7-CSVL < 10 mm was achieved in all three correction groups. In conclusion, our measures enabled sufficient correction of the UIV-CSVL and are useful for preventing CI after CMIS for ASD.

Patients With Coronal Malalignment Undergoing Adult Spinal Deformity Surgery: Does Coronal Alignment Change From Immediately Postoperative to 2-years?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objectives were to: (1) characterize the changes in coronal vertical axis (CVA) after adult spinal deformity (ASD) surgery from immediate postoperative to 2-years postoperative, and (2) assess for predictors of CVA change from immediate postoperative to 2-years postoperative.

SUMMARY OF BACKGROUND DATA

It is unknown whether coronal correction obtained immediately postoperative accurately reflects long-term coronal alignment.

MATERIALS AND METHODS

A retrospective, single-institution registry was queried for patients undergoing ASD surgery from 2015-2019, including patients undergoing ≥6-level fusions with preoperative coronal malalignment (CM), defined as CVA≥3 cm. A clinically significant change in CVA was defined a priori as ≥1 cm. Radiographic variables were obtained preoperatively, immediately postoperative, and at 2-years postoperative.

RESULTS

Of 368 patients undergoing ASD surgery, 124 (33.7%) had preoperative CM, and 64 (17.0%) completed 2-years follow-up. Among 64 patients, mean age was 53.6±15.4 years. Preoperatively, absolute mean CVA was 5.4±3.1 cm, which improved to 2.3±2.0 cm ( P <0.001) immediately postoperative and 2.2±1.6 cm ( P <0.001) at 2-years. The mean change in CVA from preoperative to immediately postoperative was 2.2±1.9 cm (0.3-14.4). During the immediate postoperative to 2-years interval, 29/64 (45.3%) patients experienced a significant change of CVA by ≥1 cm, of which 22/29 (76%) improved by a mean of 1.7 cm and 7/29 (24%) worsened by a mean of 3.5 cm. No preoperative or surgical factors were associated with changed CVA from immediately postoperative to 2-years.

CONCLUSION

Among 64 patients undergoing ASD surgery with preoperative CM, 45.3% experienced a significant (≥1 cm) change in their CVA from immediately postoperative to 2-years postoperative. Of these 29 patients, 22/29 (76%) improved, whereas 7/29 (24%) worsened. Although no factors were associated with undergoing a change in CVA, this information is useful in understanding the evolution and spontaneous coronal alignment changes that take place after major ASD coronal plane correction.

The "kickstand rod" technique for correction of coronal malalignment: two-year clinical and radiographic outcomes

PURPOSE

Restoring coronal alignment in spine deformity patients has been shown to play an important role in improving patient reported outcomes (PRO). Recently, the "kickstand rod" (KSR) technique was developed as a novel coronal correction method in complex spine deformity cases. The goal of the present study was to assess outcomes of this technique at two years of follow-up.

METHODS

Consecutive, unique adult patients who underwent KSR constructs for coronal spinal malalignment between 2015 and 2019 with a minimum 2 year clinical and radiographic follow-up were identified. A KSR construct includes a more laterally placed iliac screw and additional rod that effectively depresses the ipsilateral ilium/pelvis for coronal correction, while serving as a buttress to prevent future loss of correction. Outcomes included revision for instrumentation-related complications, radiographic alignment, and PROs.

RESULTS

Twenty patients were included with a mean age of 54 years [range: 20-73 years]. Mean follow-up time was 2.5 years [range: 2.0-5.0]. Mean number of levels fused was 17.3 [range: 10-24]. There were significant improvements in coronal alignment (CVA: 5.8 cm ± 2.6 cm vs. 1.7 cm ± 1.5 cm), sagittal alignment (SVA: 5.6 cm ± 5.9 cm vs. 1.6 cm ± 2.5 cm) and major Cobb angle (55º ± 32 vs. 26º ± 21) maintained at 2 years (p < 0.05). One patient experienced an asymptomatic fracture at the shank of the KSR iliac screw. There were significant improvements in Oswestry Disability Index and SRS-22 domains (p < 0.05).

CONCLUSION

The KSR technique is a safe and effective method for correcting coronal malalignment in complex spinal deformity patients with no revisions specific for the KSR or iliac screw and significantly improved PROs at a minimum two-year follow-up.

Sectional Correction Technique in Dystrophic Scoliosis Secondary to Neurofibromatosis Type 1: A Comparison with Traditional 2-Rod Correction Technique

OBJECTIVE

The purpose of this study was to compare the traditional 2-rod correction technique with the sectional correction technique in terms of radiographic results and clinical outcomes for patients with dystrophic scoliosis caused by neurofibromatosis type 1 (NF1).

METHODS

From May 2015 to April 2018, 53 patients with dystrophic scoliosis caused by NF1 underwent 1-stage posterior corrective surgery. Patients were separated into 2 groups based on technique: the sectional correction technique (SC group) and the traditional 2-rod technique (TT group). Before surgery and at the final follow-up, the demographic information, radiographic parameters, and clinical outcomes were compared between the groups using independent-sample t tests.

RESULTS

The SC group consisted of 24 patients, while the TT group consisted of 29 patients. Patients in the SC group showed a higher coronal balance distance after the operation (8.3 ± 8.2 mm vs. 16.2 ± 8.8 mm, P = 0.002) and at the final follow-up (9.5 ± 9.3 mm vs. 19.3 ± 10.1 mm, P < 0.0001). At the last follow-up, the loss of correction in the SC group was 2.2 ± 0.9 and 2.1 ± 0.7 in the coronal and sagittal planes, respectively, and these values were significantly lower than those in the TT group (5.3 ± 1.6 in the coronal plane and 4.5 ± 1.9 in the sagittal plane, both P < 0.05). The SC group had better improvement based on appearance and satisfaction score at the final follow-up.

CONCLUSIONS

The sectional correction technique using a concave domino connector can restore coronal imbalance and reduce the risk of implant failure.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique

STUDY DESIGN

Surgical technical note and literature review.

OBJECTIVES

To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body.

METHODS

Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times.

RESULTS

We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4 years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved.

CONCLUSION

Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

Need of vascular surgeon and comparison of value for anterior lumbar interbody fusion (ALIF) in lateral decubitus: Delphi consensus

BACKGROUND AND PURPOSE

Anterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years. The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF).

METHODS

A two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF).

RESULTS

A total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements.

CONCLUSIONS

The Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Rapidly destructive osteoarthritis of the spine: lessons learned from the first reported case

Background

Rapidly Destructive Osteoarthritis (RDOA) has been described for the hip and shoulder joints and is characterized by a quickly developing bone edema followed by extensive remodeling and joint destruction. Confronted with a similarly evolving case of endplate edema and destruction of the disk space, we offer the first described case of spinal RDOA and illustrate the challenges it presented, along with the strategies we put in place to overcome them.

Case presentation

We present a case of spinal RDOA that, also due to the delay in the diagnoses, underwent multiple revisions for implant failure with consequent coronal and sagittal imbalance. A 37-years-old, otherwise healthy female presented with atraumatic low back pain: after initial conservative treatment, subsequent imaging showed rapidly progressive endplate erosion and a scoliotic deformity. After surgical treatment, the patient underwent numerous revisions for pseudoarthrosis, coronal and sagittal imbalance and junctional failure despite initially showing a correct alignement after each surgery. As a mechanic overload from insufficient correction of the alignement of the spine was ruled out, we believe that the multiple complications were caused by an impairment in the bone structure and thus, reviewing old imaging, diagnosed the patient with spinal RDOA. In case of spinal RDOA, particular care should be placed in the choice of extent and type of instrumentation in order to prevent re-intervention.

Conclusion

Spinal RDOA is characterized by a quickly developing edema of the vertebral endplates followed by a destruction of the disk space within months from the first diagnosis. The disease progresses in the involved segment and to the adjacent disks despite surgical therapy. The surgical planning should take the impaired bone structure account and the use of large interbody cages or 4-rod constructs should be considered to obtain a stable construct.

Coronal Alignment in Adult Spinal Deformity Surgery: Definitions, Measurements, Treatment Algorithms, and Impact on Clinical Outcomes

The major focus of realignment in adult spinal deformity (ASD) surgery has been on the sagittal plane, and less emphasis has been given to the coronal plane. In light of this overlooked area within ASD surgery, we aimed to refocus the narrative on coronal alignment in ASD surgery. The objectives of the current narrative review were to (1) define coronal alignment and discuss existing measurements; (2) report the incidence and prevalence of coronal malalignment (CM); (3) discuss the impact of CM on clinical outcomes; and (4) describe our preferred treatment algorithm of surgical correction of CM in ASD.

Kickstand rods and correction of coronal malalignment in patients with adult spinal deformity

PURPOSE

Coronal malalignment (CM) is a challenging spinal deformity to treat. The kickstand rod (KR) technique is powerful for correcting truncal shift. This study tested the hypothesis that the KR technique provides superior coronal alignment correction in adult deformity compared with traditional rod techniques.

METHODS

A retrospective evaluation of a prospectively collected multicenter database was performed. A 2:1 matched cohort of non-KR accessory rod and KR patients was planned based on preoperative coronal balance distance (CBD) and a vector of global shift. Patients were subgrouped according to CM classification with a 30-mm CBD threshold defining CM, and comparisons of surgical and clinical outcomes among groups was performed.

RESULTS

Twenty-one patients with preoperative CM treated with a KR were matched to 36 controls. KR-treated patients had improved CBD compared with controls (18 vs. 35 mm, P < 0.01). The postoperative CBD did not result in clinical differences between groups in patient-reported outcomes (P ≥ 0.09). Eight (38%) of 21 KR patients and 12 (33%) of 36 control patients with preoperative CM had persistent postoperative CM (P = 0.72). CM class did not significantly affect the likelihood of treatment failure (postoperative CBD > 30 mm) in the KR cohort (P = 0.70), the control cohort (P = 0.35), or the overall population (P = 0.31).

CONCLUSIONS

Application of the KR technique to coronal spinal deformity in adults allows for successful treatment of CM. Compared to traditional rod techniques, the use of KRs did not improve clinical outcome measures 1 year after spinal deformity surgery but was associated with better postoperative coronal alignment.

How to rectify the convex coronal imbalance in patients with unstable dystrophic scoliosis secondary to type I neurofibromatosis: experience from a case series

BACKGROUND

There was a paucity of valid information on how to rectify the convex coronal imbalance effectively in dystrophic scoliosis secondary to Type I neurofibromatosis (DS-NF1), while postoperative inadvertent aggravation of CCI occurred regularly resulting in poor patient satisfaction. We aimed to identify the risk factors for persistent postoperative CCI in DS-NF1, and to optimize the coronal rebalancing strategies based on the lessons learned from this rare case series.

METHODS

NF1-related scoliosis database was reviewed and those with significant CCI (> 3 cm) were identified, sorted and the outcomes of surgical coronal rebalance were analyzed to identify the factors being responsible for failure of CCI correction.

RESULTS

CCI with dystrophic thoracolumbar/lumbar apex was prone to remain uncorrected (7 failure cases in 11) when compared to those with thoracic apex (0 failure cases in 4) (63.6% vs. 0.0%, p = 0.077). Further comparison between those with and without post-op CCI showed a higher correction of main curve Cobb angle (65.9 ± 9.1% vs. 51.5 ± 37.3%, p = 0.040), more tilted instrumentation (10.3 ± 3.6° vs. 3.2 ± 3.1°, p = 0.001) and reverse tilt and translation of upper instrumented vertebra (UIV) to convex side (8.0 ± 2.3° vs. -3.4 ± 5.9°, p < 0.001; 35.4 ± 6.9 mm vs. 12.3 ± 13.1 mm, p = 0.001) in the uncorrected imbalanced group. Multiple linear regression analysis revealed that △UIV translation (pre- to post-operation) (β = 0.832; p = 0.030) was significantly correlated with the correction of CBD.

CONCLUSION

Thoracolumbar/lumbar CCI in dystrophic scoliosis was prone to suffer high risk of persistent post-op CCI. Satisfying coronal rebalance should avoid UIV tilt and translation to the convex side, tilted morphology of instrumentation and over correction maneuvers for main curve, the upper hemi-curve region in particular.

Impact of an intraoperative coronal spinal alignment measurement technique using a navigational tool for a 3D spinal rod bending system in adult spinal deformity cases

OBJECTIVE

In corrective spinal surgery for adult spinal deformity (ASD), the focus has been on achieving optimal spinopelvic alignment. However, the correction of coronal spinal alignment is equally important. The conventional intraoperative measurement methods currently used for coronal alignment are not ideal. Here, the authors have developed a new intraoperative coronal alignment measurement technique using a navigational tool for a 3D spinal rod bending system (CAMNBS). The purpose of this study was to test the feasibility of using the CAMNBS for coronal spinal alignment and to evaluate its usefulness in corrective spinal surgery for ASD.

METHODS

In this retrospective cohort study, patients with degenerative lumbar kyphoscoliosis, a Cobb angle ≥ 20°, and lumbar lordosis ≤ 20° who had undergone corrective surgery (n = 67) were included. The pelvic teardrops on both sides, the S1 spinous process, the central point of the apex, a point on the 30-mm cranial (or caudal) side of the apex, and the central point of the upper instrumented vertebra (UIV) and C7 vertebra were registered using the CAMNBS. The positional information of all registered points was displayed as 2D figures on a monitor. Deviation of the UIV plumb line from the central sacral vertical line (UIV-CSVL) and deviation of the C7 plumb line from the CSVL (C7-CSVL) were measured using the 2D figures. Nineteen patients evaluated using the CAMNBS (BS group) were compared with 48 patients evaluated using conventional intraoperative radiography (XR group). The UIV-CSVL measured intraoperatively using the CAMNBS was compared with that measured using postoperative radiography. The prevalence of postoperative coronal malalignment (CM) and the absolute value of postoperative C7-CSVL were compared between the groups on radiographs obtained in the standing position within 4 weeks after surgery. Postoperative CM was defined as the absolute value of C7-CSVL ≥ 30 mm. Further, the measurement time and amount of radiation exposure were measured.

RESULTS

No significant differences in demographic, sagittal, and coronal parameters were observed between the two groups. UIV-CSVL was 2.3 ± 9.5 mm with the CAMNBS and 1.8 ± 16.6 mm with the radiographs, showing no significant difference between the two methods (p = 0.92). The prevalence of CM was 2/19 (10.5%) in the BS group and 18/48 (37.5%) in the XR group, and absolute values of C7-CSVL were 15.2 ± 13.1 mm in the BS group and 25.0 ± 18.0 mm in the XR group, showing statistically significant differences in both comparisons (p = 0.04 and 0.03, respectively). The CAMNBS method required 3.5 ± 0.9 minutes, while the conventional radiograph method required 13.3 ± 1.5 minutes; radiation exposure was 2.1 ± 1.1 mGy in the BS group and 2.9 ± 0.6 mGy in the XR group. Statistically significant differences were demonstrated in both comparisons (p = 0.0002 and 0.03, respectively).

CONCLUSIONS

From this study, it was evident that the CAMNBS did not increase postoperative CM compared with that seen using the conventional radiographic method, and hence can be used in clinical practice.

Improvement of coronal alignment in fractional low lumbar curves with the use of anterior interbody devices

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To determine if the addition of an anterior lumbar interbody fusion (ALIF) improves the fractional curve in adult spinal deformity correction when compared to posterior surgery alone. ALIF is commonly advocated to improve lordosis and fusion in adult deformity surgery. Improved fractional curve correction may help level the pelvis and minimize proximal malalignment.

METHODS

Patients undergoing thoracolumbar fusion to the pelvis with S2AI screws for deformity were identified and stratified into patients who had an ALIF as part of their deformity correction procedure (ALIF + PSF), and those who had a posterior approach alone. The posterior approach (PSF) includes patients who had a posterolateral fusion with or without a transforaminal lumbar interbody fusion (TLIF). Radiographic parameters measured included pre-op and post-op fractional coronal curve Cobb angle, lumbar lordosis, pelvic tilt, pelvic incidence and sacral slope, major Cobb angle, coronal and sagittal SVA.

RESULTS

There were 31 cases in the ALIF + PSF group and 28 in the PSF group. Baseline demographic characteristics of the two groups were similar. Mean pre-op fractional coronal Cobb (18.3° vs 13.4°, p = 0.027) was larger in the ALIF + PSF group, whereas lumbar lordosis (31.0° vs 33.6°, p = 0.487) and pelvic parameters were similar between the two groups. Post-op lumbar lordosis was similar (48.2° vs 43.0°, p = 0.092). Greater fractional coronal curve correction was achieved in the ALIF + PSF group (67%) compared to the PSF group (36%) with a smaller post-op fractional coronal curve in the ALIF + PSF group (6.1°) compared to the PSF group (8.6°, p = 0.053).

CONCLUSION

There is a greater correction of the fractional curve in the ALIF + PSF group compared with the PSF group. While this may not be the primary indication for ALIF, it is a benefit which may facilitate overall deformity correction and leveling of the pelvis.

Coronal imbalance after growing rod treatment in early-onset scoliosis: a minimum of 5 years' follow-up

OBJECTIVE

The objective of this study was to investigate the incidence and risk factors of coronal imbalance (CI) in patients with early-onset scoliosis (EOS) who underwent growing rod (GR) treatment.

METHODS

A consecutive series of 61 patients with EOS (25 boys and 36 girls, mean age 5.8 ± 1.7 years) who underwent GR treatment was retrospectively reviewed. Postoperative CI was defined as postoperative C7 translation on either side ≥ 20 mm. Patients were divided into an imbalanced and a balanced group. Coronal patterns were classified into three types: type A (C7 translation < 20 mm), type B (C7 translation ≥ 20 mm with C7 plumb line [C7PL] shifted to the concave side of the curve), and type C (C7 translation ≥ 20 mm and a C7PL shifted to the convex side of the curve).

RESULTS

Each patient had an average of 5.3 ± 1.0 lengthening procedures and was followed for an average of 6.2 ± 1.3 years. Eleven patients (18%) were diagnosed with CI at the latest distraction, 5 of whom graduated from GRs and underwent definitive fusion. However, these patients continued to present with CI at the last follow-up evaluation. The proportion of preoperative type C pattern (54.5% vs 16.0%, p = 0.018), immediate postoperative apical vertebral translation (30.4 ± 13.5 mm vs 21.2 ± 11.7 mm, p = 0.025), lowest instrumented vertebra tilt (11.4° ± 8.2° vs 7.3° ± 3.3°, p = 0.008), and spanned obliquity angle (SOA) (9.7° ± 10.5° vs 4.1° ± 4.5°, p = 0.006) values in the imbalanced group were significantly higher than in the balanced group. Multiple logistic regression demonstrated that a preoperative type C pattern and immediate postoperative SOA > 11° were independent risk factors for postoperative CI.

CONCLUSIONS

The incidence of CI in patients with EOS who underwent GR treatment was 18%. This complication could only be slightly improved after definitive spinal fusion because of the autofusion phenomenon. A preoperative type C pattern and immediate postoperative SOA > 11° were found to be the risk factors for CI occurrence at the latest follow-up.

Correction of a severe coronal malalignment in adult spinal deformity using the "kickstand rod" technique as primary surgery

Objective

Adult spinal deformity (ASD) is a growing healthcare issue due to the aging population. A satisfying spine balance in both sagittal and coronal planes is achieved through surgery. Only few studies about the coronal alignment correction with the kickstand rod were reported in the literature, until now. The aim of the present study was to describe clinical and radiological outcomes of the Kickstand rod (KR) technique in a series of ASD patients with severe coronal malalignment after 1 year of follow-up.

Material and methods

Six patients affected by ASD with severe CM who underwent surgery between 2018 and 2019 were retrospectively analyzed. The mean follow up was 14 months. All patients had posterior-only approach with long pelvic-thoracic fixation according to the Kickstand rod technique.

Results

Postoperative alignment and pain numerical rating scale scores significantly improved. No instrumentation complications occurred. A coronal alignment improvement from a mean of 163 mm preoperatively to a mean of 32 mm postoperatively was observed.

Conclusion

KR technique appears to be a safe and efficient way for coronal and sagittal imbalance correction in ASD patients. Although technically demanding, by using this technique good and stable radiological and functional outcomes are achieved especially in selected patients.

Comparative radiological outcomes and complications of sacral-2-alar iliac screw versus iliac screw for sacropelvic fixation

PURPOSE

To compare the outcomes of sacropelvic fixation (SPF) using sacral-2-alar iliac (S2AI) screw with SPF using iliac screw (IS).

METHODS

A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus was performed for comparative studies between S2AI and IS for SPF. Two independent investigators selected qualified studies and extracted data indispensably. With 95% confidence intervals (CI), the odds ratio (OR) was applied to dichotomous outcomes and standardized mean difference (SMD) was applied to continuous outcomes for each item.

RESULTS

We included data from thirteen studies involving 722 patients (S2AI, 357 patients; IS, 365 patients). In the pediatric population, the S2AI group had a smaller pelvic obliquity (PO) than the IS group at final follow-up (SMD, - 0.38; 95% CI, - 0.72 to - 0.04). Patients who underwent S2AI screws showed reduced rates of re-operation (S2AI, 13%; IS, 28%), implant failure (S2AI, 12%; IS, 26%) [screw loosening (S2AI, 8%; IS, 20%); screw breakage (S2AI, 2%; IS, 12%)], implant prominence (S2AI, 2%; IS, 14%), pseudarthrosis (S2AI, 3%; IS, 15%), wound infection (S2AI, 8%; IS, 22%) and less blood loss (S2AI, 2035.4 ml; IS, 2708.4 ml).

CONCLUSION

Radiological outcomes indicate an effective maintenance of the correction and arrest of progression of deformity by S2AI, which is equal or better than IS. SPF with S2AI screw has obviously lower incidence of postoperative complications and less blood loss. Given these advantages, the S2AI screw seems to be a beneficial alternative to IS.

The "Kickstand Rod" Technique for Coronal Imbalance in Patients With Spinal Deformity: A Case Report With Review of Literature

Coronal imbalance is a type of spinal deformity with deviation from midline in the coronal plane. It is challenging to correct even in the hands of experienced spine surgeons. Many conventional techniques lead to unsuccessful results or complications. However, the incorporation of “kickstand rod” (KR) instrumentation is now understood to provide a more supported coronal correction and improve spinal deformities. Sometimes it can be used to provide additional spinal support in instances where spinal fusion has already occurred. The KR is placed from a posterior approach along the lateral spine from lumbar spine to ilium and exerts distraction forces that counteract misaligned spinal segments. Our objective is to present a clinical case example with a brief review of literature. Herein, we present a case of a 62-year-old male with the development of significant coronal imbalance following his posterior lumbosacral instrumentation and fusion 11 years prior to presentation. KR supplementation to his hardware improved his functional outcome significantly. Further, we provide a literature review of the surgical characteristics, indications, and functional outcomes of KR instrumentation. A term search of “kickstand rod” was performed in PubMed, and relevant English language publications were included. The literature search yielded only six publications. A total of 45 patients across three studies were assessed. A mean postoperative coronal balance magnitude of 26.83 mm was calculated compared to the preoperative coronal magnitude of 64.16 mm. Results also showed only four cases of intraoperative or postoperative complications. Moreover, the presented case reported successful KR implementation without any intraoperative complications. KR instrumentation is a safe and effective technique for coronal imbalance correction. The results show favorable outcomes in terms of coronal adjustment and low complication rates. Nevertheless, we caution the fact that further studies are warranted with long-term follow-ups.

Segmented lordotic angles to assess lumbosacral transitional vertebra on EOS

PURPOSE

To test the vertical posterior vertebral angles (VPVA) of the most caudal lumbar segments measured on EOS to identify and classify the lumbosacral transitional vertebra (LSTV).

METHODS

We reviewed the EOS examinations of 906 patients to measure the VPVA at the most caudal lumbar segment (cVPVA) and at the immediately proximal segment (pVPVA), with dVPVA being the result of their difference. Mann-Whitney, Chi-square, and ROC curve statistics were used.

RESULTS

172/906 patients (19%) had LSTV (112 females, mean age: 43 ± 21 years), and 89/172 had type I LSTV (52%), 42/172 type II (24%), 33/172 type III (19%), and 8/172 type IV (5%). The cVPVA and dVPVA in non-articulated patients were significantly higher than those of patients with LSTV, patients with only accessory articulations, and patients with only bony fusion (all p < .001). The cVPVA and dVPVA in L5 sacralization were significantly higher than in S1 lumbarization (p < .001). The following optimal cutoff was found: cVPVA of 28.2° (AUC = 0.797) and dVPVA of 11.1° (AUC = 0.782) to identify LSTV; cVPVA of 28.2° (AUC = 0.665) and dVPVA of 8° (AUC = 0.718) to identify type II LSTV; cVPVA of 25.5° (AUC = 0.797) and dVPVA of - 7.5° (AUC = 0.831) to identify type III-IV LSTV; cVPVA of 20.4° (AUC = 0.693) and dVPVA of - 1.8° (AUC = 0.665) to differentiate type II from III-IV LSTV; cVPVA of 17.9° (AUC = 0.741) and dVPVA of - 4.5° (AUC = 0.774) to differentiate L5 sacralization from S1 lumbarization.

CONCLUSION

The cVPVA and dVPVA measured on EOS showed good diagnostic performance to identify LSTV, to correctly classify it, and to differentiate L5 sacralization from S1 lumbarization.