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Quiceno E, Seaman S, Hussein A, Dholaria N, Pico A, Abdulla E, Bauer IL, Nosova K, Moniakis A, Khan MA, Deaver C, Barbagli G, Prim M, Baaj A. Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series. World Neurosurg 2024; 185:e878-e885. [PMID: 38453010 DOI: 10.1016/j.wneu.2024.02.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians. METHODS This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians. RESULTS Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups. CONCLUSIONS This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.
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Affiliation(s)
- Esteban Quiceno
- Banner University Medical Center Phoenix USA, University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA.
| | - Scott Seaman
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Amna Hussein
- Banner University Medical Center Phoenix USA, University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Nikhil Dholaria
- The University of Arizona College of Medicine - Phoenix USA, Phoenix, Arizona, USA
| | - Annie Pico
- The University of Arizona College of Medicine - Phoenix USA, Phoenix, Arizona, USA
| | - Ebtesam Abdulla
- University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Isabel L Bauer
- The University of Arizona College of Medicine - Phoenix USA, Phoenix, Arizona, USA
| | - Kristin Nosova
- University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | | | - Monis Ahmed Khan
- University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Courtney Deaver
- University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Giovanni Barbagli
- University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Michael Prim
- Banner University Medical Center Phoenix USA, University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
| | - Ali Baaj
- Banner University Medical Center Phoenix USA, University of Arizona Department of Neurosurgery, Phoenix, Arizona, USA
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Pham MH, Hernandez NS, Stone LE. Preoperative Robotics Planning Facilitates Complex Construct Design in Robot-Assisted Minimally Invasive Adult Spinal Deformity Surgery-A Preliminary Experience. J Clin Med 2024; 13:1829. [PMID: 38610594 PMCID: PMC11012283 DOI: 10.3390/jcm13071829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: The correction of adult spinal deformity (ASD) can require long, complex constructs with multiple rods which traverse important biomechanical levels to achieve multi-pelvic fixation. Minimally invasive (MIS) placement of these constructs has historically been difficult. Advanced technologies such as spinal robotics platforms can facilitate the design and placement of these constructs and further enable these surgical approaches in MIS deformity surgery. (2) Methods: A retrospective study was performed on a series of ASD patients undergoing MIS deformity correction with ≥eight fusion levels to the lower thoracic spine with preoperative robotic construct planning and robot-assisted pedicle screw placement. (3) Results: There were 12 patients (10 female, mean age 68.6 years) with a diagnosis of either degenerative scoliosis (8 patients) or sagittal imbalance (4 patients). All underwent preoperative robotic planning to assist in MIS robot-assisted percutaneous or transfascial placement of pedicle and iliac screws with multiple-rod constructs. Mean operative values per patient were 9.9 levels instrumented (range 8-11), 3.9 interbody cages (range 2-6), 3.3 iliac fixation points (range 2-4), 3.3 rods (range 2-4), 18.7 screws (range 13-24), estimated blood loss 254 cc (range 150-350 cc), and operative time 347 min (range 242-442 min). All patients showed improvement in radiographic sagittal, and, if applicable, coronal parameters. Mean length of stay was 5.8 days with no ICU admissions. Ten patients ambulated on POD 1 or 2. Of 224 screws placed minimally invasively, four breaches were identified on intraoperative CT and repositioned (three lateral, one medial) for a robot-assisted screw accuracy of 98.2%. (4) Conclusions: Minimally invasive long-segment fixation for adult spinal deformity surgery has historically been considered laborious and technically intensive. Preoperative robotics planning facilitates the design and placement of even complex multi-rod multi-pelvic fixation for MIS deformity surgery.
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Affiliation(s)
- Martin H. Pham
- Department of Neurosurgery, UC San Diego School of Medicine, University of California, San Diego, CA 92037, USA (L.E.S.)
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Bassani R, Galvain T, Battaglia S, Maheswaran H, Wright G, Kambli A, Piemontese A. Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:13-24. [PMID: 38259876 PMCID: PMC10802124 DOI: 10.2147/ceor.s445141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective. Methods The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively. Results Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020). Conclusion Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.
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Affiliation(s)
- Roberto Bassani
- II Spinal Surgery Unit, IRCCS Galeazzi-Sant’Ambrogio Hospital, Milano, Italy
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Yi H, Chen H, Lian P, Ji X, Cunningham ME, Boachie-Adjei O, Kim HJ, Ross T, Nemani VM, Xia H. Trans-sacral interbody fixation in long fusions to the sacrum for adult spinal deformity: complications and fusion rates at minimum two years follow-up. INTERNATIONAL ORTHOPAEDICS 2024; 48:193-200. [PMID: 37620580 DOI: 10.1007/s00264-023-05951-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE This study aims to investigate the fusion rate and complications associated with trans-sacral interbody fusion (TSIF) in long fusions to the sacrum for adult spinal deformity (ASD) over a two year follow-up period. Potential predictor variables associated with pseudarthrosis were also examined. METHODS A retrospective clinical review was conducted on a consecutive series of ASD patients who underwent long fusions to the sacrum, with TSIF performed as a same-day or staged procedure. Patient demographics, bone mineral density, operative details, perioperative and late complications, and fusion rates were reviewed. Univariate analysis was used to identify the risk factors associated with pseudarthrosis. RESULTS The study included 43 patients with an average age of 55.3 ± 8.9 years. The perioperative complication rate was 28%, with 12% of the complications directly related to TSIF. The late complication rate was 33%, with 16% related to TSIF. The most common complications were pseudarthrosis (14%) and postoperative ileus (7%). The overall radiographic fusion rate at two years was 86%. Univariate analysis revealed that revision surgery was significantly associated with pseudarthrosis (p = 0.027). Over the follow-up period, patients who underwent TSIF during long posterior fusions to the sacrum showed improvement in overall SRS scores, ODI scores, and SF-36 physical health and mental health (p < 0.05). CONCLUSION TSIF is a relatively safe and minimally invasive method for achieving interbody fusion at the lumbosacral junction in the treatment of ASD, with acceptable fusion rates and a low complication rate. However, TSIF is not recommended for revision reconstruction in ASD.
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Affiliation(s)
- Honglei Yi
- People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, Guangdong, China.
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.
| | - Hu Chen
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Peirong Lian
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Xinran Ji
- Chinese PLA General Hospital, Beijing, China
| | | | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, 10021, USA
| | - Thomas Ross
- Hospital for Special Surgery, New York, NY, 10021, USA
| | - Venu M Nemani
- Hospital for Special Surgery, New York, NY, 10021, USA
| | - Hong Xia
- People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, Guangdong, China.
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China.
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Neuman BJ, Wang KY, Harris AB, Raad M, Hostin RA, Protopsaltis TS, Ames CP, Passias PG, Gupta MC, Klineberg EO, Hart R, Bess S, Kebaish KM. Return to work after adult spinal deformity surgery. Spine Deform 2023; 11:197-204. [PMID: 36219391 DOI: 10.1007/s43390-022-00552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/02/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work. METHODS Using a multicenter database of patients treated surgically for ASD from 2008 to 2015, we identified 188 patients (mean age 51 ± 15 years) who self-reported as employed preoperatively and had 2-year follow-up. Per the ASD-Surgical and Radiographical Invasiveness Index (ASD-SR), 118 patients (63%) underwent high-invasiveness (HI) surgery (ASD-SR ≥ 100) and 70 (37%) had low-invasiveness (LI) surgery (ASD-SR < 100). Patients who self-reported ≥ 75% normal level of work/school activity were considered to be working full time. Chi-squared and Fisher exact tests were used to compare categorical variables (α = .05). RESULTS Preoperatively, 69% of employed patients worked full time. Postoperatively, 15% of employed patients were full time at 6 weeks, 70% at 6 months, 83% at 1 year, and 84% at 2 years. Percentage of employed patients working full time at 2 years was greater than preoperatively (p < .001); percentage of patients returning to full time at 6 weeks was lower in the HI (5%) than in the LI group (19%) (p = .03), a difference not significant at later points. CONCLUSIONS Most adults returned to full-time work after ASD surgery. A smaller percentage of patients in the HI group than in the LI group returned to full-time work at 6 weeks. Patients employed full time preoperatively will likely return to full-time employment after ASD surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - Christopher P Ames
- Department of Neurologic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.
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Minimally invasive versus open surgery for patients undergoing intradural extramedullary spinal cord tumor resection: A systematic review and meta-analysis. Clin Neurol Neurosurg 2022; 214:107176. [DOI: 10.1016/j.clineuro.2022.107176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/18/2022]
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7
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Chou D, Lafage V, Chan AY, Passias P, Mundis GM, Eastlack RK, Fu KM, Fessler RG, Gupta MC, Than KD, Anand N, Uribe JS, Kanter AS, Okonkwo DO, Bess S, Shaffrey CI, Kim HJ, Smith JS, Sciubba DM, Park P, Mummaneni PV. Patient outcomes after circumferential minimally invasive surgery compared with those of open correction for adult spinal deformity: initial analysis of prospectively collected data. J Neurosurg Spine 2022; 36:203-214. [PMID: 34560634 DOI: 10.3171/2021.3.spine201825] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Circumferential minimally invasive spine surgery (cMIS) for adult scoliosis has become more advanced and powerful, but direct comparison with traditional open correction using prospectively collected data is limited. The authors performed a retrospective review of prospectively collected, multicenter adult spinal deformity data. The authors directly compared cMIS for adult scoliosis with open correction in propensity-matched cohorts using health-related quality-of-life (HRQOL) measures and surgical parameters. METHODS Data from a prospective, multicenter adult spinal deformity database were retrospectively reviewed. Inclusion criteria were age > 18 years, minimum 1-year follow-up, and one of the following characteristics: pelvic tilt (PT) > 25°, pelvic incidence minus lumbar lordosis (PI-LL) > 10°, Cobb angle > 20°, or sagittal vertical axis (SVA) > 5 cm. Patients were categorized as undergoing cMIS (percutaneous screws with minimally invasive anterior interbody fusion) or open correction (traditional open deformity correction). Propensity matching was used to create two equal groups and to control for age, BMI, preoperative PI-LL, pelvic incidence (PI), T1 pelvic angle (T1PA), SVA, PT, and number of posterior levels fused. RESULTS A total of 154 patients (77 underwent open procedures and 77 underwent cMIS) were included after matching for age, BMI, PI-LL (mean 15° vs 17°, respectively), PI (54° vs 54°), T1PA (21° vs 22°), and mean number of levels fused (6.3 vs 6). Patients who underwent three-column osteotomy were excluded. Follow-up was 1 year for all patients. Postoperative Oswestry Disability Index (ODI) (p = 0.50), Scoliosis Research Society-total (p = 0.45), and EQ-5D (p = 0.33) scores were not different between cMIS and open patients. Maximum Cobb angles were similar for open and cMIS patients at baseline (25.9° vs 26.3°, p = 0.85) and at 1 year postoperation (15.0° vs 17.5°, p = 0.17). In total, 58.3% of open patients and 64.4% of cMIS patients (p = 0.31) reached the minimal clinically important difference (MCID) in ODI at 1 year. At 1 year, no differences were observed in terms of PI-LL (p = 0.71), SVA (p = 0.46), PT (p = 0.9), or Cobb angle (p = 0.20). Open patients had greater estimated blood loss compared with cMIS patients (1.36 L vs 0.524 L, p < 0.05) and fewer levels of interbody fusion (1.87 vs 3.46, p < 0.05), but shorter operative times (356 minutes vs 452 minutes, p = 0.003). Revision surgery rates between the two cohorts were similar (p = 0.97). CONCLUSIONS When cMIS was compared with open adult scoliosis correction with propensity matching, HRQOL improvement, spinopelvic parameters, revision surgery rates, and proportions of patients who reached MCID were similar between cohorts. However, well-selected cMIS patients had less blood loss, comparable results, and longer operative times in comparison with open patients.
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Affiliation(s)
- Dean Chou
- 1Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, New York University, New York, New York
| | - Alvin Y Chan
- 3Department of Neurosurgery, University of California, Irvine, Orange, California
| | - Peter Passias
- 2Department of Orthopedic Surgery, New York University, New York, New York
| | - Gregory M Mundis
- 4Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Robert K Eastlack
- 5Department of Orthopedic Surgery, Scripps Health, La Jolla, California
| | - Kai-Ming Fu
- 6Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | | | - Munish C Gupta
- 8Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Khoi D Than
- 9Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Neel Anand
- 10Department of Orthopedic Surgery, Cedars-Sinai, Los Angeles, California
| | - Juan S Uribe
- 11Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adam S Kanter
- 12Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 12Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shay Bess
- 13Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Han Jo Kim
- 15Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York
| | - Justin S Smith
- 16Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Daniel M Sciubba
- 17Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
| | - Paul Park
- 18Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Praveen V Mummaneni
- 1Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Lafage R, Fong AM, Klineberg E, Smith JS, Bess S, Shaffrey CI, Burton D, Kim HJ, Elysee J, Mundis GM, Passias P, Gupta M, Hostin R, Schwab F, Lafage V. Complication rate evolution across a 10-year enrollment period of a prospective multicenter database. J Neurosurg Spine 2021:1-11. [PMID: 35349975 DOI: 10.3171/2021.10.spine21795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database. METHODS This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups' demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period. RESULTS A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008-2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014-2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016. CONCLUSIONS Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Alex M Fong
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 2Department of Orthopedic Surgery, School of Medicine, University of California, Davis, California
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Shay Bess
- 4Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Douglas Burton
- 6Department of Orthopedics, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Jonathan Elysee
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter Passias
- 8Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Munish Gupta
- 9Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri; and
| | - Richard Hostin
- 10Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Frank Schwab
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Bakaloudis G, Gioia G, Corti G, Isidori A, Ramieri A. The role of less invasive surgery in the treatment of adolescent idiopathic scoliosis and adult spinal deformity. ORTHOPAEDICS AND TRAUMA 2021. [DOI: 10.1016/j.mporth.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Pham MH, Shah VJ, Diaz-Aguilar LD, Osorio JA, Lehman RA. Minimally invasive multiple-rod constructs with robotics planning in adult spinal deformity surgery: a case series. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:95-103. [PMID: 34599407 DOI: 10.1007/s00586-021-06980-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/08/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Multiple-rod constructs (MRCs) are often used in deformity correction for increased stability and rigidity. There are currently no reports showing minimally invasive placement of MRCs in adult deformity surgery and its technical feasibility through preoperative software planning. METHODS Data were collected retrospectively from medical records of six consecutive patients who underwent minimally invasive MRCs with robotics planning by a single surgeon at an academic center between March-August 2020. RESULTS A total of six patients (4 females, mean age 69.7 years) underwent minimally invasive long-segment (6 +) posterior fixation with multiple rods (3 +) using the Mazor X Stealth Edition robotics platform. Average follow-up was 14.3 months. All patients underwent oblique lumbar interbody fusion (OLIF) as a first stage, followed by second stage posterior fixation in the same day. The mean number of levels posteriorly instrumented was 8.8. One patient underwent 3 rod fixation (1 iliac, 2 S2AI) and 5 patients underwent quad rod fixation (2 iliac, 2 S2AI). The mean time to secure all rods was 8 min 36 s. Mean improvement in spinopelvic parameters was -4.9 cm sagittal vertical axis, 18.0° lumbar lordosis, and -10.7° pelvic tilt with an average pelvic incidence of 62.5°. Estimated blood loss (EBL) was 100-250 cc with no blood transfusions, and all but one patient ambulated on postoperative day 1 or 2. CONCLUSION Spinal robotics brings us into a new era of minimally invasive construct design. To our knowledge, this is the first description of the technical feasibility of MRCs in minimally invasive adult spinal deformity surgery.
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Affiliation(s)
- Martin H Pham
- Department of Neurosurgery, UC San Diego Health, University of California San Diego School of Medicine, 9300 Campus Point Drive, MC7893, La Jolla, San Diego, CA, 92037, USA.
| | - Vrajesh J Shah
- Department of Neurosurgery, UC San Diego Health, University of California San Diego School of Medicine, 9300 Campus Point Drive, MC7893, La Jolla, San Diego, CA, 92037, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurosurgery, UC San Diego Health, University of California San Diego School of Medicine, 9300 Campus Point Drive, MC7893, La Jolla, San Diego, CA, 92037, USA
| | - Joseph A Osorio
- Department of Neurosurgery, UC San Diego Health, University of California San Diego School of Medicine, 9300 Campus Point Drive, MC7893, La Jolla, San Diego, CA, 92037, USA
| | - Ronald A Lehman
- Department of Orthopedic Surgery, The Daniel and Jane Och Spine Hospital at NewYork-Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Morse KW, Otremski H, Page K, Widmann RF. Less Invasive Pediatric Spinal Deformity Surgery: The Case for Robotic-Assisted Placement of Pedicle Screws. HSS J 2021; 17:317-325. [PMID: 34539273 PMCID: PMC8436344 DOI: 10.1177/15563316211027828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Pediatric spinal deformity involves a complex 3-dimensional (3D) deformity that increases the risk of pedicle screw placement due to the close proximity of neurovascular structures. To increase screw accuracy, improve patient safety, and minimize surgical complications, the placement of pedicle screws is evolving from freehand techniques to computer-assisted navigation and to the introduction of robotic-assisted placement. Purpose: The aim of this review was to review the current literature on the use of robotic navigation in pediatric spinal deformity surgery to provide both an error analysis of these techniques and to provide recommendations to ensure its safe application. Methods: A narrative review was conducted in April 2021 using the MEDLINE (PubMed) database. Studies were included if they were peer-reviewed retrospective or prospective studies, included pediatric patients, included a primary diagnosis of pediatric spine deformity, utilized robotic-assisted spinal surgery techniques, and reported thoracic or lumbar pedicle screw breach rates or pedicle screw malpositioning. Results: In the few studies published on the use of robotic techniques in pediatric spinal deformity surgery, several found associations between the technology and increased rates of screw placement accuracy, reduced rates of breach, and minimal complications. All were retrospective studies. Conclusions: Current literature is of a low level of evidence; nonetheless, the findings suggest the accuracy and safety of robotic-assisted spinal surgery in pediatric pedicle screw placement. The introduction of robotics may drive further advances in less invasive pediatric spinal deformity surgery. Further study is warranted.
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Affiliation(s)
- Kyle W. Morse
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Hila Otremski
- Pediatric Orthopedic Department, Dana Dwek Children’s Hospital, Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kira Page
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Roger F. Widmann
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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12
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Lovecchio F, Elysee JC, Lafage R, Varghese J, Bannwarth M, Schwab F, Lafage V, Kim HJ. The impact of preoperative supine radiographs on surgical strategy in adult spinal deformity. J Neurosurg Spine 2021; 36:71-77. [PMID: 34507286 DOI: 10.3171/2021.3.spine201739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/04/2021] [Indexed: 11/06/2022]
Abstract
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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13
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Lovecchio FC, Vaishnav AS, Steinhaus ME, Othman YA, Gang CH, Iyer S, McAnany SJ, Albert TJ, Qureshi SA. Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion? Neurosurg Focus 2021; 49:E17. [PMID: 32871566 DOI: 10.3171/2020.6.focus20393] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology. METHODS The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted. RESULTS A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016). CONCLUSIONS Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.
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Affiliation(s)
| | | | | | | | | | - Sravisht Iyer
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Steven J McAnany
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Todd J Albert
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
| | - Sheeraz A Qureshi
- 1Hospital for Special Surgery, New York, New York.,3Weill Cornell Medical College, New York, New York
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14
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Wewel JT, Ozpinar A, Walker CT, Okonkwo DO, Kanter AS, Uribe JS. Safety of lateral access to the concave side for adult spinal deformity. J Neurosurg Spine 2021; 35:100-104. [PMID: 33990079 DOI: 10.3171/2020.10.spine191270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/09/2020] [Indexed: 11/06/2022]
Abstract
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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Affiliation(s)
- Joshua T Wewel
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Alp Ozpinar
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Corey T Walker
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - David O Okonkwo
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan S Uribe
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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15
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Boddapati V, Lombardi JM, Urakawa H, Lehman RA. Intraoperative image guidance for the surgical treatment of adult spinal deformity. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:91. [PMID: 33553384 PMCID: PMC7859785 DOI: 10.21037/atm-20-2765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Operative management of adult spinal deformity (ASD) has been increasing in recent years secondary to an aging society. The advance of intraoperative image guidance, such as the development of navigation and robotics systems has contributed to the growth and safety of ASD surgery. Currently, intraoperative image guidance is mainly used for pedicle screw placement and the evaluation of alignment correction in ASD surgery. Though it is expected that the use of navigation and robotics would result in increasing pedicle screw accuracy as reported in other spine surgeries, there are no well-powered studies specifically focusing on ASD surgery. Currently, deformity correction relies heavily on preoperative planning, however, a few studies have shown the possibility that intraoperative image modalities may accurately predict postoperative spinopelvic parameters. Future developments of intraoperative image guidance are needed to overcome the remaining challenges in ASD surgery such as radiation exposure to patient and surgeon. More novel imaging modalities may result in evolution in ASD surgery. Overall there is a paucity of literature focusing on intraoperative image guidance in ASD surgery, therefore, further studies are warranted to assess the efficacy of intraoperative image guidance in ASD surgery. This narrative review sought to provide the current role and future perspectives of intraoperative image guidance focusing on ASD surgery.
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Affiliation(s)
- Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | | | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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16
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Park P, Than KD, Mummaneni PV, Nunley PD, Eastlack RK, Uribe JS, Wang MY, Le V, Fessler RG, Okonkwo DO, Kanter AS, Anand N, Chou D, Fu KMG, Haddad AF, Shaffrey CI, Mundis GM. Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study. J Neurosurg Spine 2020; 33:601-606. [PMID: 32559745 DOI: 10.3171/2020.4.spine20169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD. METHODS The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection. RESULTS Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence-lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection. CONCLUSIONS Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.
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Affiliation(s)
- Paul Park
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Khoi D Than
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Praveen V Mummaneni
- 3Department of Neurosurgery, University of California, San Francisco, California
| | | | - Robert K Eastlack
- 5Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Juan S Uribe
- 6Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael Y Wang
- 7Department of Neurosurgery, University of Miami, Florida
| | - Vivian Le
- 3Department of Neurosurgery, University of California, San Francisco, California
| | - Richard G Fessler
- 8Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - David O Okonkwo
- 9Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- 9Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dean Chou
- 3Department of Neurosurgery, University of California, San Francisco, California
| | - Kai-Ming G Fu
- 11Department of Neurosurgery, Cornell Medical Center, New York, New York
| | - Alexander F Haddad
- 12School of Medicine, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 13Departments of Orthopaedic Surgery and Neurosurgery, Duke University, Durham, North Carolina
| | - Gregory M Mundis
- 5Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
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