Considerations for focused surgical intervention in the presence of adult spinal deformity

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.

METHODS

A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence.

RESULTS

Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%.

CONCLUSIONS

Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

Utility of the MISDEF2 Algorithm and Extent of Fusion in Open Adult Spinal Deformity Surgery With Minimum 2-Year Follow-up

Objective

Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.

Methods

A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.

Results

A total of 136 patients met inclusion criteria. Mean follow-up was 46±15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p=0.03) and revision surgery rates (p=0.047). This difference was not seen in class III patients (p>0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p<0.019), comparable revision surgery rates (p=0.27), and better radiographic realignment (p<0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p<0.001).

Conclusion

The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.

Associated lumbar scoliosis does not affect outcomes in patients undergoing focal minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF) for neurogenic symptoms-a minimum 2-year follow-up study

BACKGROUND CONTEXT

There is no current literature comparing outcomes of patients with and without lumbar scoliosis having neurologic symptoms undergoing minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF) technique.

PURPOSE

This study aimed to determine whether associated lumbar scoliosis will result in different clinical, radiological, and operative outcomes in patients undergoing focal MISTLIF for neurogenic symptoms, without specific correction of the scoliosis.

STUDY DESIGN

A retrospective case comparison study from prospectively collected hospital registry data was carried out.

PATIENT SAMPLE

Two hundred and thirty eligible patients were evaluated and divided into two groups: Scoliosis Group (SG; n=57) with Cobb angle >10 degrees on anterioposterior (AP) plain lumbar spine radiographs and Non-Scoliosis Group (NSG; n=173) consisting of the remaining patients.

OUTCOME MEASURES

Clinical outcomes were assessed using the Oswestry Disability Index, the North American Spine Society (NASS) Neurogenic Symptom Score, the NASS Satisfaction with Surgery Rating, the 36-Item Short-Form Health Survey (SF-36), and the Numerical Pain Rating Scale for back and leg pain. Radiological findings included Cobb angle, fusion, implant failure or loosening, and adjacent segment degeneration (ASD).

METHODS

Both groups were compared for demographics, perioperative parameters, complications, clinical, and radiological outcomes. Interobserver agreement (kappa statistics) for measurement of Cobb angle was calculated on all cases of both groups by two authors. Patients were evaluated preoperatively, at 6 months, and 2 years after surgery.

RESULTS

The average follow-up was 2.88±1.47 years in the SG and 2.71±1.34 years in the NSG (p=.444). Differences in mean age (SG: 62.9±10.9 years and NSG: 57.6±13.1 years), estimated related risk of death (SG: 3.05±2.13 and NSG: 2.41±1.74), and gender (female=SG: 87.7% and NSG: 64.2%) were statistically significant (p<.05), whereas race distribution, body mass index |(BMI), spinal levels operated, number of levels operated, bone morphogenetic protein (BMP)-2 use, and type of bone graft were not. Fluoroscopic time, operative time, blood loss, postoperative opioid usage, time to ambulation, and length of hospitalization were similar (p>.05). Preoperative and postoperative clinical outcomes were similar in both groups (p>.05) except SF-36 physical function score, which was found to be significantly higher in the NSG at final follow-up (p<.05). Clinical outcomes scores improved significantly postoperatively (p<.05), and grade 1 fusion (Bridwell classification) was achieved in 93% in the SG and in 93.6% in the NSG (p=.417). Total complications were 11 (19.29%) in the SG and 21 (12.13%) in the NSG (p=.097). De novo ASD was found in 1 case in the SG and in 14 cases in the NSG (p=.124), with 1 case in the NSG requiring further surgery.

CONCLUSION

Associated mild lumbar scoliosis (Cobb angle <30°) does not result in significantly different perioperative, clinical, and radiological outcomes in patients undergoing focal decompression and MISTLIF for neurogenic symptoms.

Extreme lateral interbody fusion for unilateral symptomatic vertical foraminal stenosis

PURPOSE

Asymmetric loss of disc height in adult deformity patients may lead to unilateral vertical foraminal stenosis and radiculopathy. The current study aimed to investigate whether restoration of foraminal height on the symptomatic side using extreme lateral interbody fusion (XLIF) would alleviate unilateral radiculopathy.

METHODS

In a retrospective study, patients with single-level unilateral vertical foraminal stenosis and corresponding radicular pain undergoing XLIF were included. Functional data (visual analog scale (VAS) for buttock, leg and back, as well as Oswestry Disability Index (ODI)) and radiographic measurements (bilateral foraminal height, disc height, segmental coronal Cobb angle and regional lumbar lordosis) were collected preoperatively, postoperatively and at the last follow-up.

RESULTS

Twenty-three patients were included, among whom 61 % had degenerative scoliosis. History of previous surgery at the level of index was present in 43 % of patients. Additional instrumentation was performed in 91 %. The foraminal height on the stenotic side was significantly increased postoperatively (p < 0.001), and remained significantly increased at the last follow-up of 11 ± 3.7 months (p < 0.001). Additionally, VAS buttock and leg on the stenotic side, VAS back and ODI were significantly improved postoperatively and at the last follow-up (p ≤ 0.001 for all parameters). The foraminal height on the stenotic side showed correlation with the VAS leg on the stenotic side, both postoperatively and the last follow-up (r = -0.590; p = 0.013, and r = -0.537; p = 0.022, respectively).

CONCLUSIONS

Single-level XLIF is an effective procedure for treatment of symptomatic unilateral foraminal stenosis leading to radiculopathy. In deformity patients with radicular pain caused by nerve compression at a single level, when not associated with other symptoms attributable to general scoliosis, treatment with single-level XLIF can result in short- and mid-term satisfactory outcome.

Revision Rate After Adult Deformity Surgery

STUDY DESIGN

Epidemiological study.

PURPOSE

To establish the revision rate of adult spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Historically, surgical treatment of adult spinal deformity was limited by inadequate correction and high complication rates. More recently, improved techniques have produced more consistent clinical benefit. However, the need for revision surgery remains a persistent and inadequately defined problem.

METHODS

Patients who had multilevel spinal fusion for adult spinal deformity were identified from a national insurance database containing private payer and Medicare records using International Classification of Diseases, Ninth Revision or Current Procedural Terminology codes from 2005 to 2011. Revision procedures were identified based on codes for spinal instrumentation and fusion.

RESULTS

The Medicare sample included 1,879 patients (1,329 females and 550 males). The revision rate in this cohort was 6% in Year 1 postoperatively, 6% in Year 2, 4% in Year 3, and 3% in Year 4, for a cumulative 19% revision rate. In the private payer database, 803 patients (559 females and 244 males) were identified. Revision rate was 10% in Year 1 postoperatively, 3% in Year 2, 2% in Year 3, and 1% in Year 4, for a cumulative 16% revision rate. Pooling the databases yielded an overall 18% revision rate at 4 years postoperatively. Fewer revisions were noted at 1 year postoperatively in the Medicare sample and the 1-year revision rate was inversely proportional to age across the entire cohort. The revision rate equalized across age groups over time such that no differences were seen at 4 years postoperatively.

CONCLUSIONS

The value of an intervention depends on efficacy, safety, and durability. Despite improvements in technique and clinical outcome, an 18% revision rate at 4 years postoperatively is not sustainable from either a clinical or an economic standpoint. This study establishes a benchmark for the critical effort that is needed to reduce the revision rate in adult spinal deformity surgery.

Adult Lumbar Degenerative Scoliosis 40° or Less: Outcomes of Surgical Treatment With Minimum 2-Year Follow-up

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

To determine the outcomes of operative treatment of adult lumbar degenerative scoliosis (ALDS) with Cobb angles of 40° or less.

SUMMARY OF BACKGROUND DATA

Some ALDS patients have curves less than 40°. Although these curves may not need correction, the curve may alter the treatment paradigm for associated back and leg pain, requiring fusion to achieve adequate decompression and prevent deformity progression.

METHODS

We reviewed hospital records and radiographs of 105 ALDS patients with curves from 10° to 40° who had decompression and instrumented fusion. We collected Oswestry Disability Index (ODI), Short Form-36 Physical (SF36 PCS), Mental Composite Scores (MCS), and back and leg pain scores preoperatively and 2 years postoperatively.

RESULTS

The 105 patients had a mean age of 64.0 years and body mass index of 28.8 kg/m². There were 26 smokers (23%). Preoperative symptoms included both back and leg pain in 94% (mean back pain = 7.8; mean leg pain = 7.0). Mean preoperative Cobb was 22.7° and mean lumbar lordosis was 39.8°. The most common curve apex was L2 (43%) and L3 (39%). An average of 3.0 ± 1.6 levels were decompressed and fused. Mean postoperative Cobb was 17.6° and mean lumbar lordosis was 36.5°. The ODI improved 14.9 points (48.5 vs. 33.6; p < .0001), SF36 PCS improved 6.2 points (27.9 vs. 34.1; p < .0001), and SF36 MCS improved 4.7 points (40.5 vs. 45.1; p < .0001). Back (7.8 vs. 4.1; p < .0001) and leg pain (7.0 vs. 3.1; p < .0001) also improved at 2-year follow-up compared with baseline.

CONCLUSIONS

Many ALDS patients present with problems associated with lumbar degenerative disease rather than severe deformity. and may require decompression for leg pain or neurogenic claudication. Even in patients with limited back pain, fusion is often needed, because decompression alone may result in either inadequate decompression or progression of the deformity. Results of this study indicate that ALDS patients with curves less than 40° benefit from decompression and fusion.

Does prior short-segment surgery for adult scoliosis impact perioperative complication rates and clinical outcome among patients undergoing scoliosis correction?

Object

In many adults with scoliosis, symptoms can be principally referable to focal pathology and can be addressed with short-segment procedures, such as decompression with or without fusion. A number of patients subsequently require more extensive scoliosis correction. However, there is a paucity of data on the impact of prior short-segment surgeries on the outcome of subsequent major scoliosis correction, which could be useful in preoperative counseling and surgical decision making. The authors' objective was to assess whether prior focal decompression or short-segment fusion of a limited portion of a larger spinal deformity impacts surgical parameters and clinical outcomes in patients who subsequently require more extensive scoliosis correction surgery.

Methods

The authors conducted a retrospective cohort analysis with propensity scoring, based on a prospective multicenter deformity database. Study inclusion criteria included a patient age ≥ 21 years, a primary diagnosis of untreated adult idiopathic or degenerative scoliosis with a Cobb angle ≥ 20°, and available clinical outcome measures at a minimum of 2 years after scoliosis surgery. Patients with prior short-segment surgery (< 5 levels) were propensity matched to patients with no prior surgery based on patient age, Oswestry Disability Index (ODI), Cobb angle, and sagittal vertical axis.

Results

Thirty matched pairs were identified. Among those patients who had undergone previous spine surgery, 30% received instrumentation, 40% underwent arthrodesis, and the mean number of operated levels was 2.4 ± 0.9 (mean ± SD). As compared with patients with no history of spine surgery, those who did have a history of prior spine surgery trended toward greater blood loss and an increased number of instrumented levels and did not differ significantly in terms of complication rates, duration of surgery, or clinical outcome based on the ODI, Scoliosis Research Society-22r, or 12-Item Short Form Health Survey Physical Component Score (p > 0.05).

Conclusions

Patients with adult scoliosis and a history of short-segment spine surgery who later undergo more extensive scoliosis correction do not appear to have significantly different complication rates or clinical improvements as compared with patients who have not had prior short-segment surgical procedures. These findings should serve as a basis for future prospective study.

Complications and outcomes after spinal deformity surgery in the elderly: review of the existing literature and future directions

Object

The elderly population (age > 60 years) is the fastest-growing age group in the US. Spinal deformity is a major problem affecting the elderly and, therefore, the demand for surgery for spinal deformity is becoming increasingly prevalent in elderly patients. Much of the literature on surgery for adult deformity focuses on patients who are younger than 60 years, and therefore there is limited information about the complications and outcomes of surgery in the elderly population.

In this study, the authors undertook a review of the literature on spinal deformity surgery in patients older than 60 years. The authors discuss their analysis with a focus on outcomes, complications, discrepancies between individual studies, and strategies for complication avoidance.

Methods

A systematic review of the MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery” and “adult spine deformity surgery.” Exclusion criteria included patient age younger than 60 years. Data on major Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores, patient-reported outcomes, and complications were recorded.

Results

Twenty-two articles were obtained and are included in this review. The mean age was 74.2 years, and the mean follow-up period was 3 years. The mean preoperative ODI was 48.6, and the mean postoperative reduction in ODI was 24.1. The mean preoperative VAS score was 7.7 with a mean postoperative decrease of 5.2. There were 311 reported complications for 815 patients (38%) and 5 deaths for 659 patients (< 1%).

Conclusions

Elderly patient outcomes were inconsistent in the published studies. Overall, most elderly patients obtained favorable outcomes with low operative mortality following surgery for adult spinal deformity.

Clinical outcomes of microscopic decompression for degenerative lumbar foraminal stenosis: a comparison between patients with and without degenerative lumbar scoliosis

We performed microscopic lumbar foraminotomy in all the patients diagnosed with degenerative lumbar foraminal stenosis (DLFS) and retrospectively reviewed the clinical outcomes and the factors influencing them. The preoperative Japanese Orthopaedic Association (JOA) score of 13.8 significantly improved to 21.9 postoperatively. Although leg pain reduced in 44 patients (95.7%) immediately after surgery, it recurred in 9 patients (19.6%). The recurrence frequency was significantly higher and the JOA score improvement ratios significantly lower in patients with degenerative lumbar scoliosis (DLS) than in those without DLS. Even among patients with DLS, those with <3° Cobb angle difference between the supine and standing positions showed satisfactory results, with no recurrence. In conclusion, microscopic lumbar foraminotomy for DLFS produced satisfactory clinical outcomes even in patients with DLS. However, the outcomes were poor in patients with unstable DLS.

Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy

STUDY DESIGN

A retrospective clinical cohort study at a single spine center of patients with degenerative scoliosis and radiculopathy severe enough to require surgery.

OBJECTIVE

To evaluate the functional outcomes of 3 surgeries for degenerative scoliosis with radiculopathy; decompression alone, decompression and limited fusion, and decompression and full curve fusion.

SUMMARY OF BACKGROUND DATA

Although these 3 surgical treatments have all been described for this problem, there exists little information as to what outcomes to expect.

METHODS

The study cohort consisted of 85 patients who met the inclusion criteria of degenerative scoliosis and radiculopathy, who had undergone 1 of the above 3 surgeries, who had not had any previous lumbar spine surgery, who had a minimum follow-up of at least 2 years, and who had filled out preoperative and postoperative functional evaluation forms including SF-36, Oswestry Disability Index, Roland Morris Scores, and a satisfaction questionnaire. Logistic regression analysis was conducted to predict the likelihood of success as related to decompression alone of rotatory olisthetic segments, extent of fusion, and postoperative sagittal balance. Patient demographics including curve magnitude, operative blood loss, length of hospital stay, complications, and need for revision surgeries were analyzed. The patients having decompression alone had the highest mean age (76.4 years) compared to decompression and limited fusion (70.4), and decompression and full curve fusion (62.5).

RESULTS

Cobb scoliosis angles remained unchanged in the 2 groups not having full curve fusion, while the full curve fusion group changed from a mean 39° before surgery to 19° at follow-up. The complication rate was highest (56%) in the full fusion group, was 40% in the limited fusion group, and 10% in the decompression alone group. The overall SF-36 analysis showed significant improvement in bodily pain, social function, role emotional, mental health, and mental composite domains. Oswestry Disability Indexes improved significantly in the decompression alone and limited fusion groups, but not in the full fusion group. In contrast, the satisfaction questionnaire showed the highest success to be in the full-curve fusion group and the lowest in the decompression-only group.Regression analysis revealed that sacrum to curve apex fusions and positive postoperative sagittal imbalance were associated with poor outcomes.

CONCLUSION

Both good and poor results were seen with each of the 3 procedures.

Less Invasive Surgical Correction of Adult Degenerative Scoliosis, Part I

BACKGROUND

Adult scoliosis is a condition with increasing prevalence and medical and socioeconomic importance. Surgery is fraught with a significant complication rate in an elderly multimorbid patient population.

OBJECTIVE

To assess technical feasibility and radiographic results of image-guided less invasive correction of adult degenerative scoliosis.

METHODS

Thirty individuals (age, 64–88 years) with progressive deformity (coronal Cobb angles &gt; 25° and &lt; 85°), intractable back pain, radiculopathy, or neurogenic claudication were treated by less invasive decompression and fusion (unilateral transforaminal interbody cage instrumentation and bilateral facet fusions) with recombinant human bone morphogenetic protein-2, spanning 3 to 8 segments (average, 6 segments), using biplanar fluoroscopy or intraoperative computed tomography (iCT)—based navigation. Accuracy of screw placement, curve correction, and fusion rate were evaluated during a mean follow-up of 19.6 months.

RESULTS

With 415 screws implanted, misplacement (grade II or greater) was not observed, and no implants required revision. Spinal iCT with automated registration required 17.5 ± 8.5 minutes (single registration for all segments); monosegmental bilateral screw insertion required 6.8 ± 3.4 minutes. Mean sagittal (coronal) Cobb angle correction was 44.8 ± 10.7° (31.7 ± 13.7°). Mean lumbar lordosis increased from 8.8 ± 8.9° to −36 ± 6.9°, and sagittal balance was reduced from 31.6 ± 15.2 to 8 ± 8.4 mm. Solid fusion was confirmed in 90% of instrumented segments at 16 months. Average radiation dose to the surgeon was 0.025 mSv for single-level transforaminal lumbar interbody fusion with fluoroscopic guidance vs 0 mSv with iCT navigation.

CONCLUSION

Instrumented correction of adult deformity was significantly facilitated by iCT navigation, eliminating radiation exposure to the surgeon. Intraoperative biplanar CT scout views including pelvis and shoulders allow comprehensive assessment of multiplanar deformity correction. Fusion rates obtained with less invasive access equal those of conventional open technique.

Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis

Object

The goal of this study was to assess the operative outcomes of adult patients with scoliosis who were treated surgically with minimally invasive correction and fusion.

Methods

This was a retrospective study of 28 consecutive patients who underwent minimally invasive correction and fusion over 3 or more levels for adult scoliosis. Hospital and office charts were reviewed for clinical data. Functional outcome data were collected at each visit and at the last follow-up through self-administered questionnaires. All radiological measurements were obtained using standardized computer measuring tools.

Results

The mean age of the patients in the study was 67.7 years (range 22–81 years), with a mean follow-up time of 22 months (range 13–37 months). Estimated blood loss for anterior procedures (transpsoas discectomy and interbody fusions) was 241 ml (range 20–2000 ml). Estimated blood loss for posterior procedures, including L5–S1 transsacral interbody fusion (and in some cases L4–5 and L5–S1 transsacral interbody fusion) and percutaneous screw fixation, was 231 ml (range 50–400 ml). The mean operating time, which was recorded from incision time to closure, was 232 minutes (range 104–448 minutes) for the anterior procedures, and for posterior procedures it was 248 minutes (range 141–370 minutes). The mean length of hospital stay was 10 days (range 3–20 days). The preoperative Cobb angle was 22° (range 15–62°), which corrected to 7° (range 0–22°). All patients maintained correction of their deformity and were noted to have solid arthrodesis on plain radiographs. This was further confirmed on CT scans in 21 patients. The mean preoperative visual analog scale and treatment intensity scale scores were 7.05 and 53.5; postoperatively these were 3.03 and 25.88, respectively. The mean preoperative 36-Item Short Form Health Survey and Oswestry Disability Index scores were 55.73 and 39.13; postoperatively they were 61.50 and 7, respectively. In terms of major complications, 2 patients had quadriceps palsies from which they recovered within 6 months, 1 sustained a retrocapsular renal hematoma, and 1 patient had an unrelated cerebellar hemorrhage.

Conclusions

Minimally invasive surgical correction of adult scoliosis results in mid- to long-term outcomes similar to traditional surgical approaches. Whereas operating times are comparable to those achieved with open approaches, blood loss and morbidity appear to be significantly lower in patients undergoing minimally invasive deformity correction. This approach may be particularly useful in the elderly.

Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up

STUDY DESIGN

Retrospective review of a prospective, multicenter study.

OBJECTIVE

The purpose of this study was to assess the prevalence and severity of leg pain in adults with scoliosis and to assess whether surgery significantly improved leg pain compared with nonoperative management.

SUMMARY OF BACKGROUND DATA

Patients with adult scoliosis characteristically present with pain. The presence of leg pain is an independent predictor of a patient's choice for operative over nonoperative care.

METHODS

Data were extracted from a prospective, multicenter database for adult spinal deformity. At enrollment and follow-up, patients complete the Oswestry Disability Index (ODI) and assessment of leg pain using the numerical rating scale (NRS) score, with 0 and 10 representing no pain and unbearable pain, respectively. Plan for operative or nonoperative treatment was made at enrollment. The vast majority of adult scoliosis patients seen in our surgical clinics have received nonoperative therapies and are being seen for a surgical evaluation. Patients are counseled regarding operative and nonoperative management options and are in general encouraged to maximize nonoperative treatments.

RESULTS

Two hundred eight (64%) of 326 adults with scoliosis had leg pain at presentation (mean NRS score = 4.7). Ninety-six patients with leg pain (46%) were managed operatively and 112 were treated nonoperatively. The operative group had higher baseline mean NRS score for leg pain (5.4 vs. 4.1, P < 0.001) and higher mean ODI (41 vs. 30, P < 0.001). At 2-year follow-up, nonoperative patients had no significant change in ODI or NRS score for leg pain (P = 0.2). In contrast, at 2-year follow-up surgically treated patients had significant improvement in mean NRS score for leg pain (5.4 vs. 2.2, P < 0.001) and ODI (41 vs. 24, P < 0.001). Compared with nonsurgically treated patients, at 2-year follow-up operative patients had lower mean NRS score for leg pain (2.2 vs. 3.8, P < 0.001) and mean ODI (24 vs. 31, P = 0.005).

CONCLUSION

Despite having started with significantly greater leg pain and disability, surgically treated patients at 2-year follow-up had significantly less leg pain and disability than nonoperatively treated patients. Surgical treatment has the potential to provide significant improvement of leg pain in adults with scoliosis.

Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study

STUDY DESIGN

Prospective evaluation of 12 patients undergoing surgery for lumbar degenerative scoliosis.

OBJECTIVE

To assess the feasibility of minimally invasive spine surgery (MIS) techniques in the correction of lumbar degenerative deformity.

SUMMARY OF BACKGROUND DATA

Patient age, comorbidities, and blood loss may be limiting factors when considering surgical correction of lumbar degenerative scoliosis. MIS may allow for significantly less blood loss and tissue disruption than open surgery.

METHODS

Twelve patients underwent circumferential fusion. The age range of these patients was 50 to 85 years (mean of 72.8 y). Of the 12 patients, 7 were men and 5 were women. All patients underwent direct lateral transpsoas approach for discectomy and fusion with polyetheretherketone cage and rh-BMP2. All fusions to the sacrum included L5-S1 fusion with the Trans1 Axial Lumbar Interbody Fusion technique. Posteriorly, multilevel percutaneous screws were inserted using the CD Horizon Longitude system. Radiographs, visual analog scores (VAS), and treatment intensity scores (TIS) were assessed preoperatively and at last postoperative visit. Operative times and estimated blood loss were recorded.

RESULTS

Mean number of segments operated on was 3.64 (range: 2 to 8 segments). Mean blood loss for anterior procedures (transpsoas discectomy/fusion and in some cases L5-S1 interbody fusion) was 163.89 mL (SD 105.41) and for posterior percutaneous pedicle screw fixation (and in some cases L5-S1 interbody fusion) was 93.33 mL (SD 101.43). Mean surgical time for anterior procedures was 4.01 hours (SD 1.88) and for posterior procedures was 3.99 hours (SD 1.19). Mean Cobb angle preoperatively was 18.93 degrees (SD 10.48) and postoperatively was 6.19 degrees (SD 7.20). Mean preoperative VAS score was 7.1; mean preoperative TIS score was 56.0. At mean follow-up of 75.5 days, mean VAS was 4.8; TIS was 28.0.

CONCLUSIONS

A combination of 3 MIS techniques allows for correction of lumbar degenerative scoliosis. Multisegment correction can be performed with less blood loss and morbidity than for open correction.