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Bartlett AM, Dibble CF, Sykes DAW, Drossopoulos PN, Wang TY, Crutcher CL, Than KD, Bhomwick DA, Shaffrey CI, Abd-El-Barr MM. Early Experience with Prone Lateral Interbody Fusion in Deformity Correction: A Single-Institution Experience. J Clin Med 2024; 13:2279. [PMID: 38673552 PMCID: PMC11051569 DOI: 10.3390/jcm13082279] [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: 02/26/2024] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Lateral spine surgery offers effective minimally invasive deformity correction, but traditional approaches often involve separate anterior, lateral, and posterior procedures. The prone lateral technique streamlines this process by allowing single-position access for lateral and posterior surgery, potentially benefiting from the lordosing effect of prone positioning. While previous studies have compared prone lateral to direct lateral for adult degenerative diseases, this retrospective review focuses on the outcomes of adult deformity patients undergoing prone lateral interbody fusion. Methods: Ten adult patients underwent single-position prone lateral surgery for spine deformity correction, with a mean follow-up of 18 months. Results: Results showed significant improvements: sagittal vertical axis decreased by 2.4 cm, lumbar lordosis increased by 9.1°, pelvic tilt improved by 3.3°, segmental lordosis across the fusion construct increased by 12.2°, and coronal Cobb angle improved by 6.3°. These benefits remained consistent over the follow-up period. Correlational analysis showed a positive association between improvements in PROs and SVA and SL. When compared to hybrid approaches, prone lateral yielded greater improvements in SVA. Conclusions: Prone lateral surgery demonstrated favorable outcomes with reasonable perioperative risks. However, further research comparing this technique with standard minimally invasive lateral approaches, hybrid, and open approaches is warranted for a comprehensive evaluation.
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Affiliation(s)
- Alyssa M. Bartlett
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | - Christopher F. Dibble
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - David A. W. Sykes
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Timothy Y. Wang
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Khoi D. Than
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | - Deb A. Bhomwick
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Muhammad M. Abd-El-Barr
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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Shekouhi N, Tripathi S, Goel VK, Theologis AA. Biomechanical evaluation of multi-rod constructs to stabilize an S1 pedicle subtraction osteotomy (PSO): a finite element analysis. Spine Deform 2024; 12:313-322. [PMID: 38032447 PMCID: PMC10866773 DOI: 10.1007/s43390-023-00784-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/21/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE To develop and validate a finite element (FE) model of a sacral pedicle subtraction osteotomy (S1-PSO) and to compare biomechanical properties of various multi-rod configurations to stabilize S1-PSOs. METHODS A previously validated FE spinopelvic model was used to develop a 30° PSO at the sacrum. Five multi-rod techniques spanning the S1-PSO were made using 4 iliac screws and a variety of primary rods (PR) and accessory rods (AR; lateral: Lat-AR or medial: Med-AR). All constructs, except one, utilized a horizontal rod (HR) connecting the iliac bolts to which PRs and Med-ARs were connected. Lat-ARs were connected to proximal iliac bolts. The simulation was performed in two steps with the acetabula fixed. For each model, PSO ROM and maximum stress on the PRs, ARs, and HRs were recorded and compared. The maximum stress on the L5-S1 disc and the PSO forces were captured and compared. RESULTS Highest PSO ROMs were observed for 4-Rods (HR + 2 Med-AR). Constructs consisting of 5-Rods (HR + 2 Lat-ARs + 1 Med-AR) and 6-Rods (HR + 2 Lat-AR + 2 Med-AR) had the lowest PSO ROM. The least stress on the primary rods was seen with 6-Rods, followed by 5-Rods and 4-Rods (HR + 2 Lat-ARs). Lowest PSO forces and lowest L5-S1 disc stresses were observed for 4-Rod (Lat-AR), 5-Rod, and 6-Rod constructs, while 4-Rods (HR + Med-AR) had the highest. CONCLUSION In this first FE analysis of an S1-PSO, the 4-Rod construct (HR + Med-AR) created the least rigid environment and highest PSO forces anteriorly. While 5- and 6-Rods created the stiffest constructs and lowest stresses on the primary rods, it also jeopardized load transfer to the anterior column, which may not be favorable for healing anteriorly. A balance between the construct's rigidity and anterior load sharing is essential.
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Affiliation(s)
- Niloufar Shekouhi
- Engineering Center for Orthopedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
| | - Sudharshan Tripathi
- Engineering Center for Orthopedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
| | - Vijay K Goel
- Engineering Center for Orthopedic Research Excellence (E-CORE), Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
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Babu JM, Wang KY, Jami M, Durand WM, Neuman BJ, Kebaish KM. Sarcopenia as a Risk Factor for Complications Following Pedicle Subtraction Osteotomy. Clin Spine Surg 2023; 36:190-194. [PMID: 37264520 DOI: 10.1097/bsd.0000000000001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 01/25/2023] [Indexed: 06/03/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The objective was to determine if sarcopenia is an independent risk factor for complications in adult spinal deformity (ASD) patients undergoing pedicle subtraction osteotomy (PSO) and define categories of complication risk by sarcopenia severity. SUMMARY OF BACKGROUND DATA Sarcopenia is linked to morbidity and mortality in several orthopedic procedures. Data concerning sarcopenia in ASD surgery is limited, particularly with respect to complex techniques performed such as PSO. With the high surgical burden of PSOs, appropriate patient selection is critical for minimizing complications. METHODS We identified 73 ASD patients with lumbar CT/MRI scans who underwent PSO with spinal fusion ≥5 levels at a tertiary care center from 2005 to 2014. Sarcopenia was assessed by the psoas-lumbar vertebral index (PLVI). Using stratum-specific likelihood ratio analysis, patients were separated into 3 sarcopenia groups by complication risk. The primary outcome measure was any 2-year complication. Secondary outcome measures included intraoperative blood loss and length of stay. RESULTS The mean PLVI was 0.84±0.28, with 47% of patients having complications. Patients with a complication had a 27% lower PLVI on average than those without complications (0.76 vs. 0.91, P=0.021). Stratum-specific likelihood ratio analysis produced 3 complication categories: 32% complication rate for PLVI ≥ 0.81; 61% for PLVI 0.60-0.80; and 69% for PLVI < 0.60. Relative to patients with PLVI ≥ 0.81, those with PLVI 0.60-0.80 and PLVI < 0.60 had 3.2× and 4.3× greater odds of developing a complication (P<0.05). For individual complications, patients with PLVI < 1.0 had a significantly higher risk of proximal junctional kyphosis (34% vs. 0%, P=0.022), while patients with PLVI < 0.8 had a significantly higher risk of wound infection (12% vs. 0%, P=0.028) and dural tear (14% vs. 0%, P=0.019). There were no significant associations between sarcopenia, intraoperative blood loss, and length of stay. CONCLUSIONS The increasing severity of sarcopenia is associated with a significantly and incrementally increased risk of complications following ASD surgery that require PSO. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jacob M Babu
- Illinois Bone & Joint Institute, 720 Florsheim Drive, Libertyville, IL
| | - Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD
| | - Meghana Jami
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD
| | - Wesley M Durand
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD
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Lumbar Lordosis Correction With Transforaminal Lumbar Interbody Fusion in Adult Spinal Deformity Patients with Minimum 2-Year Follow-up. World Neurosurg 2022; 167:e295-e302. [PMID: 35953034 DOI: 10.1016/j.wneu.2022.08.003] [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: 05/08/2022] [Revised: 07/31/2022] [Accepted: 08/01/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the degree of lumbar lordosis (LL) correction possible via transforaminal lumbar interbody fusion (TLIF) in adult spinal deformity patients. METHODS A retrospective chart review identified patients ≥18 years of age with severe positive sagittal balance defined by the SRS-Schwab classification: pelvic incidence to LL mismatch >20°, sagittal vertical axis >9.5cm, and/or pelvic tilt >30°. All patients had surgery between 2013 to 2018 with a TLIF at L4-L5 and/or L5-S1 by the senior author (J.L.F.) with ≥2-years follow-up. RESULTS Sixty-one patients (18 men, 43 women) with 85 TLIFs were included with an average age of 66 years and average follow-up of 50 months. Average lumbar lordosis (L1-S1) improved from 27° preoperative to 48° postoperative and 45° at 2-year follow-up (P < 0.001). Average segmental lordosis at L4-L5 TLIF sites improved from 3° preoperative to 13° postoperative and persisted at 2-year follow-up (P < 0.001). Segmental lordosis at L5-S1 TLIF sites improved from 7° preoperative to 21° postoperative and 20° at 2-year follow-up (P < 0.001). Seventeen of the TLIFs (20%) had >20° of segmental lordosis improvement at long-term follow-up. The rate of revision surgery for pseudoarthrosis at the TLIF level was 5%. CONCLUSIONS Significant lordosis correction can be achieved through an open TLIF in patients with severe positive sagittal balance when utilizing meticulous deformity correction techniques, avoiding the added morbidity of an anterior approach or a 3-column osteotomy.
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Alvarez Reyes A, Jack AS, Hurlbert RJ, Ramey WL. Complications in the Elderly Population Undergoing Spinal Deformity Surgery: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1934-1942. [PMID: 35220801 PMCID: PMC9609511 DOI: 10.1177/21925682221078251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Systematic Review and Meta-Analysis. OBJECTIVES The elderly have an increased risk of perioperative complications for Adult Spinal Deformity (ASD) corrections. Stratification of these perioperative complications based on risk type and specific risk factors, however, remain unclear. This paper will systematically review perioperative risk factors in the elderly undergoing ASD correction stratified by type: medical, implant-related, proximal junctional kyphosis (PJK), and need for revision surgery. METHODS A systematic review was performed using the PRISMA guidelines. A query of PubMed was performed to identify publications pertinent to ASD in the elderly. Publications included in this review focused on patients ≥65 years old who underwent operative management for ASD to assess for risk factors of perioperative complications. RESULTS A total of 734 unique citations were screened resulting in ten included articles for this review. Pooled incidence of perioperative complications included medical complications (21%), implant-related complications (16%), PJK (29%), and revision surgery (13%). Meta-analysis calculated greater preoperative PT (WMD 2.66; 95% Cl .36-4.96; P = .02), greater preoperative SVA (WMD 2.24; 95% Cl .62-3.86; P = .01), and greater postoperative SVA (WMD .97; 95% Cl .03-1.90; P = .04) to significantly correlate with development of PJK with no evidence of publication bias or concerns in study heterogeneity. CONCLUSIONS There is a paucity of literature describing perioperative complications in the elderly following ASD surgery. Appropriate understanding of modifiable risk factors for the development of medical and implant-related complications, proximal junctional kyphosis, and revision surgeries presents an opportunity to decrease morbidity and improve patient outcomes.
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Affiliation(s)
- Angelica Alvarez Reyes
- Department of Neurosurgery, Banner University of Arizona Medical Center -
Tucson, Tucson AZ, USA
| | - Andrew S. Jack
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - R. John Hurlbert
- Department of Neurosurgery, Banner University of Arizona Medical Center -
Tucson, Tucson AZ, USA
| | - Wyatt L. Ramey
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, USA,Wyatt L. Ramey, Department of Neurosurgery, Houston
Methodist Hospital, 6565 Fannin St, Houston, TX 77030-2707, USA.
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Safaee MM, Scheer JK, Lau D, Fury M, Deviren V, Ames CP. Sacral Pedicle Subtraction Osteotomy for Treatment of High-Grade Spondylolisthesis: A Technical Note and Review of the Literature. Oper Neurosurg (Hagerstown) 2022; 23:e84-e90. [PMID: 35838456 DOI: 10.1227/ons.0000000000000251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/24/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Lumbosacral deformities are caused by high-grade spondylolisthesis, fractures, iatrogenic flat back, and other etiologies. The S1 pedicle subtraction osteotomy (PSO) can facilitate reduction of spondylolisthesis and lower the pelvic incidence. There are limited reports on the indications and outcomes of this technique. OBJECTIVE To present a technical description and literature review of the S1 PSO with video summary. METHODS This was a retrospective review of a single case to highlight the use of S1 PSO for the treatment of high-grade spondylolisthesis. A literature review was performed in accordance with STROBE guidelines. RESULTS A 47-year-old woman presented with back and right leg pain related to grade 4 spondylolisthesis at L5-S1 with sagittal imbalance and lumbosacral kyphosis. She was taken for an L2-pelvis instrumented fusion with S1 PSO. Three days later, she was taken for an L4-5 and L5-S1 anterior lumbar interbody fusion with the L5-S1 segmental plate. Her postoperative course was notable for right foot drop that resolved in 6 weeks. Postoperative x-rays showed successful reduction of spondylolisthesis with normal alignment and sagittal balance. Based on 6 studies involving 22 true sacral PSOs in the literature, the procedure carries a 27% risk of neurological deficit, typically in the form of L5 palsy. CONCLUSION The S1 PSO is a technically challenging operation that has a unique role in the treatment of high-grade spondylolisthesis. It carries a significant risk of L5 palsy and should be reserved for surgeons with experience performing complex 3-column osteotomies.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Darryl Lau
- Department of Neurological Surgery, New York University, New York, New York, USA
| | - Marissa Fury
- Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA.,Department of Orthopedic Surgery, University of California, San Francisco (UCSF), San Francisco, California, USA
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