Restoration of the sagittal profile according to the Roussouly classification reduces mechanical complications and revision surgery in older patients undergoing surgery for adult spinal deformity (ASD)

PURPOSE

The mechanical complications related to ASD remain a concern due to their morbidity and associated revision surgery. Restoration of each patient's Roussouly profile may reduce these. Our aim was to examine if the restoration of the Roussouly profile reduced these complications and revision rates in older patients operated for degenerative ASD.

METHODS

Retrospective analysis of a single-centre, 2-year minimum follow-up patient database. All patients undergoing corrective surgery (≥ 4 levels) for ASD were included with analysis of demographic data, operative records, restoration of Roussouly sagittal profile, mechanical complications and revision rates. Univariate and multivariate analysis was conducted.

RESULTS

Fifty-two patients were included (mean age was 72.3 years, average follow-up 56.3 months). Twenty-six patients had a "restored" profile (50%) and 26 an "unrestored" profile (50%). The incidence of mechanical complications was 7 (27%) and 23 (88%) for the restored and unrestored groups, respectively (p < 0.001). Revision rates were 4 (15.4%) and 18 (69.2%), respectively (p < 0.000), in the restored and unrestored profiles. Univariate analysis determined that profile restoration and BMI were associated with mechanical complications and revision surgery, whilst only the profile restoration status maintained its statistical power in multivariate analysis (p = 0.002 and p = 0.002, respectively). Age was not a significant factor in univariate analysis. The relative risk for mechanical failure and revision surgery was 5.6 times (CI 1.929-16.39) and 3.08 times (CI 1.642-5.734) greater if the profile was not restored.

CONCLUSIONS

Achieving each patient's ideal Roussouly profile is associated with a reduced incidence of mechanical complications and revision rates in the older population after surgery for degenerative ASD.

C2 stentoplasty: an alternative to conventional vertebroplasty in the treatment of axis metastatic lesions: a systematic review with meta-analysis and case series

BACKGROUND

Vertebroplasty has been recently described in the literature as a potential treatment for C2 metastatic lesions. Stentoplasty may represent a safest and equally alternative to the latter.

OBJECTIVE

To describe a novel technique, stentoplasty, as an alternative for the treatment of metastatic involvement of C2 and to assess its efficacy and safety. To systematically evaluate the pertinent literature regarding the clinical outcomes and complications of C2 vertebroplasty in patients with metastatic disease.

METHODS

A systematic review of C2 vertebroplasty, in the English language medical literature was conducted for the needs of this study. Additionally, a cohort of five patients, presenting with cervical instability (SINS > 6) and/or severe pain (VAS > 6) from metastatic involvement of C2 and treated with stentoplasty in our department is presented. Outcomes evaluated include, pain control, stability, and complications.

RESULTS

Our systematic review yielded 8 studies that met the inclusion criteria, incorporating 73 patients that underwent C2 vertebroplasty for metastatic disease. There was a reduction in VAS scores following surgery from 7.6 to 2.1. Eleven patients had complications (15%), 3 (4%) required additional stabilization and decompression, 6 (8.2%) had odynophagia and the incidence of cement leak was 31.5% (23/73). With regard to our cohort, all 5 patients presented with severe neck pain (average VAS 6.2 (2-10)) with or without instability (average SINS 10 (6-14)) and underwent C2 stentoplasty. Mean duration of the procedures was 90 min (61-145) and 2.6 mls (2-3) of cement was injected. Postoperatively VAS improved from 6.2 to 1.6 (P = 0.033). No cement leak or other complications were recorded.

CONCLUSION

A systematic review of the literature demonstrated that C2 vertebroplasty can offer significant pain improvement with a low complication rate. At the same time, this is the first study to describe stentoplasty in a small cohort of patients, as an alternative for the treatment of C2 metastatic lesions in selected cases, offering adequate pain control and improving segmental stability with a high safety profile.

The influence of osteoporotic vertebral fractures on global sagittal alignment in elderly patients: a systematic review and meta-analysis

BACKGROUND

Thoracic kyphosis, or loss of lumbar lordosis, is often equated with osteoporosis because vertebral fractures are assumed to be a major causative factor, in addition to degeneration related to age. Despite the few studies aiming to measure the natural change in global sagittal alignment (GSA) that occurs with advancing age, the overall effect of conservatively managed osteoporotic vertebral compression fractures (OVCF) on the GSA in the elderly remains poorly understood.

OBJECTIVE

To systematically evaluate the relevant literature regarding the influence of OVCF on the GSA compared to patients of similar age without fractures using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spino-sacral Angle (SSA).

METHODS

A systematic review of the English language literature dating up until October 2022, was undertaken utilizing the PRISMA guidelines.

RESULTS

Of a total of 947 articles, 10 studies met the inclusion criteria (4 Level II, 4 level III and 2 level IV evidence) and were subsequently analyzed. Overall, 584 patients (8 studies) of mean age 73.7 years (69.3-77.1) had acute OVCF of one or more vertebra that were managed conservatively. The male to female ratio was 82:412. Five studies mentioned the number of fractured vertebrae, with a total of 393 in 269 patients (average of 1.4 fractured vertebrae per patient). Their pre-operative radiological parameters on standing X-rays showed a mean PI of 54.8°, PT 24°, LL 40.8°, TK 36.5°, PI-LL 14°, SVA 4.8 cm, and SSA 115°. In addition, 437 patients were used as a control group with osteoporosis without fractured vertebrae, (6 studies) with an average age of 72.4 years (67-77.8) and male to female ratio of 96:210 (5 studies). They all had upright X-rays to assess their global sagittal alignments. Radiological parameters showed an average PI of 54.3°, PT 17.3°, LL 43.4°, TK 31.25°, PI-LL 10.95°, SVA 1.27 cm and SSA 125°. A statistical analysis comparing the OVCF group with the control group (4 studies), showed a significant increase in PT of 5.97° (95%CI 2.63, 9.32; P < 0.0005), a significant increase in TK by 8.28° (95%CI 2.15, 14.4; P < 0.008), an increase in PI-LL by 6.72° (95%CI 3.39, 10.04; P < 0.0001), an increase in SVA by 1.35 cm (95%CI 0.88, 1.83; P < 0.00001), and a decrease in SSA by 10.2° (95%CI 10.3, 23.4; P < 0.00001).

CONCLUSION

Osteoporotic vertebral compression fractures managed conservatively appear to be a significant causate factor of global sagittal imbalance.

Does kyphoplasty affect the global sagittal alignment in patients with osteoporotic vertebral fractures? A systematic review and meta-analysis

BACKGROUND

Osteoporotic vertebral compression fractures (OVCF) are common in elderly patients and may cause local kyphosis due to the vertebral collapse and wedging. Balloon kyphoplasty (BKP) with polymethyl methacrylate is widely used to relieve back pain and restore the height and kyphosis of the destroyed vertebra Johnell (Osteoporos Int 17(12):1726-33, 2006); Wasnich (Bone 18: 179S-183S, 1996); Finnern (Osteoporos Int 14:429-436, 2003). However, the influence of BKP on global sagittal alignment (GSA) in patients with OVCF remains unclear.

OBJECTIVE

To systematically evaluate the relevant literature regarding the influence of BKP on the global spinal sagittal alignment using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spinosacral Angle (SSA). Visual Analogue Score (VAS) was also recorded.

METHODS

A systematic review of the English language literature dating up until August 2022, was undertaken utilising the PRISMA guidelines.

RESULTS

Of a total of 548 articles, 4 studies met the inclusion criteria (4 level III evidence) and were analyzed. Overall, 201 patients of mean age 73.8 years (69-77) had acute OVCF of one or more vertebra. The male to female ratio was 51:128. The number of fractured vertebrae was 235 (average of 1.17 fractured vertebrae per patient). Their pre-operative radiological parameters on standing x-rays showed a mean PI of 56°, PT 24.1°, LL 44.4°, TK 42.3°, PI-LL 11.7°, SVA 4.9 cm, LL/TK 1 and SSA 114.8°. The average VAS was 7.6 (2.6-10). All the patients underwent BKP and their radiological parameters on standing x-rays post operatively showed a mean PI of 55.3°, PT 23.1°, LL 45.1°, TK 41.4°, PI-LL 10.3°, SVA 4.29 cm, LL/TK 1.07 and SSA 116.8°. Their average VAS post BPK was 2.36 (0-4.8).A statistical analysis comparing the pre/post-operative GSA (111 patients, 3 studies with standard deviations) showed no statistical difference in PT (24.1° vs. 23.5°, P = 0.93), TK (42.3° vs. 42.4°, P = 0.57), PI-LL (14.4° vs.12.4°, P = 0.4), SVA (6.1 cm vs. 5.5 cm, P = 0.19) SSA (114.8° vs. 116.7° P = 0.36). VAS was significantly reduced post BKP (7.1 vs. 2.5 P = 0.004).

CONCLUSION

Performing BKP procedures does not significantly affect the global sagittal alignment in patients with osteoporotic vertebral compression fractures. There was however, a significant improvement in pain scores in patients undergoing BKP at 1 or more levels.