Revision of Harrington rod constructs: a single-center's experience with this homogenous adult spinal deformity population at a minimum 2-year follow-up

PURPOSE

To evaluate radiographic and clinical outcomes following revision surgery after HRC fusions.

METHODS

Single-institution, retrospective study of patients revised following HRC with minimum 2-year follow-up post-revision. Demographics, perioperative information, radiographic parameters, complications, and Oswestry disability index (ODI) scores were collected. Radiographic parameters included global alignment, coronal and sagittal measurements pre and postoperatively, as well as final follow-up time points.

RESULTS

26 patients were included with a mean follow-up of 3.3 ± 1.1 years. Mean age was 55.5 ± 7.8 years, BMI 25.2 ± 5.8, and 22 (85%) were females. Instrumented levels increased from 9.7 ± 2.8 to 16.0 ± 2.2. Five (19.2%) patients underwent lumbar pedicle subtraction osteotomies, and 23 (88.4%) had interbody fusions. Patients significantly improved in all radiographic parameters at immediate and final follow-up (p < 0.005), except for thoracic kyphosis and pelvic incidence (p > 0.05). Correction was maintained from immediate postop to final follow-up (p > 0.05). 20 (76.9%) of patients experienced a complication at some point within the follow-up period with the most common being a lumbar nerve root deficit (n = 7). However, only one patient had a nerve root deficit at final follow-up, that being a 4/5 unilateral anterior tibialis function. 5 (19.2%) patients required further revision within a mean of 1.8 ± 1.1 years. On average, patients had an improvement in ODI score by final follow-up (35.6 ± 16.8 vs 25.4 ± 19.8, p = 0.035).

CONCLUSION

Patients revised for HRCs significantly improve, both clinically and radiographically by final follow-up. This group did have a propensity for distal lumbar root neurological issues, which were common but all patients except for one, recovered to full strength by two-year follow-up.

Three-column osteotomy in long constructs has lower rates of proximal junctional kyphosis and better restoration of lumbar lordosis than anterior column realignment

PURPOSE

Three-column osteotomies (TCOs) and minimally invasive techniques such as anterior column realignment (ACR) are powerful tools used to restore lumbar lordosis and sagittal alignment. We aimed to appraise the differences in construct and global spinal stability between TCOs and ACRs in long constructs.

METHODS

We identified consecutive patients who underwent a long construct lumbar or thoracolumbar fusion between January 2016 and November 2021. "Long construct" was any construct where the uppermost instrumented vertebra (UIV) was L2 or higher and the lowermost instrumented vertebra (LIV) was in the sacrum or ileum.

RESULTS

We identified 69 patients; 14 (20.3%) developed PJK throughout follow-up (mean 838 days). Female patients were less likely to suffer PJK (p = 0.009). TCO was more associated with open (versus minimally invasive) screw/rod placement, greater number of levels, higher UIV, greater rate of instrumentation to the ilium, and posterior (versus anterior) L5-S1 interbody placement versus the ACR cohort (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.005, respectively). Patients who developed PJK were more likely to have undergone ACR (12 (32.4%) versus 2 (6.3%, p = 0.007)). The TCO cohort had better improvement of lumbar lordosis despite similar preoperative measurements (ACR: 16.8 ± 3.78°, TCO: 23.0 ± 5.02°, p = 0.046). Pelvic incidence-lumbar lordosis mismatch had greater improvement after TCO (ACR: 14.8 ± 4.02°, TCO: 21.5 ± 5.10°, p = 0.042). By multivariate analysis, ACR increased odds of PJK by 6.1-times (95% confidence interval: 1.20-31.2, p = 0.29).

CONCLUSION

In patients with long constructs who undergo ACR or TCO, we experienced a 20% rate of PJK. TCO decreased PJK 6.1-times compared to ACR. TCO demonstrated greater improvement of some spinopelvic parameters.

Three-Column Osteotomy for Frail Versus Nonfrail Patients with Adult Spinal Deformity: Assessment of Medical and Surgical Complications, Revision Surgery Rates, and Cost

BACKGROUND

Three-column osteotomy (3-CO) is a powerful tool for spinal deformity correction but has been associated with substantial risk and surgical invasiveness. It is incompletely understood how frailty might affect patients undergoing 3-CO.

METHODS

The PearlDiver database was used to examine spinal deformity patients with a diagnosis of frailty who had undergone 3-CO. Frail and nonfrail patients were matched, and the revision surgery rates, complications, and hospitalization costs were calculated. Logistic regression was used to account for possible confounding variables. Of the 2871 included patients, 1460 had had frailty and 1411 had had no frailty.

RESULTS

The frail patients were older, had had more comorbidities (P < 0.001), and were more likely to have undergone posterior interbody fusion (P < 0.05), without differences in the anterior interbody fusion rates. No differences were found in the reoperation rates for ≤5 years. At 30 days, the frail patients were more likely to have experienced acute kidney injury (P = 0.018), bowel/bladder dysfunction (P = 0.014), cardiac complications (P = 0.006), and pneumonia (P = 0.039). At 2 years, the frail patients were also more likely to have experienced bowel/bladder dysfunction (P = 0.028), cardiac complications (P < 0.001), deep vein thrombosis (P = 0.027), and sepsis (P = 0.033). The cost for the procedures was also higher for the frail patients than for the nonfrail patients ($24,544.79 vs. $21,565.63; P = 0.043).

CONCLUSIONS

We found that frail patients undergoing 3-CO were more likely to experience certain medical complications and had had higher associated costs but similar reoperation rates compared with nonfrail patients. Careful patient selection and surgical strategy modification might alter the risks of medical and surgical complications after 3-CO for frail patients.

Anterior longitudinal ligament release from a posterior approach: an alternative to three-column osteotomy

PURPOSE

Expansion of the anterior column and compression of the posterior column restores lordosis and sagittal imbalance. Anterior longitudinal ligament (ALL) release has been described from lateral and anterior approaches as a technique to improve lumbar lordosis; however, posterior approach to release the ALL has not been adequately assessed.

METHODS

We demonstrate a case series of ALL release using a posterior approach performed in conjunction with posterior column osteotomy (PCO), with or without transforaminal lumbar interbody fusion (TLIF) for spinal deformity. Eleven cases were identified from billing records between 2010 and 2019. Retrospective review was conducted for perioperative complications and revision surgery. Overall and segmental lumbar lordosis (LL) correction was measured from pre- and postoperative imaging.

RESULTS

Eleven patients underwent ALL release with a PCO. Kyphosis, scoliosis, and flat back syndrome were the most common spinal deformities. On average, patients had 9 ± 3 levels fused and a single level ALL release. ALL release was most commonly performed at L1-L2 and L2-L3 levels. An overall LL correction of 28.6° ± 19.8^o was achieved; ALL release introduced 16.7° ± 11.9° of lordotic correction and accounted for 49.2 ± 30.4% of the overall lordotic correction. Average blood loss was 1030 ± 573 mL.

CONCLUSIONS

ALL release as an adjunct to PCO and TLIF is a viable technique for providing increased deformity correction without subjecting the patient to a more invasive three-column osteotomy. While this approach may not be appropriate for all patients, it represents a useful option in spinal deformity correction while limiting blood loss and additional anterior surgery.

LEVEL OF EVIDENCE

IV.

Spine-Pelvis-Hip Alignments in Degenerative Spinal Deformity Patients and Associated Procedure of One-Stage Long-Fusion with Multiple-Level PLIF or Apical-Vertebra Three Column Osteotomy-a Clinical and Radiographic Analysis Study

OBJECTIVE

To explore the spine-pelvis-hip alignments in degenerative spinal deformity (DSD) patients, and compare the outcomes in the procedure of long-fusion with posterior lumbar inter-body fusion (PLIF) or single-level three-column osteotomy (STO) at lower lumbar level (LLL, L3 -S1 ) and thoracolumbar levels (TLL, T10 -L2 ) for those patients.

METHODS

This is a retrospective study. Following institutional ethics approval, a total of 83 patients (Female, 67; Male, 16) with DSD underwent long-fusion with PLIF or STO surgery between March 2015 and December 2017 were reviewed. All of those patients were assigned into LLL and TLL groups. The average age at surgery was 65.2 years (SD, 8.1). Demographic (age, gender, BMI, and comorbidities), radiographs (both coronal and sagittal parameters) and health-related quality of life (HRQOL) assessments were documented. The radiographic parameters and HRQOL-related measurements at pre- and post-operation were compared with paired-samples t test, and those variables in the two groups were analyzed using an independent-sample t test. The relationships between pelvic incidence (PI) and other sagittal parameters were investigated with Pearson correlation analysis. The Pearson χ2 or Fisher's exact was carried out for comparison of gender, incidence of comorbidities and post-operative complications.

RESULTS

There were 53 and 30 patients in the LLL and TLL groups respectively. Those spino-pelvic radiographic parameters had significant improvements after surgeries (P < 0.001). The patients in the two group with different pre-operative thoracolumbar kyphosis (TLK, P = 0.003), PI (P = 0.02), and mismatch of PI minus lumbar lordosis (PI-LL, P = 0.01) had comparable post-operative radiographic parameters except PI (P = 0.04) and pelvic-femur angle (PFA, P = 0.02). Comparing the changes of those spine-pelvic-hip data during surgeries, the corrections of TLK in TLL group were significant larger (P = 0.004). Pearson correlation analysis showed that there were negative relationship between PI and TLK (r = -0.302, P = 0.005), positive relationship between PI and LL (r = 0.261, P = 0.016) at pre-operation. Those patients underwent the surgical procedure that long-segment instrumentation and fusion with STO would have higher incidence of complications involving longer operative timing (P = 0.018), more blood loss (P < 0.001), revision surgery (P = 0.008), and cerebrospinal fluid leakage (P = 0.001). All the HRQOL scores significantly improved at final follow-up (P < 0.001), with no difference of intra-group.

CONCLUSION

Patients suffered de-novo scoliosis or hyper-kyphosis with low PI would be vulnerable to significant thoracolumbar degeneration, and have more changes of spine-pelvis-hip data after long-fusion surgery, however, those with high PI would be closed to significant lumbar degeneration. Although spine-pelvis-hip alignments in DSD patients can be restored effectively after long-fusion with PLIF or STO, the incidence of complications in patients underwent STO was significant higher than that in patients performed multi-level PLIF.

Efficacy of lateral lumbar interbody fusion combined with posterior spinal fusion compared with three-column osteotomy for adult spinal deformity with severe lumbar sagittal deformity

PURPOSE

The clinical and radiological results of adult spinal deformity (ASD) patients with a severe lumbar sagittal deformity undergoing multilevel lateral lumbar interbody fusion (LLIF) + posterior spinal fusion (PSF) were compared to patients undergoing three-column osteotomy (3CO).

METHODS

We defined severe lumbar sagittal deformity as fulcrum backward bending (FBB) pelvic incidence minus lumbar lordosis (PI-LL) ≧ 20 degrees. A total of twenty-five patients with an ASD were enrolled between 2013 and 2018. Fifteen patients were in the LLIF + PSF group, and ten patients were in the 3CO group. We evaluated patient demographics, clinical outcomes, and radiographic parameters such as the Cobb angle and spinopelvic parameters from standing X-ray films in each group.

RESULTS

The LLIF + PSF group had a significantly shorter follow-up time than the 3CO group. Postoperatively, the LLIF + PSF group had significantly lower PI-LL and a shorter sagittal vertical axis than the 3CO group. Postoperative PI-LL changes in the LLIF + PSF group were significantly smaller than those in the 3CO group. There were no differences in other patient demographics, radiographic parameters, or clinical outcomes between the groups.

CONCLUSION

Multilevel LLIF + PSF improved the PI-LL and SVA more than did 3CO for ASD patients with severe lumbar sagittal deformity. This indicated that the multilevel LLIF with open PSF can provide good clinical outcomes even in cases with severe lumbar sagittal deformity such as large FBB PI-LL in which 3CO techniques usually are needed.

Management of Pseudarthrosis With Implant Failure at a Multilevel Vertebral Column Resection Site: A Case Report

Pseudarthrosis in the setting of 3-column osteotomies such as vertebral column resection (VCR) is not well described, and pseudarthrosis at the VCR site itself has never been reported. This study reports pseudarthrosis with 4-rod implant failure at a multilevel VCR site. The authors report a case of pseudarthrosis in a patient treated previously for severe segmental thoracolumbar kyphosis resulting in significant pain and myelopathic signs in the setting of radiation therapy for metastatic myeloma. This patient initially underwent 2-level VCR (T11, T12) and fusion from T4-sacrum. This was complicated by pseudarthrosis and associated with same-level 4-rod fracture, resulting in prominent, painful implants, and worsening kyphosis. This patient underwent revision VCR during which time significant motion was found only at the site of the prior VCR with a loose anterior cage. A new expandable VCR cage was placed and the spine was reinstrumented, resulting in significant improvement in coronal and sagittal alignment. Pseudarthrosis at a VCR site has not been previously described. Technical considerations presented in the revision procedure include a 6-rod spanning construct, meticulous endplate repreparation, and the generous use of osteo-inductive and -conductive augments to promote solid fusion.

The "Rail Technique" for Correction of Cervicothoracic Kyphosis: Case Report and Surgical Technique Description

Cervicothoracic deformity correction often necessitates a shortening operation, consisting of a 3-column osteotomy (3CO). While effective, segmental compression and in situ and cantilever bending often place screws under considerable stress and may jeopardize deformity correction. In this report, we present the surgical technique of a novel method, the “rail technique,” to shorten across a vertebral column resection (VCR) for cervicothoracic deformity correction. A 65-year-old woman with a history of a C5-pelvis posterior instrumented fusion (PSIF) presented with chin-on-chest deformity after a prior proximal junctional failure/kyphosis at T4 (30° T3–5) above a prior T5-pelvis PSIF that was stabilized in situ. She underwent an uncomplicated revision C2–T10 PSIF with shortening across a T4 VCR using the “rail technique.” Postoperatively, radiographs demonstrated excellent restoration of and normalization of cervical sagittal alignment, thoracic kyphosis, focal T3–5 kyphosis (7°), and global sagittal alignment. At 1-year postoperation, she was without neck pain and reported significant improvements in self-image, mental health, satisfaction, and subscale Scoliosis Research Society-22 scores compared to preoperative values. The “rail technique” is a safe and effective method for shortening over a 3CO to correct the cervicothoracic deformity.

Medical optimization of modifiable risk factors before thoracolumbar three-column osteotomies: an analysis of 195 patients

PURPOSE

To determine the rate of preoperative modifiable laboratory abnormalities (both major and minor) and the association with early postoperative medical and surgical complications.

METHODS

All patients undergoing thoracolumbar three-column osteotomy between 2013 and 2016 with preoperative laboratory data were identified. Potential preoperative modifiable laboratory abnormalities (major and minor) were assessed including hyponatremia (sodium < 130 and < 135 mEq/L), anemia (hematocrit < 25% and < 30%), renal insufficiency (creatinine ≥ 1.8 and ≥ 1.2 mg/dL), coagulopathy (INR ≥ 1.8 and ≥ 1.2), and hypoalbuminemia (albumin < 2.5 and < 3.5 g/dL). Multivariate logistic regression was used to determine associations with 30-day complications after controlling for possible confounding factors.

RESULTS

A total of 195 patients were identified. The rates of major and minor preoperative laboratory abnormalities were 7.7% and 31.3%, respectively. The rates of serious medical, minor medical, and surgical complications over 30-days were 6.7%, 21.5%, and 10.3%, respectively. In multivariate analysis the presence of major preoperative laboratory abnormalities had a significant association with serious medical complications (odds ratio [OR] 77.8, P < 0.001), and minor medical complications (OR 13.3, P < 0.001), but not surgical complications (P = 0.243). The presence of minor preoperative laboratory abnormalities had a significant association with serious medical complications (OR 10.4, P = 0.041) and minor medical complications (OR 2.4, P = 0.045), but not surgical complications (P = 0.490).

CONCLUSIONS

While major laboratory abnormalities had a strong association with complications, even minor modifiable laboratory abnormalities had a significant association with both serious and minor medical complications.

Surgeon-specific risk stratification model for early complications after complex adult spinal deformity surgery

STUDY DESIGN

Retrospective outcome analysis of a prospectively collected single-surgeon cases OBJECTIVES: Identify risk factors for complications in adult surgical spine deformity patients, develop a surgeon-specific risk stratification model, and predict the likelihood of 6-week postoperative complications based on prospectively collected preoperative measures. Adult spinal deformity surgery is challenging technically as well as economically. Although many risk factors are well known for spine surgery, complications after complex spine deformity surgery remain a significant problem worldwide.

METHODS

We reviewed 124 consecutive adult patients who have undergone instrumented spinal fusion with nine or more levels over a 21-month period in a single institution. We extracted data from patient medical records. Complications within the 6 weeks after surgery were identified. Univariate and logistic regression analyses (LRAs) were implemented. We generated a formula based on the LRA predictive algorithm-a numeric probabilistic likelihood statistic representing an individual patient's risk of developing a complication.

RESULTS

A total of 34 (27%) patients had complications that were categorized into either 21 (17%) medical or 17 (13.7%) surgical complications, including 3 (2.4%) proximal junctional kyphosis, 8 (6.4%) neurologic deficit, and 9 (6.5%) any wound issue. The predictive model was significant and calibrated using area under the receiver operating characteristics curve analysis. The model correctly classified 83.1% cases. Patients with a three-column osteotomy or history of deep vein thrombosis have 6 and 19 times higher overall complications, respectively, compared with patients without. Patients with a three-column osteotomy or body mass index > 30, respectively, are 24 and 11 times more likely to develop a wound complication. Patients with a three-column osteotomy have 10 times higher rates of surgical complication.

CONCLUSIONS

Complex spine deformity is often associated with complications. No single variable effectively predicts postoperative complications for such a complicated situation. However, when all risk factors are considered, patients with three-column osteotomy have a significantly higher chance to develop early complications.

LEVEL OF EVIDENCE

Level IV.

Asymmetric Pedicle Subtraction Osteotomy for Adult Spinal Deformity with Coronal Imbalance: Complications, Radiographic and Surgical Outcomes

BACKGROUND

Asymmetric pedicle subtraction osteotomy (APSO) can be utilized for adult spinal deformity (ASD) with fixed coronal plane imbalance. There are few reports investigating outcomes following APSO and no series that include multiple revision cases.

OBJECTIVE

To detail our surgical technique and experience with APSO.

METHODS

All thoracolumbar ASD cases with a component of fixed, coronal plane deformity who underwent APSO from 2004 to 2016 at one institution were retrospectively reviewed. Preoperative and latest follow-up radiographic parameters and data on surgical outcomes and complications were obtained.

RESULTS

Fourteen patients underwent APSO with mean follow-up of 37-mo. Ten (71.4%) were revision cases. APSO involved a mean 12-levels (range 7-25) and were associated with 3.0 L blood loss (range 1.2-4.5) and 457-min of operative time (range 283-540). Surgical complications were observed in 64.3%, including durotomy (35.7%), pleural injury (14.3%), persistent neurologic deficit (14.3%), rod fracture (7.1%), and painful iliac bolt requiring removal (7.1%). Medical complications were observed in 14.3%, comprising urosepsis and 2 cases of pneumonia. Two 90-d readmissions (14.3%) and 5 reoperations (4 patients, 28.6%) occurred. Mean thoracolumbar curve and coronal vertical axis improved from 31.5 to 16.4 degrees and 7.8 to 2.9 cm, respectively. PI-LL mismatch, mean sagittal vertical axis, and pelvic tilt improved from 40.0 to 27.9-degrees, 10.7 to 3.5-cm, and 34.4 to 28.3-degrees, respectively.

CONCLUSION

The APSO, in both a revision and non-revision ASD population, provides excellent restoration of coronal balance-in addition to sagittal and pelvic parameters. Employment of APSO must be balanced with the associated surgical complication rate (64.3%).

Clinical results and functional outcomes after three-column osteotomy at L5 or the sacrum in adult spinal deformity

PURPOSE

Three-column osteotomies at L5 or the sacrum (LS3COs) are technically challenging, yet they may be needed to treat lumbosacral kyphotic deformities. We investigated radiographic and clinical outcomes after LS3CO.

METHODS

We analyzed 25 consecutive patients (mean age 56 years) who underwent LS3CO with minimum 2-year follow-up. Standing radiographs and health-related quality-of-life scores were evaluated. A new radiographic parameter ["lumbosacral angle" (LSA)] was introduced to evaluate sagittal alignment distal to the S1 segment.

RESULTS

From preoperatively to the final follow-up, significant improvements occurred in lumbar lordosis (from - 34° to - 49°), LSA (from 0.5° to 22°), and sagittal vertical axis (SVA) (from 18 to 7.3 cm) (all, p < .01). Mean Scoliosis Research Society (SRS)-22r scores in activity, pain, self-image, and satisfaction (p < .05), and Oswestry Disability Index scores (p < .01) also improved significantly. Patients with SVA ≥ 5 cm at the final follow-up experienced less improvement in SRS-22r satisfaction scores than those with SVA < 5 cm. Patients with LSA < 20° at the final follow-up had significantly lower SRS-22r activity scores than those with LSA ≥ 20° (p = .014). Two patients had transient neurologic deficits, and 11 patients underwent revision for proximal junctional kyphosis (5), pseudarthrosis (3), junctional stenosis (2), or neurologic deficit (1).

CONCLUSIONS

LS3CO produced radiographic and clinical improvements. However, patients who remained sagittally imbalanced had less improvement in SRS-22r satisfaction score than those whose sagittal imbalance was corrected, and patients who maintained kyphotic deformity in the lumbosacral spine had lower SRS-22r activity scores than those whose lumbosacral kyphosis was corrected. These slides can be retrieved under Electronic Supplementary Material.

The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon's experience with 197 cases

BACKGROUND CONTEXT

Three-column osteotomy (3CO) is used to correct rigid adult spinal deformity. It presents risk of complications because it involves extensive osseous resection and spinal destabilization.

PURPOSE

Our purpose was to characterize the learning curve for performing 3CO in adult spinal deformity patients.

DESIGN

Retrospective review.

PATIENT SAMPLE

A surgical registry at a tertiary care center was used to identify 238 cases of 3CO for correction of adult spinal deformity by 1 surgeon between 2005 and 2014. Patients with at least 1 year of clinical and radiographic follow-up were included (n=197; mean duration of follow-up, 43 months; range, 12-121).

OUTCOME MEASURES

We quantified associations between surgeon experience and (1) estimated blood loss per vertebral level fused (EBL/VLF), (2) incidence of new neurologic deficits, (3) incidence of reoperation for instrumentation failure, (4) operative time in minutes, and (5) magnitude of correction at the level of the osteotomy.

METHODS

The learning curve for binary outcomes was demonstrated using a LOWESS smoother plot of the probability of occurrence. Change in risk was calculated using a generalized linear model with link identity and binomial family. The learning curve for continuous variables was demonstrated using a scatter plot and a line of best fit based on linear regression analysis. Alpha=0.05.

RESULTS

EBL/VLF decreased by a mean of 19.7 mL (95% confidence interval [CI]: 11.3-28.1) with each 10 cases (decrease of 388 mL/level fused by the end of the study period). The risk of a neurologic deficit declined by 7.98% (95% CI: 7.98%, 7.99%) with every 100 cases. The risk of reoperation declined by 1.99% (95% CI: 0.83%, 3.17%) with every 10 cases until the 100th case. After that point, there was no significant change in the probability of reoperation (p>.05). The magnitude of correction and operative time did not change with increasing surgeon experience (p>.05).

CONCLUSION

Incidence of reoperation for instrumentation failure, incidence of new neurologic deficits, and estimated blood loss improved with increasing surgeon experience at performing 3CO. Most outcomes, except the risk of reoperation, improved through the last case.

Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population

STUDY DESIGN

Retrospective review of a prospectively collected multicenter database.

OBJECTIVES

To evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients.

SUMMARY OF BACKGROUND DATA

ASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks.

METHODS

Adult patients undergoing ASD surgery from 2009 to 2016 were analyzed (n = 905). Preoperative and surgical parameters were compared across years. Subgroup analysis of 436 patients with minimum two-year follow-up was also performed.

RESULTS

From 2009 to 2016, there was a significant increase in the mean preoperative age (52 to 63.1, p < .001), body mass index (26.3 to 32.2, p = .003), Charlson Comorbidity index (1.4 to 2.2, p < .001), rate of previous spine surgery (39.8% to 53.1%, p = .01), and baseline disability (visual analog scale [VAS] back and leg pain) scores (p < .01), Oswestry Disability Index, and 22-item Scoliosis Research Society Questionnaire scores (p < .001). Preoperative Schwab sagittal alignment modifiers and overall surgical invasiveness index were similar across time. Three-column osteotomy utilization decreased from 36% in 2011 to 16.7% in 2016. Lateral lumbar interbody fusion increased from 6.4% to 24.1% (p = .004), anterior lumbar interbody fusion decreased from 22.9% to 16.7% (p = .043), and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion utilization remained similar (p = .448). Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2012 was 84.6%, declined to 58% in 2013, and rebounded to 76.3% in 2016 (p = .006). Tranexamic acid use increased rapidly from 2009 to 2016 (13.3% to 48.6%, p < .001). Two-year follow-up sagittal vertical axis, pelvic tilt, pelvic incidence-lumbar lordosis, and maximum Cobb angles were similar across years. Intraoperative complications decreased from 33% in 2010 to 9.3% in 2016 (p < .001). Perioperative (<30 days, <90 days) complications peaked in 2010 (42.7%, 46%) and decreased by 2016 (24.1%, p < .001; 29.6%, p = .007). The overall complication rate decreased from 73.2% in 2008-2014 patients to 62.6% in 2015-2016 patients (p = .03). Two-year health-related quality of life outcomes did not significantly differ across the years (p > .05).

CONCLUSIONS

From 2009 to 2016, despite an increasingly elderly, medically compromised, and obese patient population, complication rates decreased. Evolving strategies may result in improved treatment of ASD patients.

LEVEL OF EVIDENCE

Level IV.

Key Role of Preoperative Recumbent Films in the Treatment of Severe Sagittal Malalignment

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if severe sagittal malalignment (SM) patients without fixed deformities require a three-column osteotomy (3CO) to achieve favorable clinical and radiographic outcomes.

SUMMARY OF BACKGROUND DATA

3CO performed for severe SM has significantly increased in the last 15 years. Not all severe SM patients require a 3CO.

METHODS

Severe SM patients (sagittal vertical axis [SVA] >10 cm) who underwent deformity correction between 2002 and 2011. Patients with <33% change in their lumbar lordosis (LL) on a preoperative supine radiograph were classified as stiff deformities, whereas those with ≥33% change were categorized as flexible deformities. The clinical/radiographic outcomes were assessed at minimum two years postoperatively.

RESULTS

Seventy patients met the inclusion criteria, 35 patients with flexible and 35 with stiff deformities. Eighteen flexible-deformity patients underwent a 3CO versus 22 stiff-deformity patients. The remaining patients in each group underwent spinal realignment without a 3CO. The flexible-deformity patients not undergoing a 3CO had overall improvement in all sagittal radiographic parameters. Preoperative LL (22°), LL-pelvic incidence (PI) mismatch (43), SVA (17 cm), and pelvic tilt (PT, 34°) improved to 46°, 18, 6 cm, and 26°, respectively, p < .05. Flexible-deformity patients who underwent a 3CO also had overall improvement in all radiographic parameters. Preoperative LL (8.5°), LL-PI mismatch (47), SVA (19 cm), and PT (37°) improved to 39°, 15, 7 cm, and 24°, respectively (p < .05). Stiff-deformity patients who underwent a 3CO had statistically significant improvement in all radiographic parameters. However, stiff-deformity patients who did not undergo a 3CO had suboptimal improvement in all radiographic parameters, except for SVA (14 cm-9 cm, p < .05). Flexible patients who did not undergo a 3CO had statistical improvement in the SRS domains of function and self-mage as well as in their ODI scores (p < .05).

CONCLUSION

Severe SM that is flexible can be corrected without a 3CO without compromising clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level III.

Classification of coronal imbalance in adult scoliosis and spine deformity: a treatment-oriented guideline

INTRODUCTION

In adult spinal deformity (ASD), sagittal imbalance and sagittal malalignment have been extensively described in the literature during the past decade, whereas coronal imbalance and coronal malalignment (CM) have been given little attention. CM can cause severe impairment in adult scoliosis and ASD patients, as compensatory mechanisms are limited. The aim of this paper is to develop a comprehensive classification of coronal spinopelvic malalignment and to suggest a treatment algorithm for this condition.

METHODS

This is an expert's opinion consensus based on a retrospective review of CM cases where different patterns of CM were identified, in addition to treatment modifiers. After the identification of the subgroups for each category, surgical planning for each subgroup could be specified.

RESULTS

Two main CM patterns were defined: concave CM (type 1) and convex CM (type 2), and the following modifiers were identified as potentially influencing the choice of surgical strategy: stiffness of the main coronal curve, coronal mobility of the lumbosacral junction and degeneration of the lumbosacral junction. A surgical algorithm was proposed to deal with each situation combining the different patterns and their modifiers.

CONCLUSION

Coronal malalignment is a frequent condition, usually associated to sagittal malalignment, but it is often misunderstood. Its classification should help the spine surgeon to better understand the full spinal alignment of ASD patients. In concave CM, the correction should be obtained at the apex of the main curve. In convex CM, the correction should be obtained at the lumbosacral junction. These slides can be retrieved under Electronic Supplementary Material.

Three-dimensional translations following posterior three-column spinal osteotomies for the correction of severe and stiff kyphoscoliosis

BACKGROUND CONTEXT

Posterior three-column spinal osteotomies were shown to be effective to treat severe and stiff kyphoscoliosis. Translations at the site of osteotomy after deformity correction were commonly seen intraoperatively, which might cause potential neurologic deficits. However, this phenomenon was not thoroughly discussed in the current literature.

PURPOSE

This study aimed to evaluate the three-dimensional (3D) translations at the three-column osteotomy site and their effects on neurologic outcome in the surgical correction of severe and stiff kyphoscoliosis.

STUDY DESIGN/SETTING

A retrospective study was carried out.

PATIENT SAMPLE

Sixty-nine patients treated by posterior three-column spinal osteotomy for severe kyphoscoliosis of idiopathic, congenital, neuromuscular, neurofibromatosis, and tuberculosis origin were included.

OUTCOME MEASURES

General, coronal, and sagittal translations were graded three-dimensionally according to the theory of Meyerding.

METHODS

The charts of 69 clinical patients with severe and stiff kyphoscoliosis treated by posterior three-column osteotomy from January 2013 to June 2015 were reviewed. There were 35 male patients with an average age of 21.5 years and 34 female patients with an average age of 22.5 years. The etiologies of these spinal deformities were idiopathic, congenital, neuromuscular, neurofibromatosis, and tuberculosis. According to our classification system of spinal cord neurologic function, there were 41 type A, 13 type B, and 15 type C cases. The 3D spine models were reconstructed from thin-sliced computed tomography (CT) scan, and the 3D translations at the three-column osteotomy site were graded and analyzed.

RESULTS

The incidences of general translation (GT), frontal translation (FT), and sagittal translation (ST) were 62.3%, 52.2%, and 26.1%. The incidence of evoked potential (EP) change in cases with GT/FT being or more than grade II (GT, 42.9%; FT, 50.0%) was significantly higher than that with GT/FT being less than grade II (GT, 16.7%; FT, 18.2%), whereas the incidence of EP change in cases with ST being or more than grade I (33.3%) was significantly higher than that with ST being less than grade I (9.8%). No linear correlations were found between spine shortening distance, deformity correction rate, and the degree of translation.

CONCLUSIONS

The 3D translations are common in posterior three-column spinal osteotomies regardless of anterior strut graft placement. The increase of translation will increase neurologic risks, with GT or FT less than grade II and ST less than grade I being relatively safe.

Is Vertebral Column Resection Necessary in Correcting Severe and Rigid Thoracic Kyphoscoliosis? A Single-Institution Surgical Experience

BACKGROUND

Three-column spinal osteotomies were developed to address severe and stiff kyphoscoliosis. However, the optimal choice of osteotomy in these patients is still unclear. This retrospective study aims to compare the outcomes and complications between grade 4 and grade 5 osteotomies in patients with severe and stiff thoracic kyphoscoliosis.

METHODS

Forty-five patients with severe and stiff thoracic kyphoscoliosis who underwent 3-column osteotomy in the thoracic spine were classified into 2 groups according to the grade of osteotomy. The clinical data and radiologic parameters were collected and compared.

RESULTS

Fourteen patients received grade 4 osteotomy, and 31 patients received grade 5 osteotomy. The spinal column shortening distances were similar between groups. The postoperative and latest follow-up radiologic parameters were not statistically significant between groups. Postoperative and follow-up results demonstrated greater correction of the regional kyphosis angle in the grade 4 osteotomy group, but did not reach significant level. The operative time and blood loss of grade 5 osteotomies were greater than those of grade 4, but showed no significant differences. Perioperative complication rates were also similar between groups.

CONCLUSIONS

Similar clinical outcomes can be achieved with grade 4 and grade 5 spinal osteotomies. This may enrich the basis on moving down to a lower osteotomy grade when treating patients with severe and rigid thoracic kyphoscoliosis.

Posterior column reconstruction improves fusion rates at the level of osteotomy in three-column posterior-based osteotomies

PURPOSE

To determine the incidence of pseudarthrosis at the osteotomy site after three-column spinal osteotomies (3-COs) with posterior column reconstruction.

METHODS

82 consecutive adult 3-COs (66 patients) with a minimum of 2-year follow-up were retrospectively reviewed. All cases underwent posterior 3-COs with two-rod constructs. The inferior facets of the proximal level were reduced to the superior facets of the distal level. If that was not possible, a structural piece of bone graft either from the local resection or a local rib was slotted in the posterior column defect to re-establish continual structural posterior bone across the lateral margins of the resection. No interbody cages were used at the level of the osteotomy.

RESULTS

There were 34 thoracic osteotomies, 47 lumbar osteotomies and one sacral osteotomy with a mean follow-up of 52 (24-126) months. All cases underwent posterior column reconstructions described above and the addition of interbody support or additional posterior rods was not performed for fusion at the osteotomy level. Among them, 29 patients underwent one or more revision surgeries. There were three definite cases of pseudarthrosis at the osteotomy site (4%). Six revisions were also performed for pseudarthrosis at other levels.

CONCLUSION

Restoration of the structural integrity of the posterior column in three-column posterior-based osteotomies was associated with > 95% fusion rate at the level of the osteotomy. Pseudarthrosis at other levels was the second most common reason for revision following adjacent segment disease in the long-term follow-up.

Posterior Versus Three-Column Osteotomy for Late Correction of Residual Coronal Deformity in Patients With Previous Fusions for Idiopathic Scoliosis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To compare the early results of posterior column (PCO) and three-column (3CO) osteotomies performed in patients with previously fused idiopathic scoliosis and review their abilities to achieve coronal correction of residual deformities.

SUMMARY OF BACKGROUND DATA

Residual deformity of previously fused AIS can accelerate adjacent segment degeneration secondary to lowest instrumented vertebra (LIV) tilt and rotation. Many of these patients are not satisfied with their cosmetic appearance and would choose revising the deformity when future surgery is indicated.

METHODS

The data from 29 consecutive patients who underwent PCOs or 3COs for late revisions of idiopathic scoliosis were reviewed. Measurements included Cobb angle, focal osteotomy angle, and coronal balance. Perioperative data, complications, and patient-reported outcomes were also reviewed.

RESULTS

Fourteen patients were treated with PCOs and 15 with 3COs. Global coronal correction was equal between the two groups. In the PCO group, where patients underwent a mean of 2.4 osteotomies, 20.2° of correction was obtained compared to 19.5° in the 3CO group (p = .33), which all underwent single osteotomies. The average coronal correction was 9.2°/osteotomy for the PCO group and 14.1°/osteotomy for the 3CO group (p < .01). Estimated blood loss was 1,417.5 mL in the PCO group compared to 3,199.3 in the 3CO group (p < .01). Five patients (36%) had intraoperative complications in the PCO group compared to 12 (80%) in the 3CO group (p < .05). There were no differences in operative times, length of stay, or patient-reported outcomes between groups.

CONCLUSION

PCOs and 3COs performed in patients with previously fused spines for idiopathic scoliosis are effective in achieving residual deformity correction. In cases of posterior fusions, where the patient has a mobile anterior column, PCOs should be considered over 3COs because of their decreased risk of blood loss and complications.

Posterior Double Vertebral Column Resections Combined with Satellite Rod Technique to Correct Severe Congenital Angular Kyphosis

This paper presents a highly challenging technique involving posterior double vertebral column resections (VCRs) and satellite rods placement. This was a young adult case with severe angular thoracolumbar kyphosis of 101 degrees, secondary to anterior segmentation failure from T11 to L1 . There were hemivertebrae at T11 and T12 , and a wedged vertebra at L1 . He received double VCRs at T12 and T11 and instrumented fusion from T6 to L4 via a posterior only approach. Autologous grafts and a cage were placed between the bony surfaces of the osteotomy gap. Once closure of osteotomy was achieved, bilateral permanent CoCr rods were placed with addition of satellite rods. Postoperative X-ray demonstrated marked correction of kyphosis. On the 10(th) days after surgery, the patient was able to walk without assistance. In conclusion, double VCRs are effective to correct severe angular kyphosis, and addition of satellite rods may be imperative to enhance instrumentation strength and thus prevent correction loss.

Cervical sagittal deformity develops after PJK in adult thoracolumbar deformity correction: radiographic analysis utilizing a novel global sagittal angular parameter, the CTPA

PURPOSE

To describe reciprocal changes in cervical alignment after adult spinal deformity (ASD) correction and subsequent development of proximal junctional kyphosis (PJK). This study also investigated these changes using two novel global sagittal angular parameters, cervical-thoracic pelvic angle (CTPA) and the T1 pelvic angle (TPA).

METHODS

Multicenter, retrospective consecutive case series of ASD patients undergoing thoracolumbar three-column osteotomy (3CO) with fusion to the pelvis. Radiographs were analyzed at baseline and 1 year post-operatively. Patients were substratified into upper thoracic (UT; UIV T6 and above) and lower thoracic (LT; UIV below T6). PJK was defined by >10° angle between UIV and UIV + 2 and >10° change in the angle from baseline to post-op.

RESULTS

PJK developed in 29 % (78 of 267) of patients. CTPA was linearly correlated with cervical plumbline (CPL) as a measure of cervical sagittal alignment (R = 0.826, p < 0.001). PJK patients had significantly greater post-operative CTPA and SVA than patients without PJK (NPJK) (p = 0.042; p = 0.021). For UT (n = 141) but not LT (n = 136), PJK patients at 1 year had larger CTPA (4.9° vs. 3.7°, p = 0.015) and CPL (5.1 vs. 3.8 cm, p = 0.022) than NPJK patients, despite similar corrections in PT and PI-LL.

CONCLUSIONS

The prevalence of PJK was 29 % at 1 year follow-up. CTPA, which correlates with CPL as a global analog of cervical sagittal balance, and TPA describe relative proportions of cervical and thoracolumbar deformities. Patients who develop PJK in the upper thoracic spine after thoracolumbar 3CO also develop concomitant cervical sagittal deformity, with increases in CPL and CTPA.

A Comprehensive Review of Complication Rates After Surgery for Adult Deformity: A Reference for Informed Consent

OBJECTIVE

An up-to-date review of recent literatures and a comprehensive reference for informed consent specific to ASD complications is lacking. The goal of the present study was to determine current complication rates after ASD surgery, in order to provide a reference for informed consent as well as to determine differences between three-column and non-three-column osteotomy procedures to aid in shared decision making.

METHODS

A review of the literature was conducted using the PubMed database. Randomized controlled trials, nonrandomized trials, cohort studies, case-control studies, and case series providing postoperative complications published in 2000 or later were included. Complication rates were recorded and calculated for perioperative (both major and minor) and long-term complication rates. Postoperative outcomes were all stratified by surgical procedure (ie, three-column osteotomy and non-three-column osteotomy).

RESULTS

Ninety-three articles were ultimately eligible for analysis. The data of 11,692 patients were extracted; there were 3,646 complications, mean age at surgery was 53.3 years (range: 25-77 years), mean follow-up was 3.49 years (range: 6 weeks-9.7 years), estimated blood loss was 2,161 mL (range: 717-7,034 mL), and the overall mean complication rate was 55%. Specifically, major perioperative complications occurred at a mean rate of 18.5%, minor perioperative complications occurred at a mean rate of 15.7%, and long-term complications occurred at a mean rate of 20.5%. Furthermore, three-column osteotomy resulted in a higher overall complication rate and estimated blood loss than non-three-column osteotomy.

CONCLUSIONS

A review of recent literatures providing complication rates for ASD surgery was performed, providing the most up-to-date incidence of early and late complications. Providers may use such data in helping to counsel patients of the literature-supported complication rates of such procedures despite the planned benefits, thus obtaining a more thorough informed consent.