Oblique anterior column realignment with a mini-open posterior column osteotomy for minimally invasive adult spinal deformity correction: illustrative case

BACKGROUND

Adult spinal deformity (ASD) occurs from progressive anterior column collapse due to disc space desiccation, compression fractures, and autofusion across disc spaces. Anterior column realignment (ACR) is increasingly recognized as a powerful tool to address ASD by progressively lengthening the anterior column through the release of the anterior longitudinal ligament during lateral interbody approaches. Here, we describe the application of minimally invasive ACR through an oblique antepsoas corridor for deformity correction in a patient with adult degenerative scoliosis and significant sagittal imbalance.

OBSERVATIONS

A 65-year-old female with a prior history of L4-5 transforaminal lumbar interbody fusion and morbid obesity presented with refractory, severe low-back and lower-extremity pain. Preoperative radiographs showed significant sagittal imbalance. Computed tomography showed a healed L4-5 fusion and a vacuum disc at L3-4 and L5-S1, whereas magnetic resonance imaging was notable for central canal stenosis at L3-4. The patient was treated with a first-stage L5-S1 lateral anterior lumbar interbody fusion with oblique L2-4 ACR. The second-stage posterior approach consisted of a robot-guided minimally invasive T10-ilium posterior instrumented fusion with a mini-open L2-4 posterior column osteotomy (PCO). Postoperative radiographs showed the restoration of her sagittal balance. There were no complications.

LESSONS

Oblique ACR is a powerful minimally invasive tool for sagittal plane correction. When combined with a mini-open PCO, substantial segmental lordosis can be achieved while eliminating the need for multilevel PCO or invasive three-column osteotomies.

Bibliometric Analysis of the Development, Current Status, and Trends in Adult Degenerative Scoliosis Research: A Systematic Review from 1998 to 2023

Purpose

Adult degenerative scoliosis (ADS) research lacks bibliometric analysis, despite numerous studies. This study aimed to systematically analyze the development, current status, hot topics, frontier areas, and trends in ADS research.

Patients and Methods

A systematic literature review was conducted in the Web of Science Core Collection database from January 1998 to June 2023. Information regarding the country, institution, author, journal, and keywords was collected for each article. Bibliometric analysis was performed using VOSviewer and Citespace software.

Results

The final analysis covered 1695 publications, demonstrating a steady increase in ADS research. The United States was the most prolific and influential country with 684 publications, followed by China and Japan. The University of California System was the most productive institution with 113 publications. Shaffrey, CI (47 publications) and Lenke, LG (41 publications) were top authors. The analysis revealed seven main research clusters: "intervertebral disc", "adult spinal deformity", "lumbar fusion", "minimally invasive surgery", "navigation", "postoperative complications", and "mental retardation". Keywords with strong bursts of activity included degeneration, prevalence, imbalance, classification, lumbar spinal stenosis, and kyphosis.

Conclusion

In conclusion, in recent years, ADS research has undergone rapid development. This study analyzed its hot topics, advancements, and research directions, making it the latest bibliometric analysis in this field. The findings aim to provide a new perspective and guidance for clinical practitioners and researchers.

Multi-joint Charcot arthropathy caused by cervical spondylotic myelopathy and adult degenerative scoliosis with syringomyelia: a case report

BACKGROUND

Charcot arthropathy, also known as neuropathic arthropathy, is a rare disease whose early diagnosis and treatment are very difficult. Generally, diabetes is considered the most common cause of Charcot arthropathy. Although Charcot arthropathy of other secondary etiology has been reported, in most cases only a single joint is accumulated, and rarely involving the feet and shoulders. Clinically, Charcot arthropathy due to delayed diagnosis leads to joint destruction and severe cases abound.

CASE PRESENTATION

What we report is an unprecedented case, in which the patient was diagnosed as left shoulder joint, interdigital joint Charcot arthropathy caused by cervical spondylotic myelopathy (CSM) and left knee and right ankle Charcot arthropathy caused by adult degenerative scoliosis (ADS) complicated by syringomyelia. The 82-year-old male patient was admitted to the hospital for complaining of pain in the left knee joint. Except for scoliosis that was discovered 10 years ago, the patient denied any other obvious past medical history. Clinical/surgical manifestations, detailed physical examinations and auxiliary examinations all indicated the presence of polyarticular Charcot arthropathy, but common causes of Charcot arthropathy such as diabetes and syphilis have not been detected. After making a comprehensive differential diagnosis, we finally made the above diagnosis.

CONCLUSIONS

This previously unreported case describes the complexity and etiological diversity of Charcot arthropathy. We recommend that patients with CSM and/or scoliosis, spinal deformity undergo further examination and regular follow-up. A detailed medical history and careful physical examination are necessary for the correct diagnosis of Charcot arthropathy. Although the early diagnosis of Charcot arthropathy cannot change the natural course of the disease, it is beneficial to alleviate symptoms and prevent serious complications.

Prognostic Nutritional Index Is a Predictive Marker for Health-Related Quality of Life in Patients with Adult Degenerative Scoliosis

Our aim was to ascertain whether the prognostic nutritional index (PNI), could predict the health-related quality of life (HRQOL) in patients with adult degenerative scoliosis (ADS) undergoing corrective surgery. We conducted a retrospective analysis of consecutive patients diagnosed with ADS between January 2013 and June 2021. Three nutritional parameters were employed for analysis (PNI, anemia, and hypoalbuminemia). We utilized the Scoliosis Research Society-22 (SRS-22) questionnaire and the Oswestry Disability Index (ODI) questionnaire to assess clinical outcomes. Following the epidemiology guidelines, we presented results from three different models: the crude model, minimally adjusted model, and fully adjusted model. A total of 316 ADS patients were included in the statistical analysis. There was no significant difference in sagittal plane radiographic parameters between the two groups. After adjusting for important confounding factors, PNI was an independent predictor of postoperative HRQOL. Specifically, for each one-unit increase in PNI, there was an approximately 20% higher likelihood of patients achieving a better HRQOL. Furthermore, we did not observe an association between hemoglobin levels or albumin levels and HRQOL. In this study, PNI has been demonstrated to be correlated with the postoperative HRQOL in patients with ADS undergoing corrective surgery.

Risk Factors and Three Radiological Predictor Models for the Progression of Proximal Junctional Kyphosis in Adult Degenerative Scoliosis Following Posterior Corrective Surgery: 113 Cases With 2-years Minimum Follow-Up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To identify risk factors and predictive models for proximal junctional kyphosis (PJK) in a long-term follow-up of patients with adult degenerative scoliosis (ADS) following posterior corrective surgeries.

MATERIALS AND METHODS

A consecutive 113 ADS patients undergoing posterior corrective surgery between January 2008 and April 2019 with minimum 2-year follow-up were included. All patients underwent preoperative, postoperative, and final follow-up by X-ray imaging. Multivariate logistic analysis was performed on various risk factors and radiological predictor models.

RESULTS

PJK was identified radiographically in 46.9% of patients. Potential risk factors for PJK included postoperative thoracic kyphosis (TK) (P < .05), final follow-up Pelvic Tilt (PT) (P < .05), PT changes at final follow-up (P < .05), age over 55 years old at the surgery (P < .05), theoretical thoracic kyphosis-actual thoracic kyphosis mismatch (TK mismatch) (P < .05) and theoretical lumbar lordosis-acutal lumbar lordosis mismatch (LL mismatch) (P < .05). As for the predictive models, PJK was predictive by the following indicators: preoperative global sagittal alignment ≥45° (Model 1), postoperative pelvic incidence-lumbar lordosis mismatch (PI-LL)≤10° and postoperative PI-LL overcorrection (Model 2), and TK+LL≥0° (Model 3) (P < .05). Postoperative TK mismatch (OR = 1.064) was independent as risk factors for PJK, with the cut-off values respectively set at -28.56° to predict occurrence of PJK.

CONCLUSION

The risk of radiographic PJK increases with an age over 55 years old and higher postoperative TK. In addition, postoperative TK mismatch is an independent risk factor for developing PJK. All three predictive models could effectively indicate the occurrence of PJK.

Which Global Sagittal Parameter Could Most Effectively Predict the Surgical Outcome for Patients With Adult Degenerative Scoliosis?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate the predictive effect of the 3 global sagittal parameters (Sagittal Vertical Axis [SVA], T1 Pelvic Angle [TPA], and relative TPA [rTPA]) in the surgical outcome of patients with adult degenerative scoliosis (ADS), then to define the optimum corrective goal based on the best of them.

METHODS

117 ADS patients were included in this study and followed-up for an average of 3 years. Functional evaluation and radiographs were assessed preoperatively and postoperatively. The predictive accuracy of SVA, TPA, and relative TPA was analyzed through receiver operating characteristic (ROC) curve. The cutoff value of TPA was obtained at the maximal Youden index from ROC curve.

RESULTS

TPA most highly correlated with postoperative oswestry disability index (ODI). The best cutoff value of TPA was set at 19.3° (area under curve =0.701). TPA >19.3° was the highest risk factor in multivariate logistic regression analysis (OR = 7.124, P = 0.022). Patients with TPA <19.3° at 3 months after operation showed a better ODI than those with TPA >19.3°. Correcting TPA less than 19.3° for patients with preoperative TPA >19.3° attributed to a better health related quality of life (HRQOL) and sagittal balance at last follow-up. The formula "Postoperative TPA = 0.923 × PI - 0.241 × postoperative LL - 0.593 × postoperative SS - 2.471 (r = 0.914, r2 = 0.836, P < .001)" described the relation between SS, LL, PI, and TPA.

CONCLUSION

TPA was a useful global parameter for the prediction of postoperative HRQOL for patients with ADS. Keeping TPA <19.3° could improve the postoperative HRQOL for ADS patients with preoperative TPA >19.3°, and TPA <19.3° could be an optimum correction target for patients with ADS.

Correcting intervertebral rotation and scoliosis simultaneously by oblique lumbar interbody fusion: a 3D analysis of EOS images

Purpose

With advancements in minimally invasive techniques, oblique lumbar interbody fusion (OLIF) has gained widespread acceptance and is now commonly performed for adult degenerative scoliosis (ADS). The objective of this research paper is to evaluate three-dimensional (3D) intervertebral motions in EOS models before and after surgery and subsequently assess the efficacy of the 3D correction achieved through staged OLIF.

Methods

In this retrospective study, 29 consecutive patients diagnosed with ADS were included, with a mean age of 63.6 years, who underwent staged OLIF surgery between 2018 and 2021. Spinopelvic parameters were assessed using EOS images, and 3D models were reconstructed to measure intervertebral motion angles (IMAs) in 70 surgical intervertebral segments, comprising wedge, lordosis, and axial rotation angles. Regression analysis was conducted to compare IMAs in different planes before and after the staged OLIF surgery.

Results

Significant three-dimensional correction was observed in 70 intervertebral segments following the first-stage OLIF. The wedge angles decreased from 5.2°± 4.2° to 2.7°± 2.4° (P < 0.001). The lordosis angles increased from 5.1°± 5.9° to 7.8°± 4.6° (P = 0.014), while the axial rotation angles decreased from 3.8°± 2.6° to 2.3°± 2.1° (P < 0.001). Linear regression analysis revealed a positive correlation between wedge angles and axial angles preoperatively (P < 0.001, r = 0.43), as well as between corrected wedge angles and corrected axial angles (P < 0.001, r = 0.42).

Conclusion

This study demonstrated that intervertebral motions had a correlation between coronal and axial planes in lumbar degenerative scoliosis. First-stage OLIF was efficient at correcting segmental scoliosis by inserting cages while correcting rotation deformity simultaneously, as well as improving the sagittal spinopelvic parameters.

Robotics planning in minimally invasive surgery for adult degenerative scoliosis: illustrative case

BACKGROUND

Minimally invasive surgical techniques are changing the landscape in adult spinal deformity (ASD) surgery, enabling surgical correction to be achievable in increasingly medically complex patients. Spinal robotics are one technology that have helped facilitate this. Here the authors present an illustrative case of the utility of robotics planning workflow for minimally invasive correction of ASD.

OBSERVATIONS

A 60-year-old female presented with persistent and debilitating low back and leg pain limiting her function and quality of life. Standing scoliosis radiographs demonstrated adult degenerative scoliosis (ADS), with a lumbar scoliosis of 53°, a pelvic incidence-lumbar lordosis mismatch of 44°, and pelvic tilt of 39°. Robotics planning software was utilized for preoperative planning of the multiple rod and 4-point pelvic fixation in the posterior construct.

LESSONS

To the authors' knowledge, this is the first report detailing the use of spinal robotics for complex 11-level minimally invasive correction of ADS. Although additional experiences adapting spinal robotics to complex spinal deformities are necessary, the present case represents a proof-of-concept demonstrating the feasibility of applying this technology to minimally invasive correction of ASD.

Case Report: Adult degenerative scoliosis in two patients treated with percutaneous spinal endoscopic-assisted lumbar interbody fusion and percutaneous pedicle screw fixation

Adult degenerative scoliosis (ADS) is a serious disease that often affects middle-aged and elderly people. ADS does not only cause sagittal and coronal deformity of the lumbar spine but also causes severe back and leg pain secondary to the compression of the neural structures. Open surgery remains the main method for correcting the occurring deformity and decompression of the neural structures; however, its benefit is limited in cases of large trauma. Minimally invasive spinal (MIS) surgery is an alternative method that has recently witnessed rapid development. It has the advantage of providing rapid recovery with less trauma as compared to conventional open surgery. We report two cases of ADS treated with percutaneous spinal endoscopic-assisted lumbar interbody fusion (EALIF) and percutaneous pedicle screw fixation. Both cases had moderate deformities of the lumbar spine (load-sharing classification 4-7 points) with severe back and leg pain, and they underwent successful MIS surgery. At 6 months of follow-up, the visual analog scale and Oswestry disability index scores of both patients improved and the deformity was corrected. For moderate ADS, percutaneous spinal EALIF and percutaneous pedicle screw fixation may achieve an effective correction of the deformity with direct decompression of neural structures.

Whole-transcriptome sequencing identifies key differentially expressed circRNAs/lncRNAs/miRNAs/mRNAs and linked ceRNA networks in adult degenerative scoliosis

Background

Adult degenerative scoliosis (ADS) is forecast to be a prevalent disabling condition in an aging society. Universally, its pathogenesis is perceived as intervertebral disc degeneration (IDD), however, a thought-provoking issue is why precisely a subset of patients with disc degeneration develop ADS. Exploring the diversities between common IDD and ADS would contribute to unraveling the etiological mechanisms of ADS. Therefore, we aimed to integrate the circRNA, lncRNA, miRNA, and mRNA expression profiles from normal adults (Normal), patients with lumbar disc herniation (LDH), and ADS by whole transcriptome sequencing, which identifies critical functional ncRNA and ceRNA networks and crosstalk between the various transcripts.

Methods

The fresh whole blood samples (n = 3/group) were collected from ADS patients, LDH patients, and healthy volunteers (Normal group), which were examined for mRNA, miRNA, lncRNA, and circRNA expression and screened for differentially expressed (DE) ncRNAs. Then, Gene Ontology (GO) and KEGG analyses were performed for gene annotation and enrichment pathways on the DE RNAs, which were constructed as a lncRNA-miRNA-mRNA network. Eventually, DE RNAs were validated by qRT-PCR targeting disc nucleus pulposus (NP) tissue in ADS and LDH group (n = 10/group).

Results

Compared to the LDH group, we identified 3322 DE mRNAs, 221 DE lncRNAs, 20 DE miRNAs, and 15 DE circRNAs in the ADS. In contrast to Normal, 21 miRNAs and 19 circRNAs were differentially expressed in the ADS. The expression of multiple differentially expressed ncRNAs was confirmed by qRT-PCR analysis to be consistent with the sequencing results. In addition, GO, and KEGG analysis demonstrated that most DE mRNAs and ncRNAs target genes are involved in various biological processes, including Endocytosis, Apoptosis, Rap1 signaling pathway, Notch signaling pathway, and others. The constructed lncRNA-miRNA-mRNA co-expression network was primarily related to angiogenesis and regulation.

Conclusion

By focusing on comparing asymmetric and symmetric disc degeneration, whole-transcriptome sequencing and bioinformatics analysis systematically screened for key ncRNAs in the development of ADS, which provided an abundance of valuable candidates for the elucidation of regulatory mechanisms. The DE ncRNAs and the lncRNA-miRNA-mRNA network are intrinsically involved in the regulation of mediator and angiogenesis, which may contribute to the insight into the pathogenesis of ADS.

Analysis of rotational deformity correction by lateral lumbar interbody fusion with two-staged anterior-posterior combined corrective fusion surgery for adult degenerative kyphoscoliosis

The present study is retrospective analysis of consecutively collected data. Lateral lumber interbody fusion (LLIF) is widely used in cases of adult spinal deformities. However, the corrective effects of LLIF cage insertion on the vertebral rotation deformity in the axial plane and the individual effects of LLIF and direct vertebral rotation (DVR) on rotational correction are unclear. To individually examine the corrective effects of LLIF and posterior corrective fusion surgery with direct DVR on vertebral rotation deformities in adult degenerative kyphoscoliosis. We analyzed 21 patients (5 males and 16 females) who underwent two-staged anterior-posterior combined corrective fusion surgery for adult degenerative kyphoscoliosis. Surgical time, blood loss, facet joint osteoarthritis (OA) grade, disc degeneration, cage height, vertebral rotational angle, and various X-ray parameters were investigated as evaluation items. The X-ray parameters showed significant postoperative improvements. The mean vertebral rotation angle was 6.4° ± 5.2° preoperatively, 3.5° ± 3.3° after LLIF (P = .014, vs preoperative), and 1.6° ± 1.7° after posterior corrective fusion surgery with DVR (P = .011, vs preoperative). Correlation analysis between the vertebral rotation angle and various measured values revealed that the vertebral rotation angle after LLIF was correlated with the cage height (r = -0.46, P = .032). The vertebral rotation angle after DVR was correlated with the facet joint OA grade (r = -0.49, P = .018) and the wedge angle after posterior corrective fusion surgery with DVR (R = 0.57, P = .006). We conclude that the effects of rotational deformity correction with LLIF cage insertion and additional posterior corrective fixation with DVR can be useful for correcting vertebral rotation deformities.

Reliability of Hounsfield Unit for Assessing Asymmetrical Vertebral Bone Mass in Adult Degenerative Scoliosis

Objective

Hounsfield Unit (HU) has been used to investigate the asymmetrical vertebral bone mass in patients associated with adult degenerative scoliosis (ADS). Therefore, there is an inevitable need to evaluate the performance of HU values in ADS subjects.

Methods

A total of 162 patients (81 ADS patients and 81 non-ADS patients) aged ≥50 years undergoing the CT examination were reviewed. The HU values of the lumbar vertebral body (including total, convex side, and concave side) at bilateral pedicle plane were obtained and compared. The paired t-test, chi-squared test, independent samples t-test, and interclass correlation coefficient (ICC) were used for statistical analyses.

Results

The HU values were significantly different between the convex and concave sides of the lumbar vertebral body (P < 0.01). The total prevalence of osteoporosis (OP) in ADS patients was higher than that of non-ADS patients. The prevalence of OP in female or male of ADS patients was higher than that of non-ADS patients, respectively. Intra- and inter-rater reliability were very strong (both >0.8) for measuring asymmetrical vertebral bone mass in ADS patients.

Conclusion

HU value was a high reproducibility method for evaluating the vertebral bone mass in ADS patients. The HU values at the concave sides were significantly higher than that of convex sides at the lumbar vertebral body on the pedicle plane. The prevalence of OP in ADS patients was higher than that of non-ADS patients, especially for females associated with ADS. Moreover, the static asymmetric load did not enhance the bone mass at the concave side compared with the left/right side of non-ADS patients.

Therapeutic Strategy of Percutaneous Transforaminal Endoscopic Decompression for Stenosis Associated With Adult Degenerative Scoliosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate the effects of percutaneous transforaminal endoscopic decompression (PTED) for lumbar stenosis associated with adult degenerative scoliosis and to analyze the correlation between preoperative radiological parameters and postoperative surgical outcomes.

METHODS

Two years of retrospective data was collected from 46 patients with lumbar stenosis associated with adult degenerative scoliosis who underwent PTED. The visual analog scale (VAS), Oswestry Disability Index, and modified MacNab criteria were used to evaluate the clinical outcomes. Multiple linear regression analysis was used to analyze the correlation between radiological parameters and surgical outcomes.

RESULTS

The mean age of the 33 female and 13 male patients was 73.5 ± 8.1 years. The mean follow-up was 27.6 ± 3.5 months (range from 24 to 36). The average coronal Cobb angle was 24.5 ± 8.2°. There were better outcomes of the VAS for leg pain and Oswestry Disability Index after surgery. Based on the MacNab criteria, excellent or good outcomes were noted in 84.78% of patients. Multiple linear regression analysis showed that Cobb angle and lateral olisthy may be the predictors for low back pain.

CONCLUSION

Transforaminal endoscopic surgery may be an effective and safe method for geriatric patients with lumbar stenosis associated with degenerative scoliosis. The predictive factors of clinical outcomes were severe Cobb angle and high degree lateral subluxation. Transforaminal endoscopic surgery may not be recommended for patients with Cobb angle larger than 30° combined with lateral subluxation.

The effects of vertebral rotation on the position of the aorta relative to the spine in patients with adult degenerative scoliosis

Aims

This study aimed to explore the effects of vertebral rotation on the position of the aorta relative to the thracolumbar and lumbar spine, and to identify risk factors for vertebral rotation in patients with adult degenerative scoliosis (ADS).

Methods

A total of 71 patients with ADS were divided into left scoliosis (LS) group (n = 40 cases) and right scoliosis (RS) group (n = 31cases) with well-matched demographics. Apical vertebrae, Cobb angle (°), coronal horizontal movement, thoracolumbar kyphosis (TLK) and Nash-Moe rotation classification were measured on X-ray. The Cartesian coordinate system was established on T2-MRI for each level of intervertebral disc on thracolumbar and lumbar spine, where aorta-vertebrae angle (α), aorta-vertebrae distance (d), and vertebral rotation angle (γ) for each level of T12-L1 to L3-L4 on MRI were defined within the Cartesian coordinate system.

Results

There was no statistical difference in the distribution of apical vertebrae between LS and RS groups. Nash-Moe classification was of no significance between the two groups. When there was a larger Cobb angle and coronal horizontal movement, a greater γ in LS group and a lower γ in RS group were noted (both p < 0.001). There was no correlation among γ, α, and d in LS group (p = 0.908 and 0.661, respectively) nor in RS group (p = 0.738 and 0.289, respectively). In LS group, Nash-Moe classification correlated to Cobb angle, coronal movement and TLK. In RS group, it correlated to Cobb angle and coronal movement. Cobb angle was the risk factor for Nash-Moe classification in RS group while no factors were identified in LS group. Coronal movement was independent risk factor for γ (p = 0.003) in LS group. Moreover, γ was affected by Cobb angle (p = 0.001) and coronal horizontal movement (p = 0.006) in RS group.

Conclusion

Vertebral rotation could be predicted by Cobb angle or coronal horizontal movement measured on X-ray in ADS patients and aorta maintained in a relatively normal position in patients with ADS.

Muscle defects due to perturbed somite segmentation contribute to late adult scoliosis

Scoliosis is an abnormal bending of the body axis. Truncated vertebrae or a debilitated ability to control the musculature in the back can cause this condition, but in most cases the causative reason for scoliosis is unknown (idiopathic). Using mutants for somite clock genes with mild defects in the vertebral column, we here show that early defects in somitogenesis are not overcome during development and have long lasting and profound consequences for muscle fiber organization, structure and whole muscle volume. These mutants present only mild alterations in the vertebral column, and muscle shortcomings are uncoupled from skeletal defects. None of the mutants presents an overt musculoskeletal phenotype at larval or early adult stages, presumably due to compensatory growth mechanisms. Scoliosis becomes only apparent during aging. We conclude that adult degenerative scoliosis is due to disturbed crosstalk between vertebrae and muscles during early development, resulting in subsequent adult muscle weakness and bending of the body axis.

Comparative study of multilevel posterior interbody fusion plus anterior longitudinal ligament release versus classic multilevel posterior interbody fusion in the treatment of adult spinal deformities

OBJECTIVE

Sagittal imbalance and loss of lumbar lordosis are the main drivers of functional disability in adult degenerative scoliosis. The main limitations of the classic posterior lumbar interbody fusion technique are increased risk of neurological injury and suboptimal correction of the segmental lordosis. Here, the authors describe the radiological results of a modified posterior lumbar interbody fusion and compare the results with a historical cohort of patients.

METHODS

Eighty-two consecutive patients underwent surgical treatment for degenerative scoliosis/kyphosis in a single tertiary referral center for complex spinal surgery. Fifty-five patients were treated using the classic multilevel posterior lumbar interbody fusion (MPLIF) technique and 27 were treated using the modified MPLIF technique to include a release of the anterior longitudinal ligament (ALL) and the annulus. A radiographic review of both series of patients was performed by two independent observers. Functional outcomes were obtained, and patients were registered in the European Spine Tango registry.

RESULTS

The mean L4-5 disc angle increased by 3.14° in the classic MPLIF group and by 12.83° in MPLIF plus ALL and annulus release group. The mean lumbar lordosis increased by 15.23° in the first group and by 25.17° in the second group. The L4-S1 lordosis increased on average by 4.92° in the classic MPLIF group and increased by a mean of 23.7° in the MPLIF plus ALL release group when both L4-5 and L5-S1 segments were addressed. There were significant improvements in the Core Outcome Measures Index and EQ-5D score in both groups (p < 0.001). There were no vascular or neurological injuries observed in either group.

CONCLUSIONS

The authors' preliminary results suggest that more correction can be achieved at the disc level using posterior-based ALL and annulus release in conjunction with posterior lumbar interbody fusion. They demonstrate that ALL and annulus release can be performed safely using a posterior-only approach with minimal risk of vascular injury. However, the authors recommend that this approach should only be used by surgeons with considerable experience in anterior and posterior spinal surgery.

Effect of three-dimensional rotational deformity correction in surgery for adult degenerative scoliosis using lumbar lateral interbody fusion and posterior pedicle screw fixation

Introduction

Corrective surgery for adult degenerative scoliosis using lateral interbody fusion (LIF) and additional posterior fixation is an efficient procedure. However, it is unclear how this procedure affects rotational deformity correction. Therefore, the goal of the present study was to use three-dimensional (3D) images, taken during surgery, to investigate rotational deformity correction in the treatment of adult degenerative scoliosis using LIF and posterior fixation using a pedicle screw system.

Methods

The subjects were 12 females who were treated using LIF and posterior fixation for adult degenerative scoliosis. The patients had a mean age of 72 (65-76) years. 3D images were acquired before surgery, after LIF, and after additional posterior fixation. Rotational angles of the upper vertebra with respect to the lower vertebra of each fixed segment were measured in 3 planes. Correction factors for rotational deformity were investigated after LIF and additional posterior fixation.

Results

There were significant improvements in radiographical parameters for global spinal balance. The correction angles per segment were 4.7° for lateral bending, 6.9° for lordosis, and 4.5° for axial rotation. LIF was responsible for correction of four-fifths of lateral bending and axial rotation, and two-thirds of lordotic changes.

Conclusions

Lateral bending, axial rotational deformities, and lordosis were primarily corrected by LIF. Further lordosis correction was achieved using additional posterior fixation. These results indicate that corrective surgery for adult degenerative scoliosis using these procedures is effective for rotational deformity correction and leads to an ideal global spinal alignment.

Cost minimization in treatment of adult degenerative scoliosis

OBJECT

Back pain is an increasing concern for the aging population. This study aims to evaluate if minimally invasive surgery presents cost-minimization benefits compared with open surgery in treating adult degenerative scoliosis.

METHODS

Seventy-one patients with adult degenerative scoliosis received 2-stage, multilevel surgical correction through either a minimally invasive spine surgery (MIS) approach with posterior instrumentation (n = 38) or an open midline (Open) approach (n = 33). Costs were derived from hospital and rehabilitation charges. Length of stay, blood loss, and radiographic outcomes were obtained from electronic medical records. Functional outcomes were measured with Oswestry Disability Index (ODI) and visual analog scale (VAS) surveys.

RESULTS

Patients in both cohorts were similar in age (Age(MIS) = 65.68 yrs, Age(Open) = 63.58 yrs, p = 0.28). The mean follow-up was 18.16 months and 21.82 months for the MIS and Open cohorts, respectively (p = 0.34). MIS and Open cohorts had an average of 4.37 and 7.61 levels of fusion, respectively (p < 0.01). Total inpatient charges were lower for the MIS cohort ($269,807 vs $391,889, p < 0.01), and outpatient rehabilitation charges were similar ($41,072 vs $49,272, p = 0.48). MIS patients experienced reduced length of hospital stay (7.03 days vs 14.88 days, p < 0.01) and estimated blood loss (EBL) (EBL(MIS) = 470.26 ml, EBL(Open)= 2872.73 ml, p < 0.01). Baseline ODI scores were lower in the MIS cohort (40.03 vs 48.04, p = 0.03), and the cohorts experienced similar 1-year improvement (ΔODI(MIS) = -15.98, ΔODI(Open) = -21.96, p = 0.25). Baseline VAS scores were similar (VAS(MIS) = 6.56, VAS(Open)= 7.10, p = 0.32), but MIS patients experienced less reduction after 1 year (ΔVAS(MIS) = -3.36, ΔVAS(Open) = -4.73, p = 0.04). Preoperative sagittal vertical axis (SVA) were comparable (preoperative SVA(MIS) = 63.47 mm, preoperative SVA(Open) = 71.3 mm, p = 0.60), but MIS patients had larger postoperative SVA (postoperative SVA(MIS) = 51.17 mm, postoperative SVA(Open) = 28.17 mm, p = 0.03).

CONCLUSIONS

Minimally invasive surgery demonstrated reduced costs, blood loss, and hospital stays, whereas open surgery exhibited greater improvement in VAS scores, deformity correction, and sagittal balance. Additional studies with more patients and longer follow-up will determine if MIS provides cost-minimization opportunities for treatment of adult degenerative scoliosis.