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Surgery of lumbar and thoracolumbar scolioses in adults over 50. Morbidity and survival in a multicenter retrospective cohort of 180 patients with a mean follow-up of 4.5years
Abstract
The increasing life expectancy of the population and the improvement in surgical and medical management of elderly patients mean that the indication for surgical treatment of adult lumbar and thoracolumbar scolioses has been extended. However the benefit/risk ratio of these procedures is still under debate.
We reviewed 180 patients, mean age 63years old with a minimum follow-up of 1year in a retrospective, continuous, multicenter study. The incidence rate of complications from surgery and the factors influencing their frequency were evaluated by uni- and multivariate analysis. The risk of a second operation was studied by actuarial survival analysis.
After a mean follow-up of 4.5years, 79 patients (44%) presented with at least one complication, including 32% with a serious complication. The most frequent complications were mechanical. The risk factors were medical co-morbidities, the extent of fusion and the extent of the preoperative sagittal imbalance. A second operation was necessary in 25% of patients at 1year and 50% of patients at 6years of follow-up.
Studies in the literature show that functional results are better with surgical treatment than with medical treatment in the management of thoracic spine and thoracolumbar deformities in patients over 50years old. An objective assessment of this deformity and associated co-morbidity should make it possible to reduce the rate of complications for this type of surgery.
Level IV.
... Six articles discussed associations between sagittal balance in patients with DLS and clinical outcomes [10,11,13,[16][17][18]. Seven articles addressed associations between surgical treatment and outcomes among patients with DLS and sagittal imbalance [12,14,15,[19][20][21][22]. ...
... In seven studies, sagittal imbalance tended to be associated with worse postoperative symptoms and disability, as well as with operative complications [12,14,15,[19][20][21][22]. In the first study, among 448 patients with scoliosis undergoing fusion, greater residual postoperative sagittal imbalance was associated with poorer clinical outcomes, as measured by the 36item Short Form Health Survey (SF-36) and ODI, as well as adjacent segment disease, non-union, and revision surgery [21]. ...
... In the first study, among 448 patients with scoliosis undergoing fusion, greater residual postoperative sagittal imbalance was associated with poorer clinical outcomes, as measured by the 36item Short Form Health Survey (SF-36) and ODI, as well as adjacent segment disease, non-union, and revision surgery [21]. Among 180 patients with scoliosis undergoing spinal fusion in a second study, greater preoperative sagittal imbalance was associated with greater risk of complications [19]. A third study of 40 patients with DLS undergoing deformity correction and fusion reported that ODI scores improved less (p<.017 at 1 year) and complications were more common among patients with severe spinal imbalance [12]. ...
Background context:
Degenerative Lumbar Scoliosis (DLS) is often associated with sagittal imbalance, which may affect patients' health outcomes before and after surgery. The appropriateness of surgery and preferred operative approaches has not been examined in detail for patients with DLS and sagittal imbalance.
Purpose:
The goal of this paper is to describe what is currently known about the relationship between sagittal imbalance and health outcomes among patients with DLS, and to determine how indications for surgery in patients with DLS differ when sagittal imbalance is present.
Study design/setting:
Literature review and an expert panel utilizing the RAND/UCLA Appropriateness Method.
Methods:
To develop appropriate use criteria for DLS, researchers at the RAND Corporation recently employed the RAND/UCLA Appropriateness Method, which involves a systematic review of the literature and multidisciplinary expert panel process. Experts reviewed a synopsis of published literature and rated the appropriateness of 5 common operative approaches for 260 different clinical scenarios. In the present work, we updated the literature review and compared panelists' ratings in scenarios where imbalance was present vs. absent. This work was funded by the Collaborative Spine Research Foundation, a group of surgical specialty societies and device manufacturers.
Results:
On the basis of 13 eligible studies that examined sagittal imbalance and outcomes in patients with DLS, imbalance is associated with worse functional status in the absence of surgery, and worse symptoms and complications post-operatively. Panelists' ratings demonstrated a consistent pattern across the diverse clinical scenarios. In general, when imbalance is present, surgery is more likely to be appropriate or necessary, including in some situations where surgery would otherwise be inappropriate. For patients with moderate to severe symptoms and imbalance, a deformity correction procedure is usually appropriate and frequently necessary, except in some patients with severe risk factors for complications. Conversely, procedures that do not correct imbalance, when present, are usually inappropriate.
Conclusions:
Clinical experts agreed that sagittal imbalance is a major factor affecting both whether surgery is appropriate and which type of procedure is preferred among patients with DLS.
... Severe pain and trunk imbalance represent indications for instrumented fusion which can improve quality of life on long-term [1,2]. Nevertheless, surgery is associated with high rates of mechanical failure ranging between 25 and 44%, especially if fusion includes the pelvis [3][4][5][6]. Among these complications, non-union often requires revision surgery [5][6][7][8], which can influence clinical outcomes [9][10][11]. ...
... In our cohort, the combination of 4-rod instrumentation and interbody cages prevented loss of lordosis, whereas 2-rod constructs with select use of cages were associated with LL decrease, pelvic retroversion and SVA increase within the first year, which is probably related to non-union which was only evidenced in the 2R group. Infection represents a supplemental risk factor for non-union and sagittal alignment deterioration [4,5,11,40], which might have played an additional role in our study. ...
PurposeFour-rod instrumentation and interbody fusion may reduce mechanical complications in degenerative scoliosis surgery compared to 2-rod instrumentation.
The purpose was to compare clinical results, sagittal alignment and mechanical complications with both techniques.Methods
Full spine radiographs were analysed in 97 patients instrumented to the pelvis: 58 2-rod constructs (2R) and 39 4-rod constructs (4R). Clinical scores (VAS, ODI, SRS-22, EQ-5D-3L) were assessed preoperatively, at 3 months, 1 year and last follow-up (average 4.2 years). Radiographic measurements were: thoracic kyphosis, lumbar lordosis, spinopelvic parameters, segmental lordosis distribution. The incidence of non-union and PJK were investigated.ResultsAll clinical scores improved significantly in both groups between preoperative and last follow-up. In the 2R-group, lumbar lordosis increased to 52.8° postoperatively and decreased to 47.0° at follow-up (p = 0.008). In the 4R-group, lumbar lordosis increased from 46.4 to 52.5° postoperatively and remained at 53.4° at follow-up. There were 8 (13.8%) PJK in the 2R-group versus 6 (15.4%) in the 4R-group, with a mismatch between lumbar apex and theoretic lumbar shape according to pelvic incidence. Non-union requiring revision surgery occurred on average at 26.9 months in 28 patients (48.3%) of the 2R-group. No rod fracture was diagnosed in the 4R-group.Conclusion
Multi-level interbody fusion combined with 4-rod instrumentation decreased risk for non-union and revision surgery compared to select interbody fusion and 2-rod instrumentation. The role of additional rods on load sharing still needs to be determined when multiple cages are used. Despite revision surgery in the 2R group, final clinical outcomes were similar in both groups.Level of evidenceIII.
... Spine surgery for ASD patients is expected to be the final therapeutic intervention in management. Low reoperation rates are ideal, but complications or other problems could increase the risk of reoperation [8][9][10][11][12]. Regardless of corrective results, ASD surgeries always bring some complications. ...
... In our study, the average age of ASD patients at the initial surgery was 52.5 years, thus, old age may be a cause of the high complication rates. Further, history of medical complications [4,9,32] and fusions to the sacrum [32][33][34] are also risk factors for complications in ASD patients who underwent ASD surgery. In our study, most patients suffered one or more comorbidities, and approximately 80% patients with SSM and 3-COS were fused to sacrum. ...
Background
The aim of this study was to analyze and compare the surgical data, clinical outcomes, and complications between three-column osteotomy (3-COS) and standard surgical management (SSM) for the treatment of adult spine deformity (ASD).MethodsA total of 112 patients who underwent consecutive 3-COS (n¿=¿48) and SSM (n¿=¿64) procedures for ASD correction at a single institution from 2001 to 2011 were reviewed in this study. The outcomes were assessed using the Scoliosis Research Society (SRS)-22 scores. The complications of patients with 3-COS and SSM were also compared.ResultsNo significant differences were found in patient characteristics between SSM and 3-COS groups. Surgical data and radiographic parameters showed that the patients of the 3-COS group suffered more severe ASD than those of the SSM group. The distribution of surgical complications revealed that SSM group underwent more complications than 3-COS groups with no significant differences. At final follow-up, the total SRS-22 score of SSM was not significant between pre-operation and post-operation. However, the total SRS-22 score of 3-COS at final follow-up was significantly higher than pre-operation.Conclusion
For severe ASD patients with high grade pelvic incidence (PI), pelvic tilt (PT), and PI/lumbar lordosis (LL) mismatch and who have subjected to spine surgeries more than twice before, 3-COS might be more effective than SSM in improving the clinical outcomes. However, due to the higher reoperation rate of 3-COS, SSM may be more appropriate than SSM for correcting the not serious ASD patients.
... Additionally, Blamoutier et al in their retrospective review of ASD patients demonstrated that 5.5% had a medical complication. Plitter et al had a 11.8% infection rate that was higher than our outcome that involve infection incidence is highly variable [41][42]. ...
Study Design: A multicenter, retrospective review of surgical patients with adult spine deformity. Objective: Analyze the impact on the quality of life of patients who suffer complications in adult spine deformity surgery. Summary of Background Data: Adult spine deformity surgery is classically associated with a high rate of complications, in particular it is estimate around 40%. The knowledge of the impact these complications could be a useful to improve the outcome in quality of life of patients. Methods: Retrospective analysis of a prospective database of a cohort of patients who underwent spinal deformity surgery. Patients with 4 or more instrumented vertebras and 2 years follow-up of were included. We created two groups based on the development or not of complications. VAS, ODI and SRS22, as a quality of life questionnaires, were used. Statistical analysis was performed using: T Student and U Mann-Whitney tests depending if variables were adjusted or not to normality; independent and related samples were analyzed with W Wilcoxon test. Results: 65 patients from primary surgery completed all the protocols (75.4% female) , mean age of the cohort was 68 ± 6.21 years, the average number of levels fused was 7 ± 3.37, with an operative time of 305.47 ± 116.90 minutes with 406.50 ± 92.7 mL of estimated blood loss. 24 patients suffered complications including PJK, instrumentation rupture, malposition material and infection. The results of the quality of life of patients with complications showing a significant statistical improvement in all parameters except the function subdomain (Pre- Complication: 2.55 ± 0.66; Post-Complication 2.93 ± 0.85, p = 0.082) and satisfaction subdomain (Pre-Complication 3.25 ± 1.25; Post-Complication 3.84 ± 0.91, p = 0.095) of the SRS-22 regarding the preoperative. The disability, that the ODI shows, is better and statistically significant than the preoperative one although it remains at high levels (Pre-Complication 57.58 ± 16.01; Post-Complication 43.47 ± 17.1, p < 0.05). Considering the pain in the VAS back [(Pre-Complication 8 (5.50-9); Post-Complication 4 (1.50-7.50), p < 0.05] and VAS leg [(Pre-Complication: 8 (5-8); Post 2 (0.50-5), p < 0.05] this significant improvement after complication. Quality of life parameters in patients with complications were affected, although with no statistically significant differences in comparison to the group of patients without re- surgery for some complication. Conclusions: The impact on quality of life of subjects who suffer complications in comparison to those that do not is reflected in greater functional limitations and worse results in subdomains of the SRS-22 questionnaire, despite improving after the surgery and without significant differences in comparison to the group of patients free from complications.
... Although surgical treatment of ASD improves QoL, the incidence of long-term mechanical complications is reported between 30 and 40% [3,4]. These rates increase if the spinal deformity and degenerative changes require instrumentation to the sacrum [5][6][7]. Among failures related to long instrumentation including the lumbosacral junction, distal screw loosening represents a common problem. ...
Purpose:
This in vitro biomechanical study compares residual lumbar range of motion (ROM) and rod strain after lumbopelvic instrumentation using 2 rods, 4 rods and interbody cages.
Methods:
Seven human cadaveric specimens were instrumented from L1 to sacrum, and pelvic screws were implanted. The pelvis was constrained and moments up to 7.5 Nm were applied to T12. Segmental L1-S1 ROM was analyzed by tracking radiopaque balls implanted in each vertebra using biplanar radiographs. Deformation within principal rods was measured by strain gauges. Four configurations were compared: 2 rods (2R), 4 rods (4R), 4 rods + ALIF at L4-L5 and L5-S1 (4R + ALIF), 2 rods + ALIF (2R + ALIF).
Results:
Intact average global L1-S1 ROM was 42.9° (27.9°-66.0°) in flexion-extension (FE), 35.2° (26.8°-51.8°) in lateral bending (LB), 18.6° (6.7°-47.8°) in axial rotation (AR). In FE, average ROM was 1.9° with both 4-rod configurations versus 2.5° with 2R and 2.8° with 2R + ALIF (p < 0.05). In LB, ROM ranged between 1.2° and 1.5° without significant differences. In AR, ROM was 2.5° with both 4-rod configurations versus 2.9° with 2R (p = 0.07) and 3.1° with 2R ALIF (p = 0.01). In FE, strain decreased by 64% and 65% in principal rods at L3-L4 with 4-rod. When comparing 2-rod configurations, strain decreased by 1% in flexion and increased by 22% in extension at L3-L4 when adding an ALIF at L4-L5 and L5-S1.
Conclusions:
Double rods and interbody cages decrease residual ROM in FE and AT. Double rods seem efficient in limiting strain in principal rods. The use of single rods with cages at the lumbosacral junction increases strain at the first adjacent level without cage.
... Currently, the most commonly used approach for correcting spinal imbalance in ASD is the posterior. Although low reoperation rates are intended, surgical complications mostly related to instrumentation increase the risk for unplanned surgery [2,[4][5][6]. In our study, 67 female patients, suffering from ASD and spinal imbalance, underwent successful 3-level lumbar POs for primary and revision causes with similar 6.29 ± 2.3° correction per osteotomy, without a significant loss of correction 49 ± 11 months following surgery. ...
PurposeTo report on quality of life and radiological changes of Ponte osteotomies (POs) with long fixation for primary and revision surgery, in elderly women with adult spinal deformity (ASD).
Methods
Sixty-seven (67) women, aged 69 ± 7 years, received 3 POs, spinopelvic fixation plus TLIFs. Forty-nine (73%) patients received primary and 18 (27%) revision surgery. Survivorship analysis was made for unplanned revision surgery for broken rods (BR); proximal junction failure (PJF); and deep wound infection (DWI). ODI and SF-36 were used for disability (ODI) and quality of life (SF-36) evaluation.ResultsIn total, 201 lumbar POs were made and 9.55 ± 3 levels fused. All patients were available 49 ± 11 months postoperatively. Postoperatively, SVA, CSVL, PI-LL, scoliosis, PT and T9-spinopelvic inclination were reduced, while LL and SS were increased significantly. At the final visit, PI−LL ≤ 10° was achieved in 26 (39.4%) patients; ≤ 15° in 51 (76%) patients, while all 67 patients showed a PI−LL ≤ 20°. Unplanned reoperation was performed in 11 (16.4%) patients: for BR in 5 (7.5%); for PJF in 3 (4.5%) and for DWI in 3 (4.5%) patients, respectively. With end point the reoperation for any reason the survival ± SE was 67.8% ± 0.1; for PJF 89.6 ± 0.065; and for BR 76% ± 0.1 in the final evaluation. There was no difference in survival between the primary and revision surgery groups (P = 0.568). ODI and SF-36 scores were improved postoperatively.Conclusions
Three-segment lumbar POs offered and maintained sufficient improvement of lumbar lordosis along with restoration of the sagittal and coronal spinal alignment, improvement of quality of life and disability of female adult and elderly population after primary and revision surgery for ASD.
... However, further research is still needed to con rm this process. A study has shown that the age of DLS patients is an important consideration factor for surgery because they may be associated with more comorbidities and a higher risk of postoperative complications [20]. However, other studies suggest that compared with young DLS patients, elderly patients have signi cantly improved postoperative symptoms, and there is no signi cant increase in complications and mortality [21,22]. ...
Background
Degenerative lumber spondylolisthesis (DLS), a common orthopaedic disease causing low back pain, seriously affects daily life and work. Although sagittal spinopelvic parameters have been studied in single-level DLS patients, investigations into different types of double-level DLS are scarce. This study aims to analyse the demographic and radiological parameters of patients with different types of double-level DLS and compare their differences to provide a reference for guiding surgical treatment and restoring sagittal balance of DLS patients.
Methods
From January 2014 to January 2020, double-level DLS patients’ records were retrospectively reviewed and divided into three types: anterior, posterior, and combined; the anterior and combined types were studied. Two spin surgeons measured the sagittal spinopelvic parameters: C7 tilt, maximal thoracic kyphosis (TKmax), maximal lumbar lordosis (LLmax), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Following descriptive analysis, demographic and radiographic data were compared between the anterior and combined types.
Results
Patients in the anterior type group (n = 40) were older (67.68 ± 6.66 vs. 61.72 ± 10.06 years, P = 0.031), and the proportion of females were significantly higher (90% vs. 50%, P = 0.001) than the combined group (n = 18). Both groups had different levels of chronic lower back pain, but the incidence of radiating leg pain and neurogenic claudication was significantly higher in the anterior type. Owestry disability index and visual analogue scale lower back scores were also higher in the anterior type. In the anterior type, C7 tilt (7.14 ± 2.15 vs. 5.41 ± 2.28, P = 0.007), LLmax (50.02 ± 14.76 vs. 36.96 ± 14.56, P = 0.003), PI (68.28 ± 9.16 vs. 55.53 ± 14.19, P < 0.001), PT (28.68 ± 7.31 vs. 19.38 ± 4.70, P < 0.001), and PT/PI (42.45 ± 11.22 vs. 36.04 ± 9.87, P = 0.041) were significantly higher. In the anterior type, PI correlated significantly positively with LLmax (r = 0.59) and SS (r = 0.71). LLmax and SS (r = 0.65) had a positive correlation. PT/PI and SS (r = -0.77) had a negative correlation. In the combined type, PI correlated positively with LLmax (r = 0.61) and SS (r = 0.88), and PT/PI correlated negatively with SS (r = -0.81).
Conclusions
In patients with double-level DLS, the sagittal spinopelvic parameters differ between the anterior and combined types. PI and LLmax were significantly higher in the anterior type, resulting in compensation by forward flexion and pelvic retroversion. Spinal surgeons should focus on correcting sagittal deformities, relieving postoperative clinical symptoms, and improving quality of life during fusion surgery, which is proven to guarantee long-term surgical results.
... This was demonstrated by Lonner et al. [44] who showed a significantly larger number of vertebrae fused in patients treated at adulthood (12.9 vs. 9.4), a higher risk for pelvic fixation, a longer operative time, and a larger blood loss and longer hospitalizations [44]. The risk for morbidity and a revision risk of nearly 20% is also observed in adults with a corrective surgery [45,46]. ...
Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.
... called mechanical failure [8][9][10][11][12][13]. The SRS-Schwab classification was developed to guide surgical decision making and establish targets for surgical results that would minimize postoperative disability [14]. ...
Study Design: Retrospective analysis of prospectively collected data.
Objectives: To validate the Global Alignment and Proportion (GAP) score in a single-center cohort of adult spinal deformity (ASD)
patients.
Summary of Background Data: Surgical treatment for ASD is associated with a high risk of mechanical failure and consequent revision
surgery. To improve prediction of mechanical complications, the GAP score was developed with promising results. Development was based
on the assumption that not all patients would benefit from the same fixed radiographic targets as pelvic incidence is an individual,
morphological parameter that greatly influences the sagittal curves of the spine.
Methods: In a validation study of the GAP score, patients undergoing ASD surgery with four or more levels of instrumentation were
consecutively included at a tertiary spine unit. Patients were followed for a minimum of two years. Pre- and postoperative GAP score and
categories were calculated for all patients, and the association with mechanical failure and revision surgery was analyzed.
Results: A total of 149 patients with a mean age of 57.4 years were included. Overall, the rates of mechanical failure and revision surgery
were 51% and 35% respectively. The area under the curve (AUC) using receiver operating characteristic was classified as ‘‘no or low
discriminatory power’’ for the GAP score in predicting either outcome (AUC 5 0.50 and 0.49, respectively). Similarly, there were no
significant associations between GAP categories and the occurrence of mechanical failure or revision surgery when using Cochran-
Armitage test of trend (p 5 .28 for mechanical failure and p 5 .58 for revision surgery).
Conclusions: In a consecutive series of surgically treated ASD patients, we found no significant association between postoperative GAP
score and mechanical failure or revision surgery. Despite minor limitations in similarities to the original study cohort, further validation
studies or adjustments to the original scoring system are proposed.
Level of Evidence: Level II.
... These have been described as failure of the fusion, spine or instrumentation. Therefore, the reported incidence of MC after surgical treatment in ASD is heterogeneous, and varies from 3.7% to 37% [10][11][12][17][18][19][20][21][22][23][24] . Published data concerning risk factors for MC in ASD corrected with an osteotomy are fragmented and suffer from several limitations. ...
... to 41%. [2][3][4][5][6][7][8][9][10][11][12] Numerous measures had been investigated to reduce the incidence of POI in abdominal, urological, or gynecological surgeries. These included preoperative optimization, gentle bowel handling, early feeding, avoidance of nonessential use of nasogastric tubes, thoracic epidural analgesia, pharmacological agents, and chewing gum. ...
Study design:
Randomized controlled trial.
Objective:
This study investigated on the effectiveness of chewing gum on promoting faster bowel function and its ability to hasten recovery for adolescent idiopathic scoliosis (AIS) patients following posterior spinal fusion (PSF) surgery.
Summary of background data:
Sham feeding with chewing gum had been reported to reducethe incidence of post-operative ileus by accelerating recovery of bowel function.
Methods:
We prospectively recruited and randomized 60 AIS patients scheduled for PSF surgery into treatment (chewing gum) and control group.The patient controlled anesthesia usage, wound pain score, abdominal pain score, nausea score and abdominal girth were assessed and recorded at 12, 24, 36, 48 and 60 hours post-operatively. The timing for the first fluid intake, first oral intake, sitting up, walking, first flatus after surgery, first bowel opening after surgery and duration of hospital stay were also assessed and recorded.
Results:
We found that there were no significant differences (p > 0.05) patient controlled anesthesia usage, wound pain score, abdominal pain score, nausea score and abdominal girth between treatment (chewing gum) and control groups. We also found that therewere no significant difference (p > 0.05) in post-operative recovery parameters which were the first fluid intake, first oral intake, sitting up after surgery, walking after surgery, first flatus after surgery, first bowel opening after surgery and duration of hospital stay between both groups. The wound pain was the worst at 12 hours post-operatively which progressively improved in both groups. The abdominal pain progressively worsened to the highest score at 48 hours in the treatment group and 36 hours in the control group before improving after that. The pattern of severity and recovery of wound pain and abdominal pain were different.
Conclusions:
We found that chewing gum did not significantly reduce the abdominal pain, promote faster bowel function or hasten patient recovery.
Level of evidence:
1.
... 7 As a result, many authors have identified the high risk (13.8-41%) of perioperative complications associated with the surgical treatment of this condition. [8][9][10][11][12][13][14][15][16][17][18] In an effort to further understand the risk factors for occurrence, complications have been described as major or minor 8 and further differentiated as surgical or medical. 2 Differentiating complications based on surgical or medical is useful, as the risk factors for each could be potentially different. Increasing our understanding of these risk factors may lead to the ultimate goal of identifying ways to decrease the incidence of complications with adult spinal deformity surgery. ...
Study design:
Retrospective review of a prospective multi-center database evaluating surgical ASD patients.
Objective:
This study aims to identify risk factors for medical complications in ASD patients undergoing surgery SUMMARY OF BACKGROUND DATA.: Adult Spinal Deformity (ASD) surgery is known for its high complication rate. This study examines baseline patient characteristics for predictors of medical complications in surgical ASD patients.
Methods:
Intra and perioperative medical complications were included. Medical complications were: infection, pneumonia, UTI, c-difficile, sepsis, stroke, delirium, DVT, PE, MI, arrhythmia, CHF, pneumothorax, atelectasis, ARDS, bowel obstruction, ileus, and renal failure. Potential predictors were identified using univariate testing. Multivariate poisson regression was used to determine independent predictors of medical complications. HRQL were measured using the ODI and SF-36. Multivariate repeated measures mixed models were used to examine HRQL.
Results:
448 patients were included. The incidence of patients with at least one medical complication was 26.8%. Potential predictors included: age, BMI, anemia, arthritis, depression, cardiac history, hypertension, lung disease, history of PVD, Charlson Comorbidity Index, ASA, smoking, gender, and the number of years with spine problems. Independent predictors identified on multivariate logistic regression modeling included hypertension (IRR 2.43 p = 0.0001), smoking (IRR 2.49 p = 0.0001) and number of years with spine problems (IRR 1.23 p = 0.03). Despite medical complications, patients experienced significant improvements in HRQL, as measured by the SF-36 (p = 0.0001) and ODI (p = 0.0001). The rate of improvement and overall improvement compared to baseline was not statistically different than that of patients who did not experience medical complications.
Conclusion:
Risk factors for the development of postoperative medical complications and infections following correction of ASD include smoking, hypertension and duration of symptoms. Patients who have one or more of these risk factors should be identified and informed during informed consent of their increased risks. They should be optimized pre-operatively, and followed closely during the post-operative period.
Level of evidence:
3.
... Anyway, the age of these patients is important to take into consideration as they may have more comorbidities and a higher risk of postoperative complications [33]. Surgical outcomes and complications after a correction surgery for spinal deformities have been analyzed by many authors [33][34][35][36]. On one hand, some authors concluded that in elderly patients, three-column osteotomy can achieve a significant correction of sagittal and coronal alignment and these authors also reported significant functional improvement [37]. ...
Purpose
Degenerative spondylolisthesis (DS) is a common disease. The importance of sagittal malalignment in the DS population has been widely described. However, there is no study reporting sagittal alignment analysis in double-level DS. This study aims to analyze patients with double-level DS and compare them with single-level DS patients in terms of demographic and radiographic data.
Methods
Retrospective multicenter (n = 13) study. Adult patients with one (uni_DS) or two-level DS (multi_DS) were included. Sagittal radiographic parameters were measured by an experienced observer: pelvic, spinal and global parameters with C7 sagittal tilt (C7 tilt, angle between the center of C7 vertebral body and the middle of the sacral endplate with the vertical reference line). After a descriptive analysis, radiographic and demographic data were compared between single and multi_DS.
Results
78 patients were included in multi_DS group and 576 in uni_DS group. Multi_DS were older than uni_DS (70.2 ± 9.4 vs 66.9 ± 10.6 years, p = 0.009). C7tilt was greater in multi_DS (6.2° ± 5.3 vs. 4.8° ± 3.8, p = 0.003). Multi_DS had a greater pelvic incidence (62.4° ± 11.3 vs. 58.3° ± 11.1, p = 0.002). Pelvic tilt was larger in multi-DS (26.0° ± 7.5 vs. 22.6° ± 8.1, p = 0.001). L4S1 lordosis represented 40.4 % of the LLmax in multi_DS and 45.8 % in uni_DS group (p = 0.013).
Conclusions
Multi_DS have different sagittal alignment than single DS with greater PI. In multi_DS, malalignment is more important with larger anterior tilt, loss of lumbosacral lordosis and more compensatory mechanisms such as pelvic retroversion. These findings highlight the need for an adapted surgical correction in these older patients with greater sagittal malalignment.
... De plus, le nombre de niveaux instrumentés et le risque d'inclure L5 ou le bassin dans l'arthrodèse étaient significativement plus élevés dans notre série lorsque l'arthrodèse était réalisée à l'âge adulte. On retrouve dans la littérature une morbidité 2 à 3 fois plus importante et un risque de reprise de près de 20 % dans les 6 premières années associé à ce type de chirurgie à l'âge adulte [11,12]. Ces deux arguments justifient une prise en charge chirurgicale des scolioses idiopathiques à l'adolescence. ...
À ce jour, il n’existe pas de solution thérapeutique consensuelle pour les scolioses idiopathiques de l’adolescent (SIA) dont la courbure est comprise entre 30 et 60° en fin de croissance.
... Moreover, the number of levels treated and the risk of L5 or the pelvis being included in fusion were significantly greater in fusion performed in adulthood. The literature reports 2 to 3-fold greater morbidity and a revision risk of nearly 20% in the first 6 years in fusion performed in adulthood [11,12]. These two arguments combine to indicate surgical management of AIS. ...
To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth.
The objective of this study was to assess outcome in patients with moderate AIS.
A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up.
A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores.
Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation.
IV, retrospective study.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
... Nevertheless, as already discussed in another opportunity , the fact that age seems to be an important risk factor for surgical complications after complex spinal procedures (something which is very logical and intuitive) does not necessarily mean that the natural history of the conservative treatment provides better long-term results than surgery nor that older patients should be denied the possible benefits of surgical intervention solely on the basis of their age [11]. In fact, in that subgroup of patients with refractory pain after failed medical treatment and injections, with important coronal and sagittal imbalance and with significant impairment of quality of life, several studies have demonstrated that a major surgical intervention (addressing not only the symptomatic levels of compression but also the global deformity problem) provides a safe " last-resource " therapeutic alternative with acceptable morbidity and complication rates and sustained long-term clinical benefits345 17] . A recent systematic review of the literature on the issue (which included 22 previous studies combining a total of 659 patients with a mean age of 74.2 years and a mean follow-up period of 3 years) demonstrated that the surgical procedure leaded to a reduction in ODI from 48.6 to 24.1 and a reduction in the mean preoperative VAS score from 7.7 to 5.2, with estimated mortality <1 % and an overall complication rate of 38 % [5]. ...
Study Design
Retrospective review.
Objectives
We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications.
Summary of Background Data
Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions.
Methods
Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications.
Results
The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) ( P <0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) ( P <0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P =0.03) and wound complications (OR 9.47, P =0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications ( P >0.05 for all).
Conclusions
Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery.
Level of Evidence
3.
Study design:
Retrospective review.
Objective:
To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus.
Summary of background data:
Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition.
Methods:
Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables.
Results:
Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus.
Conclusions:
In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management.
Level of evidence:
Level-III.
Study design:
Prospective comparative study.
Objective:
To investigate perioperative cardiac function using echocardiography in patients undergoing surgery for adult spinal deformity (ASD).
Summary of background data:
Corrective surgery for ASD has increased, especially in older persons. However, perioperative complication rates remain high in ASD surgery, including cardiopulmonary complications.
Methods:
This study included patients with ASD who underwent surgery between May 2016 and April 2018. A cardiologist performed all echocardiography imaging preoperatively and 2 weeks postoperatively. Left ventricular contractility was measured using left ventricular ejection fraction (LVEF), and right ventricular contractility was measured using tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular peak systolic velocity (S'). Spino-pelvic radiographic parameters, the apices of thoracic kyphosis and lumbar lordosis, and the inflection point where the vertebral curvature changes from kyphosis to lordosis were also measured. Differences between pre- and postoperative measurements for continuous variables were analyzed using a paired Student t test. Differences in continuous and categorical variables between two independent groups were analyzed using an unpaired Student t test and Fisher's exact test, respectively. Multivariate logistic regression analyses were performed to detect influential factors.
Results:
Sixty-one patients were included (12 males and 49 females; average age, 64.0 [22-84] years). LVEF, TAPSE, and S' respectively changed from 64.4%, 24.9 mm, and 14.3 cm/s to 65.4%, 25 mm, and 15 cm/s postoperatively with no significance. However, in LVEF<59.3% (average-1 standard deviation), TAPSE<17 mm, and S'<11.8 cm/s cases respectively, these increased significantly from 55.7%, 17.9 mm, and 10.5 cm/s to 60.9%, 21.4 mm, and 14.2 cm/s postoperatively (P=0.036, P=0.029, and P=0.022, respectively). The LVEF<59.3% group showed a significantly lower inflection point level (1.5 vs. 2.9) preoperatively (P=0.007). The S'<11.8 cm/s group showed significantly larger thoracic kyphosis (TK) (28.3° vs. 19.4°) preoperatively (P=0.013).
Conclusion:
Perioperative cardiac function did not deteriorate after surgery in patients with ASD. In those with lower cardiac function pre-operatively, there were significant improvements noted postoperatively. The preoperative inflection point level was significantly lower in the lower left ventricular ejection fraction group. Preoperative TK was significantly larger in the lower tricuspid annular peak systolic velocity group.
Background
Surgical approaches in adult spinal deformity are associated with high rates of adverse events including hardware failure and rod fracture. Recently, some reports have emerged comparing multiple-rod constructs with 2-rod constructs suggesting potential benefits with the former. However, these have been limited by variability in observed outcomes, which have limited the change of paradigm in adult spinal deformity surgery.
Objective
To compare the rate of rod fracture, pseudoarthrosis, proximal junctional kyphosis and re-operation between 2-RC and M-RC.
Methods
MEDLINE/Pubmed, Web of Science and Embase were searched without language restrictions for relevant articles from inception until October 2021. All observational cohort studies assessing patients with ADS undergoing 3-column osteotomy and comparing 2-RC with M-RC procedures on pseudarthrosis, rod fracture, kyphosis or reoperation were included. Data were independently extracted by 2 authors. Random-effects and Bayesian meta-analysis were used.
Results
Six primary studies met inclusion criteria, yielding a total of 448 participants, with 223 receiving 2-RC and 225 M-RC. The random-effects meta-analysis pointed to a significantly lower risk of rod fracture associated with M-RC (RR = 0.43, 95 %CI = 0.28–0.66), with moderate heterogeneity being observed (I² = 20 %, p = 0.28). The random-effects meta-analysis pointed to a lower risk of pseudoarthrosis with M-RC than with 2-RC (RR = 0.49, CI = 0.28–0.84, to a lower rate of re-operation with M-RC than with 2-RC (RR = 0.52, CI = 0.28–0.97) and to a similar rate of proximal junctional kyphosis between 2-RC and M-RC patients (RR = 0.91, CI = 0.60–1.39). Low heterogeneity was observed for studies comparing pseudoarthrosis (I² = 9 %, p = 0.35), re-operation (I² = 0 %, p = 0.41) and proximal junctional kyphosis (I² = 0 %, p = 0.85).
Discussion
These findings suggest that multiple rod-fracture constructs are associated with lower rates of rod fracture, re-operation rates, pseudoarthrosis but not proximal junctional kyphosis. Future studies should address the impact of other modulators of heterogeneity such as body mass index, metal alloys and length of the constructs.
BACKGROUND
: The substantial risk for medical complication after adult spinal deformity (ASD) surgery is well known. However, the timing of medical complications during the inpatient stay have not been previously described. Accurate anticipation of complications and adverse events may improve patient counseling and post-operative management.
PURPOSE
: (1) Describe the rate of medical complication and adverse events by post-operative day after ASD surgery and (2) determine whether early ambulation is protective for complications
STUDY DESIGN/SETTING
: Single institution retrospective cohort study
PATIENT SAMPLE
: 235 patients with ASD who underwent posterior-only fusion of the lumbar spine (≥5 levels to the pelvis) between 2013-2020
OUTCOME MEASURES
: Medical complications, categorized per the International Spine Study Group-AO system (cardiopulmonary [CP], gastrointestinal [GI], central nervous system [CNS], infectious [non-surgical site], and renal) and adverse events (post-operative blood transfusion, urinary retention, and electrolyte abnormalities)
METHODS
: Patients were identified from an institutional ASD database. Outcome measures were classified by the first post-operative day the event was recognized. Demographics, year of surgery, surgical factors, radiographic parameters, surgical invasiveness (ASD-S Index), frailty (Modified Frailty Index-5 [mFI-5]), Charlson Comorbidity Index (CCI), obstructive sleep apnea (OSA), smoking, preoperative opioid use, depression, and post-operative day of ambulation were assessed as risk factors for inpatient medical complications.
RESULTS
: After exclusions of patients with incomplete medical chart data, 191 patients were available for analysis, mean age 66±10 yrs, BMI 28±5 kg/m2, PI-LL 24±20°, T1PA 28±13°. Inpatient medical complications occurred in 55 (28.8%) patients; adverse events occurred in 137 (71.7%). Length of stay was higher in patients with medical complications (mean 8.5±3.8 vs. 5.8±2.3 days, p<0.001). However, for patients who had an adverse event, but no medical complication, LOS was comparable (p>0.05). Most medical complications occurred by POD3 (58% of all complications). Risk (defined as the proportion of patients with that complication out of all inpatients that day) of CNS, CP, and GI complication peaked early in the post-operative course (CNS on POD1 [2.1% risk]; GI on POD2 [3.7%]; CP on POD3 [2.7%]). Risk for infectious and renal complications (infectious POD8 [2.7%]; renal POD7 [0.9%]) peaked later (Figure 1). On univariate analysis, patients with medical complications had higher rates of OSA (9.1% vs. 2.2%, p=0.045), ASD-S (45.9 vs. 40.8, p=0.04), max coronal cobb (46.9 vs. 36.7°, p=0.003), ASA class (2.5 vs. 2.3, p=0.01), and POD of ambulation (1.9 vs. 1.3, p=0.01). On multivariate logistic regression (c-statistic 0.78), larger coronal cobb and later POD of ambulation were independent risk factors for complications (OR 1.04, 95% CI 1.01-1.07 and OR 2.3, 95% CI 1.2-4.7, respectively).
CONCLUSIONS
: Our data may inform peri-operative management and patient expectations for hospitalization after ASD surgery. Early ambulation may reduce the risk of complications.
Riassunto
L’allineamento sagittale è stato analizzato in numerosi studi che hanno dimostrato correlazioni tra parametri vertebrali e pelvici nella popolazione asintomatica e in pazienti con deformità vertebrale. Diversi autori hanno preso in esame inoltre la relazione tra i parametri radiografici, la compromissione funzionale o la qualità della vita di questi pazienti. Hanno dimostrato che un disallineamento sagittale era significativamente correlato con il dolore e la disabilità. Allo stesso modo, una deviazione coronale superiore a 2 cm o la presenza di dislocazione rotatoria sono associati a scarsi punteggi funzionali nei pazienti con scoliosi. In caso di deformità vertebrale severa, può quindi essere necessario effettuare una correzione al fine di ridurre il disagio funzionale e il dolore del paziente. Le osteotomie vertebrali correggono un disallineamento del rachide mediante resezione di una parte o di tutta una vertebra. Sono generalmente indicati per trattare una deformità rigida, responsabile di una patologia posturale. A livello della cerniera cervicotoracica, le grandi deformità della cifosi costituiscono un’indicazione primaria per l’esecuzione di un’osteotomia per sottrazione posteriore allargata. Un’analisi radiografica del disallineamento vertebrale è un prerequisito essenziale prima di intraprendere un gesto di correzione chirurgica. È inoltre richiesta un’ottima conoscenza della chirurgia del rachide, dell’anatomia, della biomeccanica e delle tecniche strumentali. Si distinguono diverse osteotomie posteriori: artrectomie parziali o totali, osteotomie a sottrazione transpeduncolare e transdiscale, resezioni vertebrali. Ogni tecnica di osteotomia vertebrale possiede propri requisiti e limiti. Tuttavia, queste tecniche di correzione delle deformità del rachide restano complesse e richiedono una buona esperienza di chirurgia del rachide, un programma tecnico, nonché un’adeguata assistenza postoperatoria. Le complicanze peri- e postoperatorie sono piuttosto frequenti, nella maggior parte dei casi di tipo neurologico o meccanico.
Resumen
El alineamiento sagital se ha analizado en muchos estudios y las correlaciones entre los parámetros raquídeos y pélvicos se han puesto de manifiesto en la población asintomática y en los pacientes con una deformación raquídea. Varios autores también han estudiado la relación entre los parámetros radiológicos y las molestias funcionales o la calidad de vida de estos pacientes. Han demostrado que un defecto de alineamiento sagital se correlacionaba significativamente con el dolor y la discapacidad. Asimismo, una inclinación coronal mayor de 2 cm o la existencia de una luxación rotatoria se asocian a malas puntuaciones funcionales en los pacientes con escoliosis. Por tanto, en caso de deformación raquídea importante, puede ser necesario realizar una corrección para disminuir las molestias funcionales y el dolor del paciente. Las osteotomías vertebrales permiten corregir un defecto de alineamiento de la columna mediante la resección de una parte o de toda una vértebra. Suelen estar indicadas para tratar una deformación rígida, causante de un trastorno postural. Al nivel de la charnela cervicotorácica, las deformaciones en gran cifosis son una indicación de elección para la realización de una osteotomía por sustracción posterior ampliada. El análisis radiológico del defecto de alineamiento raquídeo es un prerrequisito indispensable antes de llevar a cabo el procedimiento de corrección quirúrgica. También es necesario contar con unos conocimientos amplios de la cirugía raquídea, de la anatomía, de la biomecánica y de las técnicas de instrumentación. Se distinguen diferentes osteotomías posteriores: las artrectomías simples o totales, las osteotomías de sustracción transpedicular y transdiscal, así como las resecciones vertebrales. Cada técnica de osteotomía vertebral tiene sus exigencias y sus limitaciones. Sin embargo, estas diferentes técnicas de corrección de las deformaciones de la columna vertebral son difíciles y requieren una buena experiencia quirúrgica raquídea y unos medios técnicos, así como unos cuidados postoperatorios adecuados. Las complicaciones per y postoperatorias no son infrecuentes, en la mayoría de los casos neurológicas o mecánicas.
Résumé
Introduction
Le cintrage in situ représente une technique chirurgicale de reduction de la scoliose. La correction initiale pourrait évoluer dans le temps avec une détérioration de l’alignement sagittal. L’objectif de cette étude était d’analyser la perte de correction après chirurgie de scolioses lombaires dégénératives utilisant le cintrage in situ.
Matériel et méthodes
Les télécolonnes de 73 patients (âge moyen 63,3 ans, recul moyen 27 mois) étaient analysées en préopératoire, postopératoire et au dernier recul. Les paramètres suivants étaient mesurés : lordose C2–C7, cyphose T4–T12, lordose L1–S1, incidence pelvienne, version pelvienne, pente sacrée, SVA C7 et C2, angle de Cobb lombaire. Une inférence Bayésienne comparait l’évolution des paramètres. Une probabilité >0,95 était considérée comme variation significative.
Résultats
La chirurgie augmentait la lordose lombaire de −28,4° à −37,8° en postopératoire (probabilité 0,999), avec une diminution à −32,1° au dernier recul (probabilité 0,953). La cyphose thoracique augmentait de 29,6° à 37,4° en postopératoire (probabilité 1), et progressait à 41,6° au dernier recul (probabilité 0,999). La SVA C7 augmentait de 38,5 mm à 62,3 mm (probabilité 0,999) et la version pelvienne de 19,4° à 25,1° (probabilité 1) pendant le suivi postopératoire. Dix patients étaient réopérés pour infection du site opératoire. L’infection (13,7 %) était associée à une augmentation de la SVA C7 (probabilité 0,989) et de la cyphose thoracique (probabilité 0,987). La pseudarthrose (16,4 %) était associée à une diminution de lordose lombaire (probabilité 0,756).
Conclusion
La correction des scolioses lombaires dégénératives par cintrage in situ permettait une correction de l’alignement sagittal. Il existait une perte de correction dans le suivi postopératoire. Les facteurs de risque principaux étaient l’infection du site opératoire et la pseudarthrose.
Niveau de preuve
IV ; Étude rétrospective.
Introduction: In situ contouring is one of the surgical techniques used for scoliosis reduction. The initial correction could change over time, with deterioration of the sagittal balance. The purpose of this study was to analyze the loss of correction after degenerative lumbar scoliosis surgery using in situ contouring.
Materials and Methods Full spine radiographs of 73 patients (mean age 63.3 years, mean follow-up 27 months) were analyzed before surgery, after surgery, and at the final follow-up. The following radiographic parameters were measured: C2-C7 lordosis, T4-T12 kyphosis, L1-S1 lordosis, pelvic tilt, pelvic incidence, sacral slope, SVA C7, SVA C2, Cobb angle. Bayesian inference was used to compare the changes in these parameters. A probability >0.95 was considered as a significant change.
Results: After surgery, lumbar lordosis increased from −28.4° to −37.8° (probability 0.999), then decreased to −32.1° at the final follow-up (probability 0.953). Thoracic kyphosis increased from 29.6° to 37.4° after surgery (probability 1.00) and continued to increase to 41.6° at the final follow-up (probability 0.999). SVA C7 increased from 38.5 mm to 62.3 mm (probability 0.999) and pelvic tilt from 19.4° to 25.1° (probability 1.00) during the follow-up period. Ten patients had to be reoperated because of a surgical site infection. Infection (14%) was associated with an increase of SVA C7 (probability 0.989) and thoracic kyphosis (probability 0.987). Nonunion (16%) was associated with a decrease in lumbar lordosis (probability 0.756).
Conclusion: Correction of degenerative lumbar scoliosis by in situ contouring resulted in sagittal balance correction; however, some of this correction was lost during the follow-up period. The main risk factors were deep wound infection and nonunion.
Level of evidence: IV, Retrospective study.
Background
Degenerative lumber spondylolisthesis (DLS) is a common orthopedic condition, described as a condition that compared to lower vertebra, superior vertebra to slide forward or backward in the sagittal plane without accompanying isthmic spondylolisthesis. Information pertaining to different types of double-level DLS is scarce. This study aims to analyse parameters of patients with different types of double-level DLS to provide a reference for guiding surgical treatment and restoring sagittal balance of DLS patients.
Methods
From January 2014 to January 2020, double-level DLS patients’ records were retrospectively reviewed. Double-level DLS patients were divided into three types: anterior, posterior, and combined; the anterior and combined types were studied. The sagittal spinopelvic parameters included, C7 tilt, maximal thoracic kyphosis (TKmax), maximal lumbar lordosis (LLmax), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Following descriptive analysis, demographic and radiographic data were compared.
Results
Forty and 18 patients were included in the anterior and combined type groups, respectively. Both groups had different levels of chronic low back pain, but the incidence of radiating leg pain and neurogenic claudication was significantly higher in the anterior type. ODI and VAS low back scores were also higher in the anterior type. In the anterior type, C7 tilt (7.14±2.15 vs. 5.41±2.28, P = 0.007), LLmax (50.02±14.76 vs. 36.96±14.56, P = 0.003), PI (68.28±9.16 vs. 55.53±14.19, P <0.001), PT (28.68±7.31 vs. 19.38±4.70, P <0.001), and PT/PI (42.45±11.22 vs. 36.04±9.87, P = 0.041) were significantly higher. In the anterior type, PI correlated positively with LLmax (r = 0.59) and SS (r = 0.71). LLmax and SS (r = 0.65) had a positive correlation. PT/PI and SS (r = -0.77) had a negative correlation. In the combined type, PI correlated positively with LLmax (r = 0.61) and SS (r = 0.88), and PT/PI correlated negatively with SS (r = -0.81).
Conclusions
In patients with double-level DLS, the sagittal spinopelvic parameters differed between the anterior and combined types. Overall, spinal surgeons should focus on correcting sagittal deformities, relieving postoperative clinical symptoms, and improving quality of life during fusion surgery.
Resumen
La cifosis se define como una curvatura raquídea de concavidad anterior. En el plano sagital, la columna vertebral tiene una sucesión fisiológica de curvaturas armoniosas en direcciones opuestas: lordosis cervical, cifosis torácica, lordosis lumbar. Estas curvaturas se forman durante el crecimiento, y sus amplitudes varían de una persona a otra. Para cada persona, el equilibrio sagital de la columna vertebral es el resultado de una combinación de curvaturas que conducen a una postura «económica» que se denomina fisiológica. La cifosis se clasifica como patológica tras un análisis clínico preciso de la deformación teniendo en cuenta los antecedentes del paciente, la variabilidad frecuente de la población y múltiples factores psicológicos o sociales. La cifosis patológica puede dividirse en dos grupos principales. La cifosis regular se amplía armoniosamente sobre varias vértebras. Su carácter «patológico» se basa en la magnitud de la curvatura, su rigidez, su evolución o su localización en un segmento de la columna que por lo general presenta lordosis. La cifosis angular se forma en un pequeño número de vértebras. Suelen ser deformaciones grandes y rígidas cuyo carácter «patológico» es indiscutible. Múltiples causas, congénitas o adquiridas, son responsables del desarrollo de la cifosis raquídea patológica. El análisis de la deformación y el conocimiento de su historia natural son el requisito previo indispensable para cualquier proyecto terapéutico. Se resumen y analizan los principales pasos diagnósticos y terapéuticos para cada una de las causas más frecuentes de cifosis patológica.
Bone quality of the spine should play an important role in the planning of surgical intervention for spinal deformities. Patients with osteoporosis may require spinal instrumentation for several reasons, including severe mechanical pain due to spinal imbalance associated with deformity, spinal stenosis associated with deformity (adult degenerative scoliosis), and spinal instability or neurologic deterioration after a spinal truama.
Although long spinal deformity fusions in elderly patients is controversial, some studies have shown that elderly patients can obtain as much clinical benefit as their younger counterparts (≤55 years of age) after spinal deformity surgery.
However, it has been shown that pedicle screw instru mentation of the osteoporotic spine carries an increased risk of surgical complications. Despite being the most rigid form of posterior instrumentation, pedicle screws may provide insufficient strength for rigid fixation and fusion in patients with osteoporosis. The effect of bone quality on the pullout strength of pedicle screws was demonstrated in an “in-vivo” study with patients submitted to lumbar fusion with a positive correlation between bone mineral density (BMD) and the maximum torque required to insert a pedicle screw. A 5-year followup series of instrumentation in patients with osteoporosis demonstrated that pedicle fractures and compression fractures occurred in 13% of the cases and progressive junctional kyphosis occurred in 26% of patients. These series also found an increased incidence of other late complications including pseudarthrosis with instrumentation failure, adjacent level disc degeneration with herniation, compression fractures, and progressive kyphosis.
Despite the strong evidence of the detrimental effects of poor bone quality in the postoperative outcomes of patients submitted to spinal instrumentation, it seems that the majority of the spine surgeons still fall short in per forming an adequate appraisal of a patient’s bone quality. For example, a questionnaire applied to spine surgeons attending a conference on disorders of the spine demonstrated that a large percentage of spine surgeons do not routinely screen for osteoporosis or osteomalacia.
Spinal surgery is constantly progressing with the development of innovative treatment options and a shift toward minimally invasive options that improve outcomes and reduce morbidity. Minimally invasive diskectomy procedures are found in the literature as early at the 1950s followed by the development of chemonucleolysis, laser diskectomy, tubular microscopic diskectomy, and the currently available full-endoscopic techniques. As visualization of the disk and surrounding anatomy improved, unique approaches were designed to better access and treat the broad variety of lumbar disk pathologies. This chapter reviews the evolution of surgical treatment of lumbar diskectomy and outlines modern day treatment options with a focus on endoscopic techniques.
Adult degenerative scoliosis (ADS) surgery is known for its high incidence of complications. The propose of this study was to determine current complication rates and the predictors of medical complications in surgical ASD patients. A retrospective study of 153 ADS patients who underwent long level spinal fusion with 2-year follow-up between 2012 and 2017. The patient- and surgical-related risk factors for each individual medical complication were identified by using univariate testing. All patients were divided into groups with and without medical complication, infection, neurological complications, and cardiopulmonary complications, respectively. Potential risk factors were identified using univariate testing. Multivariate Logistic regression was used to evaluate independent predictors of medical complications. The total medical complication incidence was 26.1%. Patient-related independent risk factors for the development of medical complications included diabetes, smoking; for infection were diabetes and smoking; for neurological complications were BMI and diabetes; for cardiopulmonary complications were hypertension, smoking and cardiac comorbidity. Surgical-related independent risk factors for the development of medical complications were fusion level, operative time, osteotomy, blood transfusion and LOS; for infection were fusion level, blood transfusion, and LOS; for neurological complication were fusion level, osteotomy and blood transfusion; for cardiopulmonary complication were fusion level. Diabetes and smoking were the most common patient-related independent risk factors increase the development of each individual medical complication. On the other hand, fusion levels and blood transfusion were the most common surgical-related independent risk factors increase the development of each individual medical complication. Prevention of these risk factors can reduce the incidence of complications in Chinese patients with ADS surgery.
PurposeThis study evaluates baseline patient characteristics and surgical parameters for risk factors of medical complications in ASD patients received posterior long level internal fixation. Methods
Analysis of consecutive patients who underwent posterior long-level instruction fixation for adult degenerative scoliosis (ADS) with a minimum of two year follow-up was performed. Pre-operative risk factors, intraoperative variables, peri-operative radiographic parameters, and surgical-related risk factors were collected to analyze the effect of risk factors on medical complications. Patients were separated into groups with and without medical complication. Then, complication group was further classified as major or minor medical complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of medical complications. ResultsOne hundred and thirty-one ADS patients who underwent posterior long segment pedicle screws fixation were included. Total medical complication incidence was 25.2%, which included infection (12.2%), neurological (11.5%), cardiopulmonary (7.6%), gastrointestinal (6.1%), and renal (1.5%) complications. Overall, 7.6% of patients developed major medical complications, and 17.6% of patients developed minor medical complications. The radiographic parameters of pre-operative and last follow-up had no significant difference between the groups of medical complications and the major or minor medical complications subgroups. However, the incidence of cerebrospinal fluid leak (CFL) in patients who without medical complications was much lower than that with medical complications (18.4 vs. 42.4%, P = 0.005). Independent risk factors for development of medical complications included smoking (OR = 6.45, P = 0.012), heart disease (OR = 10.07, P = 0.012), fusion level (OR = 2.12, P = 0.001), and length of hospital stay (LOS) (OR = 2.11, P = 0.000). Independent risk factors for development of major medical complications were diabetes (OR 6.81, P = 0.047) and heart disease (OR = 5.99, P = 0.049). Except for the last follow-up, Oswestry Disability Index and visual analog scale of the patient experienced medical complications trend higher score; the clinical outcomes have no significant difference between the medical and major complications groups. Conclusion
Heart disease comorbidity is an independent risk factor for both medical and major medical complications. Smoking, fusion level, and LOS are independent risk factors for medical complication. Diabetes is the independent risk factors for major medical complications.
Objective:
The aim of this study was to analyze the impact of treatment complications on outcomes in adult spinal deformity (ASD) using a decision analysis (DA) model.
Methods:
The study included 535 ASD patients (371 with non-surgical (NS) and 164 with surgical (S) treatment) from an international multicentre database of ASD patients. DA was structured in two main steps; 1) Baseline analysis (Assessing the probabilities of outcomes, Assessing the values of preference -utilities-, Combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and 2) Sensitivity analysis. Complications were analyzed as life threatening (LT) and nonlife threatening (NLT) and their probabilities were calculated from the database as well as a thorough literature review. Outcomes were analyzed as improvement, no change and deterioration. Death/complete paralysis was considered as a separate category.
Results:
All 535 patients were analyzed in regard to complications. Overall, there were 78 NLT and 12 LT complications and 3 death/paralysis. Surgical treatment offered significantly higher chances of clinical improvement but also was significantly more prone to complications (31.7% vs. 11.1%, p < 0.001).
Conclusion:
Surgical treatment of ASD is more likely to cause complications compared to NS treatment. On the other hand, surgery has been shown to provide a higher likelihood of improvement in HRQoL scores. So, the decision on the type of treatment in ASD needs to take both chances of improvement and burden associated with S or NS treatments and better be arrived by the active participation of patients and physicians equipped with the present information.
Level of evidence:
Level II, Decision analysis.
Study design:
Retrospective cohort study at a single institution.
Objective:
We aimed at estimating the rate of revision procedures and identify radiographic predictors of mechanical failure following adult spinal deformity surgery.
Summary of background data:
Mechanical failure rates following adult spinal deformity surgery range 12% to 37% in literature. While the importance of spinal and spino-pelvic alignment is well documented for surgical outcome and ideal alignment has been proposed as sagittal vertical axis (SVA) < 5 cm, pelvic tilt < 20° and lumbar lordosis (LL) = pelvic incidence ± 9°, the role of radiographic sagittal spine parameters and alignment targets as predictors for mechanical failure remains uncertain.
Methods:
A consecutive cohort of adult spinal deformity patients who underwent corrective surgery with at least 5 levels of instrumentation between January 2008 and December 2012 at a single tertiary spine unit were followed for at least 2 years. Time to death or failure was recorded and cause-specific Cox regressions were applied to evaluate predictors for mechanical failure or death.
Results:
138 patients with median age of 61 years were included for analysis. Follow-up ranged 2.1 to 6.8 years. In total 47% had revision and estimated failure rates were 16% at one year increasing to 56% at five years. A multivariate analysis adjusting for age at surgery showed increased hazard of failure from LL change > 30°, postoperative TK > 50° and SS ≤30°. LL change was mostly due to 3-column osteotomy and ending the instrumentation at L5 or S1 increased the hazard of failure more than 6 fold compared to more cranial lumbar levels.
Conclusions:
Mechanical failure rate was 47% following adult spinal deformity corrective surgery. LL change > 30°, postoperative TK > 50° and postoperative SS ≤30° were independent radiographic predictors associated with increased hazard of failure.
Level of evidence:
4.
Adult spinal deformity (ASD) is a very diverse condition that affects the quality of life of the involved individuals deeply. There is an ongoing discussion as to whether treatment should be surgical (which is potentially dangerous) or non-surgical.
In addition to a systematic review of literature on the surgical treatment of ASD with special emphasis on complications, a decision-analysis was performed using the patient information within a European multi-centric database of ASD.
The probabilities of improvement and complications as well as associated disease burden (utility) were calculated at the baseline and at first-year follow-up.
Decision-analysis suggests that the chances of clinical improvement are significantly higher with surgical treatment. Though surgical treatment is significantly more prone to complications, the likelihood of improvement remains higher than that offered by non-surgical treatment.
Surgical treatment of ASD appears to be associated with a higher likelihood of clinical improvement. Future work needs to focus on refining the criteria for appropriate patient selection and decreasing the incidence of complications.
Cite this article: Acaroglu E, European Spine Study Group. Decision-making in the treatment of adult spinal deformity. EFORT Open Rev 2016;1:167-176. DOI: 10.1302/2058-5241.1.000013.
OBJECT
Frequent complications of posterolateral instrumented fusion have been reported after treatment of degenerative scoliosis in elderly patients. Considering that in some cases, most of the symptomatology of adult degenerative scoliosis (ADS) is a consequence of the segmental instability at the dislocated level, the use of minimally invasive anterior lumbar interbody fusion (ALIF) to manage symptoms can be advocated to reduce surgical morbidity. The purpose of this study was to evaluate the midterm outcomes of 1- or 2-level minimally invasive ALIFs in ADS patients with 1- or 2-level dislocations.
METHODS
A total of 47 patients (average age 64 years; range 43–80 years) with 1- or 2-level ALIF performed for ADS (64 levels) in a single institution were included in the study. An independent spine surgeon retrospectively reviewed all the patients’ medical records and radiographs to assess operative data and surgery-related complications. Clinical outcome was reported using the Oswestry Disability Index (ODI) and the visual analog scale (VAS) for lumbar and leg pain. Intraoperative data and complications were collected. Fusion and risk for adjacent-level degeneration were assessed.
RESULTS
The mean follow-up duration was 3 years (range 1–10 years). ODI, and back and leg pain VAS scores were significantly improved at last follow-up. A majority of patients (74%) had a statistically significant improvement in their ODI score of more than 20 points at latest follow-up and 1 had a worsening of his disability. The mean operating time was 166 minutes (range 70–355 minutes). The mean estimated blood loss was 410 ml (range 50–1700 ml). Six (5 major and 1 minor) surgical complications (12.7% of patients) and 13 (2 major and 11 minor) medical complications (27.7% of patients) occurred without death or wound infection. Fusion was achieved in 46 of 47 patients. Surgery resulted in a slight but significant decrease of the Cobb angle, and improved the pelvic parameters and lumbar lordosis, but had no effect on the global sagittal balance. At latest follow-up, 9 patients (19.1%) developed adjacent-segment disease at a mean of 2 years’ delay from the index surgery; 4 were symptomatic but treated medically, and none required iterative surgery.
CONCLUSIONS
Single- or 2-level minimally invasive fusion through a minimally invasive anterior approach in some selected cases of ADS produced a good functional outcome with a high fusion rate. They were associated with a significantly lower rate of complications in this study than the historical control.
Long fusion to the sacrum has been demonstrated to increase the mechanical failure rate after adult spinal deformity (ASD) surgery, and these mechanical failures are the most common etiology for reoperation. The purpose of this study was to determine the incidence and risk factors for mechanical failure associated with reoperation after spinal fusion to the sacrum in ASD.
The study included 76 patients with ASD who underwent spinal fusion surgery including the sacrum at a single institution between 2005 and 2010. The inclusion criteria were a minimum age of 20 years and fusion of ≥5 levels. The terminal event was defined as either the first reoperation for mechanical failure or a minimum of 2 years following surgery in patients who did not undergo reoperation.
The cumulative reoperation rate for mechanical failure was 37 % (n = 28). The procedure survival rate was 79 % at 1 year and 72 % at 2 years. Mechanical failures consisted of proximal junctional complications in 16 patients and pseudarthrosis in 12 patients. Proximal junctional kyphosis (PJK) was the most frequent cause (n = 15), and seven patients were diagnosed with fractures at the UIV or one level above the UIV. Multivariate analysis identified the following as independent factors predicting mechanical failure: three or more comorbidities, smoking, and a preoperative sagittal vertical axis of >95 mm. SRS-22r and ODI scores were lower in patients with mechanical failure.
Overall, 37 % of the patients who underwent ASD surgery involving the sacrum required reoperation for mechanical failure. The most frequent form of mechanical failure associated with reoperation was surgical PJK. Significant risk factors for mechanical failure included medical comorbidities, smoking, and severe preoperative sagittal imbalance. Critical mechanical failure may have a negative influence on health status.
Introduction/purpose
In adult scoliosis surgery (AS) delineation of risk factors contributing to failure is important to improve patient care. Treatment goals include deformity correction resulting in a balanced spine and horizontal lowest instrumented vertebra (LIV) in fusions not ending at S1. Therefore, the study objectives were to determine predictors for deformity correction, complications, revision surgery, and outcomes as well as to determine predictors of postoperative evolution of the LIV-take-off angle (LIV-TO) and symptomatic adjacent segment disease (ASD).
Methods
The authors performed a retrospective analysis of 448 patients who had AS surgery. Patients’ age averaged 51 years, BMI 26, and follow-up of 40 months. According to the SRS adult scoliosis classification, 51 % of patients had major lumbar curves, 24 % each with single thoracic or double major curves. 54 % of patients had stable vertebra at L5 and 34 % of patients had fusion to S1. The mean number of posterior fusion levels was eight and implant density 73 %. Among standard radiographic measures of deformity the LIV-TO was assessed on neutral and bending/traction-films (bLIV-TO). Clinical outcomes were assessed in 145 patients with degenerative-type AS using validated measures (ODI, COMI and SF-36). Prediction analysis was conducted with stepwise multiple regression analyses.
Results
Preoperative thoracic curve (TC) was 53° and 33° at follow-up. Preoperative lumbar curve (LC) was 43° and 24° at follow-up. Curve flexibility was low (TC 34 %/LC 38 %). TC-correction (38 %) was predicted by preoperative TC (r = 0.9) and TC-flexibility (r = 0.8). LC-correction (50 %) was predicted by preoperative LC (r = 0.8), LC-flexibility (r = 0.8) and screw density (r = 0.7). Preoperative LIV-TO was 18.2° and at follow-up 9.4° (p
Propionibacterium acnes was previously considered a contaminant and its role in spine infection has been understated. Although rare, such infections are present especially after instrumented spine surgery. They are usually delayed and hard to diagnose. Delayed infection should be suspected in patients with pain and a history of spine surgery. In this article, we review the diagnostic challenges associated with delayed P. acnes infection after spine surgery, guided by relevant studies in the literature. The medical databases of PubMed, Medline and Embase were searched for the literature on delayed spine infections and osteomyelitis following spinal procedures. The medical literature was reviewed for articles published between 1955 and 2008. Our review of the literature revealed 13 cases of P. acnes osteomyelitis following surgical procedures involving the spine. We also present a clinical case of delayed P. acnes osteomyelitis following discectomy and fusion with instrumentation.
This study presents a survivorship analysis of Cotrel-Dubousset instrumentation in the surgical treatment of idiopathic scoliosis. Between 1987 and 1995, a total of 133 patients with idiopathic scoliosis received posterior spine fusion and instrumentation with the CD system at our center. The patients' mean age at surgery was 16.5 years (range 11-43 years). The magnitude of the thoracic scoliosis averaged 62.7 degrees (range 40 degrees -125 degrees ) and that of the lumbar curve was 58.8 degrees (range 40 degrees -100 degrees ). On average, 12.2 segments were fused (range 8-17) and, excluding the rods, 14.1 implants were set for each patient (range 10-21). Survivorship analysis was carried out using the Kaplan-Meier method. Implant removal was considered the terminal event, or "death". The effect of several variables on survival rate was determined with the Cox regression method. The patients remained in the study for 56.7 months (range 2-120 months). One-hundred and ten patients were withdrawn ("censored"): 90 "alive" (did not require repeat surgery and attended follow-up control in 1997) and 20 "lost" (did not attend control in 1997). Twenty-three patients attained the terminal event of implant removal for a variety of reasons: acute infection (three cases), late infection (ten cases), implant failure requiring revision (six cases) and local pain (four cases). The survival rate was 95.5% at 3 months, 94.7% at 6 months, 93.9% at 1 year, 91.5% at 2 years, 82.2% at 5 years and 76.5% at 10 years. The magnitude of the curves, total number of implants and number of fused segments did not correlate with survival probability. A positive correlation was found between survival rate and correction loss between surgery and last control. A survival rate of 76.5% at 10 years is unexpectedly low. Current data suggest that the incapacity to maintain correction after initial surgery plays a major roll in the long-term evolution of Cotrel-Dubousset instrumentation.
A retrospective analysis of adults treated with long instrumented fusion for scoliosis from the thoracic spine proximally to L4 or L5. To evaluate the long-term clinical outcomes as well as radiological changes in distal unfused mobile segments and to evaluate factors that may predispose to distal disc degeneration and/or poor outcome. A total of 151 mobile segments in 85 patients (65 female), mean age 43.2 (range 21-68), were studied. Curve type, number of fused levels and pelvic incidence were recorded. Clinical outcome was measured using the Whitecloud function scale and disc degeneration using the UCLA disc degeneration score. Spinal balance, local segmental angulations and lumbar lordosis were measured pre- and post-operatively as well as at the most recent follow up--mean 9.3 years (range 7-19). A total of 62% of patients had a good or excellent outcome. Eleven had a poor outcome of which ten underwent extension of fusion--five for pain alone, three for pain with stenosis and two for pseudarthroses. Pre-operative disc degeneration was often asymmetric and was slightly greater in older patients. Overall, there was a significant deterioration in disc degeneration (P < 0.0001) that did not correlate with clinical outcome. Disc degeneration correlated with the recent sagittal balance (Anova F = 14.285, P < 0.001) and the most recent lordosis (Anova F = 4.057, P = 0.048). The post-operative sagittal balance and local L5-S1 sagittal angulation correlated to L4 and L5 degeneration, respectively. There was no correlation between degeneration and age, pre-operative degenerative score, pelvic incidence, sacral slope, number of fused levels or distal level of fusion. Disc degeneration does occur below an arthrodesis for scoliosis in adults which does not correlate with clinical outcome. The correlation of loss of sagittal balance with disc degeneration may be as a result of degeneration causing the loss of balance or vice versa, i.e. sagittal imbalance causing degeneration. Immediate post-operative imbalance correlates with degeneration of the L4/5 disc, which may imply the latter.
Study Design. A retrospective study of adults with long fusion to the sacrum using three different fixations was performed. Objective. To compare the long-term clinical results and complications associated with three methods of lumbosacral fixation for adult spine deformities: Luque-Galveston, combined iliac and sacral screws, and sacral screws. Summary of Background Data. The preferred technique for long fusion to the sacrum is controversial, and surgery for adult deformity is fraught with significant technical difficulties and high complication rates. No clinical study compares the long-term outcome of long fusion to the sacrum using these different methods of lumbosacral fixation. Methods. This study included 54 consecutive patients who underwent elective combined anterior and posterior surgical reconstruction for adult spine deformity with a minimum follow-up period of 2 years. The patients were divided into three groups on the basis of the surgical method used for the posterior spine instrumentation. Group 1 consisted of 11 patients with smooth L-rod and segmental sublaminar wire instrumentation (Luque-Galveston technique). Group 2 consisted of 36 patients with posterior Isola segmental instrumentation and combined iliac and sacral screws. Group 3 consisted of 12 patients with Isola segmental instrumentation using bicortical sacral screws. Five patients were revised to another fixation group, giving a total of 59 cases. Radiographic, clinical results, and long-term outcome data were obtained using the modified Scoliosis Research Society (SRS) outcome instrument. Results. There were 26 late complications. Pseudarthrosis developed in 10 patients, requiring revision surgery: 4 (36%) in the Group 1, 5 (14%) in Group 2, and 1 (8.5%) in Group 3. Comparison of the modified SRS outcomes showed no difference among the groups. The average SRS grand total score was 73.4% for Group 1, 70.9% for Group 2, and 62.6% for Group 3. Overall, 76% of the patients were satisfied with their outcome. The presence of perioperative complications or pseudarthrosis significantly correlated with a lower satisfaction score (P = 0.012 and P = 0.048, respectively). Sagittal plane decompensation significantly correlated with a higher pain score (P = 0.035). Patients with prior surgeries scored lower on the self-image questions than patients with no prior surgery (P = 0.007). Conclusions. Attention to sagittal balance is critical in these patients. Revision surgery is as safe and effective as primary surgery. According to the current findings, the Luque-Galveston fixation technique has an unacceptably high rate of pseudarthrosis, and this method is not recommended for adult deformities. Currently, the authors are using bicortical and triangulated sacral screws with an anterior interbody support in patients with good bone stock, but only when the spine balance is restored. Otherwise, they recommend using iliac fixation, although there is a higher rate of painful hardware, requiring removal.
OBJECTIVE: The purpose of this study was to assess whether back pain is improved with surgical treatment compared with nonoperative management in adults with scoliosis.
METHODS: This is a retrospective review of a prospective, multicentered database of adults with spinal deformity. At the time of enrollment and follow-up, patients completed standardized questionnaires, including the Oswestry Disability Index (ODI) and Scoliosis Research Society 22 questionnaire (SRS-22), and assessment of back pain using a numeric rating scale (NRS) score, with 0 and 10 corresponding to no and maximal pain, respectively. The initial plan for surgical or nonoperative treatment was made at the time of enrollment.
RESULTS: Of 317 patients with back pain, 147 (46%) were managed surgically. Compared with patients managed nonoperatively, operative patients had higher baseline mean NRS scores for back pain (6.3 versus 4.8; P < 0.001), higher mean ODI scores (35 versus 26; P < 0.001), and lower mean SRS-22 scores (3.1 versus 3.4; P < 0.001). At the time of the 2-year follow-up evaluation, nonoperatively managed patients did not have significant change in the NRS score for back pain (P = 0.9), ODI (P = 0.7), or SRS-22 (P = 0.9). In contrast, at the 2-year follow-up evaluation, surgically treated patients had significant improvement in the mean NRS score for back pain (6.3 to 2.6; P < 0.001), ODI score (35 to 20; P < 0.001), and SRS-22 score (3.1 to 3.8; P < 0.001). Compared with nonoperatively treated patients, at the time of the 2-year follow-up evaluation, operatively treated patients had a lower NRS score for back pain (P < 0.001) and ODI (P = 0.001), and higher SRS-22 (P < 0.001).
CONCLUSIONS: Despite having started with significantly greater back pain and disability and worse health status, surgically treated patients had significantly less back pain and disability and improved health status compared with nonoperatively treated patients at the time of the 2-year follow-up evaluation. Compared with nonoperative treatment, surgery can offer significant improvement of back pain for adults with scoliosis.
Study Design. Radiographic analysis was performed retrospectively. Outcomes and complications were collected prospectively. Objectives. To assess complications after posterior fusion and instrumentation for degenerative lumbar scoliosis, to determine risk factors of complications, and to analyze the clinical outcomes of surgery. Summary of Background Data. The complications after degenerative lumbar scoliosis surgery have reported to be high. Risk factors for developing complications are unknown. Methods. Forty-seven patients (average age, 66.6 years; range, 48-83 years) with degenerative lumbar scoliosis undergoing posterior fusion and instrumentation were analyzed. Seven patients had additional posterior lumbar interbody fusion at the lumbosacral junction. The average number of levels fused was 4.7 +/- 2.2 segments. We evaluated the early perioperative ( < 3 months after surgery) and late complications. Results. There were 14 early perioperative complications and 18 late complications. There was 1 case of mortality by pulmonary embolism. Early complications included ileus, urinary tract infection, transient delirium, superficial infection, and neurologic deficit. Late complications included adjacent segment diseases, pseudarthrosis, and loosening of screws. Adjacent segment disease developed at the proximal segment in 10 patients and at the distal segment in 5 patients. Pseudarthrosis was noted at the lumbosacral junction in 2 patients. Revision surgery was performed in 7 patients. Older patients (> 65 years) had the tendency to increase early complications without statistical difference (P = 0.053). Excessive intraoperative blood loss was the most significant risk factor for the development of early perioperative complications, and number of levels fused was related to blood loss. Operative time and multiple medical comorbidities were not associated with higher complication rate. There were no specific factors related to the development of late complications. Conclusion. The complication rate after posterior fusion and instrumentation for degenerative lumbar scoliosis was 68%. Abundant blood loss was a significant risk of Oswestry disability index was less in patients with late complications.
A retrospective study of complications with minimal 5-year follow-up of 50 adults with scoliosis with fusion from T10 or higher to S1.
To document the perioperative and long-term complications and instrumentation problems, and to attempt to determine variables which may influence these problems. It is not a study of curve correction, balance, or functional outcome.
Several previous studies from this and other centers have shown a relatively high complication rate for this select group of patients. Various fusion techniques (anterior, posterior, autograft, allograft), various instrumentation techniques, and various immobilization techniques have created confusion as to the best methodology to employ. Minimal 2-year follow-ups have been standard, but longer follow-ups have shown additional problems.
The study cohort consisted of 50 adult patients from a single center who had undergone corrective scoliosis surgery from T10 or higher to the sacrum and who had at least a 5-year minimum follow-up. The mean age was 54 years (range, 18-72), and the mean follow-up was 9.7 years (range, 5-26). All radiographs, office charts, and hospital charts were combed by an independent investigator for complications, which were divided into major and minor, as well as early, intermediate and late. The curvature values and corrections were the subject of a different article, and were not included in this study.
There were no deaths or spinal cord injuries. Six patients had nerve root complications, 4 of which totally recovered. Pseudarthrosis was seen in 24% of the patients, only 25% of which were detected within the 2-year follow-up period. Pseudarthrosis was most common at the lumbosacral level. There was no statistical difference in the pseudarthrosis rate between patients with sacral-only fixation versus iliac fixation. Painful implants requiring removal were noted in 11 of the 50 patients.
Long fusions to the sacrum in adults with scoliosis continue to have a high complication rate. As compared to the original publications in the 1980s (Kostuik and Hall, Spine 1983;8:489-500; Balderston et al, Spine 1986;11:824-9) the more recent articles have shown a reduction, but not elimination of the pseudarthrosis problem using segmental instrumentation and anterior fusion of the lumbar spine coupled with structural interbody grafting at L4-L5 and L5-S1. Two-year follow-up is inadequate as pseudarthrosis and painful implants often are detected later. Only 3 of the 12 patients with pseudarthrosis were detected within the first 2 years after surgery.
Retrospective review of a prospectively collected, multicenter database.
To assess rates of new neurologic deficit (NND) associated with spine surgery.
NND is a potential complication of spine surgery, but previously reported rates are often limited by small sample size and single-surgeon experiences.
The Scoliosis Research Society morbidity and mortality database was queried for spinal surgery cases complicated by NND from 2004 to 2007, including nerve root deficit (NRD), cauda equina deficit (CED), and spinal cord deficit (SCD). Use of neuromonitoring was assessed. Recovery was stratified as complete, partial, or none. Rates of NND were stratified based on diagnosis, age (pediatric < 21; adult ≥ 21), and surgical parameters.
Of the 108,419 cases reported, NND was documented for 1064 (1.0%), including 662 NRDs, 74 CEDs, and 293 SCDs (deficit not specified for 35 cases). Rates of NND were calculated on the basis of diagnosis. Revision cases had a 41% higher rate of NND (1.25%) compared with primary cases (0.89%; P < 0.001). Pediatric cases had a 59% higher rate of NND (1.32%) compared with adult cases (0.83%; P < 0.001). The rate of NND for cases with implants was more than twice that for cases without implants (1.15% vs. 0.52%, P < 0.001). Neuromonitoring was used for 65% of cases, and for cases with new NRD, CED, and SCD, changes in neuromonitoring were reported in 11%, 8%, and 40%, respectively. The respective percentages of no recovery, partial, and complete recovery for NRD were 4.7%, 46.8%, and 47.1%, respectively; for CED were 9.6%, 45.2%, and 45.2%, respectively; and for SCD were 10.6%, 43%, and 45.7%, respectively.
Our data demonstrate that, even among skilled spinal deformity surgeons, new neurologic deficits are inherent potential complications of spine surgery. These data provide general benchmark rates for NND with spine surgery as a basis for patient counseling and for ongoing efforts to improve safety of care.
Retrospective review of a prospectively collected database.
Our objective was to assess the rates of postoperative wound infection associated with spine surgery.
Although wound infection after spine surgery remains a common source of morbidity, estimates of its rates of occurrence remain relatively limited. The Scoliosis Research Society prospectively collects morbidity and mortality data from its members, including the occurrence of wound infection.
The Scoliosis Research Society morbidity and mortality database was queried for all reported spine surgery cases from 2004 to 2007. Cases were stratified based on factors including diagnosis, adult (≥ 21 years) versus pediatric (<21 years), primary versus revision, use of implants, and whether a minimally invasive approach was used. Superficial, deep, and total infection rates were calculated. RESULTS.: In total, 108,419 cases were identified, with an overall total infection rate of 2.1% (superficial = 0.8%, deep = 1.3%). Based on primary diagnosis, total postoperative wound infection rate for adults ranged from 1.4% for degenerative disease to 4.2% for kyphosis. Postoperative wound infection rates for pediatric patients ranged from 0.9% for degenerative disease to 5.4% for kyphosis. Rate of infection was further stratified based on subtype of degenerative disease, type of scoliosis, and type of kyphosis for both adult and pediatric patients. Factors associated with increased rate of infection included revision surgery (P < 0.001), performance of spinal fusion (P < 0.001), and use of implants (P < 0.001). Compared with a traditional open approach, use of a minimally invasive approach was associated with a lower rate of infection for lumbar discectomy (0.4% vs. 1.1%; P < 0.001) and for transforaminal lumbar interbody fusion (1.3% vs. 2.9%; P = 0.005).
Our data suggest that postsurgical infection, even among skilled spine surgeons, is an inherent potential complication. These data provide general benchmarks of infection rates as a basis for ongoing efforts to improve safety of care.
Unintended durotomy is a common complication of spinal surgery. However, the incidences reported in the literature vary widely and are based primarily on relatively small case numbers from a single surgeon or institution.
To provide spine surgeons with a reliable incidence of unintended durotomy in spinal surgery and to assess various factors that may influence the risk of durotomy.
We assessed 108,478 surgical cases prospectively submitted by members of the Scoliosis Research Society to a deidentified database from 2004 to 2007.
Unintended durotomy occurred in 1.6% (1745 of 108 478) of all cases. The incidence of unintended durotomy ranged from 1.1% to 1.9% on the basis of preoperative diagnosis, with the highest incidence among patients treated for kyphosis (1.9%) or spondylolisthesis (1.9%) and the lowest incidence among patients treated for scoliosis (1.1%). The most common indication for spine surgery was degenerative spinal disorder, and among these patients, there was a lower incidence of durotomy for cervical (1.0%) vs thoracic (2.2%; P = .01) or lumbar (2.1%, P < .001) cases. Scoliosis procedures were further characterized by etiology, with the highest incidence of durotomy in the degenerative subgroup (2.2% vs 1.1%; P < .001). Durotomy was more common in revision compared with primary surgery (2.2% vs 1.5%; P < .001) and was significantly more common among elderly (> 80 years of age) patients (2.2% vs 1.6%; P = .006). There was a significant association between unintended durotomy and development of a new neurological deficit (P < .001).
Unintended durotomy occurred in at least 1.6% of spinal surgeries, even among experienced surgeons. Our data provide general benchmarks of durotomy rates and serve as a basis for ongoing efforts to improve safety of care.
Retrospective review of a prospectively collected database.
The Scoliosis Research Society (SRS) collects morbidity and mortality (M and M) data from its members. Our objectives were to assess complication rates for 3 common spine procedures, compare these results with prior literature as a means of validating the database, and to assess rates of pulmonary embolism (PE) and deep venous thrombosis (DVT) in all cases reported to the SRS over 4 years.
Few modern series document complication rates of spinal surgery as routinely practiced across academic and community settings. Those available are typically based on relatively low numbers of procedures or confined to single-surgeon experiences.
The SRS M and M database was queried for lumbar microdiscectomy (LD), anterior cervical discectomy and fusion (ACDF), and lumbar stenosis decompression (LSD) cases from 2004 to 2007. Revisions were excluded. The database was also queried for occurrence of clinically evident PE and DVT in all cases from 2004 to 2007.
A total of 9692 LDs, 6735 ACDFs, and 10,329 LSDs were identified, with overall complication rates of 3.6%, 2.4%, and 7.0%, respectively. These rates are comparable to previously published smaller series. For assessment of PE and DVT, 108,419 cases were identified and rates were calculated per 1000 cases based on diagnosis, age group, and implant use. Overall rates of PE, death due to PE, and DVT were 1.38, 0.34, and 1.18, respectively. Among 82,082 adults, the rate of PE ranged from 0.47 for LD to 12.4 for metastatic tumor. Similar variations were noted for DVT and deaths due to PE.
Overall major complication rates for LD, ACDF, and LSD based on the SRS M and M database are comparable to those in previously reported smaller series, supporting the validity of this database for study of other less common spinal disorders. In addition, our data provide general benchmarks of clinically evident PE and DVT rates as a basis for ongoing efforts to improve care.
A retrospective comparative study.
To investigate the morphologic features of proximal vertebral fractures in adults following spinal deformity surgery using segmental pedicle screw instrumentation.
Fractures above pedicle screw constructs are a clinical problem that warrants further investigation for prevention and treatment.
Ten adult patients (6 lumbar scoliosis, 4 degenerative sagittal imbalance) who underwent segmental spinal instrumented fusion were analyzed. Patients were divided into 2 groups according to the features of vertebral fracture: upper instrumented vertebral collapse + adjacent vertebral subluxation (SUB group: n = 5), and adjacent vertebral fracture (Fracture group: n = 5).
Both groups demonstrated a high frequency of osteopenia and all patients in the SUB group had comorbidities before surgery. The SUB group demonstrated a shorter interval between initial surgery and the fracture (subluxation: 3 +/- 1.9 months; fracture: 33 +/- 25.3 months, P < 0.05), and hypokyphosis (T5-T12) in the thoracic region before surgery (SUB: 13 degrees +/- 6.4 degrees; fracture: 33 degrees +/- 15.6 degrees). Both groups demonstrated severe global sagittal imbalance (SUB: 151 +/- 62.8 mm; fracture: 94 +/- 102.2 mm), and hypolordosis (T12-S1) in the lumbar spine (SUB: -19 degrees +/- 24.4 degrees ; fracture: -33 degrees +/- 22.7 degrees) before surgery. Global sagittal imbalance in the SUB group was corrected to 8 +/- 17.4 mm immediately postoperative (P < 0.05), but increased to 64 +/- 19.9 mm after the junctional fractures (P < 0.05). The SUB group demonstrated a significantly higher wedging rate (SUB: 65% +/- 12.4%; fracture: 36% +/- 16.0%, P < 0.05) and greater local kyphosis (SUB: 42 degrees +/- 11.1 degrees; fracture: 17 degrees +/- 4.1 degrees, P < 0.05) after the fracture. Two of 5 patients in the SUB group demonstrated severe neurologic deficit from E to B after the fractures by a modified Frankel classification.
Old age, osteopenia, preoperative comorbidities, and severe global sagittal imbalance were found to be frequent in patients with proximal junctional fracture. In addition, marked correction of sagittal malalignment might be considered as a risk factor of upper instrumented vertebra collapse followed by adjacent vertebral subluxation, which occurred in the first 6 months after corrective surgery with the potential for causing severe neurologic deficit because of the severe local kyphotic deformity.
Retrospective review of a prospective, multicenter study.
The purpose of this study was to assess the prevalence and severity of leg pain in adults with scoliosis and to assess whether surgery significantly improved leg pain compared with nonoperative management.
Patients with adult scoliosis characteristically present with pain. The presence of leg pain is an independent predictor of a patient's choice for operative over nonoperative care.
Data were extracted from a prospective, multicenter database for adult spinal deformity. At enrollment and follow-up, patients complete the Oswestry Disability Index (ODI) and assessment of leg pain using the numerical rating scale (NRS) score, with 0 and 10 representing no pain and unbearable pain, respectively. Plan for operative or nonoperative treatment was made at enrollment. The vast majority of adult scoliosis patients seen in our surgical clinics have received nonoperative therapies and are being seen for a surgical evaluation. Patients are counseled regarding operative and nonoperative management options and are in general encouraged to maximize nonoperative treatments.
Two hundred eight (64%) of 326 adults with scoliosis had leg pain at presentation (mean NRS score = 4.7). Ninety-six patients with leg pain (46%) were managed operatively and 112 were treated nonoperatively. The operative group had higher baseline mean NRS score for leg pain (5.4 vs. 4.1, P < 0.001) and higher mean ODI (41 vs. 30, P < 0.001). At 2-year follow-up, nonoperative patients had no significant change in ODI or NRS score for leg pain (P = 0.2). In contrast, at 2-year follow-up surgically treated patients had significant improvement in mean NRS score for leg pain (5.4 vs. 2.2, P < 0.001) and ODI (41 vs. 24, P < 0.001). Compared with nonsurgically treated patients, at 2-year follow-up operative patients had lower mean NRS score for leg pain (2.2 vs. 3.8, P < 0.001) and mean ODI (24 vs. 31, P = 0.005).
Despite having started with significantly greater leg pain and disability, surgically treated patients at 2-year follow-up had significantly less leg pain and disability than nonoperatively treated patients. Surgical treatment has the potential to provide significant improvement of leg pain in adults with scoliosis.
Prospective observational cohort study with matched and unmatched comparisons. Level II evidence.
The purpose of this study is to compare results of adult symptomatic lumbar scoliosis (ASLS) patients treated nonoperatively and operatively. This is an evidence-based prospective multicenter study to answer the question of whether nonoperative and operative treatment improves the quality of life (QOL) in these patients at 2-year follow-up.
Only 1 paper in the peer-reviewed published data directly addresses this question. That paper suggested that operative treatment was more beneficial than nonoperative care, but the limitations relate to historical context (all patients treated with Harrington implants) and the absence of validated patient-reported QOL (QOL) data.
This study assesses 160 consecutively enrolled patients (ages 40-80 years) with baseline and 2-year follow-up data from 5 centers. Lumbar scoliosis without prior surgical treatment was defined as a minimum Cobb angle of 30 degrees (mean: 54 degrees for patients in this study). All patients had either an Oswestry Disability Index (ODI) score of 20 or more (mean: 33) or Scoliosis Research Society (SRS) domain scores of 4 or less in pain, function, and self-image (mean: 3.2) at baseline. Pretreatment and 2-year follow-up data collected prospectively included basic radiographic parameters, complications and SRS QOL, ODI, and Numerical Rating Scale back and leg pain scores.
At 2 years, follow-up on the operative patients was 95% and for the nonoperative patients it was 45%. The demographics for the nonoperative patients who were followed up for 2 years versus those who were lost to follow-up were identical. The operative cohort significantly improved in all QOL measures. The nonoperative cohort did not improve and nonsignificant decline in QOL scores was common. At minimum 2-year follow-up, operative patients outperformed nonoperative patients by all measures.
It would appear from this study that common nonoperative treatments do not change the QOL in patients with ASLS at 2-year follow-up. However, operative treatment does significantly improve the QOL for this group of patients. Our conclusions are limited by the fact that we were only able to follow-up 45% of the nonoperative group to 2-year follow-up, in spite of extensive efforts on our part to accomplish such.
Retrospective review with matched-cohort analysis performed at a single institution.
To determine risk factors and outcomes for acute fractures at the proximal aspect of long pedicle screw constructs.
Acute fractures at the top of long segmental pedicle screw constructs (FPSC) can be catastrophic. Substantial surgical increase in lordosis may precipitate this problem. In relation to a matched cohort, we postulated that age, body mass index (BMI), and significant correction of lumbar lordosis would increase risk of FPSC and patients with FPSC would have lesser improvements in outcomes.
Thirteen patients who sustained FPSC between 2000 and 2007 were evaluated. During this time, 264 patients aged 40 or older had a spinal fusion from the thoracic spine to the sacrum using an all-pedicle screw construct. A cohort of 31 of these patients without FPSC but with all pedicle screw constructs was matched for diagnosis of positive sagittal imbalance, gender, preoperative C7 sagittal plumb, and number of levels fused.
There was a significant difference in age (P = 0.02) and BMI (P = 0.006) between the matched groups. There was no significant difference in preoperative/postoperative C7 plumb or change in lumbar lordosis between groups. Acute neurological deficit developed in 2 patients; both patients improved substantially after revision surgery. Nine patients underwent proximal extension of the fusion. For 7 of the 13 FPSC patients with bone mineral density data (BMD) available, average T score was-1.73; -0.58 for the matched group (10/31 with bone mineral density data) (P = 0.02).
Factors that increased the risk of FPSC included obesity and older age. Osteopenia increased the risk as evidenced by BMD (based on 17 patients) and the older age of these patients. There was no statistical difference in clinical improvement between groups based on ODI, but the FPSC group did demonstrate a smaller improvement in ODI score than the matched cohort.
Retrospective case-control study.
The purpose of this study was to compare the self-reported outcomes between operatively and nonoperatively treated patients over the age of 65 with adult scoliosis, using 4 distinct self-assessment questionnaires (SRS-22, SF-12, EQ5D, and Oswestry disability index [ODI]) and standard radiographic measurement parameters.
The current spine literature contains no studies that directly compare the self-reported and radiographic outcomes of operatively and nonoperatively treated patients over the age of 65 years with adult scoliosis.
We retrospectively analyzed the self-reported outcomes of 83 adult scoliosis in patients over the age of 65 years. A total of 34 patients were treated operatively, whereas 49 patients were managed nonoperatively. For each of these patients, standard radiographic measurements were recorded both before and after treatment, and each patient received 4 questionnaires (SRS-22, SF-12, EQ5D, and ODI) that were completed with a minimum of 2-year follow-up from the time the treatment was initiated. The outcomes of both groups were then statistically compared.
As compared to the nonoperative group, the operative group reported significantly better self-assessment scores for the EQ5D index, EQ5D Visual Analogue Score, and SRS-22 questionnaires. However, no statistically significant difference between the groups was detected for the ODI, SF-12 Mental Health Component Summary, and SF-12 PCS. Furthermore, the operative group also had a significant improvement in radiographic measurements.
Adult scoliosis patients over the age of 65 years treated operatively had significantly less pain, a better health-related quality of life, self image, mental health, and were more satisfied with their treatment than patients treated conservatively. However, we found no statistically significant differences in their degree of disability as measured by the ODI as well as physical and mental health by the SF-12 instrument. Preoperative radiographic deformity was not determined to be a significant factor for predicting whether an operative or nonoperative treatment course was chosen.
Retrospective cohort study of consecutive patients undergoing primary fusion with segmental fixation for adult spinal deformity.
We sought to determine the survivorship of primary fusion for adult spinal deformity and identify patient-specific predictors of complications requiring reoperation.
Compared with the adolescent population, surgery for adult deformity is often more complex and technically difficult, contributing to a high reported rate of complications that can result in the need for reoperation. Reported complication rates vary widely.
From 1999-2004 all patients who underwent primary instrumented fusion for nonparalytic adult spinal deformity at a single center were included. Inclusion criteria included minimum age at surgery of 20 years and minimum fusion length of 4 motion segments. Surgical, demographic, and comorbidity data were recorded. Reoperation was defined as any additional surgery involving levels of the spine operated on during the index procedure and/or adjacent levels. Comparisons were performed between patients who required reoperation and those who did not.
Eighty-nine patients met inclusion criteria. Endpoint (minimum 2 years follow-up or reoperation) was reached for 91%. Mean follow-up was 3.8 years. Cumulative reoperation rate was 25.8%. Survival was 86.4% at 1 year, 77.2% at 2 years, and 75.2% at 3 years. Reasons for reoperation included infection (n = 8), pseudarthrosis (n = 3), adjacent segment problems (n = 5), implant failure (n = 4), and removal of painful implants (n = 3). Multivariate analysis showed smoking was significantly higher in the reoperation group.
Using a strict definition of reoperation for a well-defined cohort, in the presence of relevant risk factors, many patients undergoing primary fusion for adult spinal deformity required reoperation. The results indicate that complex medical and surgical factors contribute to the treatment challenges posed by patients with adult spinal deformity. This represents the largest cohort reported to date of patients undergoing primary fusion using third-generation instrumentation techniques.
Retrospective case control study.
Determine the impact of infection on clinical outcome in patients undergoing posterior spinal fusion surgery.
The outcome of patients treated for infection after spinal surgery is not well established because of variability in cohort identification, definition of infection, outcomes instrument, use of a control group, and/or sample size.
Thirty-two patients were included. Sixteen patients ("infection group") met inclusion criteria of deep wound infection after spinal fusion with posterior segmental instrumentation (including combined approach). A 1:1 matched cohort ("control group") was created based on primary or revision status, length of fusion, diagnosis, and age. Postoperative patient outcomes were evaluated using the physical components of SF-36 v2.0 with minimum 2-year follow-up.
No significant difference in the Physical Function, Role Physical, Bodily Pain, and General Health domains was detected between the infection group and control group. Mean follow-up was 62 months. Mean Physical Component Summary was 41.4 in the infection group and 44.3 in the control group (P = 0.6). Infection occurred early in 12 patients and late in 4 patients. Most common organisms isolated were Staphylococcus epidermidis, Enterococcus sp., and Staphylococcus aureus. Multiple debridements were significantly associated with polymicrobial infections and later pseudarthrosis requiring reoperation.
An aggressive approach to deep wound infection emphasizing early irrigation and debridement allowed preservation of instrumentation and successful fusion in most cases. At the conclusion of treatment, patients can expect a medium-term clinical outcome similar to patients in whom this complication did not occur.
A retrospective case series.
To determine if implant retention is possible in spinal deformity cases which present as a delayed (greater than 3 months) surgical site infection.
The retention of spinal implants in deformity surgery is possible with an acute surgical site infection. Currently, the decision whether or not to retain implants in a delayed surgical site infection is unclear.
A retrospective review of 26 cases of delayed surgical site infections after spinal deformity surgery. Data and information was recorded regarding the initial management of the surgical site infection, the number of operations performed related to the infection, and whether or not the infection could be cleared with implant retention. The number of operations, hospital days, and charges related to the treatment of the infection were recorded.
In this series, no patient was able to clear their infection without spinal implant removal. The number of operations required to clear the infection, length of hospitalization, and financial charges were proportionate to the timing of implant removal.
Delayed surgical site infections after spinal instrumentation for deformity need to be treated with implant removal to clear the surgical site infection. Patients may require to undergo repeat instrumentation and fusion at a later date if they develop progressive deformity or symptomatic pseudarthrosis after implant removal.
: A Cumulative Illness Rating Scale, designed to meet the need for a brief, comprehensive and reliable instrument for assessing physical impairment, has been developed and tested. The scale format provides for 13 relatively independent areas grouped under body systems. Ratings are made on a 5-point “degree of severity” scale, ranging from “none” to “extremely severe.” Findings, in terms of reliability and validity, reflect statistical significance at the P < .01 level. As a rapid assessment technique which is objective and easily quantified, the scale is well suited to a variety of research uses.
A retrospective analysis of eight cases of delayed spinal infection after elective posterior or combined anterior and posterior spinal instrumentation and fusion.
These cases are reviewed to identify risk factors for delayed spinal infection after elective instrumentation and to describe the treatment of this complication.
Delayed spinal infection after elective spinal instrumentation and fusion is uncommon. This diagnosis is frequently difficult.
Five cases seen in the senior author's practice and three referral cases are reviewed.
Of these eight cases, the organisms were Staphylococcus epidermidis in six cases, Propionibacterium acnes in one cases, and in the final patient, all intraoperative cultures were negative. Clinical presentations were variable; however, all patients reported back pain. Seven patients had elevated erythrocyte sedimentation rates, averaging 57 mm/hour. Only two had elevated white blood cell counts. No distant foci of infection were identified in any patient. Five-patients were found to have at least one pseudarthrosis. All patients were treated with debridement, instrumentation removal, and primary wound closure over drains followed by a minimum 6-week course of culture-directed postoperative antibiotics. At an average follow-up of 18 months, no patient has evidence of infection.
The diagnosis of delayed infection after elective spinal instrumentation and fusion requires a high index of suspicion. These infections may have been caused by intraoperative inoculation. All patients were successfully treated with debridement, instrumentation removal, and culture-directed postoperative antibiotics.
The authors of this prospective study examined the preoperative and 3-year postoperative magnetic resonance images of 14 patients undergoing anterior and posterior fusion and/or posterior fusion only for scoliosis. All magnetic resonance images were ready by two independent neuroradiologists, who were blinded to the purposes of the study, for the presence of disc narrowing, signal decrease on T2, or herniated nucleus pulposus before and after surgery. Particular attention was paid to the disc changes at the level directly below the end vertebral level of the fusion and two levels below the fusion in the lumbosacral spine existing before surgical intervention.
To evaluate the potential for disc degeneration distal to long scoliosis fusions with end fusion levels in the mid to lower lumbar spine.
The determination of end levels of fusion for contructs presently used to manage adult scoliotic deformity has been evaluated in terms of correction of curvature and late decompensation in coronal and sagittal plane balance after fusion. However, the natural history of the caudal, free-motion segments in terms of degeneration and/or correlation with pain has not yet been addressed.
Fourteen patients undergoing scoliosis fusion underwent magnetic resonance imaging before surgery and approximately 3 years after surgery. The scans were reviewed by two independent neuroradiologists who looked at three degenerative indices at the disc below the area of scoliosis fusion. The authors analyzed rates of change of the three degenerative indices in the pre- and postoperative magnetic resonance images and created associations between the observed changes on the magnetic resonance images and the clinical outcomes of pain, the presence or absence of solid fusion, and the need for repeat surgery.
Estimates of the rates of change of the three degenerative indices one or two levels below the fusion were as follow: the chance of disc narrowing, .2-34%; the chance of a decreasing signal on T2, 5-54%, with a 23% incidence among this group; and the chance of herniated nucleus pulposus, 0-34%. There was a significant correlation between the presence of back and/or leg pain and the signal decrease one level below the fusion (P = .04).
If these results are corroborated in a larger sample size, surgeons who manage deformity may have to consider altering fusion levels at the time of fusion based on magnetic resonance imaging predictors. The present data may help to inform patients about the risk of developing junctional degenerative changes and potential symptoms from these changes below scoliosis fusions.
To determine the incidence of delayed infections in idiopathic scoliosis treated with TSRH instrumentation, proper wound management after instrumentation removal, and whether the previously identified bacterial trend remains consistent.
All patients with idiopathic scoliosis > or =2 years after surgery with posterior TSRH instrumentation were included. Those cases with delayed infections were retrospectively reviewed. Time of presentation (infection) from index operation, clinical picture, sedimentation rate, presence of pseudarthrosis, organisms grown on culture, type of wound closure, and duration of antibiotics were examined.
A total of 489 patients were identified > or =2 years postoperation; 23 had delayed infections (4.7%). Time of presentation averaged 27 months after initial surgery. Spontaneous drainage occurred in 15 patients, fluctuance in 6, and neither in the remaining 2 (pain and fever). Sedimentation rate averaged 48 mm/hr. All patients had instrumentation removed. Primary closure (1 stage) was performed in 14 patients, and delayed primary closure (> or =2 stages) was performed in nine patients. All wounds healed uneventfully. Cultures at the time of instrumentation removal grew Propionibacterium acnes in 12 patients, Staphylococcus epidermidis (or Staphylococcus coagulase-negative) in 4, Micrococcus varians in 1, and Staphylococcus aureus in 1. Five patients had negative cultures. After removal, patients received parenteral antibiotics; in 21 of these patients this was followed by oral antibiotics.
Low-virulent skin organisms are primarily responsible for delayed infections. Intraoperative seeding followed by subclinical quiescent periods appears to be the method by which infection occurs. The increased bulk and modularity of modern instrumentation systems can lead to inflammation and bursa formation, thus contributing significantly to the activation of these infections. Primary wound closure results in successful wound healing. Delayed closure after 48 hours is unnecessary. Short-term postoperative parenteral antibiotics (2-5 days) followed by short-term oral antibiotics (7-14 days) is recommended.
A retrospective study of adults with long fusion to the sacrum using three different fixations was performed.
To compare the long-term clinical results and complications associated with three methods of lumbosacral fixation for adult spine deformities: Luque-Galveston, combined iliac and sacral screws, and sacral screws.
The preferred technique for long fusion to the sacrum is controversial, and surgery for adult deformity is fraught with significant technical difficulties and high complication rates. No clinical study compares the long-term outcome of long fusion to the sacrum using these different methods of lumbosacral fixation.
This study included 54 consecutive patients who underwent elective combined anterior and posterior surgical reconstruction for adult spine deformity with a minimum follow-up period of 2 years. The patients were divided into three groups on the basis of the surgical method used for the posterior spine instrumentation. Group 1 consisted of 11 patients with smooth L-rod and segmental sublaminar wire instrumentation (Luque-Galveston technique). Group 2 consisted of 36 patients with posterior Isola segmental instrumentation and combined iliac and sacral screws. Group 3 consisted of 12 patients with Isola segmental instrumentation using bicortical sacral screws. Five patients were revised to another fixation group, giving a total of 59 cases. Radiographic, clinical results, and long-term outcome data were obtained using the modified Scoliosis Research Society (SRS) outcome instrument.
There were 26 late complications. Pseudarthrosis developed in 10 patients, requiring revision surgery: 4 (36%) in the Group 1, 5 (14%) in Group 2, and 1 (8.5%) in Group 3. Comparison of the modified SRS outcomes showed no difference among the groups. The average SRS grand total score was 73.4% for Group 1, 70.9% for Group 2, and 62.6% for Group 3. Overall, 76% of the patients were satisfied with their outcome. The presence of perioperative complications or pseudarthrosis significantly correlated with a lower satisfaction score (P = 0.012 and P = 0.048, respectively). Sagittal plane decompensation significantly correlated with a higher pain score (P = 0.035). Patients with prior surgeries scored lower on the self-image questions than patients with no prior surgery (P = 0.007).
Attention to sagittal balance is critical in these patients. Revision surgery is as safe and effective as primary surgery. According to the current findings, the Luque-Galveston fixation technique has an unacceptably high rate of pseudarthrosis, and this method is not recommended for adult deformities. Currently, the authors are using bicortical and triangulated sacral screws with an anterior interbody support in patients with good bone stock, but only when the spine balance is restored. Otherwise, they recommend using iliac fixation, although there is a higher rate of painful hardware, requiring removal.
A retrospective clinical and radiographic analysis of long adult deformity fusions terminating at L5.
To define the results of thoracolumbar fusions to L5 in adult deformity patients with critical evaluation for potential subsequent L5-S1 disc degeneration and L5 implant loosening.
Few studies have reported the results of long adult fusions to L5 and the potential for subsequent advanced L5-S1 disc degeneration is unknown.
Thirty-four consecutive patients fused from the thoracic spine to L5 at a single institution were evaluated at a mean follow-up of 5.6 years (2.1-14.3 years). SRS-24 functional outcome questionnaire results were obtained for all patients at most recent follow-up.
By latest follow-up, subsequent advanced L5-S1 disc degeneration (SAD) developed in 19 of 31 patients (61%) assessed as having "healthy" discs before surgery. SAD was associated with a forward shift in sagittal balance (P = 0.02) and need for revision surgery (P = 0.02). Risk factors for the development of SAD were preoperative positive sagittal balance (P = 0.01), younger age (P = 0.03), and the presence of even mild radiographic degeneration before surgery (P = 0.004). Loss of L5 implant fixation occurred in six patients (18%) and was associated with deep seating of L5 within the pelvis (P = 0.0001). Inferior SRS-24 outcome measures were associated with preoperative advanced L5-S1 disc degeneration and the development of postoperative sagittal imbalance.
Subsequent L5-S1 DDD developed in 61% of patients after long adult fusions to L5 and was associated with a significant loss of sagittal alignment and an increased likelihood for or definite need for another operation. Loss of L5 implant fixation is not uncommon, especially in patients with a deep-seated L5 vertebra.
A retrospective study was conducted to investigate the incidence and prognosis of postoperative lumbar nerve root palsy after surgical treatment for adult spinal deformity.
To decipher the incidence of postoperative lumbar nerve root palsy and recovery in 361 adult spinal deformity patients who underwent 407 spinal fusion surgeries.
Although lumbar nerve root palsy is a known complication of spinal surgery, there are no large studies that have examined its incidence or prognosis.
Three hundred and sixty-one consecutive patients who underwent 407 procedures for adult deformity spinal surgery were reviewed. Patients in this study did not have spinal cord injury or nerve root compression on the postoperative imaging study (obtained for change in neurologic examination). The incidence of nerve root palsy was based on postoperative muscle strength, which was followed for a minimum of 3 and an average of 7 years.
The overall incidence of lumbar nerve root palsy was 2.9% with a 1.4% incidence in primary and 3.8% incidence in revision surgery. The incidence was 0.9, 1.5, and 7.4% for fusion of <5 levels, 5 to 10 levels, and >10 levels, respectively. The incidence of nerve root palsy for posterior only, same day anterior-posterior, and staged posterior was 1.3, 3, and 7.2%, respectively. While L5 was the most commonly injured nerve root, all other lumbar nerve roots were also involved. There were no S1 injuries. Although there was some recovery in most injuries, Grade IV injuries had the best recovery at 1-year follow-up.
Patients with increasingly complex spinal deformities are at a higher risk for postoperative lumbar nerve root palsy. These injuries can be treated nonoperatively when there is no identifiable cause on postoperative imaging studies.
Retrospective follow-up of patients over the age of 65 with a minimum of five-level fusions.
To determine the effect on outcomes of long constructs in patients with poor bone stock, and to review surgical techniques used in patients with poor bone stock.
Scoliotic deformities in patients with poor bone stock require alterations in both the surgical technique and preoperative planning. To our knowledge, complications of long constructs in poor bone stock have not been specifically reported.
Patients over the age of 65 that underwent a minimum of five-level fusion over a 5-year period were reviewed. We reviewed both operative reports and clinic notes and recorded both early and late complications.
Early complications included pedicle fractures and compression fractures with an overall rate of 13%. Late complications included pseudarthroses with instrumentation failure, adjacent level disc degeneration with herniation, compression fractures, and progressive kyphosis. Progressive junctional kyphosis occurred in 26% of patients.
Spinal stabilization surgery in patients with poor bone stock is associated with high complication rates. Complications such as progressive kyphosis adjacent to the fusion are difficult to address with instrumentation alone.
Review article of preoperative evaluation of surgical patients as relates to adult spine patients.
To determine which patients should undergo preoperative evaluation and review options for improved preoperative preparation for these patients.
There is increasing attention paid to preoperative preparation for surgical patients to decrease perioperative morbidity. Better preoperative evaluation may lead to decreased complication rates and may improve outcomes.
The literature to date, including surgical, hospitalist, and critical care, was reviewed and combined with the authors' experience.
Suggestions for preoperative screening questions are summarized.
Better recognition of preoperative risk factors may help spine surgeons improve preoperative preparation in their patients, leading to decreased complication rates.
Retrospective study.
To analyze the causes, prevalence of, and risk factors for sagittal thoracic decompensation in adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1.
To our knowledge, no studies on sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1 have been published.
A clinical and radiographic assessment of 99 patients with adult lumbar spinal deformity (average age 56.7 years) who underwent long (> or = 4 vertebrae; range 4-10/average 6.7) spinal instrumentation and fusion (from lower thoracic or upper lumbar spine to L5 or S1) at a single institution between 1985 and 2003 with a minimum 2-year follow-up (average 4.5 years) was performed. We defined sagittal thoracic decompensation as a progressive kyphotic deformity of the thoracic spine without pseudarthrosis after a long lumbar fusion, which subsequently resulted in a C7 plumb relative to the posterior aspect of the L5-S1 disc > or = 8 cm.
The prevalence of sagittal thoracic decompensation after long adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1 was 23% (23/99 cases). The etiologies were 14 acute sharp angular kyphoses and 9 long sweeping kyphoses above the instrumented fusion. Of the 14 sharp angular kyphoses, 10 occurred from severe disc degeneration and 4 were caused by compression fractures at the uppermost instrumented vertebra.
Risk factors for sagittal thoracic decompensation developing were sagittal imbalance at 8 weeks postoperatively (> or = 5 cm), smaller lumbar lordosis compared with thoracic kyphosis (< 10 degrees) at 8 weeks postoperatively, preoperative sagittal imbalance (> or = 5 cm), age at surgery (older than 55 years), and associated comorbidities. Sagittal thoracic decompensation adversely affected Scoliosis Research Society 24 outcomes scores.
Retrospective study.
To analyze the incidence of and risk factors for pseudarthrosis in long adult spinal instrumentation and fusion to S1.
Few studies on pseudarthrosis in long adult spinal instrumentation and fusion to S1 exist.
A clinical and radiographic assessment of 144 adult patients with spinal deformity (average age 52.0 years; range 21.1-77.6) who underwent long (5-17 vertebrae, average 11.9) spinal instrumentation and fusion to the sacrum at a single institution between 1985 and 2002, with a minimum 2-year follow-up (average 3.9; range 2-14) was performed.
Of 144 patients, 34 (24%) had pseudarthroses. There were 17 patients who had pseudarthroses at T10-L2 and 15 at L5-S1. A total of 24 patients (71%) presented with multiple levels involved (2-6). Pseudarthrosis was most commonly detected within 4 years postoperatively (31 patients; 94%). Factors that statistically increased the risk of pseudarthrosis were: thoracolumbar kyphosis (T10-L2 > or = 20 degrees vs. < 20 degrees, P < 0.0001); osteoarthritis of the hip joint (P = 0.002); thoracoabdominal approach (vs. paramedian approach, P = 0.009); positive sagittal balance > or = 5 cm at 8 weeks postoperatively (vs. < or = 5 cm, P = 0.012); age at surgery older than 55 years (vs. 55 years or younger, P = 0.019); and incomplete sacropelvic fixation (vs. complete sacropelvic fixation, P = 0.020). Fusion from upper thoracic spine (T2-T5) did not statistically increase the pseudarthrosis rate compared to lower thoracic spine (T9-T12) (P = 0.20). Patients with pseudarthrosis had significantly lower Scoliosis Research Society 24 outcome scores (average score 71/120) than those without (average score 90/120; P < 0.0001) at ultimate follow-up.
The overall prevalence of pseudarthrosis following long adult spinal deformity instrumentation and fusion to S1 was 24%. Thoracolumbar kyphosis, osteoarthritis of the hip joint, thoracoabdominal approach (vs. paramedian approach), positive sagittal balance > or = 5 cm at 8 weeks postoperatively, older age at surgery (older than 55 years), and incomplete sacropelvic fixation significantly increased the risks of pseudarthrosis to an extent that was statistically significant. Scoliosis Research Society 24 outcomes scores at ultimate follow-up were adversely affected when pseudarthrosis developed.
Instrumentation loosening and metal corrosion are predisposal factors under investigation for late Postoperative infections.
To investigate the contribution of the instrumentation material (stainless steel versus titanium implants) and the mechanical loosening in the development of late postoperative spinal infection.
The first group of patients involves 50 idiopathic scoliotic patients who were treated with first generation posterior stainless steel spinal segmental multihook instrumentation. The minimum post operative follow up was 4 years. Five patients presented with late infections 1 to 5 years post operatively. Removal of instrumentation was the effective solution to this problem. Common intraoperative findings were some degree of instrumentation loosening and corrosion. The second group involves 40 idiopathic scoliotic patients who were treated with newer generation posterior titanium spinal segmental multihook-multiscrew instrumentation system. More extensive use of pedicle screws was performed to the second group resulting in a more stable mechanical construct. Follow up ranged from 2 to 5 years. None of those patients presented late postoperative infection or any evidence of instrumentation loosening or failure.
We believe that newer multihook-multiscrew titanium spinal instrumentation systems have smaller incidence of late postoperative infections because they provide a more stable construct (pedicle screws) with fewer tendencies for micro motion or failure, and they may give the advantage of greater bone adhesion on the implant resulting in the production of thinner biofilm, thus decreasing the chances of infection.
Clinical, radiographic, and outcomes assessment focusing on neurologic complications in patients undergoing pedicle subtraction osteotomy (PSO). Clinical data were collected prospectively. Radiographic analysis was performed retrospectively.
To evaluate intraoperative and postoperative neurologic deficits following lumbar PSOs in order to determine risk factors, treatment strategies, and patient outcome.
Although technically demanding, PSOs have been increasingly used to restore lumbar lordosis and correct sagittal deformity. Although some reports have commented on various complications of the procedure, to our knowledge, there have been no studies focusing on neurologic complications of the osteotomy.
An analysis of 108 consecutive patients with an average age of 54.8 +/- 14.0 years and treated with a lumbar PSO at 1 institution over a 10-year period (1995-2005) was performed. Medical records, radiographs, and neuromonitoring data were analyzed. Clinical outcome was assessed using the Oswestry Disability Index and the Scoliosis Research Society (SRS)-24 instruments.
A total of 108 PSOs were performed. Following surgery, lumbar lordosis increased from -17.1 degrees +/- 19.3 degrees to -49.3 degrees +/- 14.7 degrees (P < 0.000), and sagittal balance improved from 131 +/- 73 mm to 23 +/- 48 mm (P < 0.000). Intraoperative and postoperative deficits (defined as motor loss of 2 grades or more or loss of bowel/bladder control) were seen in 12 patients (11.1%) and were permanent in 3 patients (2.8%). With time motor function improved by 1 grade in 2 patients and all 3 were able to ambulate. Intraoperative neuromonitoring did not detect the deficits. In 9 patients, additional surgical intervention consisted of central enlargement and further decompression. Deficits were thought to be due to a combination of subluxation, residual dorsal impingement, and dural buckling.
Intraoperative or postoperative neurologic deficits are relatively common following a PSO; however, in a majority of cases, deficits are not likely to be permanent.
A retrospective analysis, including prospectively collected patient outcomes data.
To determine the rate of complications and outcomes in patients >or=60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure.
As the population ages, an increasing number of older patients are presenting with spinal deformity disorders that may require major reconstructive procedures. Previous studies have reported complication rates as high as 80% in this age group for 1- and 2-level fusion procedures. The prevalence of complications was found to increase with the greater number of levels fused.
Forty-six patients who were 60 years of age or older underwent a thoracic or lumbar arthrodesis procedure consisting of 5 levels or greater. Diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Oswestry Disability Index (ODI) Scores were used to evaluate clinical outcomes.
Thirty-eight females and 8 males with a mean age of 67 years (range, 60-85 years) and a mean follow-up of 4.2 years (range, 2-11 years) had complete records. Thirty-six (78%) patients had at least 1 comorbidity. Twenty-nine (63%) patients had at least 1 prior spinal surgery. A mean of 9 levels (range, 5-16 levels) were fused in each patient. The overall complication rate was 37%. The major complication rate was 20%. ODI improved from 49 to 25 for a mean improvement of 24 (49%) (P < 0.0001).
The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (P < 0.05) in predicting the presence of a complication. Patients older than 69 years had more complications. The presence of a comorbidity had no association with complication rates and neither had an effect on final patient reported outcomes, which showed significant improvement (ODI preoperative, 49; postoperative, 25) (P < 0.0001).
Radiographic analysis was performed retrospectively. Outcomes and complications were collected prospectively.
To assess complications after posterior fusion and instrumentation for degenerative lumbar scoliosis, to determine risk factors of complications, and to analyze the clinical outcomes of surgery.
The complications after degenerative lumbar scoliosis surgery have reported to be high. Risk factors for developing complications are unknown.
Forty-seven patients (average age, 66.6 years; range, 48-83 years) with degenerative lumbar scoliosis undergoing posterior fusion and instrumentation were analyzed. Seven patients had additional posterior lumbar interbody fusion at the lumbosacral junction. The average number of levels fused was 4.7 +/- 2.2 segments. We evaluated the early perioperative (<3 months after surgery) and late complications.
There were 14 early perioperative complications and 18 late complications. There was 1 case of mortality by pulmonary embolism. Early complications included ileus, urinary tract infection, transient delirium, superficial infection, and neurologic deficit. Late complications included adjacent segment diseases, pseudarthrosis, and loosening of screws. Adjacent segment disease developed at the proximal segment in 10 patients and at the distal segment in 5 patients. Pseudarthrosis was noted at the lumbosacral junction in 2 patients. Revision surgery was performed in 7 patients. Older patients (>65 years) had the tendency to increase early complications without statistical difference (P = 0.053). Excessive intraoperative blood loss was the most significant risk factor for the development of early perioperative complications, and number of levels fused was related to blood loss. Operative time and multiple medical comorbidities were not associated with higher complication rate. There were no specific factors related to the development of late complications.
The complication rate after posterior fusion and instrumentation for degenerative lumbar scoliosis was 68%. Abundant blood loss was a significant risk factor for early perioperative complications. The improvement of Oswestry disability index was less in patients with late complications.
A retrospective long-term follow-up study.
Evaluate the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk factors for degeneration at minimum 5-year follow-up (average 9-year follow-up).
Two previous studies reported the results of long deformity fusions terminating at L5 with minimum 2-year follow-up only.
Thirty-one consecutive patients with an average age of 45 years (range, 20-62 years) were fused from the thoracic spine to L5 and were evaluated at a mean follow-up of 9.4 years (range, 5-20.1 year). Patients were evaluated before surgery, after surgery, and latest follow-up with radiographs and Scoliosis Research Society Patient Questionnaire-24 scores. Disc degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs were "healthy" and Grade 2 to 3 were degenerated. Patients with "healthy" discs preoperative that subsequently degenerated were designated subsequent advanced degeneration (SAD).
Two out of 31 patients had preoperative advanced degeneration of the L5-S1 disc (Weiner grade 2-3). Three additional patients had an early revision to the sacrum secondary to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31 patients were assessed as "healthy discs" preoperative (Weiner grade 0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18 of these 26 patients (69%). Risk factors for the development of SAD included long fusions extending into the upper thoracic spine down to L5 (P = 0.02) and having a circumferential lumbar fusion (P = 0.02). Although preoperative sagittal balance was not significantly different between the "healthy" and SAD group, sagittal balance at follow-up was: C7 plumb >5 cm in 67% of SAD patients and only 13% of "healthy" disc patients (P = 0.009). There was a trend toward inferior Scoliosis Research Society Patient Questionnaire-24 pain scores at follow-up in SAD patients (average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion to the sacrum. An additional 6 of 31 (19%) were considered for extension to the sacrum but comorbidities precluded surgery (3 patients) or the patients declined further surgery (3 patients).
Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.
Retrospective case-control series.
The purpose of this study is to determine whether perioperative complications alter subsequent clinical outcome measures in adult spinal deformity surgery.
Increasingly, the benefit of surgical intervention is being evaluated based on patient reported outcomes and standardized health related quality of life (HRQOL) measures. As improvement or deterioration in HRQOL scores becomes a standard for clinical evaluation in adult spinal deformity, the correlation between HRQOL outcome scores and historic benchmarks, such as curve correction, sagittal balance, fusion healing, or the occurrence of a complication, must be clarified.
This study analyzes a prospective multicenter data base for adult spinal deformity. Patients with major, minor, and no complications were matched using a logistic regression technique producing 46 patients in each group. Standardized outcome measures at baseline and at 1 year postop were compared.
Forty-seven major complications were reported in 46 patients. Sixty-two minor complications were noted in 46 patients. Comparison between the 3 complication groups revealed that 1-year postoperative outcome measures were not statistically different for the Scoliosis Research Society Outcomes Instrument, Medical Outcomes Short Form-36 (SF-12), Oswestry Disability Index, or Numerical Pain Scales. The only significant interaction was in the rate of change from preop to 1-year postop for the SF-12 general health subscale. For the group with major complications, SF-12 general health deteriorated by 2.1 points from preop to 1-year postop. During the same period, the group with minor complications experienced an improvement of 4.2 points and the group with no complications experienced an improvement of 1.5 points.
This study suggests that risk for minor complications may be a less substantial obstacle than previously assumed for surgical treatment in adult spinal deformity. In contrast, major complications were reported in approximately 10% of cases and adversely affected outcome as evidenced by the deterioration in SF-12 general health scores at 1 year after surgery.
Delayed infection after elective spinal instrumentation and fusion. A retrospec-tive analysis of eight cases
- Viola Rw Ha King
- Adler
- Sm
- Wilson
- Cb
Viola RW, King HA, Adler SM, Wilson CB. Delayed infection after elective spinal instrumentation and fusion. A retrospec-tive analysis of eight cases. Spine 1997;22:2444—50 [Discission: 2450—2451].
Rates of infection after spine surgery based on 108,419 procedures: a report from the scoliosis research society morbidity and mortality committee
- Smith Js
- Shaffrey Ci
- Ca Sansur
- Berven
- Sh
- Fu Km
- Pa
Smith JS, Shaffrey CI, Sansur CA, Berven SH, Fu KM, Broad-stone PA, et al. Rates of infection after spine surgery based on 108,419 procedures: a report from the scoliosis research society morbidity and mortality committee. Spine 2011;36:556—63.
Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients
- Jk Weistroffer
- Jh Perra
- Je Lonstein
- Jd Schwender
- Ta Garvey
- Ee Transfeldt
Weistroffer JK, Perra JH, Lonstein JE, Schwender JD, Garvey
TA, Transfeldt EE, et al. Complications in long fusions to the
sacrum for adult scoliosis: minimum five-year analysis of fifty
patients. Spine 2008;33:1478—83.
The impact of perioperative complications on clinical outcome in adult deformity surgery
- Sd Glassman
- Cl Hamill
- Kh Bridwell
- Fj Schwab
- Jr Dimar
- Tg Lowe
Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR,
Lowe TG. The impact of perioperative complications on clinical
outcome in adult deformity surgery. Spine 2007;32:2764—70.
The impact of perioperative complications on clinical outcome in adult deformity surgery
- Glassman
Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients
- Weistroffer