Upper Thoracic Versus Lower Thoracic Upper Instrumented Vertebrae Endpoints Have Similar Outcomes and Complications in Adult Scoliosis at Two-Year Follow-Up

Spine (Impact Factor: 2.3). 04/2014; 13(9). DOI: 10.1097/BRS.0000000000000339
Source: PubMed


Study Design. Retrospective Review - Multicenter DatabaseObjective. The purpose of this study was to compare the UT and lower thoracic (LT) UIV in long fusions to the sacrum for Adult Scoliosis.Summary of Background Data. The optimal upper instrumented vertebrae (UIV) for stopping long fusions to the sacrum/pelvis are controversial. While a upper thoracic (UT) endpoint may lead to greater operative times, blood loss and higher rates of pseudarthrosis, the risk for the development of proximal junctional kyphosis (PJK) and need for revision surgery is likely lower.Methods. Retrospective analysis of a prospective database of adult spinal deformity patients, Patients were selected based on fusions to the sacrum/pelvis with UIV of T1-6 (UT Group) and those with a UIV of T9-L1 (LT group). Demographic data, operative details and radiographic outcomes with Scoliosis Research Society Scores (SRS) and Oswestry Disability Index (ODI) were collected as well as complication data were compared. Fisher Exact T-tests were used for statistical analysis.Results. A total of 198 patients (UT = 91, LT = 107) with the mean age of 61.6 were followed for an average of 2.5 yrs. Demographic variables were similar between groups except for higher numbers of females in the UT group and a slightly higher BMI in the LT group. Pre-operatively, the UT group demonstrated significant more lumbar scoliosis, thoracic scoliosis and thoracolumbar kyphosis. The UT group demonstrated a higher number of fused segments length of stay (LOS) and longer operative times. There was slightly higher blood loss in the UT group.The total number of complications and number of revision surgeries were similar between groups. The UT group had a higher percentage of patients with ≥2 complications. Both groups had similar PJK angles and number of cases requiring revision for PJK. SRS and ODI Outcomes were similar between groups.Conclusion. UT and LT groups had similar outcomes. The UT group may have a higher rate of total complications, but major complications requiring return to the operative room were similar. The LOS and operative times were higher in the UT group but may have been necessary evidenced by the significantly higher coronal deformity and greater thoracolumbar kyphosis in the UT group.

Download full-text


Available from: Virginie Lafage, Aug 10, 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Proximal junctional kyphosis (PJK) is a common radiographic finding following long spinal fusions. Whether PJK leads to negative clinical outcome is currently debatable. A systematic review was performed to assess the prevalence, risk factors, and treatments of PJK. Literature search was conducted on PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials using the terms 'proximal junctional kyphosis' and 'proximal junctional failure'. Excluding reviews, commentaries, and case reports, we analyzed 33 studies that reported the prevalence rate, risk factors, and discussions on PJK following spinal deformity surgery. The prevalence rates varied widely from 6 to 61.7 %. Numerous studies reported that clinical outcomes for patients with PJK were not significantly different from those without, except in one recent study in which adult patients with PJK experienced more pain. Risk factors for PJK included age at operation, low bone mineral density, shorter fusion constructs, upper instrumented vertebrae below L2, and inadequate restoration of global sagittal balance. Prevalence of PJK following long spinal fusion for adult spinal deformity was high but not clinically significant. Careful and detailed preoperative planning and surgical execution may reduce PJK in adult spinal deformity patients.
    No preview · Article · Sep 2014 · European Spine Journal
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Degenerative changes have the potential to greatly disrupt the normal curvature of the spine, leading to sagittal malalignment. This phenomenon is often treated with operative modalities, such as osteotomies, though even with surgery, only one-third of patients may reach neutral alignment. Improvement in surgical outcomes may be achieved through better understanding of radiographic spino-pelvic parameters and their association with deformity. Methodical surgical planning, including selection of levels of instrumentation and site of the osteotomy, is crucial in determining the optimal plan for a patient’s specific pathology and may minimize risk of developing postoperative proximal junctional kyphosis/failure. While sagittal alignment is essential in operative strategy, the coronal plane should not be overlooked, as it may affect the osteotomy technique. The concepts of sagittal balance and alignment are further complicated in patients with neuromuscular diseases such as Parkinson’s disease, and appreciation of the interplay between anatomic and postural deformities is necessary to properly treat these patients. Finally, given the importance of sagittal alignment and the role of osteotomies in treatment for deformity, the need for future research becomes apparent. Novel intraoperative measurement techniques and three-dimensional analysis of the spine may allow for vastly improved operative correction. Furthermore, awareness of the relationship between alignment and balance, the soft tissue envelope, and compensatory mechanisms will provide a more comprehensive conception of the nature of spinal deformity and the modalities with which it is treated.
    Full-text · Article · Nov 2014 · European Spine Journal
  • [Show abstract] [Hide abstract]
    ABSTRACT: Adult degenerative scoliosis is a progressive disease that develops from the asymptomatic degeneration of intervertebral discs and facet joints. The clinical spectrum of adult scoliosis ranges from asymptomatic to severe degenerative stenosis with neurogenic claudication and radicular symptoms. Adult degenerative scoliosis involves a complex three-dimensional deformity, and although the surgical advances in the treatment of adult scoliosis are vast, controversies still exist. Debate between selective decompression vs decompression and fusion vs. limited fusion, identification of proximal fusion levels and choosing distal fusion levels, including fusion to the pelvis, all remain sources of controversy. This paper will provide a review on surgical indications for surgical decompression and fusion, with an emphasis on choosing proximal and distal fusion levels for the treatment of adult degenerative scoliosis.
    No preview · Article · Mar 2015 · Seminars in Spine Surgery
Show more