OBJECTIVE
The efficacy of anterior column realignment (ACR) remains relatively unclear, possibly because some safety concerns have limited its adoption and extensive evaluation. The authors aimed to study whether a minimally invasive surgery (MIS) triad consisting of ACR, lateral lumbar interbody fusion, and percutaneous pedicle screw fixation in a select group of adult spinal deformity (ASD) patients helps shorten fusion length without compromising clinical and radiographic outcomes over a minimum 2-year follow-up period.


METHODS
A series of 61 ASD patients (mean age 72.8 years) with pelvic incidence (PI) - lumbar lordosis (LL) (PI-LL) mismatch > 10° underwent the short-segment MIS triad (mean fusion length 3.0 levels) as a single-stage operation with a mean operative time and estimated blood loss of 157 minutes and 127 mL, respectively. Exclusion criteria were 1) thoracic scoliosis as the main deformity, 2) thoracolumbar junction kyphosis > 25°, 3) ankylosed facet joints, and 4) previous spinal fusion surgery. Seven patients, who needed fusion to be extended to S1, underwent mini-open transforaminal lumbar interbody fusion at L5-S1.


RESULTS
The segmental disc angle at the ACR level more than quintupled, averaging from 2.9° preoperatively to 18.9° at the latest follow-up (p < 0.0001). LL, in turn, nearly doubled from 17.0° to 32.8° (p < 0.0001) and PI-LL decreased by nearly half from 28.8° to 13.2° (p < 0.0001). At the same time, other spinopelvic deformity parameters as well as Oswestry Disability Index (ODI) scores significantly improved. Patients were divided into two groups at the latest postoperative evaluation: 36 patients whose PI-LL improved to < 10° and 25 patients who maintained a PI-LL mismatch > 10°. Binary logistic regression revealed preoperative PI-LL mismatch as the only factor that significantly influenced this dichotomous separation postoperatively. Receiver operating characteristic curve analysis identified the critical preoperative mismatch of 26.4° with 68% sensitivity and 84% specificity. Despite this different radiographic consequence, the two groups had an equally successful clinical outcome with no significant difference in ODI scores.


CONCLUSIONS
As long as the ASD characteristics are consistent with the authors' exclusion criteria, the short-segment MIS triad served as an excellent surgical option in the patients with preoperative PI-LL mismatch < 26.4°, but the technique also worked well even in those with a mismatch > 26.4°, although ideal spinopelvic alignment targets were not necessarily achieved in these patients.

Lumbar lordosis restoration by minimally invasive short-segment fusion with anterior column realignment for adult spinal deformity: minimum 2-year follow-up.

The use of lateral lumbar interbody fusion for identifying adult patients with spinal deformities treatable by short corrective fusion in 2-stage surgery.

Abstract Extensive surgical spinopelvic fusion for patients with adult spinal deformity (ASD) to achieve optimal radiological parameters should be avoided. The aim of this study was to review clinical and imaging findings in patients with ASD with postural and radiological abnormalities who underwent a novel three-level limited lumbar fusion as two-stage surgery in an attempt to propose a better tolerated alternative to spinopelvic long fusion to the pelvis. The subjects were 26 patients with a minimum follow-up period of 2 years. Cobb angle, C7 sagittal vertical axis, and pelvic incidence (PI) minus lumbar lordosis (LL) were significantly improved after surgery and maintained at follow-up. Most radiological parameters were corrected with lateral interbody fusion (LIF) as the initial surgery, and few with posterior fusion. PI-LL remained high after limited lumbar fusion, but scores on patient-based questionnaires and sagittal and coronal tilt in gait analysis improved. In cases with postoperative progression of proximal junctional kyphosis (11.5%), residual L1–L2 local kyphosis after LIF was the most significant radiological feature. In some cases of ASD with postural abnormalities, short limited lumbar fusion gives sufficient postoperative clinical improvement with preservation of spinal mobility and activities of daily living. The range of fixation should be determined based on radiological parameters after LIF to avoid postoperative complications. 

/pdf/clinical-impact-of-short-limited-lumbar-fusion-for-adult-1agtj6yc.pdf

Clinical impact of short limited lumbar fusion for adult spinal deformity with postural and radiological abnormalities

Study Design: This is a retrospective cohort study using data from the adult spinal deformity (ASD) database of a single institution. Purpose: To investigate the incidence of proximal junctional failure and distal junctional failure (DJF) after ASD surgery with a lower instrumented vertebra (LIV) at L5. Overview of Literature: Spinopelvic fixation from the lower thoracic vertebra to the pelvis is the current gold standard treatment for ASD. However, the LIV at L5 is acceptable in some cases. Methods: Fifty-six patients who underwent corrective surgery for ASD with LIV at L5 were included. The upper instrumented vertebra (UIV) was T7 in one patient, T9 in 14, T10 in three, T11 in four, T12 in eight, L1 in 10, and L2 in 16. Regarding clinical parameters, age, sex, curve types of Scoliosis Research Society-Schwab classification, number of levels fused, follow-up period, hip bone mallow density, revision surgery rate, and radiographic measurements were compared between the T (UIV: T7 - 10) and TL (UIV: T11 - L2) groups. Results: The revision surgery rate was 19.6% overall. In the T and TL groups, it was 27.8%, and 15.8%, respectively (p = 0.305). The rate of DJF in the T group (33.3%) was significantly higher than in the TL group (5.3%). The rate of proximal junctional kyphosis in the T group (55.6%) was higher than in the TL group (28.9%), with no significant difference. The mean global alignment, sagittal vertical axis, and C7 plumb line-central sacral vertical line were not different between both groups. Conclusions: ASD surgery with LIV set at L5 and UIV set at the thoracic vertebrae (T7 - T10) has a risk of adjacent segment disease. 

Adjacent Segment Disease after Long Spinal Fusion Ending at L5 for Adult Spinal Deformity: A Retrospective Cohort Study

Introduction This study aimed to compare the outcomes of corrective fusion for adult spinal deformity (ASD) in older people using two different sagittal correction goals: the conventional formula of “pelvic incidence (PI)-lumbar lordosis (LL) mismatch <10°” and an undercorrection strategy based on the range of 10°≤PI-LL≤20°. Methods A total of 102 consecutive patients (11 male and 91 female patients; mean age, 72.0 years) aged above 65 years with scoliosis >20° or LL<20° who had undergone long-segment fusion from the lower thoracic spine to the pelvis for ASD and had been followed-up for a minimum of two years at our institution since March 2013 were included in this retrospective study. After excluding patients with PI-LL≤−10° on postoperative standing radiographs, the remaining patients were divided into two groups: 31 patients with 10°≤PI-LL≤20° (U group) and 63 patients with −10°<PI-LL<10° (M group). Radiological and clinical outcomes were compared between the groups. Results The incidence of proximal junctional kyphosis and mechanical failure was not significantly different between the groups (p=0.659 and 1.000, respectively). After excluding patients who underwent reoperation due to mechanical failure, there were no differences in the Oswestry Disability Index (ODI) and each domain of the Visual Analog Scale score, Scoliosis Research Society-22r patient questionnaire (SRS-22r), or the short form 36 health survey questionnaire at the final observation between the U (n=27) and M (n=57) groups. In addition, the non-inferiority and equivalence of the U group to the M group were demonstrated in all domains of the SRS-22r and ODI. Furthermore, the superiority of the U group was demonstrated by the functional domain of SRS-22r. Conclusions For the sagittal correction goal in corrective fusion surgery for ASD in the elderly, strict adherence to “PI-LL mismatch <10°” is not necessary and “PI-LL≤20°” may be acceptable.

Spinopelvic Parameters In The Elderly: Does Inadequate Correction Portend Worse Outcomes?

OBJECTIVE Issues with spinopelvic fixation for adult spinal deformity (ASD) include loss of the physiological mobility of the entire lumbar spine, perioperative complications, and medical costs. Little is known about the factors associated with successful short fusion for ASD. The authors evaluated radiographic and clinical outcomes after shorter fusion for different subtypes of ASD at 2 years postoperatively and examined factors associated with successful short fusion. METHODS This was a single-center study of 37 patients who underwent short fusion and a minimum 2 years of follow-up for ASD in which lumbar kyphosis was the main deformity. The exclusion criteria were 1) age 20°, 5) scoliotic deformity with an upper end vertebra (UEV) above T12, and 6) concomitant Parkinson's disease or neurological disease. The surgical procedures, radiographic course, and Oswestry Disability Index (ODI) were assessed, and correlations between radiographic parameters and postoperative ODI at 2 years were analyzed. RESULTS A mean of 3.5 levels were fused. The mean radiographic parameters preoperatively, at 2 weeks, and at 2 years, respectively, were as follows: coronal Cobb angle: 22.9°, 11.5°, and 12.6°; lumbar lordosis (LL): 12.9°, 35.8°, and 32.2°; pelvic incidence (PI) minus LL: 35.5°, 14.7°, and 19.2°; pelvic tilt: 29.4°, 23.1°, and 25.0°; and sagittal vertical axis 85.3, 36.7, and 59.2 mm. Abnormal proximal junctional kyphosis occurred in 8 cases. Revision surgery was performed to extend the length of fusion from a lower thoracic vertebra to the pelvis in 2 cases. The mean ODI scores preoperatively and at 2 years were 50.7% and 24.1%, respectively. Patient age, number of fused intervertebral segments, and radiographic parameters were analyzed by the stepwise method to identify factors contributing to the ODI score at 2 years, preoperative PI, and sagittal vertical axis at 2 years. On receiver operating characteristic curve analysis of the minimal clinically important difference of ODI (15%) and preoperative PI, the cutoff value of the preoperative PI was 47° (area under the curve 0.75). CONCLUSIONS In terms of subtypes of ASD in which lumbar kyphosis is the main deformity, if the PI is < 47°, then the use of short fusion preserving mobile intervertebral segments can produce adequate LL for the PI, improving both postoperative global spinal alignment and quality of life.

Can we use shorter constructs while maintaining satisfactory sagittal plane alignment for adult spinal deformity

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Can we use shorter constructs while maintaining satisfactory sagittal plane alignment for adult spinal deformity