Anterior Column Realignment (ACR) in adult sagittal deformity correction

Saigal, Rajiv; Mundis, Gregory M.; Eastlack, Robert; Uribe, Juan S.; Phillips, Frank M.; Akbarnia, Behrooz A.

doi:10.1097/brs.0000000000001483

Cited by 45 publications

(47 citation statements)

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“…complications with LLIF-ACR are less than with PSO, 52,60 and this is supported by our data from the present study, although further studies will be needed to substantiate this assertion.…”

Section: Discussionsupporting

confidence: 80%

Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Lévêque

Yanamadala

Buchlak

et al. 2017

Neurosurgical Focus

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OBJECTIVEPedicle subtraction osteotomy (PSO) provides extensive correction in patients with fixed sagittal plane imbalance but is associated with high estimated blood loss (EBL). Anterior column realignment (ACR) with lateral graft placement and sectioning of the anterior longitudinal ligament allows restoration of lumbar lordosis (LL). The authors compare peri- and postoperative measures in 2 groups of patients undergoing correction of a sagittal plane imbalance, either through PSO or the use of lateral lumbar fusion and ACR with hyperlordotic (20°–30°) interbody cages, with stabilization through standard posterior instrumentation in all cases.METHODSThe authors performed a retrospective chart review of cases involving a lumbar PSO or lateral lumbar interbody fusion and ACR (LLIF-ACR) between 2010 and 2015 at the authors’ institution. Patients who had a PSO in the setting of a preexisting fusion that spanned more than 4 levels were excluded. Demographic characteristics, spinopelvic parameters, EBL, operative time, and LOS were analyzed and compared between patients treated with PSO and those treated with LLIF-ACR.RESULTSThe PSO group included 14 patients and the LLIF-ACR group included 13 patients. The mean follow-up was 13 months in the LLIF-ACR group and 26 months in the PSO group. The mean EBL was significantly lower in the LLIF-ACR group, measuring approximately 50% of the mean EBL in the PSO group (1466 vs 2910 ml, p < 0.01). Total LL correction was equivalent between the 2 groups (35° in the PSO group, 31° in the LLIF-ACR group, p > 0.05), as was the preoperative PI-LL mismatch (33° in each group, p > 0.05) and the postoperative PI-LL mismatch (< 1° in each group, p = 0.05). The fusion rate as assessed by the need for reoperation due to pseudarthrosis was lower in the LLIF-ACR group but not significantly so (3 revisions in the PSO group due to pseudarthrosis vs 0 in the LLIF-ACR group, p > 0.5). The total operative time and LOS were not significantly different in the 2 groups.CONCLUSIONSThis is the first direct comparison of the LLIF-ACR technique with the PSO in adult spinal deformity correction. The study demonstrates that the LLIF-ACR provides equivalent deformity correction with significantly reduced blood loss in patients with a previously unfused spine compared with the PSO. This technique provides a powerful means to avoid PSO in selected patients who require spinal deformity correction.

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“…complications with LLIF-ACR are less than with PSO, 52,60 and this is supported by our data from the present study, although further studies will be needed to substantiate this assertion.…”

Section: Discussionsupporting

confidence: 80%

Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Lévêque

Yanamadala

Buchlak

et al. 2017

Neurosurgical Focus

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“…To date there is evidence that suggests minimally invasive lateral procedures are more effective in correcting coronal deformities than sagittal deformities such as regional lordosis, which is more clinically significant (48). While studies are still limited, there are newer minimally invasive techniques such as anterior column realignment (ACR), which can effectively correct sagittal deformities with potentially less surgical complications (49,50). Nevertheless, the current evidence suggests that minimally invasive fusion approaches may be associated with improved deformity correction.…”

Section: Deformity Correctionmentioning

confidence: 93%

Minimally invasive surgery in adult degenerative scoliosis: a systematic review and meta-analysis of decompression, anterior/lateral and posterior lumbar approaches

et al. 2016

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Background: Minimally invasive approaches for the treatment of adult degenerative scoliosis have been increasingly implemented. However, little data exists regarding the safety and complication profiles of minimally invasive lumbar interbody fusion (LIF) for adult degenerative scoliosis. This study aimed to greater understand different minimally invasive surgical approaches for adult degenerative scoliosis with respect to clinical outcomes, changes in radiographic measurements, and complication profiles via metaanalytical techniques.Methods: A systematic search of six databases from inception to September 2015 was performed by two independent reviewers. Relevant studies were those that described the safety and/or effectiveness of minimally invasive anterior or lateral LIF (LLIF), transforaminal LIF (TLIF), and decompression only.Meta-analytical techniques and meta-regression were used to pool overall rates, and compare the different techniques. There was no financial funding or conflict of interest.Results: A total of 29 studies (1,228 patients) were included in this meta-analysis. Total pooled fusion rate was 95.9% (95% CI: 92.7-98.2%) for the anterior/lateral approach. The pooled construct or hardwarerelated complications was 4.3%, and was similar among anterior/lateral (4.4%) and posterior (5.2%) techniques. The total pooled pseudoarthrosis rate was 4.3% for the lateral approach. The overall pooled rate of motor deficit was 2.7% (95% CI: 1.7-4.0%). Subgroup meta-regression demonstrated that the anterior/ lateral approach had the highest rate of motor deficits (3.6% LLIF vs. 0.7% TLIF vs. 0.5% decompression, P=0.004). The overall pooled rate of sensory deficit was 2.4%, highest for the anterior/lateral technique (3.3%) compared to TLIF (0.7%) and decompression (0.5%). The infection rate, dural tears/CSF leak, cardiac and pulmonary events were similar among the techniques, with a pooled value of 2.6%, 3.9%, 1.7%, and 1.4%, respectively. Similarly satisfactory radiological outcomes were obtained amongst the different approaches.Conclusions: Minimally invasive spine technologies may be used for the surgical treatment of lumbar degenerative scoliosis with acceptable complication rates, functional and radiological outcome. Future studies, specifically multi-centered longitudinal, examining the adequacy of minimally invasive spine surgery is warranted to compare long-term outcomes with the traditional procedure.

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“…Recent work published on anterior column realignment (ACR) has renewed the interest in anterior-based correction strategies for sagittal plane deformity. 1,4,7,9,11,15,19 Release of the anterior longitudinal ligament (ALL) and the use of hyperlordotic interbody cages to achieve lengthening and fusion of the anterior column of the spine are important principles underlying ACR. However, ACR is conventionally performed using minimally invasive lateral transpsoas-or anterolateral-based approaches, which have limited utility for the more severe spectrum of sagittal plane deformity cases.…”

mentioning

confidence: 99%

Overpowering posterior lumbar instrumentation and fusion with hyperlordotic anterior lumbar interbody cages followed by posterior revision: a preliminary feasibility study

Kadam¹,

Wigner²,

Saville³

et al. 2017

Journal of Neurosurgery: Spine

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OBJECTIVEThe authors’ aim in this study was to evaluate whether sagittal plane correction can be obtained from the front by overpowering previous posterior instrumentation and/or fusion with hyperlordotic anterior lumbar interbody fusion (ALIF) cages in patients undergoing revision surgery for degenerative spinal conditions and/or spinal deformities.METHODSThe authors report their experience with the application of hyperlordotic cages at 36 lumbar levels for ALIFs in a series of 20 patients who underwent revision spinal surgery at a single institution. Included patients underwent staged front-back procedures: ALIFs with hyperlordotic cages (12°, 20°, and 30°) followed by removal of posterior instrumentation and reinstrumentation from the back. Patients were divided into the following 2 groups depending on the extent of posterior instrumentation and fusion during the second stage: long constructs (≥ 6 levels with extension into thoracic spine and/or pelvis) and short constructs (< 6 levels). Preoperative and postoperative standing radiographs were evaluated to measure segmental lordosis (SL) along with standard sagittal parameters. Radiographic signs of pseudarthrosis at previously fused levels were also sought in all patients.RESULTSThe average patient age was 54 years (range 30–66 years). The mean follow-up was 11.5 months (range 5–26 months). The mean SL achieved with 12°, 20°, and 30° cages was 13.1°, 19°, and 22.4°, respectively. The increase in postoperative SL at the respective surgically treated levels for 12°, 20°, and 30° cages that were used to overpower posterior instrumentation/fusion averaged 6.1° (p < 0.05), 12.5° (p < 0.05), and 17.7° (p < 0.05), respectively. No statistically significant difference was found in SL correction at levels in patients who had pseudarthrosis (n = 18) versus those who did not (n = 18). The mean overall lumbar lordosis increased from 44.3° to 59.8° (p < 0.05). In the long-construct group, the mean improvement in sagittal vertical axis was 85.5 mm (range 19–249.3 mm, p < 0.05). Endplate impaction/collapse was noted in 3 of 36 levels (8.3%). The anterior complication rate was 13.3%. No neurological complications or vascular injuries were observed.CONCLUSIONSALIF in which hyperlordotic cages are used to overpower posterior spinal instrumentation and fusion can be expected to produce an increase in SL of a magnitude that is roughly half of the in-built cage lordotic angle. This technique may be particularly suited for lordosis correction from the front at lumbar levels that have pseudarthrosis from the previous posterior spinal fusion. Meticulous selection of levels for ALIF is crucial for safely and effectively performing this technique.

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Anterior Column Realignment (ACR) in adult sagittal deformity correction

Abstract: 4.

Cited by 45 publications

References 0 publications

Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Correction of severe spinopelvic mismatch: decreased blood loss with lateral hyperlordotic interbody grafts as compared with pedicle subtraction osteotomy

Minimally invasive surgery in adult degenerative scoliosis: a systematic review and meta-analysis of decompression, anterior/lateral and posterior lumbar approaches

Overpowering posterior lumbar instrumentation and fusion with hyperlordotic anterior lumbar interbody cages followed by posterior revision: a preliminary feasibility study

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