Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)–only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of &lt; 10 cm, and underwent a minimum of 2 years’ follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were −1.2 (VAS back pain), −1.6 (VAS leg pain), −15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary).</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of &lt; 10 cm, a pelvic incidence–lumbar lordosis (LL) mismatch of &gt; 10°, a pelvic tilt of &gt; 20°, a lumbar Cobb angle of &gt; 20°, and a thoracic Cobb angle of &gt; 15°. Preoperative SVA, LL, pelvic incidence–LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.</jats:p></jats:sec>

Correction of marked sagittal deformity with circumferential minimally invasive surgery using oblique lateral interbody fusion in adult spinal deformity

“…Significantly earlier PJK onset was observed in the OLIF51 group (8.6 months) than in the TLIF51 group (26.3 months), which was also earlier than that of previous reports (18.6-34.8 months) [38,39]. Other reports found that the incidence of PJK could be reduced by minimally invasive lumbar interbody fusion and percutaneous fixation, which suggests that other factors may have accelerated PJK development after cMIS with OLIF at L5-S1 in our study [40,41]. Faundez et al reported an exaggerated upper lumbar lordosis resulting in junctional failure [39].…”

Minimally Invasive Spinal Surgery for Adult Spinal Deformity

“…It is different from cMISS in terms of paraspinal muscle dissection. In ASD with moderate sagittal deformity, a hybrid surgical approach involving a combination of MISS interbody fusion and open posterior approach has been used in the alternation of traditional open posterior-only approach [ 9 , 10 ].…”

“…Wang [ 33 ] reported significant improvement of sagittal balance with multilevel facet osteotomies and MISS TLIF in addition to percutaneous screw fixation for ASD. Anterior lumbar interbody fusion (ALIF) offers several advantages over LLIF, including direct decompression of neural foramina, accessibility to L5–S1, less mobilization of the psoas muscle, resection of the ALL, wide discectomies, and insertion of wedge-shaped lordotic grafts that result in greater segmental lordosis restoration in the lower lumbar spine compared with TLIF [ 10 , 34 ]. However, it does carry the risks related to mobilization of the abdominal viscera and large vessels.…”

Factors Affecting Postoperative Sagittal Alignment after Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: Posterior Osteotomy, Anterior Longitudinal Ligament Rupture, and Endplate Injury

“…Disk degeneration is the main cause of ASD, and a correction at the interbody space is one of the most appropriate surgical methods [3,4]. Lateral lumbar interbody fusion (LIF) is widely used for ASD [5][6][7]. This technique, which was recently introduced, uses a lateral trans-psoas approach to the disk, which involves less invasive surgical exposure, avoids the major vessels, and permits the placement of large interbody cages that allow the correction of the deformity [6][7][8].…”