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

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Pedicle 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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The 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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The 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 &lt; 0.01). Total LL correction was equivalent between the 2 groups (35° in the PSO group, 31° in the LLIF-ACR group, p &gt; 0.05), as was the preoperative PI-LL mismatch (33° in each group, p &gt; 0.05) and the postoperative PI-LL mismatch (&lt; 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 &gt; 0.5). The total operative time and LOS were not significantly different in the 2 groups.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This 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.</jats:p></jats:sec>

The Radiologic and Clinical Outcomes of Oblique Lateral Interbody Fusion for Correction of Adult Degenerative Lumbar Deformity

“…Mean estimated blood loss as high as 2900 mL has been reported with the PSO technique 1037. The mean pooled blood loss (anterior + posterior approach) of 863 ml indicates that OLIF significantly reduces the intraoperative blood loss compared to that of posterior osteotomies 18.…”

“…and Leveque et al . reported a mean blood loss of 655 and 800 ml, respectively, with lateral interbody fusion techniques 1737…”

Minimally Invasive Spinal Surgery for Adult Spinal Deformity

“…Recent reports of minimally invasive ACR technique showed successful correction of both regional and global sagittal parameters [ 27 - 32 ]. A single level ACR restored around 30° of lordosis which is comparable with a pedicle substraction osteotomy and 10° of reduction in the pelvic tilt [ 28 , 29 ].…”

Limitations and complications of minimally invasive spinal surgery in adult deformity

“…A guideline for the role of MIS techniques in the treatment of adult spinal deformity has been previously published, reserving MIS for patients with either coronal Cobb angles less than 30 degrees or those with >30 degrees of deformity but little to no sagittal imbalance [sagittal vertical axis (SVA) <5 cm] (1). Yet the introduction of MIS anterior column realignment (ACR) with anterior longitudinal ligament release (ALLR) in 2013 has provided an improved ability to restore sagittal balance, and allows for similar radiographic outcomes to open surgery using MIS alone or a combination of hybrid techniques (2)(3)(4)(5). While the indications for MIS have been greatly expanded, the limitations of these techniques need to be clearly understood.…”