Pseudarthrosis in adult spine deformity surgery: risk factors and treatment options

Marques, Maria Luís; Fière, Vincent; Obeid, Ibrahim; Charles, Yann-Philippe; El-Youssef, K.; Lahoud, Georges Abi; Faddoul, Joe; Ferrero, Emmanuelle; Riouallon, Guillaume; Silvestre, Clément; Huec, Jean-Charles Le; Kieser, David; Boissière, Louis; Rachidienne, Sfcr Société Française de Chirurgie

doi:10.1007/s00586-021-06861-w

Cited by 11 publications

(8 citation statements)

References 29 publications

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“…13 To prevent these challenging clinical situations, meticulous preoperative planning is crucial. 14 Based on our findings, it is not necessary to avoid or delay lumbar fusion surgery in patients who have had ESI at any time point before surgery, unless they have additional risk factors for pseudarthrosis. This study was limited by its retrospective design, which only identified patients who received ESI at our institution and patients who received ESI at other institutions were not identified.…”

Section: Discussionmentioning

confidence: 63%

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion

Coskun,

Wellington,

Desai

et al. 2024

Clinical Spine Surgery

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Study Design: Retrospective cohort study. Objective: The goal of this study is to evaluate the effects of preoperative lumbar epidural steroid injection on the rate of pseudarthrosis following lumbar spine fusion surgery. Summary of Background Data: Epidural corticosteroids help to reduce nerve root edema and suppress proinflammatory cytokines in patients with radiculopathy. Corticosteroids may inhibit bone formation and reduce bone matrix synthesis rates. Thus, there is concern that corticosteroids may reduce lumbar fusion capability, potentially resulting in increased rates of symptomatic pseudarthrosis. Materials and Methods: We identified all patients who underwent 1-level or 2-level lumbar fusion surgery between 2018 and 2022. Patients were categorized into one of 3 groups: no preoperative epidural steroid injection (ESI) history (group 0), preoperative ESI within 90 days of surgery (group 1), or most recent ESI >90 days before surgery (group 2). The primary outcome of this study was pseudarthrosis. Binominal regression analyses were performed to determine the relationships between potential risk factors (sex, age, body mass index, smoking history, diabetes status, history of systemic steroid use, preoperative ESI, perioperative intravenous steroid administration, type of surgery, and postoperative ESI within 6 mo) and the development of postoperative pseudarthrosis. Results: A total of 446 patients were included in this study. Of those, 106 patients (23.7%) did not have a preoperative ESI (group 0), 132 patients (29.5%) had an ESI within 90 days of surgery (group 1), and 208 patients (46.6%) had their most recent ESI >90 days before surgery (group 2). The overall incidence of pseudarthrosis following lumbar fusion was 8.7% (39 of 446). Although the incidence of pseudarthrosis following ESI at any time point was higher than in our control cohort (group 0), this difference was not statistically significant. Conclusions: This study found no increased risk of postoperative pseudarthrosis in patients who underwent 1-level or 2-level lumbar fusions after preoperative ESI. Level of Evidence: Level III.

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Section: Discussionmentioning

confidence: 63%

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion

Coskun,

Wellington,

Desai

et al. 2024

Clinical Spine Surgery

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“…found increased stability and flexibility with the four-rod model compared with the conventional two-rod construct. 32 A recent retrospective study by Villazón et al compared a pelvic fixation with a multirod construct to two-rod constructs in the setting of ASD and found no difference in complication rates in the use of additional rods. 33 This study of 33 patients with multirod fixation and 33 patients with a dual-rod approach found a higher rate of rod breakage and revision surgery in the dual-rod cohort.…”

Section: Discussionmentioning

confidence: 99%

Pelvic Fixation With a Quad-Rod Technique Using S2 Alar Iliac and Medialized Entry Iliac Screws for Long Fusion Constructs

Sherif,

Ling,

Zapolsky

et al. 2023

JAAOS Glob Res Rev

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Purpose: Patients with adult spinal deformity (ASD) may have risk factors for nonunion and subsequent instrumentation failure. This study reviews a novel surgical technique for a quad-rod construct to the pelvis using both S2 alar iliac (S2AI) screw fixation and medialized entry iliac screw fixation as described through three separate cases and a review of the literature. Methods: This technique facilitates alignment of the construct and rod insertion into the tulip heads. The medialized iliac screw technique also avoids the potential soft-tissue complications of the conventional iliac screw bolt given that it is deeper and has more soft-tissue coverage. Results: Three cases performed by the most senior author (V.A.) in which this novel technique was used are presented in this report along with clinical and radiographic images to educate the reader on appropriate execution of this technique. A review of the existing literature regarding pelvic fixation techniques for ASD was also done. Conclusion: Quad-rod augmentation of long thoracolumbar spinal constructs with two independent SI anchoring points is potentially an effective technique to increase lumbar sacral construct rigidity, thereby promoting fusion rates and decreasing revision rates. The described technique provides spine surgeons with an additional tool in their armamentarium to treat patients with complex ASD.

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“…54 Among the risk factors for the occurrence of pseudarthrosis, biomechanical factors such as osteoporosis, pelvic fixation, lack of circumferential fusion, and sharply angulated 3CO, play a major role. 54,55 However, LLIF may provide anterior column support and more solid interbody fusion by using a large footprint cage. Compared with PLIF or TLIF, LLIF exhibits more stable mechanical properties, as shown in several biomechanical studies.…”

Section: Discussionmentioning

confidence: 99%

“…Our results coincided with those of a recent multicenter study reporting that the incidence of pseudarthrosis is 14.7% when using the posterior-only approach and only 7.6% when using the combined anterior-posterior approach for ASD surgery. 54 Among the risk factors for the occurrence of pseudarthrosis, biomechanical factors such as osteoporosis, pelvic fixation, lack of circumferential fusion, and sharply angulated 3CO, play a major role. 54,55 However, LLIF may provide anterior column support and more solid interbody fusion by using a large footprint cage.…”

Section: Discussionmentioning

confidence: 99%

What Are the Benefits of Lateral Lumbar Interbody Fusion on the Treatment of Adult Spinal Deformity: A Systematic Review and Meta-Analysis Deformity

Yang

Liu

Hai

et al. 2022

Global Spine Journal

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Study Design A systematic review and meta-analysis Objective The purpose of this systematic review and meta-analysis was to compare the efficacy of lateral lumbar interbody fusion (LLIF) combined with posterior spinal fusion (PSF) with that of conventional PSF in the treatment of adult spinal deformity (ASD). Methods A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Spinopelvic parameters, surgical data, complications, and clinical outcomes at the last follow-up were compared between patients with ASD who underwent LLIF combined with PSF (LLIF+PSF group) and those who underwent conventional PSF (only-PSF group). Results Ten studies, comprising 621 patients with ASD (313 in the LLIF+PSF group and 308 in the only-PSF group), were included. The level of evidence was III for 7 studies and IV for 3 studies. There was no significant difference in the improvement in the visual analog scale score, systemic complication rate, and revision rate between groups. In the LLIF+PSF group, we noted a superior restoration of lumbar lordosis (weighted mean difference [WMD], 9.77; 95% confidence interval [CI] 7.10 to 12.44, P < .001), pelvic tilt (WMD, −2.50; 95% CI −4.25 to −.75, P = .005), sagittal vertical axis (WMD, −21.92; 95% CI −30.73 to −13.11, P < .001), and C7 plumb line-center sacral vertical line (WMD, −4.03; 95% CI −7.52 to −.54, P = .024); a lower estimated blood loss (WMD, −719.99; 95% CI −1105.02 to −334.96, P < .001) while a prolonged operating time (WMD, 104.89; 95% CI 49.36 to 160.43, P < .001); lower incidence of pseudarthrosis (risk ratio [RR], .26; 95% CI .08 to .79, P = .017) while higher incidence of neurologic deficits (RR, 2.04; 95% CI 1.27 to 3.25, P = .003); and a better improvement in Oswestry Disability Index score (WMD, −7.04; 95% CI −10.155 to −3.93, P < .001) and Scoliosis Research Society-22 total score (WMD, .27; 95% CI .11 to .42, P = .001). The level of evidence in this systematic review and meta-analysis was II. Conclusion Compared with conventional PSF, LLIF combined with PSF was associated with superior restoration of sagittal and coronal alignment, lower incidence of pseudarthrosis, better improvement in quality of life, and less surgical invasiveness in the treatment of ASD, albeit at the cost of prolonged surgical times and substantially high incidence of lower extremity symptoms. Surgeons should weigh the advantages and disadvantages of this procedure, and inform patients about its side effects.

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Pseudarthrosis in adult spine deformity surgery: risk factors and treatment options

Cited by 11 publications

References 29 publications

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion

Pelvic Fixation With a Quad-Rod Technique Using S2 Alar Iliac and Medialized Entry Iliac Screws for Long Fusion Constructs

What Are the Benefits of Lateral Lumbar Interbody Fusion on the Treatment of Adult Spinal Deformity: A Systematic Review and Meta-Analysis Deformity

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