Treatment of adult thoracolumbar spinal deformity: past, present, and future

Abstract

<jats:p>Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.</jats:p><jats:p>In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.</jats:p><jats:p>Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.</jats:p>

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

“…Several factors are crucial for structural decision-making, as follows: identification of deformity drivers, setting of alignment target, and determination of flexibility. Generally, the main deformity driver is loss of LL [10,44,48]. These factors can be quantified by PI/LL mismatch.…”

“…Lateral supine radiographs are essential for assessing the flexibility of sagittal deformities. Bridwell [50] described the following flexibility categories: (1) a totally flexible deformity that corrects in the supine position, (2) a deformity that partially corrects, and (3) a totally inflexible deformity [48]. More inflexible deformities require more aggressive techniques for appropriate correction [10].…”

Cost-Effectiveness of Adult Spinal Deformity Surgery

“…Nonetheless, between the expanding elderly population and the increase in spinal fusion procedures being performed, the prevalence of ASD will continue to rise and presents a considerable financial burden on the health care system. 2,3 In value-based health care, an evidence-based approach to the treatment of ASD requires examination of clinical outcomes, risks, costs, and methods for quality improvement. Multiple factors contribute to the decision-making process in undertaking ASD surgery.…”

Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery

“…[4][5][6] Historically, the treatment of ASD included few surgical options because of the high-risk nature of the procedure, though in recent decades improvements in surgical technique, anesthesia, and critical care have led to an increase in these operations. 7 These surgical interventions have been successful in lessening the significant burden of pain and disability faced by these patients 8 ; However, ASD surgery remains complex, with rates of complications ranging from 34% to 75%. 4,[9][10][11][12][13][14] Obesity is an epidemic in the United States, with the Centers for Disease Control estimating the prevalence of obesity to be 39.8% in 2016.…”