TY - JOUR
T1 - Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion
T2 - A case-matched evaluation of 32 patients
AU - International Spine Study Group
AU - Theologis, Alexander A.
AU - Mundis, Gregory M.
AU - Nguyen, Stacie
AU - Okonkwo, David O.
AU - Mummaneni, Praveen V.
AU - Smith, Justin S.
AU - Shaffrey, Christopher I.
AU - Fessler, Richard
AU - Bess, Shay
AU - Schwab, Frank
AU - Diebo, Bassel G.
AU - Burton, Douglas
AU - Hart, Robert
AU - Deviren, Vedat
AU - Ames, Christopher
N1 - Funding Information:
Funding for the International Spine Study Group Foundation (ISSGF), through which this study was conducted, was provided by research grants from DePuy Spine and individual donations. Dr. Mundis reports consultant relationships with NuVasive, K2M, and Misonix, and a patent holder relationship with K2M. Dr. Okonkwo reports receiving royalties from Biomet. Dr. Mummaneni reports a consultant relationship with and receipt of royalties from DePuy; direct stock ownership in Spinicity/ISD; receipt of royalties from Taylor and Francis Group, Springer, and Thieme (publishers); and receipt of honoraria from AOSpine. Dr. Smith reports consultant relationships with Zimmer Biomet, NuVasive, and Cerapedics; clinical or research support from DePuy Synthes and NuVasive for the study described; support of non-study-related clinical or research effort by DePuy Synthes; and receipt of royalties from Zimmer Biomet. Dr. Shaffrey reports consultant relationships with Zimmer Biomet, Medtronic, and NuVasive; direct stock ownership in NuVasive; patent holder relationships with Zimmer Biomet, Medtronic, and NuVasive; and receipt of support for this study from DePuy Synthes to the ISSGF. Dr. Fessler reports an ownership interest in InQ Innovations, a consultant relationship with DePuy Synthes and Benvenue, and patent holder relationships with DePuy Synthes, Medtronic Sofamor Danek, and Stryker. Dr. Bess reports consultant relationships with K2 Medical, NuVasive, and AlloSource; patent holder relationships with K2 Medical and Innovasis; support for the study described from DePuy Spine; and support for non-study-related clinical or research efforts from Medtronic, NuVasive, K2 Medical, Innovasis, and Stryker. Dr. Schwab reports direct stock ownership in Nemaris Inc.; a consultant relationship with Zimmer Biomet, K2M, MSD, Medicrea, and NuVasive and royalty payments or potential future royalty income from those companies due to development activities; and support of non-study-related clinical or research efforts from SRS, AO, and DePuy Spine (paid through ISSGF). Dr. Burton reports a consultant relationship with, a patent holder relationship with, and receipt of support for the study described from DePuy Spine. Dr. Hart reports a consultant relationship with DePuy Synthes and Globus; a patent holder relationship with Oregon Health and Science University; support of non-study-related clinical or research effort from ISSGF and Medtronic; and receipt of royalties and/or honoraria from SeaSpine, DePuy Synthes, and Globus. Dr. Deviren reports a consultant relationship with NuVasive and Guidepoint and receipt of royalties from NuVasive. Dr. Ames reports a consultant relationship with DePuy, Stryker, and Medtronic; a patent holder relationship with Fish and Richardson, P.C.; and receipt of royalties from Biomet Spine and Stryker.
Publisher Copyright:
©AANS, 2017.
PY - 2017/2
Y1 - 2017/2
N2 - OBJECTIVE: The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS: Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS: Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS: Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.
AB - OBJECTIVE: The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS: Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS: Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS: Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.
KW - Adult spinal deformity
KW - Complications
KW - Health-related quality of life
KW - Lateral interbody fusion
KW - Lumbosacral interbody fusion
KW - Minimally invasive
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U2 - 10.3171/2016.8.SPINE151543
DO - 10.3171/2016.8.SPINE151543
M3 - Article
C2 - 27767682
AN - SCOPUS:85013694127
SN - 1547-5654
VL - 26
SP - 208
EP - 219
JO - Journal of neurosurgery. Spine
JF - Journal of neurosurgery. Spine
IS - 2
ER -