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Zhao J, Nie Z, Zhang Z, Liao D, Liu D. Multiple-Rod Constructs in Adult Spinal Deformity Surgery: A Systematic Review and Meta-Analysis. Asian Spine J 2023; 17:985-995. [PMID: 37690991 PMCID: PMC10622826 DOI: 10.31616/asj.2022.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/09/2022] [Accepted: 11/14/2023] [Indexed: 09/12/2023] Open
Abstract
The purpose of this research was to compare the therapeutic efficacy of multiple-rod constructs vis-a-vis 2-rod constructs in the treatment of adult spinal deformity. A systematic review and meta-analysis were performed to determine whether the multiple-rod construct outperformed the 2-rod construct. We initially retrieved 357 papers, but only 12 were chosen for further meta-analysis. The rod breakage rates in the multiple-rod and the 2-rod groups were 10.66% and 29.87%, respectively. The multiple-rod construct inhibited rod breakage (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.19-0.41; p<0.001), pseudarthrosis (OR, 0.30; 95% CI, 0.18-0.50; p<0.001) and rod fracture at the osteotomy site (OR, 0.34; 95% CI, 0.13-0.89; p=0.03). Furthermore, the multiple-rod construct reduces the risk of revision surgery (OR, 0.38; 95% CI, 0.20-0.73; p=0.04) as well as the revision risk of pseudarthrosis/rod fracture in the multiple- rod group (OR, 0.31; 95% CI, 0.18-0.52; p<0.001), but increases the risk of caudal screw loosening (OR, 4.99; 95% CI, 1.87-13.30; p=0.001). There was no statistically significant difference in proximal junctional kyphosis (PJK) parameters (p=0.85), cerebrospinal fluid leakage (p=0.09), wound infection (p =0.71), age at surgery (p=0.62), gender distribution (p=0.93), body mass index (p =0.86), smoking status (p=0.05), hospital stay (p=0.09), osteoporosis (p=0.95), CoCr rod material (p=0.15), bone morphogenetic protein-2 (p=0.58), L5/S1 interbody fusion (p=0.07), high-grade osteotomies (p=0.07), the number of fusion levels (p=0.11), operation time (p=0.30), and blood loss volume (p=0.34). Regarding radiographic parameters, only preoperative sagittal vertical axis was found to be higher (weight means difference [WMD], 25.60; 95% CI, 15.43-35.77; p<0.001) in the multiple-rod group. There was no difference in preoperative Oswestry Disability Index (ODI) (WMD, -3.32; 95% CI, -7.38 to 0.73; p=0.11), but the multiple-rod group had a lower ODI at follow-up (WMD, -7.71; 95% CI, -11.62 to -3.86; p<0.001). Multiple-rod constructs could prevent rod breakage and pseudarthrosis while also lowering the revision rate, resulting in a better clinical outcome than the 2-rod construct. Nonetheless, due consideration should be given to PJK and screw loosening in multiple-rod constructs, possibly due to the increased stiffness caused by the multiple-rod structure.
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Affiliation(s)
- Jian Zhao
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu, P. R.
China
| | - Zheng Nie
- Department of Anatomy, Development and Regeneration Key Lab of Sichuan Province, Chengdu Medical College, Chengdu, P.R.
China
| | - Zhengping Zhang
- Department of Spinal Surgery, Honghui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, P.R.
China
| | - Dongfa Liao
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu, P. R.
China
| | - Da Liu
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu, P. R.
China
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Saad M, Arfa M, Attia A, Lamas V, Sauleau EA, Charles YP. Proximal and distal mechanical repercussions of instrumentation by double rods and interbody grafts in adult scoliosis. Orthop Traumatol Surg Res 2023; 109:103544. [PMID: 36621636 DOI: 10.1016/j.otsr.2023.103544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/08/2022] [Accepted: 09/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Correction of adult scoliosis by instrumentation with double rods and interbody grafts aims to reduce the risk of pseudarthrosis with rod fracture. An increase in instrumentation rigidity can lead to an increase in stresses at the proximal and distal ends of the construct. The aim of this study was to analyze the incidence and clinical repercussions of proximal junctional kyphosis (PJK), proximal junctional failure (PJF) and iliac screw loosening. MATERIEL AND METHODS An analysis of patients operated on for adult scoliosis with instrumentation to the pelvis using 4 rods and interbody cages was carried out from a prospective register. The Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Scoliosis Research Society 22 (SRS-22) clinical scores and radiological parameters were collected preoperatively, postoperatively at 3 months, 1 year and 2 years. The appearance of PJK, PJF or distal screw loosening was sought; the clinical impact and the risk factors were analyzed by Bayesian inference. RESULTS Fifty-one patients with a mean age of 64.5 years were included. The clinical scores improved significantly (Pr>0.95) at 2 years: VAS back 6.9 versus 2.6, VAS leg 4.9 versus 2.5, ODI 48.2 versus 25.4, SRS-22 2.4 versus 3.5. The radiological parameters were corrected (Pr>0.95): Cobb angle 63.9° versus 22.8°, spinosacral angle (SSA) 112.4° versus 118.8°, T1-pelvic angle (TPA) 24, 8° versus 20.8°, lumbar lordosis 43.8° versus 51.0°, thoracic kyphosis 45.2° versus 53.6°. Thirteen patients (25.5%) presented with PJK and 11 (21.6%) with PJF. Seven patients (13.7%) presented with iliac screw loosening. None of these complications was associated with a significant deterioration in clinical scores. Cranial migration of the lumbar apex increased the risk of distal screw loosening: Odds-Ratio 10.31 (Pr>0.999). Two patients were re-operated on for PJF and one patient for iliac screw loosening (5.9%). No rod fracture with pseudarthrosis was found. CONCLUSION Instrumentation with double rods and interbody grafts was associated with a rate of 47.1% of mechanical repercussions at the extremity of the construct. However, these complications were not associated with a significant deterioration in clinical scores. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Maxime Saad
- Service de chirurgie orthopédique et traumatologique, CHU de Grenoble, hôpital Nord, boulevard de la Chantourne, université Grenoble Alpes, 38700 la Tronche, Grenoble, France.
| | - Maher Arfa
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, faculté de médecine, maïeutique et sciences de la santé, université de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - Aymen Attia
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, faculté de médecine, maïeutique et sciences de la santé, université de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - Vincent Lamas
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, faculté de médecine, maïeutique et sciences de la santé, université de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - Erik André Sauleau
- Service de santé publique, hôpitaux universitaires de Strasbourg, faculté de médecine, maïeutique et sciences de la santé, université de Strasbourg, 1, Place de l'hôpital, 67091 Strasbourg cedex, France
| | - Yann Philippe Charles
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, faculté de médecine, maïeutique et sciences de la santé, université de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
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Yang H, Li Z, Hai Y, Pan A, Guan L, Liu Y. Comparison of complications, revisions, spinopelvic parameters, and health-related quality of life after posterior spinal fusion using multiple-rod constructs or two-rod constructs for adult spinal deformity: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3634-3650. [PMID: 37555956 DOI: 10.1007/s00586-023-07876-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The incidence of mechanical complications is high in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD), especially for cases with severe sagittal malalignment or a prior spinal fusion requiring three-column osteotomy (3-CO) or spinopelvic fixation (SPF). The purpose of this systematic review and meta-analysis was to compare the complications, revisions, radiographic spinopelvic parameters, health-related quality of life (HRQoL), and surgical data of PSF using multiple-rod constructs to those of two-rod constructs for the treatment of ASD. METHODS A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Complications, revisions, spinopelvic parameters, HRQoL, and surgical date were compared between patients with ASD who underwent PSF using multiple-rod constructs (multi-rod group) and two-rod constructs (two-rod group). RESULTS Ten studies, comprising 797 patients with ASD (399 in the multi-rod group and 398 in the two-rod group), were included. All these studies were retrospective cohort studies. There were no significant differences in the surgical, wound-related, and systemic complications between the groups. In the multi-rod group, we noted a significantly lower incidence of rod fracture (RR, 0.43; 95% CI 0.33 to 0.57, P < 0.01), pseudoarthrosis (RR, 0.38; 95% CI 0.28 to 0.53, P < 0.01), and revisions (RR, 0.44; 95% CI 0.33 to 0.58, P < 0.01); a superior restoration of PI-LL (WMD, 3.96; 95% CI 1.03 to 6.88, P < 0.01) and SVA (WMD, 31.53; 95% CI 21.16 to 41.90, P < 0.01); a better improvement of ODI score (WMD, 6.82; 95% CI 2.33 to 11.31, P < 0.01), SRS-22 total score (WMD, 0.44; 95% CI 0.06 to 0.83, P = 0.02), and VAS-BP score (WMD, 1.02; 95% CI 0.31 to 1.73, P < 0.01). CONCLUSION Compared with the two-rod constructs, PSF using multiple-rod constructs was associated with a lower incidence of mechanical complications, a lower revision rate, a superior restoration of sagittal alignment, and a better improvement of HRQoL, without increasing surgical invasiveness. Multiple-rod constructs should be routinely considered to for ASD patients, especially for cases with severe sagittal malalignment or a prior spinal fusion requiring 3-CO or SPF.
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Affiliation(s)
- Honghao Yang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China
| | - Zhangfu Li
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China.
| | - Aixing Pan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China
| | - Li Guan
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China
| | - Yuzeng Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South Rd, No. 8, Beijing, 100020, China
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Treatment of degenerative lumbar scoliosis using transforaminal lumbar interbody fusion based on the concept of intervertebral correction. INTERNATIONAL ORTHOPAEDICS 2023; 47:1303-1313. [PMID: 36933036 DOI: 10.1007/s00264-023-05774-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/10/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE The study aimed to examine the outcomes of posterior approach transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar scoliosis (DLS) based on the concept of intervertebral correction. METHODS A retrospective analysis was performed on 76 surgical patients (36 males and 40 females) who underwent posterior TLIF and internal fixation based on the concept of intervertebral correction in Shenzhen Traditional Chinese Medicine Hospital from February 2014 to March 2021.The operation duration, intraoperative blood loss, incision length, and complications were recorded. Clinical efficacy was evaluated preoperatively and postoperative time points through the visual analog scale (VAS) and the Oswestry disability index (ODI). The changes in the coronal scoliosis curve (Cobb angle), coronal balance distance (CBD), the sagittal vertical axis (SVA), lumbar lordosis (LL), and pelvic tilt angle (PT) were assessed perioperatively at the last follow-up. RESULTS All patients successfully underwent the operation. The average operation duration was 243.81 ± 35.35 (220 - 350) min; the average intraoperative blood loss was 836.27 ± 50.28 (700 - 2500) mL; the average incision length was 8.30 ± 2.33 (8 - 15) cm. The total complication rate was 18.42% (14/76). The VAS score of low back pain, lower extremity pain, and ODI score of patients at the last follow-up was significantly improved compared with those before the operation (P < 0.05). At the last follow-up, the Cobb Angle, CBD, SVA, and PT of patients were significantly lower than those before the operation (P < 0.05), and LL was higher than those before the operation (P < 0.05). CONCLUSION TLIF based on the concept of intervertebral correction for the treatment of DLS may provide favourable clinical outcomes.
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Yang H, Pan A, Hai Y, Cheng F, Ding H, Liu Y. Biomechanical evaluation of multiple pelvic screws and multirod construct for the augmentation of lumbosacral junction in long spinal fusion surgery. Front Bioeng Biotechnol 2023; 11:1148342. [PMID: 36998811 PMCID: PMC10043192 DOI: 10.3389/fbioe.2023.1148342] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/06/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Posterior long spinal fusion was the common procedure for adult spinal deformity (ASD). Although the application of sacropelvic fixation (SPF), the incidence of pseudoarthrosis and implant failure is still high in long spinal fusion extending to lumbosacral junction (LSJ). To address these mechanical complications, advanced SPF technique by multiple pelvic screws or multirod construct has been recommended. This was the first study to compare the biomechanical performance of combining multiple pelvic screws and multirod construct to other advanced SPF constructs for the augmentation of LSJ in long spinal fusion surgery through finite element (FE) analysis.Methods: An intact lumbopelvic FE model based on computed tomography images of a healthy adult male volunteer was constructed and validated. The intact model was modified to develop five instrumented models, all of which had bilateral pedicle screw (PS) fixation from L1 to S1 with posterior lumbar interbody fusion and different SPF constructs, including No-SPF, bilateral single S2-alar-iliac (S2AI) screw and single rod (SS-SR), bilateral multiple S2AI screws and single rod (MS-SR), bilateral single S2AI screw and multiple rods (SS-MR), and bilateral multiple S2AI screws and multiple rods (MS-MR). The range of motion (ROM) and stress on instrumentation, cages, sacrum, and S1 superior endplate (SEP) in flexion (FL), extension (EX), lateral bending (LB), and axial rotation (AR) were compared among models.Results: Compared with intact model and No-SPF, the ROM of global lumbopelvis, LSJ, and sacroiliac joint (SIJ) was decreased in SS-SR, MS-SR, SS-MR, and MS-MR in all directions. Compared with SS-SR, the ROM of global lumbopelvis and LSJ of MS-SR, SS-MR, and MS-MR further decreased, while the ROM of SIJ was only decreased in MS-SR and MS-MR. The stress on instrumentation, cages, S1-SEP, and sacrum decreased in SS-SR, compared with no-SPF. Compared with SS-SR, the stress in EX and AR further decreased in SS-MR and MS-SR. The most significantly decreased ROM and stress were observed in MS-MR.Conclusion: Both multiple pelvic screws and multirod construct could increase the mechanical stability of LSJ and reduce stress on instrumentation, cages, S1-SEP, and sacrum. The MS-MR construct was the most adequate to reduce the risk of lumbosacral pseudarthrosis, implant failure, and sacrum fracture. This study may provide surgeons with important evidence for the application of MS-MR construct in the clinical settings.
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Affiliation(s)
| | | | - Yong Hai
- *Correspondence: Yong Hai, ; Yuzeng Liu,
| | | | | | - Yuzeng Liu
- *Correspondence: Yong Hai, ; Yuzeng Liu,
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Pizones J, Boissiere L, Moreno-Manzanaro L, Vila-Casademunt A, Perez-Grueso FJS, Sánchez-Márquez JM, Baíllo NF, Kleinstück F, Alanay A, Pellisé F, Obeid I. Does the use of postoperative brace help preventing mechanical complications following adult deformity surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:914-925. [PMID: 36592207 DOI: 10.1007/s00586-022-07521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE There is scarce information regarding the effectiveness of postoperative braces in decreasing mechanical complications and reinterventions following adult deformity surgery. METHODS Retrospective matched cohort study from a prospective adult deformity multicenter database. We selected operated patients, fused to the pelvis, > 6 instrumented levels, and minimum 2 year follow-up. Three hundred and eighty patients were separated into two groups (Brace-3 months TLSO-vs No Brace) and then matched controlling for age, gender and frailty. We studied demographic, intraoperative, and postoperative spinopelvic parameters. Both groups were compared regarding complications and reinterventions in the first 2 postoperative years, using univariate and multivariate logistic regression analysis. RESULTS We finally analyzed 359 matched patients, mean age of 65.3 ± 8.9 years, frailty-index (0.43 ± 0.15), and mostly females (84%). 224 patients wore a postoperative brace (B) and 135 didn't (NoB). They showed no difference in intraoperative variables and postoperative spinopelvic alignment. They differed (P < 0.05) in: Pelvic incidence (B:58° ± 13 vs NoB:54.5° ± 13); BMI (B:25.8 ± 4 vs NoB:27.4 ± 5); upper instrumented vertebra (B:81.7% T8-L1 vs NoB:72.6% T8-L1), and the use of multiple rods (B:47.3% vs NoB:18.5%). Univariate analysis showed a higher rate of mechanical complications and reinterventions when not using a brace. As well as higher NRS-back and leg pain at 6 weeks. However, multivariate analysis selected the use of multiple rods as the only independent factor protecting against mechanical complications (OR: 0.38; CI 95% 0.22-0.64) and reinterventions (OR: 0.41; CI 95% 0.216-0.783). CONCLUSION After controlling for potential confounders, our study could not identify the protective effect of postoperative braces preventing mechanical complications and reinterventions in the first two postoperative years.
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Affiliation(s)
- Javier Pizones
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
| | - Louis Boissiere
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
| | - Lucía Moreno-Manzanaro
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | | | - José Miguel Sánchez-Márquez
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Nicomedes Fernández Baíllo
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Frank Kleinstück
- Department of Orthopedics, Schulthess Klinik, Zurich, Switzerland
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Ibrahim Obeid
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
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Baroncini A, Berjano P, Migliorini F, Lamartina C, Vanni D, Boriani S. Rapidly destructive osteoarthritis of the spine: lessons learned from the first reported case. BMC Musculoskelet Disord 2022; 23:735. [PMID: 35915481 PMCID: PMC9340694 DOI: 10.1186/s12891-022-05686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Rapidly Destructive Osteoarthritis (RDOA) has been described for the hip and shoulder joints and is characterized by a quickly developing bone edema followed by extensive remodeling and joint destruction. Confronted with a similarly evolving case of endplate edema and destruction of the disk space, we offer the first described case of spinal RDOA and illustrate the challenges it presented, along with the strategies we put in place to overcome them. Case presentation We present a case of spinal RDOA that, also due to the delay in the diagnoses, underwent multiple revisions for implant failure with consequent coronal and sagittal imbalance. A 37-years-old, otherwise healthy female presented with atraumatic low back pain: after initial conservative treatment, subsequent imaging showed rapidly progressive endplate erosion and a scoliotic deformity. After surgical treatment, the patient underwent numerous revisions for pseudoarthrosis, coronal and sagittal imbalance and junctional failure despite initially showing a correct alignement after each surgery. As a mechanic overload from insufficient correction of the alignement of the spine was ruled out, we believe that the multiple complications were caused by an impairment in the bone structure and thus, reviewing old imaging, diagnosed the patient with spinal RDOA. In case of spinal RDOA, particular care should be placed in the choice of extent and type of instrumentation in order to prevent re-intervention. Conclusion Spinal RDOA is characterized by a quickly developing edema of the vertebral endplates followed by a destruction of the disk space within months from the first diagnosis. The disease progresses in the involved segment and to the adjacent disks despite surgical therapy. The surgical planning should take the impaired bone structure account and the use of large interbody cages or 4-rod constructs should be considered to obtain a stable construct.
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Affiliation(s)
- Alice Baroncini
- IRCCS Istituto Ortopedico Galeazzi, Milano, Italy.,Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | | | - Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany.
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