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Zuckerman SL, Chanbour H, Hassan FM, Lai CS, Shen Y, Kerolus MG, Ha A, Buchanan I, Lee NJ, Leung E, Cerpa M, Lehman RA, Lenke LG. The Lumbosacral Fractional Curve vs Maximum Coronal Cobb Angle in Adult Spinal Deformity Patients with Coronal Malalignment: Which Matters More? Global Spine J 2024; 14:1968-1977. [PMID: 36987946 PMCID: PMC11418742 DOI: 10.1177/21925682231161564] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES In patients undergoing adult spinal deformity (ASD) surgery we sought to: 1) report preoperative and postoperative lumbosacral fractional (LSF) curve and maximum coronal Cobb angles and 2) determine their impact on radiographic, clinical, and patient-reported outcomes (PROs). METHODS A single-institution cohort study was undertaken. The LSF curve was the cobb angle between the sacrum and most tilted lower lumbar vertebra. Coronal/sagittal vertical axis (CVA/SVA) were collected. Patients were compared between 4 groups: 1) Neutral Alignment (NA); 2) coronal malalignment only (CM); 3) Sagittal malalignment only (SM); and 4) Combined-Coronal-Sagittal-Malalignment (CCSM). Outcomes including postoperative CM, postoperative coronal vertical axis, complications, readmissions, reoperation, and PROs. RESULTS A total of 243 patients underwent ASD surgery with mean total instrumented levels of 13.5. Mean LSF curve was 12.1±9.9°(0.2-62.3) and mean max Cobb angle was 43.0±26.5° (0.0-134.3). The largest mean LSF curves were seen in patients with CM (14.6°) and CCSM (13.1°) compared to NA (12.1°) and SM (9.5°) (p=0.100). A higher LSF curve was seen in patients with fusion to the sacrum and instrumentation to the pelvis (p=0.009), and a higher LSF curve was associated with more TLIFs (p=0.031). Postoperatively, more TLIFs were associated with greater amount of LSF curve correction (p<0.001). Comparing the LSF and the max Cob angle among Qiu types, the highest mean max Cobb angle was in Qiu Type B patients (p=0.025), whereas the highest mean LSF curve was in Qiu Type C patients (p=0.037). Moreover, 82.7% of patients had a LSF curve opposite the max Cobb angle. The LSF curve was larger than the max Cobb angle in 22/243 (9.1%) patients, and most of these 22 patients were Qiu Type A (59.1%). Regarding correction, the max Cobb angle achieved more correction than the LSF curve, judged by the percent improved from preop (54.5% Cobb vs. 46.5% LSF, p=0.025) in patients with max cobb>20° and LSF curve >5°. The LSF curve underwent greater correction in Qiu Type C patients (9.2°) compared to Type A (5.7°) and Type B (5.1°) (p=0.023); however, the max Cobb angle was similarly corrected among Qiu Types: Type A 21.8°, Type B 24.6°, and Type C 25.4° (p=0.602). Minimal differences were seen comparing the preop/postop/change in LSF curve and max Cobb angle regarding postop CM, postop CVA, complications, readmissions, reoperation, and PROs. CONCLUSIONS The LSF curve was highest in patients with CM, CCSM, and Qiu Type C curves. Most patients had a LSF curve opposite the max Cobb angle. The max Cobb angle was more often corrected than the LSF curve. The LSF curve underwent greater correction among Qiu Type C patients, whereas the max Cobb angle was similarly corrected among all Qiu Types. No clear trend was seen regarding postoperative complications and PROs between the LSF curve and max Cobb angle.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fthimnir M Hassan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Christopher S Lai
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yong Shen
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Alex Ha
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ian Buchanan
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Eric Leung
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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Sharfman ZT, Clark AJ, Gupta MC, Theologis AA. Coronal Alignment in Adult Spine Surgery. J Am Acad Orthop Surg 2024; 32:417-426. [PMID: 38354413 DOI: 10.5435/jaaos-d-23-00961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/28/2023] [Indexed: 02/16/2024] Open
Abstract
Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.
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Affiliation(s)
- Zachary T Sharfman
- From the Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA (Sharfman and Theologis), Department of Neurological Surgery, UCSF, San Francisco, CA (Clark), Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Gupta)
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Cummins DD, Clark AJ, Gupta MC, Theologis AA. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100299. [PMID: 38193108 PMCID: PMC10772279 DOI: 10.1016/j.xnsj.2023.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Background Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined. Purpose To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis. Methods A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared. Results Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment. Conclusions Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.
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Affiliation(s)
- Daniel D. Cummins
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
| | - Aaron J. Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, Eighth Floor, San Francisco, CA 94143, United States
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 Euclid Avenue, Saint Louis, MO 63110, United States
| | - Alekos A. Theologis
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
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Chung NS, Lee HD, Park KH, Sunwoo J, Chung HW. Oblique lateral interbody fusion for lumbosacral fractional curve correction in degenerative lumbar scoliosis. 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 2024; 33:582-589. [PMID: 38227212 DOI: 10.1007/s00586-023-08113-5] [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: 08/23/2023] [Revised: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE In combined anterior-posterior adult spinal deformity surgery, the optimal combination of anterior and posterior procedures remains unclear. We aimed to demonstrate the radiological outcomes and relevant factors in oblique lateral interbody fusion (OLIF) for lumbosacral fractional curve (FC) correction combined with open posterior surgery in degenerative lumbar scoliosis (DLS). METHODS This study involved 42 consecutive patients with DLS who had a major curve (MC) ≥ 20° and an FC (L4 to S1) ≥ 10°, and underwent a combined anterior-posterior surgery Changes in the MC, FC, coronal balance distance, type of coronal imbalance, coronal/sagittal disc angle at L4-5 and L5-S1, L4 and L5 tilt, and sagittal parameters were examined. The associations between FC correction and demographic, surgical, and radiological factors were analysed. RESULTS The FC decreased from 16.9 ± 7.3° preoperatively to 6.6 ± 4.4° at the last follow-up (P < 0.001). The coronal disc angle at L4-5 and L5-S1 were, respectively, 6.8 ± 2.2° and 6.0 ± 4.1° preoperatively and decreased to 2.2 ± 2.1 and 1.2 ± 1.3° at the last follow-up (both P < 0.001). The changes in FC were greater in uppermost instrumented level > T10 (P < 0.001), and associated with the preoperative FC (r = 0.820, P < 0.001), L4 tilt (r = 0.434, P = 0.007), and L5 tilt (r = 0.462, P = 0.003). CONCLUSION OLIF at the FC combined with open posterior surgery is an effective combined anterior-posterior correction strategy in DLS.
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Affiliation(s)
- Nam-Su Chung
- Department of Orthopaedic Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, Geyounggi-do, 16499, South Korea
| | - Han-Dong Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, Geyounggi-do, 16499, South Korea
| | - Ki-Hoon Park
- Department of Orthopaedic Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, Geyounggi-do, 16499, South Korea
| | - Jung Sunwoo
- Department of Orthopaedic Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, Geyounggi-do, 16499, South Korea
| | - Hee-Woong Chung
- Department of Orthopaedic Surgery, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon, Geyounggi-do, 16499, South Korea.
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Baroncini A, Frechon P, Bourghli A, Smith JS, Larrieu D, Pellisé F, Pizones J, Kleinstueck F, Alanay A, Kieser D, Cawley DT, Boissiere L, Obeid I. Adherence to the Obeid coronal malalignment classification and a residual malalignment below 20 mm can improve surgical outcomes in adult spine 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; 32:3673-3680. [PMID: 37393421 DOI: 10.1007/s00586-023-07831-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/17/2023] [Accepted: 06/17/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Coronal balance is a major factor impacting the surgical outcomes in adult spinal deformity (ASD). The Obeid coronal malalignment (O-CM) classification has been proposed to improve the coronal alignment in ASD surgery. Aim of this study was to investigate whether a postoperative CM < 20 mm and adherence to the O-CM classification could improve surgical outcomes and decrease the rate of mechanical failure in a cohort of ASD patients. METHODS Multicenter retrospective analysis of prospectively collected data on all ASD patients who underwent surgical management and had a preoperative CM > 20 mm and a 2-year follow-up. Patients were divided in two groups according to whether or not surgery had been performed in adherence to the guidelines of the O-CM classification and according to whether or not the residual CM was < 20 mm. The outcomes of interest were radiographic data, rate of mechanical complications and Patient-Reported Outcome Measures. RESULTS At 2 years, adherence to the O-CM classification led to a lower rate of mechanical complications (40 vs. 60%). A coronal correction of the CM < 20 mm allowed for a significant improvement in SRS-22 and SF-36 scores and was associated with a 3.5 times greater odd of achieving the minimal clinical important difference for the SRS-22. CONCLUSION Adherence to the O-CM classification could reduce the risk of mechanic complications 2 years after ASD surgery. Patients with a residual CM < 20 mm showed better functional outcomes and a 3.5 times greater odd of achieving the MCID for the SRS-22 score.
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Affiliation(s)
- Alice Baroncini
- Department of Orthopaedics and Trauma Surgery, RWTH Uniklinik Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Paul Frechon
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- Department of Neurosurgery, Caen University Hospital, Caen, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel Larrieu
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
| | - Ferran Pellisé
- Spine Surgery Unit, Vall D'Hebron Hospital, Barcelona, Spain
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ahmet Alanay
- Spine Center, Acibadem University School of Medicine, Istanbul, Turkey
| | - David Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand
| | - Derek T Cawley
- Department of Spine Surgery, Mater Private Hospital, Dublin, Ireland
| | - Louis Boissiere
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- ELSAN, Polyclinique Jean Villar, Brugge Cedex, France
| | - Ibrahim Obeid
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- ELSAN, Polyclinique Jean Villar, Brugge Cedex, France
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Ruffilli A, Barile F, Paolucci A, Manzetti M, Viroli G, Ialuna M, Vita F, Cerasoli T, Faldini C. Independent Risk Factors of Postoperative Coronal Imbalance after Adult Spinal Deformity Surgery. J Clin Med 2023; 12:jcm12103559. [PMID: 37240665 DOI: 10.3390/jcm12103559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
The aim of the present study is to elucidate preoperative risk factors for inadequate correction of coronal imbalance and/or creation of new postoperative coronal imbalance (iatrogenic CIB) in patients who undergo surgery for Adult Spinal Deformity (ASD). A retrospective review of adults who underwent posterior spinal fusion (>5 levels) for ASD was performed. Patients were divided into groups according to the Nanjing classification: type A (CSVL < 3 cm), type B (CSVL > 3 cm and C7 plumb line shifted to major curve concavity), and type C (CSVL > 3 cm and C7 plumb line shifted to major curve convexity). They were also divided according to postoperative coronal balance in balanced (CB) vs. imbalanced (CIB) and according to iatrogenic coronal imbalance (iCIB). Preoperative, postoperative, and last follow-up radiographical parameters and intraoperative data were recorded. A multivariate analysis was performed to identify independent risk factors for CIB. A total of 127 patients were included (85 type A, 30 type B, 12 type C). They all underwent long (average levels fused 13.3 ± 2.7) all-posterior fusion. Type C patients were more at risk of developing postoperative CIB (p = 0.04). Multivariate regression analysis indicated L5 tilt angle as a preoperative risk factor for CIB (p = 0.007) and indicated L5 tilt angle and age as a preoperative independent risk factors for iatrogenic CIB (p = 0.01 and p = 0.008). Patients with a preoperative trunk shift towards the convexity of the main curve (type C) are more prone to postoperative CIB and leveling the L4 and L5 vertebrae is the key to achieve coronal alignment preventing the "takeoff phenomenon".
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Affiliation(s)
- Alberto Ruffilli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Barile
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Azzurra Paolucci
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Manzetti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Giovanni Viroli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Ialuna
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Fabio Vita
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Tosca Cerasoli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Risk factors for coronal oblique take-off following adult spinal deformity surgery using lateral lumbar interbody fusion and open posterior corrective fusion. Spine Deform 2022; 10:647-656. [PMID: 34773630 DOI: 10.1007/s43390-021-00438-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate risk factors associated with oblique take-off (OT) following lateral lumbar interbody fusion (LLIF) for adult spinal deformity. METHODS Thirty-nine consecutive patients (mean age 67.9 years) with scoliosis of the lumbar curve (> 30°) were evaluated. Multilevel LLIF, followed by open thoraco-pelvic posterior corrective fusion after 1 week, was performed. We defined OT as a distance of > 25 mm between the C7 plumb line and the central sacral vertical line and examined risk factors by dividing the patients into the OT and non-OT groups. RESULTS OT occurred in 11 patients (28%), all showing a tilt to the convex side. The correction rate of the lumbar curve was approximately 70% range for both groups, which indicated good correction. Preoperative radiographs showed a high L1-central sacral vertical line in the standing position; high L5 tilt in the supine position; high L3, L4, and L5 tilts to the convex side in the supine-bending position; and a high L4 vertebral wedge on the convex side in OT cases. Multiple logistic regression analysis showed that an L4 tilt to the concave side in the bending position was the most effective predictor of OT (odds ratio = 1.104, P = 0.047). For a cutoff value of 16°, the sensitivity and specificity were 73% and 61%, respectively, according to the receiver operating characteristic curve analysis (area under the curve = 0.73). CONCLUSION OT occurred in 28% of adult scoliosis patients following LLIF. An L4 tilt > 16° to the concave side in the bending position was the most valuable risk factor. LEVEL OF EVIDENCE IV.
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Zuckerman SL, Lai CS, Shen Y, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Leung E, Cerpa M, Lehman RA, Lenke LG. Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience. J Neurosurg Spine 2022; 36:585-594. [PMID: 34678769 DOI: 10.3171/2021.6.spine21575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent). METHODS A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis. RESULTS In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar. CONCLUSIONS Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.
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Affiliation(s)
- Scott L Zuckerman
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher S Lai
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Yong Shen
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Nathan J Lee
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Mena G Kerolus
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Alex S Ha
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Ian A Buchanan
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Eric Leung
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Meghan Cerpa
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Ronald A Lehman
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Lawrence G Lenke
- 1Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
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