Adult thoracolumbar and lumbar scoliosis treated with long vertebral fusion to the sacropelvis: a comparison between new hybrid selective spinal fusion versus anterior-posterior spinal instrumentation

Outcomes of Short Fusion versus Long Fusion for Adult Degenerative Scoliosis: A Systematic Review and Meta-analysis

The objective of this study was to evaluate differences in clinical and radiographic outcomes between short (<3 levels) and long (≥3 levels) fusions in the setting of degenerative lumbar scoliosis. A literature search was performed from six electronic databases. The key terms of "degenerative scoliosis" OR "lumbar scoliosis" AND "fusion" were combined and used as MeSH subheadings. From relevant studies identified, demographic data, complication rates, Oswestry Disability Index (ODI), and radiographic parameters were extracted and the data was pooled and analyzed. Long fusion was associated with comparable overall complication rates to short fusion (17% vs 14%, P = 0.20). There was a significant difference in the incidence of pulmonary complications when comparing short versus long fusion (0.42% vs 2.70%; P = 0.02). No significant difference was found in terms of motor, sensory complications, infections, construct-related or cardiac complications, pseudoarthrosis, dural tears, cerebrospinal fluid (CSF) leak, or urinary retention. A longer fusion was associated with a greater reduction in coronal Cobb angle and increases in lumbar lordosis, but both findings failed to achieve statistical significance. The ODI was comparable across both cohorts. If shorter fusion lengths are clinically indicated, they should be used instead of longer fusion lengths to reduce perioperative time, costs, and some other complications. However, there are no statistically significant differences in terms of radiographically measurable restoration associated with a short or long fusion.

Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors

We conducted a systematic review with meta-analysis and qualitative synthesis. This study aims to characterize pseudarthrosis after long-segment fusion in spinal deformity by identifying incidence rates by etiology, risk factors for its development, and common features. Pseudarthrosis can be a painful and debilitating complication of spinal fusion that may require reoperation. It is poorly characterized in the setting of spinal deformity. The MEDLINE, EMBASE, and Cochrane databases were searched for clinical research including spinal deformity patients treated with long-segment fusions reporting pseudarthrosis as a complication. Meta-analysis was performed on etiologic subsets of the studies to calculate incidence rates for pseudarthrosis. Qualitative synthesis was performed to identify characteristics of and risk factors for pseudarthrosis. The review found 162 articles reporting outcomes for 16,938 patients which met inclusion criteria. In general, the included studies were of medium to low quality according to recommended reporting standards and study design. Meta-analysis calculated an incidence of 1.4% (95% CI 0.9-1.8%) for pseudarthrosis in adolescent idiopathic scoliosis, 2.2% (95% CI 1.3-3.2%) in neuromuscular scoliosis, and 6.3% (95% CI 4.3-8.2%) in adult spinal deformity. Risk factors for pseudarthrosis include age over 55, construct length greater than 12 segments, smoking, thoracolumbar kyphosis greater than 20°, and fusion to the sacrum. Choice of graft material, pre-operative coronal alignment, post-operative analgesics, and sex have no significant impact on fusion rates. Older patients with greater deformity requiring more extensive instrumentation are at higher risk for pseudarthrosis. Overall incidence of pseudarthrosis requiring reoperation is low in adult populations and very low in adolescent populations.

Teriparatide improves volumetric bone mineral density and fine bone structure in the UIV+1 vertebra, and reduces bone failure type PJK after surgery for adult spinal deformity

We conducted a prospective comparative study of the effect of teriparatide therapy for preventing vertebral-failure-type PJK after reconstructive surgery for adult spinal deformity. Prophylactic teriparatide improved the volumetric bone mineral density and fine bone structure of the vertebra above the upper-instrumented vertebra and reduced the incidence of vertebral-failure-type PJK.

INTRODUCTION

Proximal junctional kyphosis (PJK) is a complication after corrective surgery for spinal deformity. This study sought to determine whether teriparatide (TP) is an effective prophylactic against PJK type 2 (vertebral fracture) in surgically treated patients with adult spinal deformity (ASD).

METHODS

Forty-three patients who started TP therapy immediately after surgery and 33 patients who did not receive TP were enrolled in this prospective case series. These patients were female, over 50, surgically treated for ASD, and followed for at least 2 years. Preoperative and postoperative standing whole-spine X-rays and dual-energy X-ray absorptiometry scans, and multidetector CT images obtained before and 6 months after surgery were used to analyze the bone strength in the vertebra above the upper-instrumented vertebra (UIV+1).

RESULTS

Mean age was 67.9 years. After 6 months of treatment, mean hip-bone mineral density (BMD) increased from 0.721 to 0.771 g/cm² in the TP group and decreased from 0.759 to 0.729 g/cm² in the control group. This percent BMD change between groups was significant (p < 0.05). The volumetric BMD (326 to 366 mg/cm³) and bone mineral content (BMC) (553 to 622 mg) at UIV+1 were also significantly increased in TP group. The bone volume/tissue volume ratio increased from 46 to 54 % in the TP group, and the trabecular bone thickness and number increased by 14 and 5 %, respectively. At the 2-year follow-up, the PJK type 2 incidence was significantly lower in the TP group (4.6 %) than in the control group (15.2 %; p = .02).

CONCLUSIONS

Prophylactic TP treatment improved the volumetric BMD and fine bone structure at UIV+1 and reduced the PJK-type 2 incidence.

Validity, Reliability, and Responsiveness of SRS-7 as an Outcomes Assessment Instrument for Operatively Treated Patients With Adult Spinal Deformity

STUDY DESIGN

A retrospective analysis.

OBJECTIVE

The aim of our study was to compare the normality, concurrent validity, internal consistency, responsiveness, and dimensionality of an item response theory-derived seven-question instrument (SRS-7), against the Scoliosis Research Society-22r (SRS-22r) questionnaire in operatively treated patients with adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

Compared with SRS-22r, SRS-7 (which has been validated in operatively treated patients with adolescent idiopathic scoliosis) has advantages of being short, unidimensional, and linear.

METHODS

A prospective database of ASD patients was queried for patients 18 years or older who were operatively treated, and who answered pre- and postoperative (at 2-year follow-up) SRS-22r questions (n = 276). Corresponding SRS-7 scores were calculated using answers to SRS-22r items 1, 4, 6, 10, 18, 19, and 20. Significance was set at a P value less than 0.01.

RESULTS

SRS-7 and SRS-22r were normally distributed preoperatively but not postoperatively. SRS-7 and SRS-22r scores had high correlation both preoperatively (r = 0.76, P < 0.01) and postoperatively (r = 0.83, P < 0.01). The internal consistency reliability Cronbach α values were 0.61 (SRS-7) and 0.83 (SRS-22r) preoperatively and 0.91 (SRS-7) and 0.95 (SRS-22r) postoperatively. SRS-7 was found to be more responsive than SRS-22r with measures of effect size: Cohen d = 1.21 versus 1.13, Hedge g = 1.21 versus 1.13, and effect size correlation r = 0.52 versus 0.49. Iterative principal factor analysis of pre- and postoperative scores showed the presence of one dominant latent factor in SRS-7 (unidimensionality) and four latent factors in SRS-22r (multidimensionality).

CONCLUSION

SRS-7 is a valid, reliable, responsive, and unidimensional instrument, which can be used as a short-form alternative to the SRS-22r for assessing global changes in patient-reported outcomes over time in patients with ASD.

LEVEL OF EVIDENCE

3.

A Comprehensive Review of Complication Rates After Surgery for Adult Deformity: A Reference for Informed Consent

OBJECTIVE

An up-to-date review of recent literatures and a comprehensive reference for informed consent specific to ASD complications is lacking. The goal of the present study was to determine current complication rates after ASD surgery, in order to provide a reference for informed consent as well as to determine differences between three-column and non-three-column osteotomy procedures to aid in shared decision making.

METHODS

A review of the literature was conducted using the PubMed database. Randomized controlled trials, nonrandomized trials, cohort studies, case-control studies, and case series providing postoperative complications published in 2000 or later were included. Complication rates were recorded and calculated for perioperative (both major and minor) and long-term complication rates. Postoperative outcomes were all stratified by surgical procedure (ie, three-column osteotomy and non-three-column osteotomy).

RESULTS

Ninety-three articles were ultimately eligible for analysis. The data of 11,692 patients were extracted; there were 3,646 complications, mean age at surgery was 53.3 years (range: 25-77 years), mean follow-up was 3.49 years (range: 6 weeks-9.7 years), estimated blood loss was 2,161 mL (range: 717-7,034 mL), and the overall mean complication rate was 55%. Specifically, major perioperative complications occurred at a mean rate of 18.5%, minor perioperative complications occurred at a mean rate of 15.7%, and long-term complications occurred at a mean rate of 20.5%. Furthermore, three-column osteotomy resulted in a higher overall complication rate and estimated blood loss than non-three-column osteotomy.

CONCLUSIONS

A review of recent literatures providing complication rates for ASD surgery was performed, providing the most up-to-date incidence of early and late complications. Providers may use such data in helping to counsel patients of the literature-supported complication rates of such procedures despite the planned benefits, thus obtaining a more thorough informed consent.

Surgical treatments for degenerative lumbar scoliosis: a meta analysis

PURPOSE

Degenerative lumbar scoliosis (DLS) is a spinal deformity that typically develops in adults over 50 years old. Although its etiology is unclear, asymmetric degeneration of the spine is the main cause. Individuals with DLS may experience no symptoms of the deformity, mild symptoms, or severe disability. Most patients with DLS receive conservative treatment, while a small number of patients receive surgery for severe DLS with back pain and/or progressive neurological symptoms. A variety of surgical procedures have emerged. However, a systemic comparison of these surgical procedures is currently unavailable. This study reviews the main outcomes and complications of surgical treatments.

METHODS

A meta analysis of main outcomes and complications of surgical treatments of DLS was conducted through searching PubMed and EMbase databases.

RESULTS

A total of 45 studies were included in this study, which were classified into four surgical categories. Nine studies utilized isolated decompression, 12 used short interbody fusion, 17 used long interbody fusion, and 11 studies included patients using short or long interbody fusion or surgery other than fusion, respectively. Decompression surgery is used to release the symptoms of neurogenic claudication. Spine fusion is widely utilized to prevent worsening of the curve. Instrumentation has been used together with fusion to straighten the spine, correct sagittal imbalance, and repair rotational defects. Decompression is commonly combined with fusion surgery when treating an individual with DLS.

CONCLUSION

Despite a high rate of complications, this review demonstrates that surgery is an effective and reasonable treatment intervention for severe DLS and ultimately improves spine function and deformity. This review also suggests that large scale, high quality studies with long term follow-up are needed to provide more reliable evidence for future evaluation.