1
|
Bourghli A, Boissiere L, Konbaz F, Larrieu D, Almusrea K, Obeid I. Domino connector for thoracic pedicle subtraction osteotomy reduction: surgical technique and patient series. 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; 32:1800-1809. [PMID: 36935453 DOI: 10.1007/s00586-023-07650-3] [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: 01/16/2023] [Revised: 01/16/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE Different techniques have been previously described to close the pedicle subtraction osteotomy (PSO) site for correction of sagittal malalignment; the use of a side-to-side domino connector as a correction tool in the thoracic spine has not been specifically studied. METHODS Twenty adult patients who underwent single-level thoracic PSO from T1 to T12 were included and retrospectively reviewed (two centers). Preoperative and postoperative full-body X-rays, perioperative data, clinical data and complications were recorded with a minimum 2 years of follow-up. Surgical technique and the nuances in using the domino connector were described in detail. RESULTS Patients had a mean age of 40y; 40% were female. Two different techniques involving the domino were applied for closure of the PSO site depending on the type of kyphosis (smooth vs. angular deformity). Both techniques provided significant correction of the local kyphosis (from 48° to 18°) with reciprocal reduction of compensatory cervical lordosis (from 37.6° to 18.6°, p < 0.01) in upper thoracic PSO or lumbar lordosis (from 74.5° to 46.6°, p < 0.01) in lower thoracic PSO. Four patients presented postoperative complications that resolved (hemothorax, GI bleeding), and two patients presented transient neurological deficit. Oswestry Disability Index score improved in the majority of the patients (from 32.7 to 22.5, p < 0.05). There were no pseudarthroses, symptomatic instrumentation breakage, or surgical site infection. CONCLUSION Use of a side-to-side domino connector in combination with two different rod cantilever techniques is effective for the reduction of thoracic pedicle subtraction osteotomy achieving satisfactory radiological and clinical outcome.
Collapse
Affiliation(s)
- Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Faisal Konbaz
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Daniel Larrieu
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Khaled Almusrea
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| |
Collapse
|
2
|
Team management in complex posterior spinal surgery allows blood loss limitation. INTERNATIONAL ORTHOPAEDICS 2023; 47:225-231. [PMID: 36194284 DOI: 10.1007/s00264-022-05586-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/18/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding. METHODS We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( -)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL. RESULTS One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL. CONCLUSION With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.
Collapse
|
3
|
Bourghli A, Boissiere L, Cawley D, Larrieu D, Pizones J, Alanay A, PelIise F, Kleinstück F, Obeid I. Domino connector is an efficient tool to improve lumbar lordosis correction angle after pedicle subtraction osteotomy for adult spinal deformity. 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 2022; 31:2408-2414. [PMID: 35857129 DOI: 10.1007/s00586-022-07322-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/10/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To compare the radiological outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either a domino connector was applied for osteotomy correction or not. METHODS Retrospective review of a prospective, multicenter adult spinal deformity database (5 sites). Inclusion criteria were adult patients who underwent PSO between L3 and L5 with a minimum follow-up of 2 years. Among 1243 patients in the database, 79 met the inclusion criteria, 41 in the no-domino (ND) group and 38 in the domino (D) group. The domino technique consisted of using 2 parallel rods connected by a domino on one side of the PSO in order to achieve gradual and controlled compression at the osteotomy site. Demographic data, operative parameters, spinopelvic parameters and complications were collected. RESULTS Demographic data and operative parameters were globally similar between both groups, and they showed a comparable preoperative sagittal malalignment. Segmental lordosis improved by 22° and 31° (p < 0.05) and L1S1 lordosis improved by 23° and 32° (p < 0.05) in the ND and D group, respectively. The use of multiple rods was similar between the groups (58% vs. 57%). Also, mechanical complications rate was globally similar between both groups with no statistically significant difference (22% vs. 28.9%). CONCLUSION Domino connector is a safe, powerful and efficient tool for pedicle subtraction osteotomy site closure. It improved the lumbar lordosis correction angle with an acceptable rate of complications.
Collapse
Affiliation(s)
- Anouar Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, P.O.Box 84400, Riyadh, 11671, Saudi Arabia.
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | | | - Daniel Larrieu
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Ahmet Alanay
- Spine Surgery Unit, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Ferran PelIise
- Spine Surgery Unit, Hospital Universitario Val Hebron, Barcelona, Spain
| | | | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| |
Collapse
|
4
|
Cho W, Lenke LG, Bridwell KH, Nessim A, Dorward IG, Zebala LP, Pahys JM, Cho SK, Kang MM, Koester LA. Geometric analysis of pedicle subtraction osteotomy (PSO) for Kyphosis correction: anterior lengthening may occur at the osteotomized body as well as at the discs above and below. 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 2022; 31:2415-2422. [PMID: 35831481 DOI: 10.1007/s00586-022-07312-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/22/2021] [Accepted: 06/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To validate the authors kyphosis correction formula for pedicle subtraction osteotomy (PSO) cases. Additionally, to use the formula to evaluate the safety of PSO by determining if there is anterior lengthening. METHODS Twenty-two patients with primarily kyphosis corrected by PSO and with clear landmarks on preoperative and postoperative x-rays were selected. Several anatomical lines and angle measurements were utilized as depicted previously in the Vertebral Column Resection formula (see below). Two approximations were calculated: the geometric approximation (G) = (tanG°*2 + 1)*15° and the rough approximation (R) which is about the same amount of actual shortening (x), if parallel length (y) ≥ 40; twice of x, if y < 40. For each patient, the change of segmental kyphosis angle (K°) was measured and compared with G° and R°, and the correlation between each value was analyzed. RESULTS The absolute Mean ± SE for K - G and K - R was 2.33° ± 0.34 and 6.09° ± 0.58, respectively. K - G is < 3° (p = 0.03). K - R is < 8° (p = 0.001). In other words, K was close to G and R and thus can be predicted by these approximations. Average posterior shortening, anterior shortening, and kyphosis correction at each level were 20.8 ± 2.0 mm, - 3.64 ± 1.5 mm (which equates to anterior lengthening), and 31.05° ± 2.0, respectively. Anterior lengthening occurred in 13 cases (in 4 cases, both at the body as well as at the disc above and below.) The correlation between posterior and anterior shortening was 0.03 (p = 0.88). There were 3 cage insertion cases: 1 had anterior lengthening, while 2 had anterior shortening even with the cage. CONCLUSION This study validated the geometric and rough approximations originally used in PVCR patients, for PSO patients. Additionally, this study found that anterior lengthening may occur in PSOs usually at the discs, but occasionally at the osteotomized body.
Collapse
Affiliation(s)
- Woojin Cho
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, 6th Fl., Bronx, NY, 10467, USA.
| | - Lawrence G Lenke
- The Daniel and Jane Och Spine Hospital, New York-Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Keith H Bridwell
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Adam Nessim
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, 3400 Bainbridge Avenue, 6th Fl., Bronx, NY, 10467, USA
| | - Ian G Dorward
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Lukas P Zebala
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew M Kang
- Department of Neurosurgery, Regions Hospital, 640 Jackson Street, St. Paul, MN, 55101, USA
| | - Linda A Koester
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
5
|
Faundez AA, Tsoupras A, Le Huec JC. Rationale and techniques for Posterior Opening Wedge Osteotomy (POWO) in proximal junctional failure due to iatrogenic lumbar hyperlordosis. Orthop Traumatol Surg Res 2021; 107:102657. [PMID: 32778438 DOI: 10.1016/j.otsr.2020.04.015] [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: 08/15/2019] [Revised: 04/05/2020] [Accepted: 04/14/2020] [Indexed: 02/03/2023]
Abstract
Proximal junctional kyphosis (PJK) is a compensatory phenomenon in reaction to pathologic lumbar hyperlordosis. Inappropriate spinal curve harmony incurs risk of PJK. Postoperative failure of posterior instrumentation, with kyphosis resistant to revision surgery at the proximal junction, may be caused by excessive iatrogenic lumbar lordosis. The surgical attitude should be to decrease lumbar lordosis by posterior opening wedge osteotomy (POWO). We describe the rationale for POWO and surgical techniques at L3. The technique is illustrated by a case report at 24 months' follow-up. Based on rational analysis of the distribution of lordosis along the lumbar spine and of adaptation of the sitting position, POWO may be indicated to avoid PJK after revision surgery in adult spinal Deformation revision surgery.
Collapse
Affiliation(s)
- Antonio A Faundez
- Orthopaedic Surgery Division, Department of Surgery, Geneva University Hospitals, Hôpital La Tour Meyrin, 4, rue Perret-Gentil, 1211 Geneva, Switzerland.
| | - Andreas Tsoupras
- Orthopaedic Surgery Division, Department of Surgery, Geneva University Hospitals, Hôpital La Tour Meyrin, 4, rue Perret-Gentil, 1211 Geneva, Switzerland
| | - Jean-Charles Le Huec
- Polyclinique Bordeaux Nord, Centre Vertebra, 15, rue Boucher, 33000 Bordeaux, France
| |
Collapse
|
6
|
Chryssikos T, Wessell A, Pratt N, Cannarsa G, Sharma A, Olexa J, Han N, Schwartzbauer G, Sansur C, Crandall K. Enhanced Safety of Pedicle Subtraction Osteotomy Using Intraoperative Ultrasound. World Neurosurg 2021; 152:e523-e531. [PMID: 34098140 DOI: 10.1016/j.wneu.2021.05.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pedicle subtraction osteotomy (PSO) can improve sagittal alignment but carries risks, including iatrogenic spinal cord and nerve root injury. Critically, during the reduction phase of the technique, medullary kinking or neural element compression can lead to neurologic deficits. METHODS We describe 3 cases of thoracic PSO and evaluate the feasibility, findings, and utility of intraoperative ultrasound in this setting. RESULTS Intraoperative ultrasound can provide a visual assessment of spinal cord morphology before and after PSO reduction and influences surgical decision making with regard to the final amount of sagittal plane correction. This modality is particularly useful for confirming ventral decompression of disc-osteophyte complex before reduction and also after reduction maneuvers when there is kinking of the thecal sac but uncertainty about the underlying status of the spinal cord. Intraoperative ultrasound is a reliable modality that fits well into the technical sequence of PSO, adds a minimal amount of operative time, and has few limitations. CONCLUSIONS We propose that intraoperative ultrasound is a useful supplement to standard neuromonitoring modalities for ensuring safe PSO reduction and decompression of neural elements.
Collapse
Affiliation(s)
- Timothy Chryssikos
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA.
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Ashish Sharma
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Nathan Han
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Kenneth Crandall
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Girod PP, Kögl N, Molliqaj G, Lener S, Hartmann S, Thomé C. Flexing a standard hinge-powered operating table for lumbosacral three-column osteotomy (3-CO) site closure in 84 consecutive patients. Neurosurg Rev 2021; 45:517-524. [PMID: 33963469 DOI: 10.1007/s10143-021-01559-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/22/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
Three-column osteotomy (3-CO) is a powerful technique in adult deformity surgery, and pedicle subtraction osteotomy (PSO) is the workhorse to correct severe kyphotic spinal deformities. Aging of the population, increasing cases of iatrogenic flat back deformities and understanding the importance of sagittal balance have led to a dramatic increase of this surgical technique. Surgery, however, is demanding and associated with high complication rates so that every step of the procedure requires meticulous technique. Particularly, osteotomy closure is associated with risks like secondary fracture, translation, or iatrogenic stenosis. This step is traditionally performed by compression or a cantilever maneuver with sometimes excessive forces on the screws or instrumentation. Implant loosening or abrupt subluxation resulting in construct failure and/or neurological deficits can result. The aim of this prospective registry study was to assess the efficacy and safety of our surgical PSO technique as well as the osteotomy closure by flexing a hinge-powered OR table. In a series of 84 consecutive lumbosacral 3-CO, a standardized surgical technique with special focus on closure of the osteotomy was prospectively evaluated. The surgical steps with the patients positioned prone on a soft frame are detailed. Osteotomy closure was achieved by remote controlled bending of a standard OR table without compressive or cantilever forces in all 84 cases. This technique carries a number of advantages, particularly the reversibility and the slow speed of closure with minimum force. There was not a single mechanical intraoperative complication such as vertebral body fracture, subluxation, or adjacent implant loosening during osteotomy closure, compared to external cohorts using the cantilever technique (p = 0.130). The feasibility of controlled 3-CO closure by flexing a standard OR table is demonstrated. This technique enables a safe, gentle closure of the osteotomy site with minimal risk of implant failure or accidental neurological injury.
Collapse
Affiliation(s)
- Pierre-Pascal Girod
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, MZA 3rd floor, Tyrol, 6020, Austria.
| | - Nikolaus Kögl
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, MZA 3rd floor, Tyrol, 6020, Austria
| | - Granit Molliqaj
- Department of Neurosurgery, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Sara Lener
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, MZA 3rd floor, Tyrol, 6020, Austria
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, MZA 3rd floor, Tyrol, 6020, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, MZA 3rd floor, Tyrol, 6020, Austria
| |
Collapse
|