Abstract
Purpose
The global alignment and proportion (GAP) score was recently developed to consider proportional analysis of spinopelvic alignment and has been indicated for setting surgical goals to decrease the prevalence of mechanical complications. The goal of this study was to clarify the limitations and problems with spinal corrective surgery with minimally invasive lateral lumbar interbody fusion (LLIF) without osteotomy using GAP score, and to establish a preoperative radiographical evaluation to understand the necessity for three-column osteotomy.
Methods
We included data from 57 consecutive patients treated with spinal corrective surgery with LLIF and without Schwab grade 3–6 osteotomy for ASD. To evaluate flexibility of the pelvis and lumbar spine, we examined full-length lateral radiographs with patients standing and prone. Correlations between pre- and postoperative radiographic parameters and GAP score were determined.
Results
Most patients achieved a sufficiently ideal lumbar lordosis (87.7%), but ideal sacral slope (SS) was achieved in only 50.8% of patients. Preoperative prone SS showed a significant positive correlation with postoperative SS and a significant negative correlation with GAP score. Patients whose preoperative prone SS was larger than pelvic incidence × 0.59–7.5 tended to achieve proportioned spinopelvic alignment by using LLIF.
Conclusions
The cause of poor outcome of GAP score for ASD corrective surgery with LLIF without osteotomy is a postoperative small SS. Preoperative prone SS is useful for predicting postoperative SS. When preoperative SS in prone patients is relatively small to ideal as calculated using PI, osteotomy or other correctors should be considered to achieve satisfactory spinopelvic parameters.
Level of evidence
III.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
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References
Gum JL, Bridwell KH, Lenke LG, Bumpass DB, Sugrue PA, Karikari IO, Carreon LY (2015) SRS22R appearance domain correlates most with patient satisfaction after adult deformity surgery to the sacrum at 5-year follow-up. Spine (Phila Pa 1976) 40:1297–1302. https://doi.org/10.1097/brs.0000000000000961
Ohba T, Ebata S, Koyama K, Haro H (2018) Prevalence and key radiographic spinal malalignment parameters that influence the risk for gastroesophageal reflux disease in patients treated surgically for adult spinal deformity. BMC Gastroenterol 18:8. https://doi.org/10.1186/s12876-018-0738-6
Soroceanu A, Burton DC, Oren JH, Smith JS, Hostin R, Shaffrey CI, Akbarnia BA, Ames CP, Errico TJ, Bess S, Gupta MC, Deviren V, Schwab FJ, Lafage V, International Spine Study G (2016) Medical complications after adult spinal deformity surgery: incidence, risk factors, and clinical impact. Spine (Phila Pa 1976). https://doi.org/10.1097/brs.0000000000001636
Rodgers WB, Gerber EJ, Rodgers JA (2010) Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976) 35:S355–360. https://doi.org/10.1097/brs.0b013e3182023796
Isaacs RE, Hyde J, Goodrich JA, Rodgers WB, Phillips FM (2010) A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976) 35:S322–330. https://doi.org/10.1097/brs.0b013e3182022e04
Phillips FM, Isaacs RE, Rodgers WB, Khajavi K, Tohmeh AG, Deviren V, Peterson MD, Hyde J, Kurd M (2013) Adult degenerative scoliosis treated with XLIF: clinical and radiographical results of a prospective multicenter study with 24-month follow-up. Spine (Phila Pa 1976) 38:1853–1861. https://doi.org/10.1097/brs.0b013e3182a43f0b
Park HY, Ha KY, Kim YH, Chang DG, Kim SI, Lee JW, Ahn JH, Kim JB (2018) Minimally invasive lateral lumbar interbody fusion for adult spinal deformity: clinical and radiological efficacy with minimum two years follow-up. Spine (Phila Pa 1976) 43:E813–e821. https://doi.org/10.1097/brs.0000000000002507
Than KD, Mummaneni PV, Bridges KJ, Tran S, Park P, Chou D, La Marca F, Uribe JS, Vogel TD, Nunley PD, Eastlack RK, Anand N, Okonkwo DO, Kanter AS, Mundis GM Jr (2017) Complication rates associated with open versus percutaneous pedicle screw instrumentation among patients undergoing minimally invasive interbody fusion for adult spinal deformity. Neurosurg Focus 43:E7. https://doi.org/10.3171/2017.8.Focus17479
Kanter AS, Tempel ZJ, Ozpinar A, Okonkwo DO (2016) A review of minimally invasive procedures for the treatment of adult spinal deformity. Spine (Phila Pa 1976). https://doi.org/10.1097/brs.0000000000001481
Eskilsson K, Sharma D, Johansson C, Hedlund R (2017) Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome? J Neurosurg Spine 27:56–62. https://doi.org/10.3171/2016.12.Spine16585
Qiao J, Xiao L, Sun X, Shi B, Liu Z, Xu L, Zhu Z, Qian B, Qiu Y (2018) Vertebral subluxation during three-column osteotomy in surgical correction of adult spine deformity: incidence, risk factors, and complications. Eur Spine J 27:630–635. https://doi.org/10.1007/s00586-017-5285-2
Dangelmajer S, Zadnik PL, Rodriguez ST, Gokaslan ZL, Sciubba DM (2014) Minimally invasive spine surgery for adult degenerative lumbar scoliosis. Neurosurg Focus 36:E7. https://doi.org/10.3171/2014.3.FOCUS144
Janjua MB, Tishelman JC, Vasquez-Montes D, Vaynrub M, Errico TJ, Buckland AJ, Protopsaltis T (2018) The value of sitting radiographs: analysis of spine flexibility and its utility in preoperative planning for adult spinal deformity surgery. J Neurosurg Spine. https://doi.org/10.3171/2018.2.spine17749
Yasuda T, Hasegawa T, Yamato Y, Togawa D, Kobayashi S, Yoshida G, Banno T, Arima H, Oe S, Matsuyama Y (2018) Effect of position on lumbar lordosis in patients with adult spinal deformity. J Neurosurg Spine. https://doi.org/10.3171/2018.3.spine1879
Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstuck F, Perez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A, European Spine Study G (2017) Global alignment and proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 99:1661–1672. https://doi.org/10.2106/JBJS.16.01594
Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, Ames C, Smith JS, Shaffrey CI, Glassman S, Farcy JP, Lafage V (2015) The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76(Suppl 1):33–41. https://doi.org/10.1227/01.neu.0000462076.73701.09(discussion S41)
Oba H, Ebata S, Takahashi J, Ikegami S, Koyama K, Haro H, Kato H, Ohba T (2018) Loss of pelvic incidence correction after long fusion using iliac screws for adult spinal deformity: cause and effect on clinical outcome. Spine (Phila Pa 1976). https://doi.org/10.1097/brs.0000000000002775
Hasegawa K, Okamoto M, Hatsushikano S, Shimoda H, Ono M, Watanabe K (2016) Normative values of spino-pelvic sagittal alignment, balance, age, and health-related quality of life in a cohort of healthy adult subjects. Eur Spine J 25:3675–3686. https://doi.org/10.1007/s00586-016-4702-2
Inami S, Moridaira H, Takeuchi D, Shiba Y, Nohara Y, Taneichi H (2016) Optimum pelvic incidence minus lumbar lordosis value can be determined by individual pelvic incidence. Eur Spine J 25:3638–3643. https://doi.org/10.1007/s00586-016-4563-8
Yamato Y, Hasegawa T, Kobayashi S, Yasuda T, Togawa D, Arima H, Oe S, Iida T, Matsumura A, Hosogane N, Matsumoto M, Matsuyama Y (2016) Calculation of the target lumbar lordosis angle for restoring an optimal pelvic tilt in elderly patients with adult spinal deformity. Spine (Phila Pa 1976) 41:E211–217. https://doi.org/10.1097/brs.0000000000001209
Ebata S, Ohba T, Oba H, Haro H (2018) Bilateral dual iliac screws in spinal deformity correction surgery. J Orthop Surg Res 13:260. https://doi.org/10.1186/s13018-018-0969-9
Ryan DJ, Protopsaltis TS, Ames CP, Hostin R, Klineberg E, Mundis GM, Obeid I, Kebaish K, Smith JS, Boachie-Adjei O, Burton DC, Hart RA, Gupta M, Schwab FJ, Lafage V, International Spine Study G (2014) T1 pelvic angle (TPA) effectively evaluates sagittal deformity and assesses radiographical surgical outcomes longitudinally. Spine (Phila Pa 1976) 39:1203–1210. https://doi.org/10.1097/brs.0000000000000382
Obeid I, Boissiere L, Yilgor C, Larrieu D, Pellise F, Alanay A, Acaroglu E, Perez-Grueso FJ, Kleinstuck F, Vital JM, Bourghli A, European Spine Study Group E (2016) Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J 25:3644–3649. https://doi.org/10.1007/s00586-016-4649-3
Le Huec JC, Thompson W, Mohsinaly Y, Barrey C, Faundez A (2019) Sagittal balance of the spine. Eur Spine J. https://doi.org/10.1007/s00586-019-06083-1
Fujiwara A, Kobayashi N, Saiki K, Kitagawa T, Tamai K, Saotome K (2003) Association of the Japanese orthopaedic association score with the oswestry disability index, Roland–Morris Disability Questionnaire, and short-form 36. Spine (Phila Pa 1976) 28:1601–1607
Schwab F, Lafage V, Patel A, Farcy JP (2009) Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976) 34:1828–1833. https://doi.org/10.1097/brs.0b013e3181a13c08
Kato S, Fehlings MG, Lewis SJ, Lenke LG, Shaffrey CI, Cheung KMC, Carreon LY, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellise F, Berven SH (2018) An analysis of the incidence and outcomes of major versus minor neurological decline after complex adult spinal deformity surgery: a subanalysis of Scoli-RISK-1 study. Spine (Phila Pa 1976) 43:905–912. https://doi.org/10.1097/brs.0000000000002486
Passias PG, Soroceanu A, Yang S, Schwab F, Ames C, Boniello A, Smith J, Shaffrey C, Boachie-Adjei O, Mundis G, Burton D, Klineberg E, Hart R, Hamilton DK, Sciubba DM, Bess S, Lafage V (2016) Predictors of revision surgical procedure excluding wound complications in adult spinal deformity and impact on patient-reported outcomes and satisfaction: a two-year follow-up. J Bone Joint Surg Am 98:536–543. https://doi.org/10.2106/JBJS.14.01126
Yilgor C, Yavuz Y, Sogunmez N, Haddad S, Mannion AF, Abul K, Boissiere L, Obeid I, Kleinstuck F, Perez-Grueso FJS, Acaroglu E, Pellise F, Alanay A (2018) Relative pelvic version: an individualized pelvic incidence-based proportional parameter that quantifies pelvic version more precisely than pelvic tilt. Spine J. https://doi.org/10.1016/j.spinee.2018.03.001
Ohba T, Ebata S, Oba H, Koyama K, Haro H (2018) Correlation between postoperative distribution of lordosis and reciprocal progression of thoracic kyphosis and occurrence of proximal junctional kyphosis following surgery for adult spinal deformity. Clin Spine Surg. https://doi.org/10.1097/bsd.0000000000000702
Roussouly P, Nnadi C (2010) Sagittal plane deformity: an overview of interpretation and management. Eur Spine J 19:1824–1836. https://doi.org/10.1007/s00586-010-1476-9
Roussouly P, Pinheiro-Franco JL (2011) Sagittal parameters of the spine: biomechanical approach. Eur Spine J 20(Suppl 5):578–585. https://doi.org/10.1007/s00586-011-1924-1
Lee JH, Na KH, Kim JH, Jeong HY, Chang DG (2016) Is pelvic incidence a constant, as everyone knows? Changes of pelvic incidence in surgically corrected adult sagittal deformity. Eur Spine J 25:3707–3714. https://doi.org/10.1007/s00586-015-4199-0
Cecchinato R, Redaelli A, Martini C, Morselli C, Villafane JH, Lamartina C, Berjano P (2017) Long fusions to S1 with or without pelvic fixation can induce relevant acute variations in pelvic incidence: a retrospective cohort study of adult spine deformity surgery. Eur Spine J 26:436–441. https://doi.org/10.1007/s00586-017-5154-z
Riviere C, Hardijzer A, Lazennec JY, Beaule P, Muirhead-Allwood S, Cobb J (2017) Spine-hip relations add understandings to the pathophysiology of femoro-acetabular impingement: a systematic review. Orthop Traumatol Surg Res 103:549–557. https://doi.org/10.1016/j.otsr.2017.03.010
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Ohba, T., Ebata, S., Ikegami, S. et al. Indications and limitations of minimally invasive lateral lumbar interbody fusion without osteotomy for adult spinal deformity. Eur Spine J 29, 1362–1370 (2020). https://doi.org/10.1007/s00586-020-06352-4
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DOI: https://doi.org/10.1007/s00586-020-06352-4