Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients

Free access

Object

Various surgical approaches, including open, minimally invasive, and hybrid techniques, have gained momentum in the management of adult spinal deformity. However, few data exist on the radiographic outcomes of different surgical techniques. The objective of this study was to compare the radiographic and clinical outcomes of the surgical techniques used in the treatment of adult spinal deformity.

Methods

The authors conducted a retrospective review of two adult spinal deformity patient databases, a prospective open surgery database and a retrospective minimally invasive surgery (MIS) and hybrid surgery database. The time frame of enrollment in this study was from 2007 to 2012. Spinal deformity patients were stratified into 3 surgery groups: MIS, hybrid surgery, and open surgery. The following pre- and postoperative radiographic parameters were assessed: lumbar major Cobb angle, lumbar lordosis, pelvic incidence minus lumbar lordosis (PI−LL), sagittal vertical axis, and pelvic tilt. Scores on the Oswestry Disability Index (ODI) and a visual analog scale (VAS) for both back and leg pain were also obtained from each patient.

Results

Of the 234 patients with adult spinal deformity, 184 patients had pre- and postoperative radiographs and were thus included in the study (MIS, n = 42; hybrid, n = 33; open, n = 109). Patients were a mean of 61.7 years old and had a mean body mass index of 26.9 kg/m2. Regarding radiographic outcomes, the MIS group maintained a significantly smaller mean lumbar Cobb angle (13.1°) after surgery compared with the open group (20.4°, p = 0.002), while the hybrid group had a significantly larger lumbar curve correction (26.6°) compared with the MIS group (18.8°, p = 0.045). The mean change in the PI−LL was larger for the hybrid group (20.6°) compared with the open (10.2°, p = 0.023) and MIS groups (5.5°, p = 0.003). The mean sagittal vertical axis correction was greater for the open group (25 mm) compared with the MIS group (≤ 1 mm, p = 0.008). Patients in the open group had a significantly larger postoperative thoracic kyphosis (41.45°) compared with the MIS patients (33.5°, p = 0.005). There were no significant differences between groups in terms of pre- and postoperative mean ODI and VAS scores at the 1-year follow-up. However, patients in the MIS group had much lower estimated blood loss and transfusion rates compared with patients in the hybrid or open groups (p < 0.001). Operating room time was significantly longer with the hybrid group compared with the MIS and open groups (p < 0.001). Major complications occurred in 14% of patients in the MIS group, 14% in the hybrid group, and 45% in the open group (p = 0.032).

Conclusions

This study provides valuable baseline characteristics of radiographic parameters among 3 different surgical techniques used in the treatment of adult spinal deformity. Each technique has advantages, but much like any surgical technique, the positive and negative elements must be considered when tailoring a treatment to a patient. Minimally invasive surgical techniques can result in clinical outcomes at 1 year comparable to those obtained from hybrid and open surgical techniques.

Abbreviations used in this paper:ASA = American Society of Anesthesiologists; BMI = body mass index; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; PI−LL = pelvic incidence minus lumbar lordosis; SVA = sagittal vertical axis; VAS = visual analog scale.

Object

Various surgical approaches, including open, minimally invasive, and hybrid techniques, have gained momentum in the management of adult spinal deformity. However, few data exist on the radiographic outcomes of different surgical techniques. The objective of this study was to compare the radiographic and clinical outcomes of the surgical techniques used in the treatment of adult spinal deformity.

Methods

The authors conducted a retrospective review of two adult spinal deformity patient databases, a prospective open surgery database and a retrospective minimally invasive surgery (MIS) and hybrid surgery database. The time frame of enrollment in this study was from 2007 to 2012. Spinal deformity patients were stratified into 3 surgery groups: MIS, hybrid surgery, and open surgery. The following pre- and postoperative radiographic parameters were assessed: lumbar major Cobb angle, lumbar lordosis, pelvic incidence minus lumbar lordosis (PI−LL), sagittal vertical axis, and pelvic tilt. Scores on the Oswestry Disability Index (ODI) and a visual analog scale (VAS) for both back and leg pain were also obtained from each patient.

Results

Of the 234 patients with adult spinal deformity, 184 patients had pre- and postoperative radiographs and were thus included in the study (MIS, n = 42; hybrid, n = 33; open, n = 109). Patients were a mean of 61.7 years old and had a mean body mass index of 26.9 kg/m2. Regarding radiographic outcomes, the MIS group maintained a significantly smaller mean lumbar Cobb angle (13.1°) after surgery compared with the open group (20.4°, p = 0.002), while the hybrid group had a significantly larger lumbar curve correction (26.6°) compared with the MIS group (18.8°, p = 0.045). The mean change in the PI−LL was larger for the hybrid group (20.6°) compared with the open (10.2°, p = 0.023) and MIS groups (5.5°, p = 0.003). The mean sagittal vertical axis correction was greater for the open group (25 mm) compared with the MIS group (≤ 1 mm, p = 0.008). Patients in the open group had a significantly larger postoperative thoracic kyphosis (41.45°) compared with the MIS patients (33.5°, p = 0.005). There were no significant differences between groups in terms of pre- and postoperative mean ODI and VAS scores at the 1-year follow-up. However, patients in the MIS group had much lower estimated blood loss and transfusion rates compared with patients in the hybrid or open groups (p < 0.001). Operating room time was significantly longer with the hybrid group compared with the MIS and open groups (p < 0.001). Major complications occurred in 14% of patients in the MIS group, 14% in the hybrid group, and 45% in the open group (p = 0.032).

Conclusions

This study provides valuable baseline characteristics of radiographic parameters among 3 different surgical techniques used in the treatment of adult spinal deformity. Each technique has advantages, but much like any surgical technique, the positive and negative elements must be considered when tailoring a treatment to a patient. Minimally invasive surgical techniques can result in clinical outcomes at 1 year comparable to those obtained from hybrid and open surgical techniques.

Adult spinal deformity is a condition associated with increasing age.11,24 Recently, the prevalence of adult spinal deformity in elderly patients has been shown to exceed 60%.22 This can be explained by the progressive degeneration of intervertebral discs, facet joints, and ligamentous structures of the spine, resulting in deformity and potential neurological compromise. The management of adult spinal deformity involves both surgical and nonsurgical approaches. Nonetheless, the decision making process depends on several important factors, including the deformity severity, medical comorbidities, and surgeon experience.13 Nonsurgical approaches among disabled patients have been shown to be less efficient and less cost-effective compared with surgical approaches.7,10,16 Accordingly, various surgical approaches, including open surgery, minimally invasive surgery (MIS), and hybrid techniques, have gained momentum in the management of adult spinal deformity. The impact of radiographic parameters on surgical decision making for patients with adult spinal deformity cannot be overemphasized.3 The primary goals of surgery are to restore global sagittal and coronal balance, achieve fusion, and restore function. Despite the growing body of literature that currently demonstrates satisfactory clinical outcomes of deformity surgery,2,11,14,20,23,24,28 few data exist on the radiographic outcomes of different surgical techniques.25,29 The objective of this study was to compare the radiographic and clinical outcomes among the 3 surgical techniques for adult spinal deformity.

Methods

Study Population

This study was a retrospective review of radiographic and clinical parameters of two multicenter databases for the surgical treatment of adult spinal deformity: a prospective open surgery database and a retrospective MIS and hybrid surgery database. Institutional review board approval was obtained at each participating site (San Diego Center for Spinal Disorders, University of Michigan, Louisiana Spine Institute, University of Pittsburgh Medical Center, University of Miami, University of South Florida, Oregon Health and Science University, University of California, San Francisco, and Cedars-Sinai Medical Center). Inclusion criteria for the current analysis included the following: 1) Thirty-six-inch standing radiographs (preoperative, early postoperative, and last follow-up); 2) health-related quality of life measures pre- to postsurgery; 3) a Cobb angle greater than 20°; 4) at least 45 years of age; 5) fusion of 4 or more segments; and 6) a minimum 1-year follow-up. Exclusion criteria included deformity due to tumor, infection, and prior fusions greater than 2 levels (the latter exclusion criteria did not apply in the open group). The two databases were further stratified into 3 groups: 1) circumferential MIS (MIS group), 2) hybrid surgery group, and 3) open surgery group. The time frame of enrollment in this study was from 2007 to 2012. A total of 184 patients met the inclusion and minimum follow-up criteria.

Patients in the MIS group underwent a combination of minimally invasive approaches including lumbar lateral interbody fusion, anterior lumbar interbody fusion, transforaminal lumbar interbody fusion, and percutaneous screw insertion. Hybrid patients underwent initial lumbar lateral interbody fusion followed by open posterior pedicle-screw fixation and spinal fusion, and facet osteotomies if needed. Finally, patients in the open group underwent a traditional open posterior spinal fusion with instrumentation with or without osteotomies.

Radiographic Outcome Assessment

The following spinal parameters were assessed: 1) lumbar major Cobb angle, 2) lumbar lordosis (measured from T12 to S1), 3) pelvic incidence minus lumbar lordosis (PI−LL), 4) sagittal vertical axis (SVA), defined as the offset from the C-7 plumb line to the posterosuperior corner of S-1, and 5) pelvic tilt, the angle subtended by a vertical reference line from the center of the femoral heads to the midpoint of the sacral endplate.

Clinical Outcome Assessment

Two self-assessment health-related quality of life measures were obtained from each patient: the Oswestry Disability Index (ODI) and a visual analog scale (VAS) for both back and leg pain preoperatively and then 1-year postoperatively.

Statistical Analysis

Means and standard deviations were used to describe continuous variables, and frequency analyses were used for categorical variables. Comparisons between groups were performed using ANOVA and chi-square analysis. Changes between preoperative and postoperative parameters were analyzed using a paired t-test. A p value < 0.05 with a confidence interval of 95% was considered to be statistically significant. All analyses were performed with the Statistical Package for the Social Sciences (SPSS version 21, IBM).

Results

Demographics

The initial pool of data included 234 patients with adult spinal deformity. The data were then filtered to retain only patients with pre- and postoperative radiographs (including PI−LL, SVA, and lumbar Cobb angle). The final number of patients included in the current study was 184 patients (MIS, n = 42; hybrid, n = 33; open, n = 109) who had a mean age of 61.7 ± 8.4 years and a mean body mass index (BMI) of 26.9 kg/m2. Table 1 shows the evolution of the patient population from the initial pool of data to the final population used in the analysis. The majority of the patients were females (N = 154, 84.2%), and 57 patients (31.1%) presented with a history of prior spine surgery (Table 2). There were 42 patients in the MIS group, 33 in the hybrid group, and 109 in the open group. There were no significant differences between groups in terms of age, sex distribution, history of prior spine surgery, and mean American Society of Anesthesiologists (ASA) physical status classification (Table 2). The hybrid group had a significantly larger number of comorbidities (average 2.88 per patient) than the 2 other groups (1.73 [p = 0.004] for the open group, 1.86 [p = 0.004] for the MIS group), without any significant difference in terms of ASA class (mean 2.21). The mean follow-up duration was 25.7 months.

TABLE 1:

Evolution of the patient population from the initial pool of data (n = 234) to the final 184 patients used in the analysis

Surgery GroupAllPreop RadiographsPreop Radiographs & ODIPreop Radiographs & ODI & Postop RadiographsPre- & Postop Radiographs, & Pre- & Postop ODI
open136119118117109
MIS4846464242
hybrid5044433633
total234209207195184
TABLE 2:

Patient demographics

ParameterAllOpenMISHybridANOVA/Chi-Square
mean age ± SD (yrs)61.7 ± 8.460.4 ± 8.563.9 ± 6.963.4 ± 9.10.03 (> 0.05 on post hoc test)
% females84.285.278.687.90.494
% smokers10.89.816.76.20.318
% w/ revision31.136.121.427.30.190
no. of comorbidities ± SD2.0 ± 1.81.7 ± 1.71.9 ± 1.92.9 ± 1.90.005
BMI ± SD (kg/m2)26.9 ± 4.826.7 ± 4.626.2 ± 5.228.3 ± 4.70.158
mean ASA Class2.212.252.052.180.41

Radiographic Parameters

The MIS group had a smaller preoperative mean lumbar coronal Cobb angle (32.0°) than the open group (43.2°, p < 0.001) and hybrid group (44.3°, p = 0.002). Postoperatively, the MIS group maintained a smaller mean lumbar Cobb angle (13.1°) than the open group (20.4°, p = 0.002); the hybrid group had a larger lumbar curve correction (26.6°) than the MIS group (18.8°, p = 0.045; Table 3).

TABLE 3:

Summary of results comparing the radiographic outcomes in the MIS, hybrid, and open surgery groups*

MeasurementMISHybridOpenANOVA
p ValueGroup Comparison
Cobb angle (°)
 preop32.044.343.20.000MIS < hybrid, open
 postop13.117.720.40.003MIS < open
 change−18.8−26.6−22.90.049MIS < hybrid
 p value (preop to postop)0.0000.0000.000NA
lordosis (°)
 preop33.831.942.70.002MIS, hybrid < open
 postop39.448.553.20.000MIS < hybrid, open
 change5.616.610.40.022MIS < hybrid
 p value (preop to postop)0.0010.0000.000NA
SVA (mm)
 preop33.056.554.40.116
 postop32.731.021.40.400
 change−0.3−25−33.00.011MIS < open
 p value (preop to postop)0.9620.0040.000NA
pelvic tilt (°)
 preop27.630.423.20.002open < hybrid
 postop26.629.221.20.000open < MIS, hybrid
 change–1.1–1.2–2.00.817
 p value (preop to postop)0.4630.5190.013NA
thoracic kyphosis (°)
 preop31.228.233.80.193
 postop33.538.741.50.007MIS < open
 change2.310.57.70.018MIS < open
 p value (preop to postop)0.1250.0000.000NA
PI–LL (°)
 preop21.622.012.30.003open < MIS, hybrid
 postop16.02.12.00.000hybrid, open < MIS
 change5.619.910.30.05hybrid > MIS

Includes a comparison within the same group (pre- to postoperative change) as well as comparisons between groups (ANOVA, with post hoc Bonferroni test). Boldface type indicates statistical significance. NA = not applicable.

In the sagittal plane, preoperatively the patients in the open group had a smaller mean PI−LL (12.3°) compared with the MIS (21.6°, p = 0.018) and hybrid (22°, p = 0.026) patients. The postoperative mean PI−LL for patients in the MIS group (16.1°) was greater than for the patients in the open (2°, p < 0.001) and hybrid groups (2.1°, p = 0.001). The mean change in PI−LL was larger for the hybrid group (19.9°) than for either the open (10.3°, p = 0.023) or MIS (5.6°, p = 0.05) groups. Pre- and postoperatively, there were no significant differences in terms of SVA, but the mean SVA correction was greater for the open group (25 mm) than for the MIS group (≤ 1 mm, p = 0.008). Finally, while no significant differences were found in terms of preoperative thoracic kyphosis, postoperative kyphosis was significantly larger for the patients in the open group (41.45°) than for the patients in the MIS group (33.5°, p = 0.005).

All 3 groups exhibited a significant decrease in lumbar Cobb angle (p < 0.001) and increase in lumbar lordosis (p < 0.005). In addition, the open and hybrid groups had significant increases in thoracic kyphosis (+7.7° and +10.5°, respectively; p < 0.001), and decreases in SVA (−33 mm and −25 mm, respectively; p < 0.005). Finally, a small but significant decrease in mean pelvic tilt was observed for the open group (23.2 to 21.2°, p = 0.013).

Clinical Outcomes

There were no significant differences between groups in terms of pre- and postoperative mean ODI, VAS back pain, and VAS leg pain scores (Table 4). For each group independently, the comparison between preoperative and postoperative clinical scores revealed significant improvements in all 3 measures (all p < 0.001).

TABLE 4:

Differences between groups in pre- and postoperative mean ODI and VAS scores

ScaleMISHybridOpenANOVA p Value
mean ODI ± SD
 preop41.6 ± 15.245.8 ± 19.141.1 ± 17.80.394
 postop23.3 ± 16.429.4 ± 20.725.2 ± 17.80.345
 change−18.3 ± 17−16.4 ± 13.9−15.9 ± 17.40.736
 p value (preop to postop)<0.001<0.001<0.001NA
mean VAS back score ± SD
 preop6.2 ± 1.87 ± 2.47.1 ± 2.40.130
 postop3.1 ± 2.22.5 ± 2.53.3 ± 2.90.256
 change−3.1 ± 2.1−4.5 ± 3.3−3.8 ± 30.261
 p value (preop to postop)<0.001<0.001<0.001NA
mean VAS leg score ± SD
 preop4.4 ± 3.14.6 ± 2.94.2 ± 3.30.748
 postop2.3 ± 2.42.4 ± 32.4 ± 2.80.985
 change−2.1 ± 3.8−2.2 ± 3.9−1.8 ± 3.80.906
 p value (preop to postop)<0.001<0.001<0.001NA

Surgical Data

Surgical data indicated significant differences between the 3 groups of patients who underwent adult spinal deformity surgical correction. Minimally invasive surgery had much lower estimated blood loss and transfusion rates (507 ml and 23.8%) than hybrid or open surgery (2003 ml and 63.6%, 2109 ml and 85.3%, respectively; p < 0.001). Operating room time was significantly longer with hybrid surgery (710 min) than with MIS and open surgery (462 and 434 minutes, respectively; p < 0.001). Major complications occurred in 14% of patients in the MIS group, 14% in the hybrid group, and 45% in the open group (p = 0.032; Table 5).6 The mean anterior and posterior fusion levels among groups are summarized in Table 6.

TABLE 5:

Summary of surgical data

Surgical VariableMISHybridOpenp ValuePost Hoc
mean EBL ± SD (ml)507 ± 8412003 ± 11922109 ± 1744<0.001 (ANOVA)MIS < hybrid, open
mean OR time ± SD (min)462 ± 177710 ± 264434 ± 147<0.001 (ANOVA)hybrid > MIS, open
transfusion %23.863.685.3<0.001 (chi-square)
% major complications*1414450.003 (chi-square)

Major complications are defined as:6 “Patient required reoperation, death, blindness, cardiac arrest, deep venous thrombosis, pulmonary embolism, implant failure, neurological deficit, pneumonia, sepsis, stroke, vascular injury, visceral injury, wound dehiscence, deep wound infection, hematoma formation with reoperation and proximal junctional kyphosis with reoperation.” EBL = estimated blood loss; OR = operating room.

TABLE 6:

Mean anterior and posterior fusion levels among groups*

Mean No. of Levels Fused ± SDMISHybridOpenANOVA
p ValuePost Hoc
posteriorly4.7 ± 2.88.7 ± 3.810.5 ± 4.3<0.001MIS had significantly fewer number of levels fused posteriorly than the 2 other groups; no difference btwn open & hybrid
anteriorly4.3 ± 1.04.1 ± 1.21.9 ± 1.8<0.001open group had significantly fewer number of levels fused (interbody); no difference bt n MIS & hybrid groups

Major osteotomies (p = 0.002, chi-square analysis): MIS = 0%, hybrid = 27.3%, and open = 21.1% of patients. Fusion to pelvis (p < 0.001, chi-square analysis): MIS = 16.7%, hybrid = 75.8%, and open = 85% of patients.

Discussion

A complete understanding of important physiological parameters, including PI−LL mismatch, SVA, pelvic tilt, and Cobb angle, is critical for proper surgical planning in patients with adult spinal deformity. Failure to account for these important parameters and the inability to predict postoperative changes has been shown to result in global malalignment and clinical failure.3 A large body of literature demonstrating satisfactory clinical outcomes of various surgical techniques for correction of deformity is currently available.2,11,13,14,20,23,24,28 Minimally invasive techniques were developed to minimize morbidity associated with traditional open surgery.1,19,27 However, to date there are no multicenter studies that compare radiographic and clinical outcomes of different deformity surgical techniques.

Open surgery is the gold standard for correction of adult spinal deformity. In their retrospective review of 105 consecutive patients who presented with fixed sagittal imbalance or kyphoscoliosis and underwent pedicle subtraction osteotomy or vertebral column resection, Auerbach et al. reported a postoperative major complication rate of 35% in spinal deformity procedures, but described a good overall clinical outcome at the 2-year follow-up.6 The presence of 3 or more medical comorbidities, an initial increased sagittal imbalance (≥ 40 mm), and an age of 60 years and older were significant risk factors for major complications.6 In another review of 34 adult patients who underwent lumbar pedicle subtraction osteotomy (fusion limited to T-10 level and below), Lafage et al. reported significant improvement in lumbar lordosis (from 20° to 49°; p < 0.001), SVA (from 14 to 4 cm; p < 0.001), and pelvic tilt (from 33° to 25°; p < 0.001).15 Of note, the impact of pedicle subtraction osteotomy on the unfused thoracic spinal segments was unfavorable in 18 patients (53%) and favorable in only 5 patients (15%). The study concluded that careful patient selection should be undertaken in the open surgical management of spinal deformity. Patients of older age and those with severely altered spinopelvic parameters are likely to benefit less from open surgery and may carry higher risks for complications.

In their retrospective review of 8 patients who underwent a combined transpsoas and posterior approach (similar to the hybrid group in this study) for degenerative thoracolumbar scoliosis, Tormenti et al. reported significant improvement in Cobb angle (from 38.5° to 10°; p < 0.0001).26 Additionally, improvement in the apical vertebral translation (from 3.6 to 1.8 cm; p = 0.031) and lumbar lordosis (from 47.3° to 40.4°) were reported. This group of patients was compared with 4 control patients who underwent open posterior approach only. The mean values for curve correction were higher in the hybrid group; however, the apical vertebral translation was higher in the open (posterior approach only) group.26 In terms of clinical outcomes, the mean VAS scores in both groups decreased dramatically after surgery: from 8.8 to 3.5 in the hybrid group, and from 9.5 to 4 in the open or posterior approach only group. The study concluded that this technique may carry the advantages of both open and MIS techniques, leading to less blood loss comparable to that of MIS and good radiographic outcomes comparable to those of open surgery.26

In our study, we found improvement in lumbar lordosis, SVA, and PI−LL mismatch among all groups. In general, open and hybrid techniques achieved superior correction in the sagittal plane (PI−LL and SVA) compared with MIS techniques. Coronal correction, however, appeared to be equally well accomplished using open or MIS techniques, with the exception that the hybrid technique achieved a larger Cobb correction. No group significantly improved pelvic tilt in our study (ideally aimed to be corrected to < 20°). Significant improvements in the coronal curve, lumbar lordosis, and PI−LL were noted in patients in the hybrid group. In fact, this resulted in the most statistically significant improvement of these important pelvic parameters. However, patients in the hybrid group also had the most significantly prolonged operative room time of any group, as well as larger estimated blood loss and higher numbers of complications compared with the MIS group.

Advances in technology, surgical techniques, and experience have made it feasible to apply MIS approaches to the treatment of spinal deformity. Minimally invasive deformity surgery carries several potential advantages over traditional open surgical techniques. It causes less traumatic injury to normal tissues surrounding the spine and is associated with less blood loss compared with open surgery.5,8,21 Additionally, MIS techniques are associated with less postoperative pain,9,12 better postoperative recovery,8,9,12,21 and decreased rates of infection.18 While current MIS techniques carry all these benefits, their efficiency in improving certain parameters, such as sagittal balance and lumbar lordosis, remains to be established.27 These parameters are essential for achieving good clinical outcomes after adult spinal deformity. In their retrospective review of 28 consecutive patients who underwent minimally invasive deformity correction and anterior/posterior fusion, Anand et al. reported significant improvement in clinical outcomes as measured by the 36-Item Short Form Health Survery and ODI scales.5 A mean Cobb angle correction of 15° was reported (from 22.3° to 7.47°; p < 0.0001). The average number of levels fused was 4.8 and the average follow-up was 22 months.5 The study noted significant reduction in blood loss and morbidity for MIS-treated patients compared with controls treated with open techniques, especially in the elderly population.5 Isaacs et al. also reported good perioperative outcomes at 6 weeks in their prospective, nonrandomized, multicenter evaluation of minimally invasive extreme lateral interbody fusion performed on 107 patients.13 In this study, an average of 4.4 levels was fused. The study concluded that minimally invasive techniques can reduce morbidity, blood loss, hospital time, infection, and major complication rates compared with other conventional surgical techniques.13

Our data showed that MIS techniques for adult spinal deformity results in significant improvement in coronal deformity and clinical outcome scores (ODI/VAS) at 1 year, with significant decreases in perioperative blood loss and complication rates compared with hybrid and open techniques. Of note, patients in the MIS group had large coronal deformities but normal to near-normal sagittal balance, and thus did not need sagittal realignment. The goal for mean PI−LL was < 10°, and although it improved, it did not reach statistical significance, and of the 3 groups, the MIS group had the least amount of improvement. Despite this result, the functional outcome success for the patients in the MIS group was similar to that for the patients in the hybrid and open groups at 1 year postoperatively. We believe that as MIS techniques and instrumentation evolve to further improve lumbar lordosis and SVA, we will also see improvements in these important radiographic parameters, while still maintaining the advantages of reduced blood loss, infection, and complications noted with MIS. Current MIS techniques are considered safe for the correction of adult spinal deformity, particularly in elderly patients and patients without significant sagittal imbalance.4,17 Because of this, we believe that MIS will be an invaluable option for the subset of adult spinal deformity patients who are symptomatic and have multiple comorbidities but limited sagittal imbalance.

Conclusions

This study provides valuable baseline characteristics of radiographic parameters among 3 different surgical techniques (MIS, hybrid, and open surgery) used in the treatment of adult spinal deformity. Each technique has advantages, but much like any surgical technique, the positive and negative elements must be considered when tailoring a treatment to a patient. Minimally invasive surgery techniques can result in clinical outcomes at 1 year comparable to those obtained from hybrid and open techniques. As surgical techniques and instrumentation improve over time, it is our belief that minimally invasive techniques will evolve to allow for correction of more severe deformities.

Disclosure

Dr. Mundis has served as a consultant to NuVasive and K2M, has received support of non–study-related clinical or research effort from NuVasive and ISSGF, and has received fellowship support from Pioneer, OREF, and NuVasive. Dr. Wang has served as a consultant to, and is a patent holder for, DePuy Spine. Dr. Mummaneni has direct stock ownership in Spinicity; has received royalties from DePuy Spine, Thieme Publishing, and Quality Medical Publishers; and has received honoraria from DePuy Spine and Globus. Dr. Uribe has served as a consultant to NuVasive. Dr. Okonkwo has received royalties from Lanx. Dr. Eastlack has direct stock ownership in NuVasive, Alphatec, DiFusion, and Invuity; has served as a consultant to NuVasive, Aesculap, Alphatec, and DePuy/Synthes; is a patent holder for Globus, Invuity, and NuTech; has received assistance for statistical analysis for study/writing or editorial assistance on manuscript from NuVasive; has received support of non–study-related clinical or research effort from Pioneer; and has served as a speaker for Eli Lilly. Dr. Anand is a patent holder for Medtronic, and has served as a consultant to Medtronic and Baxano Surgical. Dr. Kanter has received support of non–study-related clinical or research effort from NuVasive; and has received royalties from Lanx. Dr. La Marca has served as a consultant to Globus and Biomet, and has also received royalties from Globus. Dr. Park has served as a consultant to Globus and Medtronic, and has received royalties from Globus. Dr. Shaffrey has served as a consultant to Biomet, Globus, Medtronic, NuVasive, and Stryker, and is a patent holder for, and has received royalties from, Biomet and Medtronic. Dr. Klineberg has received fellowship grants from DePuy/Synthes and OREF, a research grant and speakers fees from AO Spine, and speaker's fees from DePuy/Synthes and Stryker. Dr. Deviran has served as a consultant to NuVasive, Guidepoint, and Stryker.

Author contributions to the study and manuscript preparation include the following. Conception and design: Fessler, Haque, Mundis, Wang, Mummaneni, Uribe, Eastlack, Anand, Kanter, La Marca, Akbarnia, Park, Lafage, Terran, Shaffrey, Klineberg, Deviran. Acquisition of data: all authors. Analysis and interpretation of data: Fessler, Haque, Mundis, El Ahmadieh, Wang, Mummaneni, Uribe, Eastlack, Anand, Kanter, La Marca, Akbarnia, Park, Terran, Shaffrey, Klineberg, Deviran. Drafting the article: Haque, Ahmed, El Ahmadieh, Lafage, Terran. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Fessler. Statistical analysis: Lafage, Terran. Administrative/technical/material support: Fessler, Haque, Mundis, Shaffrey. Study supervision: Fessler, Wang, Mummaneni, Uribe, Eastlack, Anand, Kanter, La Marca, Akbarnia, Park, Shaffrey, Klineberg, Deviran.

References

  • 1

    Acosta FLLiu JSlimack NMoller DFessler RKoski T: Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. Clinical article. J Neurosurg Spine 15:92962011

    • Search Google Scholar
    • Export Citation
  • 2

    Ames CPJian BShaffrey CI: Spinal deformity surgery. Neurosurg Clin N Am 24:xiiixiv2013

  • 3

    Ames CPSmith JSScheer JKBess SBederman SSDeviren V: Impact of spinopelvic alignment on decision making in deformity surgery in adults. A review. J Neurosurg Spine 16:5475642012

    • Search Google Scholar
    • Export Citation
  • 4

    Anand NBaron EMThaiyananthan GKhalsa KGoldstein TB: Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 21:4594672008

    • Search Google Scholar
    • Export Citation
  • 5

    Anand NRosemann RKhalsa BBaron EM: Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE62010

    • Search Google Scholar
    • Export Citation
  • 6

    Auerbach JDLenke LGBridwell KHSehn JKMilby AHBumpass D: Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:119812102012

    • Search Google Scholar
    • Export Citation
  • 7

    Bridwell KHGlassman SHorton WShaffrey CSchwab FZebala LP: Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976) 34:217121782009

    • Search Google Scholar
    • Export Citation
  • 8

    Dhall SSWang MYMummaneni PV: Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up. Clinical article. J Neurosurg Spine 9:5605652008

    • Search Google Scholar
    • Export Citation
  • 9

    Fessler RGKhoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 51:5 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS37S452002

    • Search Google Scholar
    • Export Citation
  • 10

    Glassman SDCarreon LYShaffrey CIPolly DWOndra SLBerven SH: The costs and benefits of nonoperative management for adult scoliosis. Spine (Phila Pa 1976) 35:5785822010

    • Search Google Scholar
    • Export Citation
  • 11

    Good CRAuerbach JDO'Leary PTSchuler TC: Adult spine deformity. Curr Rev Musculoskelet Med 4:1591672011

  • 12

    Harrington JFFrench P: Open versus minimally invasive lumbar microdiscectomy: comparison of operative times, length of hospital stay, narcotic use and complications. Minim Invasive Neurosurg 51:30352008

    • Search Google Scholar
    • Export Citation
  • 13

    Isaacs REHyde JGoodrich JARodgers WBPhillips FM: 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) 35:26 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS322S3302010

    • Search Google Scholar
    • Export Citation
  • 14

    Khoo LTPalmer SLaich DTFessler RG: Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 51:5 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS2-166S2-1812002

    • Search Google Scholar
    • Export Citation
  • 15

    Lafage VAmes CSchwab FKlineberg EAkbarnia BSmith J: Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: a comprehensive radiographic analysis. Spine (Phila Pa 1976) 37:E180E1872012

    • Search Google Scholar
    • Export Citation
  • 16

    Li GPassias PKozanek MFu EWang SXia Q: Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine (Phila Pa 1976) 34:216521702009

    • Search Google Scholar
    • Export Citation
  • 17

    Mundis GMAkbarnia BAPhillips FM: Adult deformity correction through minimally invasive lateral approach techniques. Spine (Phila Pa 1976) 35:26 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS312S3212010

    • Search Google Scholar
    • Export Citation
  • 18

    O'Toole JEEichholz KMFessler RG: Surgical site infection rates after minimally invasive spinal surgery. Clinical article. J Neurosurg Spine 11:4714762009

    • Search Google Scholar
    • Export Citation
  • 19

    Ozgur BMAryan HEPimenta LTaylor WR: Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:4354432006

    • Search Google Scholar
    • Export Citation
  • 20

    Peng CWYue WMPoh SYYeo WTan SB: Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976) 34:138513892009

    • Search Google Scholar
    • Export Citation
  • 21

    Rahman MSummers LERichter BMimran RIJacob RP: Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the “classic” open approach. Minim Invasive Neurosurg 51:1001052008

    • Search Google Scholar
    • Export Citation
  • 22

    Schwab FDubey APagala MGamez LFarcy JP: Adult scoliosis: a health assessment analysis by SF-36. Spine (Phila Pa 1976) 28:6026062003

    • Search Google Scholar
    • Export Citation
  • 23

    Schwab FPatel AUngar BFarcy JPLafage V: Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:222422312010

    • Search Google Scholar
    • Export Citation
  • 24

    Schwab FJHawkinson NLafage VSmith JSHart RMundis G: Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:260326102012

    • Search Google Scholar
    • Export Citation
  • 25

    Smith JSShaffrey CIFu KMScheer JKBess SLafage V: Clinical and radiographic evaluation of the adult spinal deformity patient. Neurosurg Clin N Am 24:1431562013

    • Search Google Scholar
    • Export Citation
  • 26

    Tormenti MJMaserati MBBonfield CMOkonkwo DOKanter AS: Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE72010

    • Search Google Scholar
    • Export Citation
  • 27

    Wang MY: Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation. Clinical article. J Neurosurg Spine 18:4122013

    • Search Google Scholar
    • Export Citation
  • 28

    Wang MYMummaneni PV: Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE92010

    • Search Google Scholar
    • Export Citation
  • 29

    Zeng YChen ZQi QGuo ZLi WSun C: Clinical and radiographic evaluation of posterior surgical correction for the treatment of moderate to severe post-tuberculosis kyphosis in 36 cases with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine 16:3513582012

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Address correspondence to: Richard G. Fessler, M.D., Ph.D., Rush University Medical Center, Department of Neurological Surgery, 1725 W. Harrison St., Ste. 855, Chicago, IL 60612. email: rfessler@rush.edu.

Please include this information when citing this paper: DOI: 10.3171/2014.3.FOCUS1424.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Acosta FLLiu JSlimack NMoller DFessler RKoski T: Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. Clinical article. J Neurosurg Spine 15:92962011

    • Search Google Scholar
    • Export Citation
  • 2

    Ames CPJian BShaffrey CI: Spinal deformity surgery. Neurosurg Clin N Am 24:xiiixiv2013

  • 3

    Ames CPSmith JSScheer JKBess SBederman SSDeviren V: Impact of spinopelvic alignment on decision making in deformity surgery in adults. A review. J Neurosurg Spine 16:5475642012

    • Search Google Scholar
    • Export Citation
  • 4

    Anand NBaron EMThaiyananthan GKhalsa KGoldstein TB: Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 21:4594672008

    • Search Google Scholar
    • Export Citation
  • 5

    Anand NRosemann RKhalsa BBaron EM: Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE62010

    • Search Google Scholar
    • Export Citation
  • 6

    Auerbach JDLenke LGBridwell KHSehn JKMilby AHBumpass D: Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:119812102012

    • Search Google Scholar
    • Export Citation
  • 7

    Bridwell KHGlassman SHorton WShaffrey CSchwab FZebala LP: Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976) 34:217121782009

    • Search Google Scholar
    • Export Citation
  • 8

    Dhall SSWang MYMummaneni PV: Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up. Clinical article. J Neurosurg Spine 9:5605652008

    • Search Google Scholar
    • Export Citation
  • 9

    Fessler RGKhoo LT: Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery 51:5 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS37S452002

    • Search Google Scholar
    • Export Citation
  • 10

    Glassman SDCarreon LYShaffrey CIPolly DWOndra SLBerven SH: The costs and benefits of nonoperative management for adult scoliosis. Spine (Phila Pa 1976) 35:5785822010

    • Search Google Scholar
    • Export Citation
  • 11

    Good CRAuerbach JDO'Leary PTSchuler TC: Adult spine deformity. Curr Rev Musculoskelet Med 4:1591672011

  • 12

    Harrington JFFrench P: Open versus minimally invasive lumbar microdiscectomy: comparison of operative times, length of hospital stay, narcotic use and complications. Minim Invasive Neurosurg 51:30352008

    • Search Google Scholar
    • Export Citation
  • 13

    Isaacs REHyde JGoodrich JARodgers WBPhillips FM: 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) 35:26 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS322S3302010

    • Search Google Scholar
    • Export Citation
  • 14

    Khoo LTPalmer SLaich DTFessler RG: Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 51:5 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS2-166S2-1812002

    • Search Google Scholar
    • Export Citation
  • 15

    Lafage VAmes CSchwab FKlineberg EAkbarnia BSmith J: Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: a comprehensive radiographic analysis. Spine (Phila Pa 1976) 37:E180E1872012

    • Search Google Scholar
    • Export Citation
  • 16

    Li GPassias PKozanek MFu EWang SXia Q: Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine (Phila Pa 1976) 34:216521702009

    • Search Google Scholar
    • Export Citation
  • 17

    Mundis GMAkbarnia BAPhillips FM: Adult deformity correction through minimally invasive lateral approach techniques. Spine (Phila Pa 1976) 35:26 SupplAdult Spinal Deformity: Pathophysiology and Corrective MeasuresS312S3212010

    • Search Google Scholar
    • Export Citation
  • 18

    O'Toole JEEichholz KMFessler RG: Surgical site infection rates after minimally invasive spinal surgery. Clinical article. J Neurosurg Spine 11:4714762009

    • Search Google Scholar
    • Export Citation
  • 19

    Ozgur BMAryan HEPimenta LTaylor WR: Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:4354432006

    • Search Google Scholar
    • Export Citation
  • 20

    Peng CWYue WMPoh SYYeo WTan SB: Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976) 34:138513892009

    • Search Google Scholar
    • Export Citation
  • 21

    Rahman MSummers LERichter BMimran RIJacob RP: Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the “classic” open approach. Minim Invasive Neurosurg 51:1001052008

    • Search Google Scholar
    • Export Citation
  • 22

    Schwab FDubey APagala MGamez LFarcy JP: Adult scoliosis: a health assessment analysis by SF-36. Spine (Phila Pa 1976) 28:6026062003

    • Search Google Scholar
    • Export Citation
  • 23

    Schwab FPatel AUngar BFarcy JPLafage V: Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:222422312010

    • Search Google Scholar
    • Export Citation
  • 24

    Schwab FJHawkinson NLafage VSmith JSHart RMundis G: Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:260326102012

    • Search Google Scholar
    • Export Citation
  • 25

    Smith JSShaffrey CIFu KMScheer JKBess SLafage V: Clinical and radiographic evaluation of the adult spinal deformity patient. Neurosurg Clin N Am 24:1431562013

    • Search Google Scholar
    • Export Citation
  • 26

    Tormenti MJMaserati MBBonfield CMOkonkwo DOKanter AS: Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE72010

    • Search Google Scholar
    • Export Citation
  • 27

    Wang MY: Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation. Clinical article. J Neurosurg Spine 18:4122013

    • Search Google Scholar
    • Export Citation
  • 28

    Wang MYMummaneni PV: Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes. Neurosurg Focus 28:3Adult Spinal Deformity: Pathophysiology and Corrective MeasuresE92010

    • Search Google Scholar
    • Export Citation
  • 29

    Zeng YChen ZQi QGuo ZLi WSun C: Clinical and radiographic evaluation of posterior surgical correction for the treatment of moderate to severe post-tuberculosis kyphosis in 36 cases with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine 16:3513582012

    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 279 279 14
PDF Downloads 240 240 16
EPUB Downloads 0 0 0

PubMed

Google Scholar