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Zachary J. Tempel, Gurpreet S. Gandhoke, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

Object

A hybrid approach of minimally invasive lateral lumbar interbody fusion (LLIF) followed by supplementary open posterior segmental instrumented fusion (PSIF) has shown promising early results in the treatment of adult degenerative scoliosis. Studies assessing the impact of this combined approach on correction of segmental and regional coronal angulation, sagittal realignment, maximum Cobb angle, restoration of lumbar lordosis, and clinical outcomes are needed. The authors report their results of this approach for correction of adult degenerative scoliosis.

Methods

Twenty-six patients underwent combined LLIF and PSIF in a staged fashion. The patient population consisted of 21 women and 5 men. Ages ranged from 40 to 77 years old. Radiographic measurements including coronal angulation, pelvic incidence, lumbar lordosis, and sagittal vertical axis were taken preoperatively and 1 year postoperatively in all patients. Concurrently, the visual analog score (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were used to assess clinical outcomes in 19 patients.

Results

At 1-year follow-up, all patients who underwent combined LLIF and PSIF achieved statistically significant mean improvement in regional coronal angles (from 14.9° to 5.8°, p < 0.01) and segmental coronal angulation at all operative levels (p < 0.01). The maximum Cobb angle was significantly reduced postoperatively (from 41.1° to 15.1°, p < 0.05) and was maintained at follow-up (12.0°, p < 0.05). The mean lumbar lordosis–pelvic incidence mismatch was significantly improved postoperatively (from 15.0° to 6.92°, p < 0.05). Although regional lumbar lordosis improved (from 43.0° to 48.8°), it failed to reach statistical significance (p = 0.06). The mean sagittal vertical axis was significantly improved postoperatively (from 59.5 mm to 34.2 mm, p < 0.01). The following scores improved significantly after surgery: VAS for back pain (from 7.5 to 4.3, p < 0.01) and leg pain (from 5.8 to 3.1, p < 0.01), ODI (from 48 to 38, p < 0.01), and PCS (from 27.5 to 35.0, p = 0.01); the MCS score did not improve significantly (from 43.2 to 45.5, p = 0.37). There were 3 major and 10 minor complications.

Conclusions

A hybrid approach of minimally invasive LLIF and open PSIF is an effective means of achieving correction of both coronal and sagittal deformity, resulting in improvement of quality of life in patients with adult degenerative scoliosis.

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Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

Object

The authors recently used a combined approach of minimally invasive transpsoas extreme lateral interbody fusion (XLIF) and open posterior segmental pedicle screw instrumentation with transforaminal lumbar interbody fusion (TLIF) for the correction of coronal deformity. The complications and radiographic outcomes were compared with a posterior-only approach for scoliosis correction.

Methods

The authors retrospectively reviewed all deformity cases that were surgically corrected at the University of Pittsburgh Medical Center Presbyterian Hospital between June 2007 and August 2009. Eight patients underwent combined transpsoas and posterior approaches for adult degenerative thoracolumbar scoliosis. The comparison group consisted of 4 adult patients who underwent a posterior-only scoliosis correction. Data on intra- and postoperative complications were collected. The pre- and postoperative posterior-anterior and lateral scoliosis series radiographic films were reviewed, and comparisons were made for coronal deformity, apical vertebral translation (AVT), and lumbar lordosis. Clinical outcomes were evaluated by comparing pre- and postoperative visual analog scale scores.

Results

The median preoperative coronal Cobb angle in the combined approach was 38.5° (range 18–80°). Following surgery, the median Cobb angle was 10° (p < 0.0001). The mean preoperative AVT was 3.6 cm, improving to 1.8 cm postoperatively (p = 0.031). The mean preoperative lumbar lordosis in this group was 47.3°, and the mean postoperative lordosis was 40.4°. Compared with posterior-only deformity corrections, the mean values for curve correction were higher for the combined approach than for the posterior-only approach. Conversely, the mean AVT correction was higher in the posterior-only group. One patient in the posterior-only group required revision of the instrumentation. One patient who underwent the transpsoas XLIF approach suffered an intraoperative bowel injury necessitating laparotomy and segmental bowel resection; this patient later underwent an uneventful posterior-only correction of her scoliotic deformity. Two patients (25%) in the XLIF group sustained motor radiculopathies, and 6 of 8 patients (75%) experienced postoperative thigh paresthesias or dysesthesias. Motor radiculopathy resolved in 1 patient, but persisted 3 months postsurgery in the other. Sensory symptoms persisted in 5 of 6 patients at the most recent follow-up evaluation. The mean clinical follow-up time was 10.5 months for the XLIF group and 11.5 months for the posterior-only group. The mean visual analog scale score decreased from 8.8 to 3.5 in the XLIF group, and it decreased from 9.5 to 4 in the posterior-only group.

Conclusions

Radiographic outcomes such as the Cobb angle and AVT were significantly improved in patients who underwent a combined transpsoas and posterior approach. Lumbar lordosis was maintained in all patients undergoing the combined approach. The combination of XLIF and TLIF/posterior segmental instrumentation techniques may lead to less blood loss and to radiographic outcomes that are comparable to traditional posterior-only approaches. However, the surgical technique carries significant risks that require further evaluation and proper informed consent.

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Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, Peter C. Gerszten, John J. Moossy, Adam S. Kanter, Richard M. Spiro and David O. Okonkwo

Object

Since its original description in 1982, transforaminal lumbar interbody fusion (TLIF) has grown in popularity as a means for achieving circumferential fusion. The authors sought to define the perioperative complication rates of the TLIF procedure at a large academic medical center.

Methods

For all eligible patients from a consecutive series of 531 TLIF procedures, the institution's complication database and the medical record were reviewed to identify complications. Medical, nonprocedure-related complications such as myocardial infarction and pulmonary embolism were excluded due to inconsistency in the recording of these complications in the database. Rates were calculated for each type of complication, and subgroup analysis was performed to investigate the effect of previous lumbar surgery, and of multilevel versus single-level interbody fusion on complication rates. Odds ratios were calculated and evaluated using chi-square analysis.

Results

Five hundred thirty-one patients underwent a TLIF procedure during the study period. Two hundred forty-four patients (46%) had undergone a previous lumbar operation. Interbody fusion was performed at 1 level in 317 patients, at 2 levels in 188 patients, at 3 levels in 24 patients, and at 4 levels in 2 patients. One hundred thirty-five patients (25.4%) had at least one procedure-related complication. The most common complications were durotomy (14.3% of patients) and infection (3.8% of patients). Symptomatic screw misplacement (2.1% of patients) and interbody cage migration (1.8% of patients) were less common complications. The overall complication rate was greater in those patients who had undergone a previous operation (OR 1.75, 95% CI 1.18–2.59; p < 0.01) and in those who had multilevel surgery (OR 1.54, 95 % CI 1.04–2.28; p = 0.03), and the incidence of durotomy was higher in patients who had a previous operation (OR 1.75, 95% CI 1.07–2.87; p = 0.03). These differences were statistically significant. Durotomy also occurred more frequently in patients who had multilevel interbody fusion (OR 1.49, 95% CI 0.92–2.43; p = 0.13). A trend toward higher infection rates in those patients who underwent multilevel interbody fusion was observed (OR 1.5, 95% CI 0.62–3.68; p = 0.49), but this was not statistically significant. Infection rates did not differ between revision and first-time surgeries.

Conclusions

Transforaminal lumbar interbody fusion has gained widespread popularity as a procedure for achieving arthrodesis in the lumbar spine. Complications occurred more often in patients undergoing revision surgery or multilevel interbody fusion. Durotomy and infection were the most common complications in this series.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010