Degenerative scoliosis is a prevalent issue among the aging population. Controversy remains over the role of surgical intervention in patients with this disease. The authors discuss a suitable approach to help guide surgical treatment, including decompression, instrumented posterior spinal fusion, anterior spinal fusion, and osteotomy. These treatment options are based on clinical analysis, radiographic analysis of the mechanical stability of the deformity, given pain generators, and necessary sagittal balance. The high potential complication rates appear to be outweighed by the eventual successful clinical outcomes in patients suitable for operative intervention. This approach has had favorable outcomes and could help resolve the controversy.
Fernando E. Silva and Lawrence G. Lenke
Ian G. Dorward and Lawrence G. Lenke
In addressing adult spinal deformities through a posterior approach, the surgeon now may choose from among a variety of osteotomy techniques. The Ponte or Smith-Petersen osteotomy provides the least correction, but it can be used at multiple levels with minimal blood loss and a lower operative risk. Pedicle subtraction osteotomies provide nearly 3 times the per-level correction of Ponte/Smith-Petersen osteotomies but carry increased technical demands, longer operative time, and greater blood loss and associated morbidity. Vertebral column resections serve as the most powerful method, providing the most correction in the coronal and sagittal planes, but posing both the greatest technical challenge and the greatest risk to the patient in terms of possible neurological injury, operative time, and potential morbidity. The authors reviewed the literature relating to these osteotomy methods. They also provided case illustrations and suggestions for their proper application.
JNSPG 75th Anniversary Invited Review Article
Justin S. Smith, Christopher I. Shaffrey, Christopher P. Ames, and Lawrence G. Lenke
Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.
In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.
Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.
Max S. Riley, Keith H. Bridwell, Lawrence G. Lenke, Jonathan Dalton, and Michael P. Kelly
Significant health-related quality of life (HRQOL) benefits have been observed for patients undergoing primary and revision adult spinal deformity (ASD) surgery. The purpose of this study was to report changes in HRQOL measures in a consecutive series of patients undergoing complex spinal reconstructive surgery, using Scoli-RISK-1 (SR-1) inclusion criteria.
This was a single-center, retrospective cohort study. The SR-1 inclusion criteria were used to define patients with complex ASD treated between June 1, 2009, and June 1, 2011. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)–22r instrument. The HRQOL changes were evaluated at a minimum 2-year follow-up. Standardized forms were used to collect surgery-related complications data for all patients. Complications were defined as minor, transient major, or permanent major. Patients who achieved a minimum 2-year follow-up were included in the analysis.
Eighty-four patients meeting SR-1 criteria were identified. Baseline demographic and surgical data were available for 74/84 (88%) patients. Forty-seven of 74 (64%) patients met the additional HRQOL criteria with a minimum 2-year follow-up (mean follow-up 3.4 years, range 2–6.5 years). Twenty-one percent of patients underwent posterior fusion only, 40% of patients had a posterior column osteotomy, and 38% had a 3-column osteotomy. Seventy-five percent of patients underwent a revision procedure. Significant improvements were observed in all SRS-22r domains: Pain: +0.8 (p < 0.001); Self-Image: +1.4 (p < 0.001); Function: +0.46 (p < 0.001); Satisfaction: +1.6 (p < 0.001); and Mental Health: +0.28 (p = 0.04). With the exception of Mental Health, more than 50% of patients achieved a minimum clinically important difference (MCID) in SRS-22r domain scores (Mental Health: 20/47, 42.6%). A total of 65 complications occurred in 31 patients. This includes 29.8% (14/47) of patients who suffered a major complication and 17% (8/47) who suffered a postoperative neurological deficit, most commonly at the root level (10.6%, 5/47). Of the 8 patients who suffered a neurological deficit, 1 (13%) was able to achieve MCID in the SRS Function domain.
The majority of patients experienced clinically relevant improvement in SRS-22r HRQOL scores after complex ASD surgery. The greatest improvements were seen in the SRS Pain and SRS Self-Image domains. Although 30% of patients suffered a major or permanent complication, benefits from surgery were still attained. Patients sustaining a neurological deficit or major complication were unlikely to achieve HRQOL improvements meeting or exceeding MCID for the SRS Function domain.
Justin S. Smith, Christopher I. Shaffrey, Michael Wang, Mohamad Bydon, and Lawrence Lenke
Melvin C. Makhni, Ying Zhang, Paul J. Park, Meghan Cerpa, Ming Yang, Martin H. Pham, J. Alex Sielatycki, Eduardo C. Beauchamp, and Lawrence G. Lenke
The objective of this study was to describe and evaluate a new surgical procedure for the correction of coronal imbalance (CI) in adult spinal deformity patients, called the “kickstand rod” technique.
The authors analyzed the records of 24 consecutive patients with pediatric and adult spinal deformity and CI treated between July 2015 and October 2017 with a long-segment fusion and a kickstand rod. For the kickstand rod technique, an iliac screw was placed on the ipsilateral side of the trunk shift and connected proximally through a side-by-side domino link to the thoracolumbar junction; this rod was distracted to promote coronal plane balancing. Distraction occurred with the rod on the contralateral side locked in order to preserve sagittal correction. Radiographic and clinical analyses were conducted to evaluate the outcomes and possible complications of the kickstand rod technique.
The mean age of the patients was 55 years (range 14–73 years). Eighteen of the 24 patients were female. CI preoperatively was a mean of 63 mm, and the mean measurement at the final follow-up (mean duration 1.4 years) was 47 mm. There were no neurological, vascular, or implant-related complications in any of the patients. One patient developed wound dehiscence that was successfully treated without implant removal, and one developed proximal junctional kyphosis requiring extension of the construct proximally. One patient also returned to the operating room for excision of a spinous process. There were no complaints about screw prominence, kickstand construct failure, or significant worsening of CI after surgery.
The kickstand rod technique is safe and effective for the correction of CI in spinal deformity patients. This technique was found to provide marked coronal correction and additional strength to the overall construct without significant adverse consequences.
Nathan J. Lee, Michael W. Fields, Venkat Boddapati, Meghan Cerpa, Jalen Dansby, James D. Lin, Zeeshan M. Sardar, Ronald Lehman Jr., and Lawrence Lenke
With the continued evolution of bundled payment plans, there has been a greater focus within orthopedic surgery on quality metrics up to 90 days of care. Although the Centers for Medicare and Medicaid Services does not currently penalize hospitals based on their pediatric readmission rates, it is important to understand the drivers for unplanned readmission to improve the quality of care and reduce costs.
The National Readmission Database provides a nationally representative sample of all discharges from US hospitals and allows follow-up across hospitals up to 1 calendar year. Adolescents (age 10–18 years) who underwent idiopathic scoliosis surgery from 2012 to 2015 were included. Patients were separated into those with and those without readmission within 30 days or between 31 and 90 days. Demographics, operative conditions, hospital factors, and surgical outcomes were compared using the chi-square test and t-test. Independent predictors for readmissions were identified using stepwise multivariate logistic regression.
A total of 30,677 patients underwent adolescent idiopathic scoliosis surgery from 2012 to 2015. The rates of 30- and 90-day readmissions were 2.9% and 1.4%, respectively. The mean costs associated with the index admission and 30- and 90-day readmissions were $60,680, $23,567, and $16,916, respectively. Common risk factors for readmissions included length of stay > 5 days, obesity, neurological disorders, and chronic use of antiplatelets or anticoagulants. The index admission complications associated with readmissions were unintended durotomy, syndrome of inappropriate antidiuretic hormone, and superior mesenteric artery syndrome. Hospital factors, discharge disposition, and operative conditions appeared to be less important for readmission risk. The top reasons for 30-day and 90-day readmissions were wound infection (34.7%) and implant complications (17.3%), respectively. Readmissions requiring a reoperation were significantly higher for those that occurred between 31 and 90 days after the index readmission.
Readmission rates were low for both 30- and 90-day readmissions for adolescent idiopathic scoliosis surgery patients. Nevertheless, readmissions are costly and appear to be associated with potentially modifiable risk factors, although some risk factors remain potentially unavoidable.
Lawrence G. Lenke
Yong-Chan Kim, Ji Hao Cui, Ki-Tack Kim, Gyu-Taek Park, Keun-Ho Lee, Sung-Min Kim, and Lawrence G. Lenke
In this study, the authors’ goal was to develop and validate novel radiographic parameters that better describe total body sagittal alignment (TBSA).
One hundred sixty-six consecutive operative spinal deformity patients were evaluated using full-body stereoradiographic imaging. Seven TBSA parameters were measured and then correlated to 6 commonly used spinopelvic measurements. TBSA measures consisted of 4 distance measures relating the cranial center of mass (CCOM) to the sacrum, hips, knees, and ankles, and 3 angular measures relating the CCOM to the hips, knees, and ankles. Furthermore, each TBSA parameter was correlated to patient-reported outcome (PRO) scores using the Oswestry Disability Index (ODI) and Scoliosis Research Society–22 (SRS-22) instruments. Thirty patients were randomly selected for inter- and intraobserver reliability testing of the TBSA parameters using intraclass correlation coefficients (ICCs).
All TBSA radiographic parameters demonstrated strong linear correlation with the currently accepted primary measure of sagittal balance, the C7 sagittal vertical axis (r = 0.55–0.96, p < 0.001). Moreover, 5 of 7 TBSA measures correlated strongly with ODI and SRS-22 total scores (r = 0.42–0.51, p < 0.001). Inter- and intraobserver reliability for all TBSA measures was good to excellent (interrater ICC = 0.70–0.98, intrarater ICC = 0.77–1.0).
In spine deformity patients, novel TBSA radiographic parameters correlated well with PROs and with currently utilized spinal sagittal measurements. Inter- and intrarater reliability was high for these novel parameters. This is the first study to propose a reliable method for measuring head-to-toe global spinal alignment.
Brian J. Kelley, Anas A. Minkara, Peter D. Angevine, Michael G. Vitale, Lawrence G. Lenke, and Richard C. E. Anderson
The long-term effects of instrumentation and fusion of the occipital-cervical-thoracic spine on spinal growth in young children are poorly understood. To mitigate the effects of this surgery on the growing pediatric spine, the authors report a novel technique used in 4 children with severe cervical-thoracic instability. These patients underwent instrumentation from the occiput to the upper thoracic region for stabilization, but without bone graft at the craniovertebral junction (CVJ). Subsequent surgery was then performed to remove the occipital instrumentation, thereby allowing further growth and increased motion across the CVJ.
Three very young children (15, 30, and 30 months old) underwent occipital to thoracic posterior segmental instrumentation due to cervical or upper thoracic dislocation, progressive kyphosis, and myelopathy. The fourth child (10 years old) underwent similar instrumentation for progressive cervical-thoracic scoliosis. Bone graft was placed at and distal to C-2 only. After follow-up CT scans demonstrated posterior arthrodesis without unintended fusion from the occiput to C-2, 3 patients underwent removal of the occipital instrumentation.
Follow-up cervical spine flexion/extension radiographs demonstrated partial restoration of motion at the CVJ. One patient has not had the occipital instrumentation removed yet, because only 4 months have elapsed since her operation.
Temporary fixation to the occiput provides increased biomechanical stability for spinal stabilization in young children, without permanently eliminating motion and growth at the CVJ. This technique can be considered in children who require longer instrumentation constructs for temporary stabilization, but who only need fusion in more limited areas where spinal instability exists.