Sagittal realignment failures following pedicle subtraction osteotomy surgery: are we doing enough?

Clinical article

Frank J. Schwab Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Frank J. Schwab in
jns
Google Scholar
PubMed
Close
 M.D.
,
Ashish Patel Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Ashish Patel in
jns
Google Scholar
PubMed
Close
 M.D.
,
Christopher I. Shaffrey Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;

Search for other papers by Christopher I. Shaffrey in
jns
Google Scholar
PubMed
Close
 M.D.
,
Justin S. Smith Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;

Search for other papers by Justin S. Smith in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Jean-Pierre Farcy Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Jean-Pierre Farcy in
jns
Google Scholar
PubMed
Close
 M.D.
,
Oheneba Boachie-Adjei Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;

Search for other papers by Oheneba Boachie-Adjei in
jns
Google Scholar
PubMed
Close
 M.D.
,
Richard A. Hostin Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas;

Search for other papers by Richard A. Hostin in
jns
Google Scholar
PubMed
Close
 M.D.
,
Robert A. Hart Department of Orthopedic Surgery, Oregon Health & Science University, Portland, Oregon;

Search for other papers by Robert A. Hart in
jns
Google Scholar
PubMed
Close
 M.D.
,
Behrooz A. Akbarnia Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California;

Search for other papers by Behrooz A. Akbarnia in
jns
Google Scholar
PubMed
Close
 M.D.
,
Douglas C. Burton Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and

Search for other papers by Douglas C. Burton in
jns
Google Scholar
PubMed
Close
 M.D.
,
Shay Bess Orthopedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, Colorado

Search for other papers by Shay Bess in
jns
Google Scholar
PubMed
Close
 M.D.
, and
Virginie Lafage Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

Search for other papers by Virginie Lafage in
jns
Google Scholar
PubMed
Close
 Ph.D.
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $392.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $392.00
USD  $636.00
Print or Print + Online Sign in

Object

Pedicle subtraction osteotomy (PSO) is a surgical procedure that is frequently performed on patients with sagittal spinopelvic malalignment. Although it allows for substantial spinopelvic realignment, suboptimal realignment outcomes have been reported in up to 33% of patients. The authors' objective in the present study was to identify differences in radiographic profiles and surgical procedures between patients achieving successful versus failed spinopelvic realignment following PSO.

Methods

This study is a multicenter retrospective consecutive PSO case series. The authors evaluated 99 cases involving patients who underwent PSO for sagittal spinopelvic malalignment. Because precise cutoffs of acceptable residual postoperative sagittal vertical axis (SVA) values have not been well defined, comparisons were focused between patient groups with a postoperative SVA that could be clearly considered either a success or a failure. Only cases in which the patients had a postoperative SVA of less than 50 mm (successful PSO realignment) or more than 100 mm (failed PSO realignment) were included in the analysis. Radiographic measures and PSO parameters were compared between successful and failed PSO realignments.

Results

Seventy-nine patients met the inclusion criteria. Successful realignment was achieved in 61 patients (77%), while realignment failed in 18 (23%). Patients with failed realignment had larger preoperative SVA (mean 217.9 vs 106.7 mm, p < 0.01), larger pelvic tilt (mean 36.9° vs 30.7°, p < 0.01), larger pelvic incidence (mean 64.2° vs 53.7°, p < 0.01), and greater lumbar lordosis–pelvic incidence mismatch (−47.1° vs −30.9°, p < 0.01) compared with those in whom realignment was successful. Failed and successful realignments were similar regarding the vertebral level of the PSO, the median size of wedge resection 22.0° (interquartile range 16.5°−28.5°), and the numerical changes in pre- and postoperative spinopelvic parameters (p > 0.05).

Conclusions

Patients with failed PSO realignments had significantly larger preoperative spinopelvic deformity than patients in whom realignment was successful. Despite their apparent need for greater correction, the patients in the failed realignment group only received the same amount of correction as those in the successfully realigned patients. A single-level standard PSO may not achieve optimal outcome in patients with high preoperative spinopelvic sagittal malalignment. Patients with large spinopelvic deformities should receive larger osteotomies or additional corrective procedures beyond PSOs to avoid undercorrection.

Abbreviations used in this paper:

ASD = adult spinal deformity; BMI = body mass index; IQR = interquartile range; LL = lumbar lordosis; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SS = sacral slope; SVA = sagittal vertical axis; TK = thoracic kyphosis; TL-Kypho = thoracolumbar kyphosis.
  • Collapse
  • Expand
  • 1

    Baldus C, , Bridwell KH, , Harrast J, , Edwards C II, , Glassman S, & Horton W, et al.: Age-gender matched comparison of SRS instrument scores between adult deformity and normal adults: are all SRS domains disease specific?. Spine (Phila Pa 1976) 33:22142218, 2008

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Boachie-Adjei O, , Ferguson JA, , Pigeon RG, & Peskin MR: Transpedicular lumbar wedge resection osteotomy for fixed sagittal imbalance: surgical technique and early results. Spine (Phila Pa 1976) 31:485492, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bradford DS, & Tribus CB: Current concepts and management of patients with fixed decompensated spinal deformity. Clin Orthop Relat Res 306 6472, 1994

  • 4

    Bridwell KH: Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs vertebral column resection for spinal deformity. Spine (Phila Pa 1976) 31:19 Suppl S171S178, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bridwell KH, , Glassman S, , Horton W, , Shaffrey C, , Schwab F, & Zebala LP, et al.: 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) 34:21712178, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bridwell KH, , Lewis SJ, , Edwards C, , Lenke LG, , Iffrig TM, & Berra A, et al.: Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976) 28:20932101, 2003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Bridwell KH, , Lewis SJ, , Rinella A, , Lenke LG, , Baldus C, & Blanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg Am 86-A:Suppl 1 4450, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cho KJ, , Bridwell KH, , Lenke LG, , Berra A, & Baldus C: Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine (Phila Pa 1976) 30:20302038, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dubousset J, Three-dimensional analysis of the scoliotic deformity. Weinstein SL: The Pediatric Spine: Principles and Practice New York, Raven Press, 1994. 479496

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Farcy JP, & Schwab FJ: Management of flatback and related kyphotic decompensation syndromes. Spine (Phila Pa 1976) 22:24522457, 1997

  • 11

    Gill JB, , Levin A, , Burd T, & Longley M: Corrective osteotomies in spine surgery. J Bone Joint Surg Am 90:25092520, 2008

  • 12

    Glassman SD, , Berven S, , Bridwell K, , Horton W, & Dimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine 30:682688, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Glassman SD, , Bridwell K, , Dimar JR, , Horton W, , Berven S, & Schwab F: The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 30:20242029, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gottfried ON, , Daubs MD, , Patel AA, , Dailey AT, & Brodke DS: Spinopelvic parameters in postfusion flatback deformity patients. Spine J 9:639647, 2009

  • 15

    Ikenaga M, , Shikata J, , Takemoto M, & Tanaka C: Clinical outcomes and complications after pedicle subtraction osteotomy for correction of thoracolumbar kyphosis. J Neurosurg Spine 6:330336, 2007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jackson RP, & Hales C: Congruent spinopelvic alignment on standing lateral radiographs of adult volunteers. Spine 25:28082815, 2000

  • 17

    Kim KT, , Suk KS, , Cho YJ, , Hong GP, & Park BJ: Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine (Phila Pa 1976) 27:612618, 2002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Kim YJ, , Bridwell KH, , Lenke LG, , Cheh G, & Baldus C: Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976) 32:21892197, 2007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kim YJ, , Bridwell KH, , Lenke LG, , Rhim S, & Cheh G: Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine (Phila Pa 1976) 31:23292336, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kumar MN, , Baklanov A, & Chopin D: Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 10:314319, 2001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Lafage V, , Schwab F, , Patel A, , Hawkinson N, & Farcy JP: Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:E599E606, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Lafage V, , Schwab F, , Vira S, , Hart R, , Burton D, & Smith JS, et al.: Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction? Clinical article. J Neurosurg Spine 14:184191, 2011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Lafage V, , Schwab F, , Vira S, , Patel A, , Ungar B, & Farcy JP: Spino-pelvic parameters following surgery can be predicted: a preliminary formula and validation of standing alignment. Spine (Phila Pa 1976) 10371045, 2011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Legaye J, , Duval-Beaupère G, , Hecquet J, & Marty C: Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 7:99103, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Mummaneni PV, , Dhall SS, , Ondra SL, , Mummaneni VP, & Berven S: Pedicle subtraction osteotomy. Neurosurgery 63:3 Suppl 171176, 2008

  • 26

    Murrey DB, , Brigham CD, , Kiebzak GM, , Finger F, & Chewning SJ: Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients. Spine (Phila Pa 1976) 27:23382345, 2002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Potter BK, , Lenke LG, & Kuklo TR: Prevention and management of iatrogenic flatback deformity. J Bone Joint Surg Am 86-A:17931808, 2004

  • 28

    Rose PS, , Bridwell KH, , Lenke LG, , Cronen GA, , Mulconrey DS, & Buchowski JM, et al.: Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine (Phila Pa 1976) 34:785791, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Schwab F, , Farcy JP, , Bridwell K, , Berven S, , Glassman S, & Harrast J, et al.: A clinical impact classification of scoliosis in the adult. Spine (Phila Pa 1976) 31:21092114, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Schwab F, , Lafage V, , Patel A, & Farcy JP: Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976) 34:18281833, 2009

  • 31

    Schwab F, , Patel A, , Ungar B, , Farcy JP, & Lafage 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) 35:22242231, 2010

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Smith JS, , Shaffrey CI, , Berven S, , Glassman S, , Hamill C, & Horton W, et al.: Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:8694, 2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Yang BP, & Ondra SL: A method for calculating the exact angle required during pedicle subtraction osteotomy for fixed sagittal deformity: comparison with the trigonometric method. Neurosurgery 59:4 Suppl 2 ONS458ONS463, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Yang BP, , Ondra SL, , Chen LA, , Jung HS, , Koski TR, & Salehi SA: Clinical and radiographic outcomes of thoracic and lumbar pedicle subtraction osteotomy for fixed sagittal imbalance. J Neurosurg Spine 5:917, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1277 265 67
Full Text Views 266 43 0
PDF Downloads 249 27 0
EPUB Downloads 0 0 0