Radiographic outcome and complications after single-level lumbar extended pedicle subtraction osteotomy for fixed sagittal malalignment: a retrospective analysis of 55 adult spinal deformity patients with a minimum 2-year follow-up

Restricted access

OBJECTIVE

Fixed sagittal spinal malalignment is a common problem in adult spinal deformity (ASD). Various three-column osteotomy techniques, including the extended pedicle subtraction osteotomy (ePSO), may correct global and regional malalignment in this patient population. In contrast to the number of reports on traditional PSO (Schwab grade 3 osteotomy), there is limited literature on the outcomes of ePSO (Schwab grade 4 osteotomy) in ASD surgery. The objective of this retrospective study was to provide focused investigation of radiographic outcomes and complications of single-level lumbar ePSO for ASD patients with fixed sagittal malalignment.

METHODS

Consecutive ASD patients in whom sagittal malalignment had been treated with single-level lumbar ePSO at the authors’ institution between 2010 and 2015 were analyzed, and those with a minimum 2-year follow-up were included in the study. Radiographic analyses included assessments of segmental lordosis through the ePSO site (sagittal Cobb angle measured from the superior endplate of the vertebra above and inferior endplate of the vertebra below the ePSO), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence and LL mismatch, thoracic kyphosis (TK), and sagittal vertical axis (SVA) on standing long-cassette radiographs. Complications were analyzed for the entire group.

RESULTS

Among 71 potentially eligible patients, 55 (77%) had a minimum 2-year follow-up and were included in the study. Overall, the average postoperative increases in ePSO segmental lordosis and overall LL were 41° ± 14° (range 7°–69°, p < 0.001) and 38° ± 11° (range 9°–58°, p < 0.001), respectively. The average SVA improvement was 13 ± 7 cm (range of correction: −33.6 to 3.4 cm, p < 0.001). These measurements were maintained when comparing early postoperative to last follow-up values, respectively (mean follow-up 52 months, range 26–97 months): ePSO segmental lordosis, 34° vs 33°, p = 0.270; LL, 47.3° vs 46.7°, p = 0.339; and SVA, 4 vs 5 cm, p = 0.330. Rod fracture (RF) at the ePSO site occurred in 18.2% (10/55) of patients, and pseudarthrosis (PA) at the ePSO site was confirmed by CT imaging or during rod revision surgery in 14.5% (8/55) of patients. Accessory supplemental rods across the ePSO site, a more recently employed technique, significantly reduced the occurrence of RF or PA on univariate (p = 0.004) and multivariable (OR 0.062, 95% CI 0.007–0.553, p = 0.013) analyses; this effect approached statistical significance on Kaplan-Meier analysis (p = 0.053, log-rank test). Interbody cage placement at the ePSO site resulted in greater ePSO segmental lordosis correction (45° vs 35°, p = 0.007) without significant change in RF or PA (p = 0.304). Transient and persistent motor deficits occurred in 14.5% (8/55) and 1.8% (1/55) of patients, respectively.

CONCLUSIONS

Extended PSO is an effective technique to correct fixed sagittal malalignment for ASD. In comparison to traditional PSO techniques, ePSO may allow greater focal correction with comparable complication rates, especially with interbody cage placement at the ePSO site and the use of accessory supplemental rods.

ABBREVIATIONS ASD = adult spinal deformity; ePSO = extended PSO; FSM = fixed sagittal spinal malalignment; LL = lumbar lordosis; PA = pseudarthrosis; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; RF = rod fracture; SVA = sagittal vertical axis; TK = thoracic kyphosis.

Article Information

Correspondence Thomas J. Buell: University of Virginia Health System, Charlottesville, VA. tjb4p@hscmail.mcc.virginia.edu.

INCLUDE WHEN CITING Published online November 9, 2018; DOI: 10.3171/2018.7.SPINE171367.

C.I.S. and J.S.S. share senior authorship.

Disclosures Dr. C. I. Shaffrey has been a consultant for Medtronic, Nuvasive, Zimmer Biomet, and K2M; has received royalties from Medtronic, Nuvasive, and Zimmer Biomet; is a stock holder in Nuvasive; and has received grants from the NIH, Department of Defense, and the North American Clinical Trials Network for non–study-related effort. Dr. Smith has received royalties from Zimmer Biomet; has been a consultant for Zimmer Biomet, Cerapedics, Nuvasive, K2M, and AlloSource; has received honoraria from Zimmer Biomet, Nuvasive, and K2M; has received support from DePuy Synthes for the study described; has received support from DePuy Synthes and ISSGF for non–study-related effort; and has received fellowship support from the NREF and AOSpine.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A: The classic or traditional PSO technique, which is classified as Schwab grade 3 osteotomy.35 The posterior closing bony wedge resection respects the superior endplate of the index vertebra and adjacent superior disc space. Also note the ePSO technique (Schwab grade 4 osteotomy), which was utilized by the two senior authors (C.I.S., J.S.S.) in this study. The wedge resection is extended superiorly to include the adjacent disc space for radical discectomy. B: An interbody cage spacer can be placed at the osteotomy site to act as a fulcrum for additional lordosis or to increase the contact surface area for arthrodesis. C: Preoperative (left) and postoperative (right) long-cassette standing scoliosis radiographs for a 65-year-old woman who presented with thoracolumbar kyphoscoliosis above a previous L3–S1 dynamic stabilization system. She underwent surgical correction with an ePSO at L3, interbody cage placement at the ePSO site, and re-instrumentation for fusion from T10 to iliac. In this case, the L3 ePSO segmental lordosis is the sagittal Cobb angle measured between the L2 superior endplate and L4 inferior endplate. The early postoperative change in ePSO segmental correction measured 41°.

  • View in gallery

    This case demonstrates postoperative bilateral RFs at L2–3 after T10-iliac posterior instrumentation and fusion with L2 ePSO for adult idiopathic scoliosis. Approximately 3 years after the index operation, the patient presented with increasing low-back pain and muscle spasms. Note the bilateral RFs (arrows) at L2–3 adjacent to the ePSO (A and B). The patient underwent revision surgery with replacement of both primary rods and placement of two accessory supplemental rods across the original osteotomy level (C). During surgery, PA was noted at the L2–3 osteotomy level. The patient recovered from the revision operation without complication, and symptoms resolved.

  • View in gallery

    The protective effect of accessory supplemental rods to avoid RF or PA approached statistical significance on Kaplan-Meier analysis (p = 0.053, log-rank test). The figure demonstrates Kaplan-Meier curves or probability distribution functions for all patients dichotomized based on the use of accessory supplemental rods.

References

  • 1

    Berven SHDeviren VSmith JAEmami AHu SSBradford DS: Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy. Spine (Phila Pa 1976) 26:203620432001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Boachie-Adjei O: Role and technique of eggshell osteotomies and vertebral column resections in the treatment of fixed sagittal imbalance. Instr Course Lect 55:5835892006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Booth KCBridwell KHLenke LGBaldus CRBlanke KM: Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine (Phila Pa 1976) 24:171217201999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bradford DSTribus CB: Current concepts and management of patients with fixed decompensated spinal deformity. Clin Orthop Relat Res (306):64721994

  • 5

    Bridwell KHLewis SJEdwards CLenke LGIffrig TMBerra A: Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976) 28:209321012003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bridwell KHLewis SJLenke LGBaldus CBlanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am 85-A:4544632003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Bridwell KHLewis SJRinella ALenke LGBaldus CBlanke K: Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. Surgical technique. J Bone Joint Surg Am 86-A (Suppl 1):44502004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Buell TJBuchholz ALQuinn JCBess SLine BGAmes CP: A pilot study on posterior polyethylene tethers to prevent proximal junctional kyphosis after multilevel spinal instrumentation for adult spinal deformity. Oper Neurosurg (Hagerstown) [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Buell TJBuchholz ALQuinn JCMullin JPGarces JMazur MD: Extended asymmetrical pedicle subtraction osteotomy for adult spinal deformity: 2-dimensional operative video. Oper Neurosurg (Hagerstown) [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Buell TJChen CJQuinn JCBuchholz ALMazur MDMullin JP: Alignment risk factors for proximal junctional kyphosis and the effect of lower thoracic junctional tethers for adult spinal deformity. World Neurosurg [epub ahead of print]2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Buell TJMullin JPNguyen JHTaylor DGGarces JMazur MD: A novel junctional tether weave technique for adult spinal deformity: 2-dimensional operative video. Oper Neurosurg (Hagerstown) [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Burton DC: Smith-Petersen osteotomy of the spine. Instr Course Lect 55:5775822006

  • 13

    Casey MPAsher MAJacobs RROrrick JM: The effect of Harrington rod contouring on lumbar lordosis. Spine (Phila Pa 1976) 12:7507531987

  • 14

    Charosky SGuigui PBlamoutier ARoussouly PChopin D: Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976) 37:6937002012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Cho KJBridwell KHLenke LGBerra ABaldus C: Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine (Phila Pa 1976) 30:203020382005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Cho KJKim KTKim WJLee SHJung JHKim YT: Pedicle subtraction osteotomy in elderly patients with degenerative sagittal imbalance. Spine (Phila Pa 1976) 38:E1561E15662013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Choi HYHyun SJKim KJJahng TAKim HJ: Surgical and radiographic outcomes after pedicle subtraction osteotomy according to surgeon’s experience. Spine (Phila Pa 1976) 42:E795E8012017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Cummine JLLonstein JEMoe JHWinter RBBradford DS: Reconstructive surgery in the adult for failed scoliosis fusion. J Bone Joint Surg Am 61:115111611979

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Dickson DDLenke LGBridwell KHKoester LA: Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine (Phila Pa 1976) 39:119011952014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Eskilsson KSharma DJohansson CHedlund R: Pedicle subtraction osteotomy: a comprehensive analysis in 104 patients. Does the cause of deformity influence the outcome? J Neurosurg Spine 27:56622017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Farcy JPSchwab FJ: Management of flatback and related kyphotic decompensation syndromes. Spine (Phila Pa 1976) 22:245224571997

  • 22

    Gill JBLevin ABurd TLongley M: Corrective osteotomies in spine surgery. J Bone Joint Surg Am 90:250925202008

  • 23

    Glassman SDBerven SBridwell KHorton WDimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:6826882005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Glassman SDBridwell KDimar JRHorton WBerven SSchwab F: The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 30:202420292005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Gupta MCFerrero EMundis GSmith JSShaffrey CISchwab F: Pedicle subtraction osteotomy in the revision versus primary adult spinal deformity patient: is there a difference in correction and complications? Spine (Phila Pa 1976) 40:E1169E11752015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Gupta SEksi MSAmes CPDeviren VDurbin-Johnson BSmith JS: A novel 4-rod technique offers potential to reduce rod breakage and pseudarthrosis in pedicle subtraction osteotomies for adult spinal deformity correction. Oper Neurosurg (Hagerstown) 14:4494562018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Hyun SJLenke LGKim YCKoester LABlanke KM: Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976) 39:189919042014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Kim YCLenke LGHyun SJLee JHKoester LABlanke KM: Results of revision surgery after pedicle subtraction osteotomy for fixed sagittal imbalance with pseudarthrosis at the prior osteotomy site or elsewhere: minimum 5 years post-revision. Spine (Phila Pa 1976) 39:181718282014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kim YJBridwell KHLenke LGCheh GBaldus C: Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976) 32:218921972007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Lafage VSchwab FVira SHart RBurton DSmith JS: Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction? J Neurosurg Spine 14:1841912011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Lagrone MOBradford DSMoe JHLonstein JEWinter RBOgilvie JW: Treatment of symptomatic flatback after spinal fusion. J Bone Joint Surg Am 70:5695801988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Nguyen NLKong CYHart RA: Proximal junctional kyphosis and failure—diagnosis, prevention, and treatment. Curr Rev Musculoskelet Med 9:2993082016

  • 33

    Park JHHyun SJKim KJJahng TA: Comparative study between pedicle subtraction osteotomy (PSO) and closing-opening wedge osteotomy (fish-mouth PSO) for sagittal plane deformity correction. Spine (Phila Pa 1976) 42:E899E9052017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Popa IOprea MAndrei DMercedesz PMardare MPoenaru DV: Utility of the pedicle subtraction osteotomy for the correction of sagittal spine imbalance. Int Orthop 40:121912252016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 74:1121202014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Schwab FJSmith VABiserni MGamez LFarcy JPPagala M: Adult scoliosis: a quantitative radiographic and clinical analysis. Spine (Phila Pa 1976) 27:3873922002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Smith JSKlineberg ELafage VShaffrey CISchwab FLafage R: Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 25:1142016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Smith JSSansur CADonaldson WF IIIPerra JHMudiyam RChoma TJ: Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976) 36:9589642011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:86942009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up. Spine (Phila Pa 1976) 34:169316982009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Smith JSShaffrey CIKlineberg ELafage VSchwab FLafage R: Complication rates associated with 3-column osteotomy in 82 adult spinal deformity patients: retrospective review of a prospectively collected multicenter consecutive series with 2-year follow-up. J Neurosurg Spine 27:4444572017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Smith JSShaffrey EKlineberg EShaffrey CILafage VSchwab FJ: Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine 21:99410032014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Steyerberg EWVickers AJCook NRGerds TGonen MObuchowski N: Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology 21:1281382010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Tang JALeasure JMSmith JSBuckley JMKondrashov DAmes CP: Effect of severity of rod contour on posterior rod failure in the setting of lumbar pedicle subtraction osteotomy (PSO): a biomechanical study. Neurosurgery 72:2762832013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Thomasen E: Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop Relat Res (194):1421521985

  • 47

    Toyone TShiboi ROzawa TInada KShirahata TKamikawa K: Asymmetrical pedicle subtraction osteotomy for rigid degenerative lumbar kyphoscoliosis. Spine (Phila Pa 1976) 37:184718522012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Wang MYBerven SH: Lumbar pedicle subtraction osteotomy. Neurosurgery 60 (2 Suppl 1):ONS140ONS1462007

  • 49

    Yagi MKing ABCunningham MEBoachie-Adjei O: Long-term clinical and radiographic outcomes of pedicle subtraction osteotomy for fixed sagittal imbalance: does level of proximal fusion affect the outcome? Minimum 5-year follow-up. Spine Deform 1:1231312013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Zhang ZWang HZheng W: Postoperative dysesthesia in lumbar three-column resection osteotomies. Eur Spine J 25:262226282016

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 476 476 34
Full Text Views 107 107 7
PDF Downloads 100 100 8
EPUB Downloads 0 0 0

PubMed

Google Scholar