Many options exist for the surgical management of adult spinal deformity. Radiculopathy and lumbosacral pain from the fractional curve (FC), typically from L4 to S1, is frequently a reason for scoliosis patients to pursue surgical intervention. The purpose of this study was to evaluate the outcomes of limited fusion of the FC only versus treatment of the entire deformity with long fusions.
All adult scoliosis patients treated at the authors’ institution in the period from 2006 to 2016 were retrospectively analyzed. Patients with FCs from L4 to S1 > 10° and radiculopathy ipsilateral to the concavity of the FC were eligible for study inclusion and had undergone three categories of surgery: 1) FC only (FC group), 2) lower thoracic to sacrum (LT group), or 3) upper thoracic to sacrum (UT group). Primary outcomes were the rates of revision surgery and complications. Secondary outcomes were estimated blood loss, length of hospital stay, and discharge destination. Spinopelvic parameters were measured, and patients were stratified accordingly.
Of the 99 patients eligible for inclusion in the study, 27 were in the FC group, 46 in the LT group, and 26 in the UT group. There were no significant preoperative differences in age, sex, smoking status, prior operation, FC magnitude, pelvic tilt (PT), sagittal vertical axis (SVA), coronal balance, pelvic incidence–lumbar lordosis (PI-LL) mismatch, or proportion of well-aligned spines (SVA < 5 cm, PI-LL mismatch < 10°, and PT < 20°) among the three treatment groups. Mean follow-up was 30 (range 12–112) months, with a minimum 1-year follow-up. The FC group had a lower medical complication rate (22% [FC] vs 57% [LT] vs 58% [UT], p = 0.009) but a higher rate of extension surgery (26% [FC] vs 13% [LT] vs 4% [UT], p = 0.068). The respective average estimated blood loss (592 vs 1950 vs 2634 ml, p < 0.001), length of hospital stay (5.5 vs 8.3 vs 8.3 days, p < 0.001), and rate of discharge to acute rehabilitation (30% vs 46% vs 85%, p < 0.001) were all lower for FC and highest for UT.
Treatment of the FC only is associated with a lower complication rate, shorter hospital stay, and less blood loss than complete scoliosis treatment. However, there is a higher associated rate of extension of the construct to the lower or upper thoracic levels, and patients should be counseled when considering their options.
ABBREVIATIONSASA = American Society of Anesthesiologists; CVA = coronal vertical axis; FC = fractional curve; HRQOL = health-related quality of life; LC = lower thoracic; LL = lumbar lordosis; PI = pelvic incidence; PI-LL = pelvic incidence–lumbar lordosis; PJK = proximal junctional kyphosis; PT = pelvic tilt; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion; UT = upper thoracic.
Correspondence Dominic Amara: UCSF Spine Center, University of California, San Francisco, CA. firstname.lastname@example.org.
INCLUDE WHEN CITING Published online February 1, 2019; DOI: 10.3171/2018.9.SPINE18505.
Disclosures Dr. Ames has served as a consultant to DePuy Synthes, Medicrea, K2M, Stryker, and Medtronic and has received royalties from Stryker, DePuy Synthes, NuVasive, and Biomet Spine. Dr. Berven reports being a consultant for Medtronic Spine, Stryker Spine, Globus Medical, Innovasis, and RTI; has ownership in Providence Medical and Green Sun Medical; and holds patents with Medtronic, Stryker, and CoorsTek Medical. Dr. Burch has served as a consultant for Medtronic and has received research support from Lilly Inc. Dr. Chou has served as a consultant for Medtronic and Globus and has received royalties from Globus. Dr. Deviren has served as a consultant for NuVasive, Biomet, Alphatec, Pfizer, Medicrea, Seaspine, and Guidepoint and has received royalties from NuVasive. Dr. Mummaneni has served as a consultant for DePuy Synthes, has direct ownership in Spinicity/ISD, has received honoraria from AOSpine, and has received royalties from DePuy Synthes, Thieme Publishing, and Springer Publishing. Dr. Tay has served as a consultant for Lumetra, Stryker Spine, DePuy Synthes, and Biomet and has received research support from AOSpine North America, NuVasive, and Globus.
FuXSunXLHarrisJAShengSRXuHZChiYL: Long fusion correction of degenerative adult spinal deformity and the selection of the upper or lower thoracic region as the site of proximal instrumentation: a systematic review and meta-analysis. BMJ Open6:e0121032016
FuX, SunXL, HarrisJA, ShengSR, XuHZ, ChiYL, : Long fusion correction of degenerative adult spinal deformity and the selection of the upper or lower thoracic region as the site of proximal instrumentation: a systematic review and meta-analysis. 6:e012103, 20162785270910.1136/bmjopen-2016-012103)| false
HaYMaruoKRacineLSchairerWWHuSSDevirenV: Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae. J Neurosurg Spine19:360–3692013
HaY, MaruoK, RacineL, SchairerWW, HuSS, DevirenV, : Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae. 19:360–369, 201310.3171/2013.5.SPINE1273723848349)| false
HasegawaT, AnHS, HaughtonVM, NowickiBH: Lumbar foraminal stenosis: critical heights of the intervertebral discs and foramina. A cryomicrotome study in cadavera. 77:32–38, 1995782235310.2106/00004623-199501000-00005)| false
LauDClarkAJScheerJKDaubsMDCoeJDPaonessaKJ: Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976)39:2093–21022014
LauD, ClarkAJ, ScheerJK, DaubsMD, CoeJD, PaonessaKJ, : Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. 39:2093–2102, 20142527151610.1097/BRS.0000000000000627)| false
MadhavanK, ChiengLO, McGrathL, HofstetterCP, WangMY: Early experience with endoscopic foraminotomy in patients with moderate degenerative deformity. 40(2):E6, 201610.3171/2015.11.FOCUS1551126828887)| false
NichollsFHBaeJTheologisAAEksiMSAmesCPBervenSH: Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients. Spine (Phila Pa 1976)42:1693–16982017
NichollsFH, BaeJ, TheologisAA, EksiMS, AmesCP, BervenSH, : Factors associated with the development of and revision for proximal junctional kyphosis in 440 consecutive adult spinal deformity patients. 42:1693–1698, 20172844130810.1097/BRS.0000000000002209)| false
PhanK, XuJ, MaharajMM, LiJ, KimJS, Di CapuaJ, : Outcomes of short fusion versus long fusion for adult degenerative scoliosis: a systematic review and meta-analysis. 9:342–349, 20172917830610.1111/os.12357)| false
PloumisATransfeldtEEGilbertTJMehbodAAPintoMRDenisF: Radiculopathy in degenerative lumbar scoliosis: correlation of stenosis with relief from selective nerve root steroid injections. Pain Med12:45–502011
QuanXGuoKWangYHuangLChenBYeZ: Mechanical compression insults induce nanoscale changes of membrane-skeleton arrangement which could cause apoptosis and necrosis in dorsal root ganglion neurons. Biosci Biotechnol Biochem78:1631–16392014
QuanX, GuoK, WangY, HuangL, ChenB, YeZ, : Mechanical compression insults induce nanoscale changes of membrane-skeleton arrangement which could cause apoptosis and necrosis in dorsal root ganglion neurons. 78:1631–1639, 201410.1080/09168451.2014.93266425126715)| false
SchwabFJBlondelBBessSHostinRShaffreyCISmithJS: Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976)38:E803–E8122013
SchwabFJ, BlondelB, BessS, HostinR, ShaffreyCI, SmithJS, : Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. 38:E803–E812, 2013)| false
TanZY, DonnellyDF, LaMotteRH: Effects of a chronic compression of the dorsal root ganglion on voltage-gated Na+ and K+ currents in cutaneous afferent neurons. 95:1115–1123, 200610.1152/jn.00830.2005)| false
WangTHurwitzOShimadaSGQuLFuKZhangP: Chronic compression of the dorsal root ganglion enhances mechanically evoked pain behavior and the activity of cutaneous nociceptors in mice. PLoS One10:e01375122015
WangT, HurwitzO, ShimadaSG, QuL, FuK, ZhangP, : Chronic compression of the dorsal root ganglion enhances mechanically evoked pain behavior and the activity of cutaneous nociceptors in mice. 10:e0137512, 20152635663810.1371/journal.pone.0137512)| false