Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit? An analysis of patients who underwent circumferential minimally invasive surgery or hybrid surgery with open posterior instrumentation

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  • 1 Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan;
  • | 2 Department of Neurosurgery, Cornell Medical Center, New York, New York;
  • | 3 Department of Orthopaedic Surgery, Scripps Clinic, La Jolla;
  • | 4 San Diego Center for Spinal Disorders, San Diego, California;
  • | 5 Barrow Neurologic Institute, Phoenix, Arizona;
  • | 6 Department of Neurosurgery, University of Miami, Florida;
  • | 7 Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon;
  • | 8 Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;
  • | 9 Spine Institute of Louisiana, Shreveport, Louisiana;
  • | 10 Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California;
  • | 11 Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois; and
  • | 12 Department of Neurosurgery, University of California, San Francisco, California
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OBJECTIVE

It is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB).

METHODS

A multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score.

RESULTS

There were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (−0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31–1.33) or an SCB (OR 0.644, 95% CI 0.31–1.35) for ODI score.

CONCLUSIONS

Achieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors’ findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.

ABBREVIATIONS

AL = aligned; ASD = adult spinal deformity; cMIS = circumferential minimally invasive surgery; MAL = malaligned; MCID = minimum clinically important difference; ODI = Oswestry Disability Index; PI-LL = pelvic incidence to lumbar lordosis; PT = pelvic tilt; SCB = substantial clinical benefit; SVA = sagittal vertical axis; VAS = visual analog scale.

Spine - 1 year subscription bundle (Individuals Only)

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

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