The minimally invasive interbody selection algorithm for spinal deformity

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  • 1 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 2 Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida;
  • | 3 Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, North Carolina;
  • | 4 Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California;
  • | 5 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona;
  • | 6 Department of Neurosurgery, Rush University, Chicago, Illinois
  • | 7 Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan;
  • | 8 Enloe Neurosurgery and Spine, Chico, California;
  • | 9 University of California, Berkeley, California;
  • | 10 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;
  • | 11 Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana;
  • | 12 Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan; and
  • | 13 Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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OBJECTIVE

Minimally invasive surgery (MIS) for spinal deformity uses interbody techniques for correction, indirect decompression, and arthrodesis. Selection criteria for choosing a particular interbody approach are lacking. The authors created the minimally invasive interbody selection algorithm (MIISA) to provide a framework for rational decision-making in MIS for deformity.

METHODS

A retrospective data set of circumferential MIS (cMIS) for adult spinal deformity (ASD) collected over a 5-year period was analyzed by level in the lumbar spine to identify surgeon preferences and evaluate segmental lordosis outcomes. These data were used to inform a Delphi session of minimally invasive deformity surgeons from which the algorithm was created. The algorithm leads to 1 of 4 interbody approaches: anterior lumbar interbody fusion (ALIF), anterior column release (ACR), lateral lumbar interbody fusion (LLIF), and transforaminal lumbar interbody fusion (TLIF). Preoperative and 2-year postoperative radiographic parameters and clinical outcomes were compared.

RESULTS

Eleven surgeons completed 100 cMISs for ASD with 338 interbody devices, with a minimum 2-year follow-up. The type of interbody approach used at each level from L1 to S1 was recorded. The MIISA was then created with substantial agreement. The surgeons generally preferred LLIF for L1–2 (91.7%), L2–3 (85.2%), and L3–4 (80.7%). ACR was most commonly performed at L3–4 (8.4%) and L2–3 (6.2%). At L4–5, LLIF (69.5%), TLIF (15.9%), and ALIF (9.8%) were most commonly utilized. TLIF and ALIF were the most selected approaches at L5–S1 (61.4% and 38.6%, respectively). Segmental lordosis at each level varied based on the approach, with greater increases reported using ALIF, especially at L4–5 (9.2°) and L5–S1 (5.3°). A substantial increase in lordosis was achieved with ACR at L2–3 (10.9°) and L3–4 (10.4°). Lateral interbody arthrodesis without the use of an ACR did not generally result in significant lordosis restoration. There were statistically significant improvements in lumbar lordosis (LL), pelvic incidence–LL mismatch, coronal Cobb angle, and Oswestry Disability Index at the 2-year follow-up.

CONCLUSIONS

The use of the MIISA provides consistent guidance for surgeons who plan to perform MIS for deformity. For L1–4, the surgeons preferred lateral approaches to TLIF and reserved ACR for patients who needed the greatest increase in segmental lordosis. For L4–5, the surgeons’ order of preference was LLIF, TLIF, and ALIF, but TLIF failed to demonstrate any significant lordosis restoration. At L5–S1, the surgical team typically preferred an ALIF when segmental lordosis was desired and preferred a TLIF if preoperative segmental lordosis was adequate.

ABBREVIATIONS

ACR = anterior column release; ALIF = anterior lumbar interbody fusion; ASD = adult spinal deformity; cMIS = circumferential MIS; LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; MIISA = minimally invasive interbody selection algorithm; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; PCO = posterior column osteotomy; PI = pelvic incidence; PT = pelvic tilt; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion.

IIllustration from Godzik et al. (pp 691–699). © Barrow Neurological Institute, Phoenix, Arizona. Published with permission.

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