Less invasive spinal deformity surgery: the impact of the learning curve at tertiary spine care centers

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OBJECTIVE

The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques.

METHODS

Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion.

RESULTS

Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0–26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.

Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized.

CONCLUSIONS

The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.

ABBREVIATIONS ACR = anterior column resection; ALIF = anterior lumbar interbody fusion; ASD = adult spinal deformity; LLIF = lateral lumbar interbody fusion; MIS = minimally invasive surgery; MIS-ISSG = MIS section of the International Spine Study Group; NRS = numeric rating scale; ODI = Oswestry Disability Index; PI-LL = pelvic incidence–lumbar lordosis; SVA = sagittal vertical axis.
Article Information

Contributor Notes

Correspondence Michael Y. Wang: Lois Pope LIFE Center, Miami, FL. mwang2@med.miami.edu.INCLUDE WHEN CITING Published online August 23, 2019; DOI: 10.3171/2019.6.SPINE19531.Disclosures Dr. Wang is a consultant for DePuy-Synthes Spine, Stryker, K2M, and Spineology; he is a patent holder with DePuy-Synthes Spine; and he has direct stock ownership in ISD, Spinicity, and Medical Device Partners. Dr. Eastlack is a consultant for Aesculap, Baxter, K2M-Stryker, NuVasive, Seaspine, SI-Bone, Spine Innovation, Carevature, and Titan; receives royalties from Globus Medical; has direct stock ownership in Carevature, DiFusion, NuVasive, Alphatec, Spine Innovation, Seaspine, and Invuity; has received clinical or research support from NuVasive, Scripps Clinic Medical Group, and Seaspine for the study described; and holds patents with Invuity, Globus Medical, NuVasive, Aesculap, Spine Innovation, and NuTech. Dr. Park is a consultant for Globus Medical, NuVasive, AlloSource, and Medtronic; receives royalties from Globus Medical; and receives research support from Pfizer and Vertex. Dr. Nunley is a consultant for K2M, Zimmer Biomet, Spineology, Vertiflex, Camber, Integrity, and Centinel; receives royalties from K2M and LDR; has stock or stock options in Amedica, Paradigm Spine, Camber, and Spineology; holds patents with K2M, Zimmer Biomet, Camber, and Integrity; and receives research support from Mesoblast, Organogenesis, Pfizer, Seikagaku, Simplify, Spinal Kinetics, Spineology, Vertiflex, and Zimmer Biomet. Dr. Kanter receives royalties from and is a consultant for NuVasive and Zimmer Biomet. Dr. Uribe is a consultant for NuVasive, SI-Bone, and Misonix; receives royalties, research support, and has stock options in NuVasive. Dr. Anand is a consultant for Medtronic and Spinal Balance; has direct stockownership in Atlas Spine, Globus Medical, GYS Tech, Medtronic, Paradigm Spine, Spinal Balance, and Theracell; is a patent holder with Medtronic; and receives royalties from Medtronic, Globus Medical, and Elsevier. Dr. Okonkwo is a consultant for NuVasive, Zimmer Biomet, and Stryker; is a patent holder with Zimmer Biomet; and receives royalties from Zimmer Biomet and NuVasive. Dr. Than is a consultant for Bioventus and Medtronic. Dr. Shaffrey is a consultant for Medtronic, NuVasive, Siemans, and EOS; has direct stock ownership in NuVasive; and is a patent holder with Medtronic, NuVasive, and Zimmer Biomet. Dr. Lafage has direct stock ownership in Nemaris, Inc.; receives support from DePuy Synthes Spine, NuVasive, K2M, Medtronic, Globus, AlloSource, Orthofix, SI-Bone, and Stryker for non–study-related clinical or research effort; receives grants from NASS and SRS; and has speaking/teaching arrangements with AOSpine, DePuy Synthes Spine, and K2M. Dr. Mundis is a consultant for NuVasive, K2M, Viseon, Seaspine, and AlloSource; receives royalties from K2M and NuVasive; has direct stock ownership in NuVasive; holds a patent with K2M; has a personal relationship with Global Spine Outreach and San Diego Spine Foundation; and is a speaker for DePuy. Dr. Mummaneni is a consultant for Globus, DePuy Synthes Spine, and Stryker; has direct stock ownership in Spinicity/ISD; receives support from NREF and AOSpine for a non–study-related clinical or research effort; receives honoraria from AOSpine and Spineart; receives support from ISSG for the study described; and receives royalties from DePuy Spine, Thieme Publishing, Taylor & Francis, and Springer Publishing.
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