Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study

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

Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.

METHODS

The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.

RESULTS

Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence–lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.

CONCLUSIONS

Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; ASD = adult spinal deformity; CC = coronal curve; LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; MIS = minimally invasive spinal; NRS = numerical rating scale; ODI = Oswestry Disability Index; OLIF = oblique lumbar interbody fusion; OR = odds ratio; PI = pelvic incidence; PT = pelvic tilt; SRS-22 = Scoliosis Research Society 22-item questionnaire; SVA = sagittal vertical axis; TK = thoracic kyphosis; TLIF = transforaminal lumbar interbody fusion; TPA = T1 pelvic angle.

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Contributor Notes

Correspondence Paul Park: University of Michigan, Ann Arbor, MI. ppark@med.umich.edu.

INCLUDE WHEN CITING Published online June 19, 2020; DOI: 10.3171/2020.4.SPINE20169.

Disclosures Dr. Park reports being a consultant to Globus and NuVasive, receiving royalties from Globus, and receiving support of non–study-related clinical or research effort from DePuy and ISSG. Dr. Than reports being a consultant to Bioventus, and receiving honoraria from LifeNet Health and DJO. Dr. Mummaneni reports being a consultant to Stryker Spine, DePuy Synthes, and Globus; having direct stock ownership in Spinicity/ISD; receiving statistical analysis for study/writing or editorial assistance on the manuscript from ISSG; receiving royalties from DePuy Synthes, Thieme Publishers, and Springer Publishers; and receiving support of non–study-related clinical or research effort from AO Spine and NREF. Dr. Eastlack reports direct stock ownership in Seaspine, Alphatec, NuVasive, and Spine Innovation; being a consultant to NuVasive, Seaspine, SI Bone, Baxter, Stryker, and Medtronic; being a patent holder for NuTech, Globus, Seaspine, SI Bone, Spine Innovation, and Stryker; being on the Speakers Bureau for Radius; and receiving support of non–study-related clinical or research effort from Seaspine, NuVasive, Medtronic, and SI Bone. Dr. Uribe reports being a consultant to NuVasive. Dr. Wang reports being a consultant to DePuy-Synthes Spine, Medtronic, Stryker, Globus, and Spineology; being a patent holder for DePuy-Synthes Spine; and having direct stock ownership in ISD and Medical Device Partners. Dr. Okonkwo reports receiving royalties from NuVasive and Zimmer Biomet, and being a patent holder for Zimmer Biomet. Dr. Kanter reports receiving royalties from NuVasive and Zimmer Biomet. Dr. Anand reports being a consultant to Medtronic and DePuy Synthes; receiving royalties from Medtronic, Globus Medical, and Elsevier; being a patent holder for Medtronic; and having direct stock ownership in Globus Medical, Spinal Balance, and Spinal Simplicity. Dr. Chou reports being a consultant to Globus and Medtronic, and receiving royalties from Globus. Dr. Fu reports being a consultant to Globus, Johnson & Johnson, SI Bone, and Atlas Spine. Dr. Shaffrey reports direct stock ownership in NuVasive; being a consultant to NuVasive, Medtronic, and SI Bone; receiving royalties from NuVasive and Medtronic; and being a patent holder for NuVasive, Medtronic, and Zimmer Biomet. Dr. Mundis reports being a consultant to NuVasive, Viseon, Seaspine, and Carlsmed; having direct stock ownership in NuVasive and Viseon; being a patent holder for K2M; and receiving royalties from NuVasive and K2M.

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