Complication profile associated with S1 pedicle subtraction osteotomy compared with 3-column osteotomies at other thoracolumbar levels for adult spinal deformity: series of 405 patients with 9 S1 osteotomies

View More View Less
  • 1 Departments of Neurological Surgery and
  • 2 Orthopedic Surgery, University of California, San Francisco, California
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00
Print or Print + Online

OBJECTIVE

There is an increased recognition of disproportional lumbar lordosis (LL) and artificially high pelvic incidence (PI) as a cause for positive sagittal imbalance and spinal pelvic mismatch. For such cases, a sacral pedicle subtraction osteotomy (PSO) may be indicated, although its morbidity is not well described. In this study, the authors evaluate the specific complication risks associated with S1 PSO.

METHODS

A retrospective review of all adult spinal deformity patients who underwent a 3-column osteotomy (3CO) for thoracolumbar deformity from 2006 to 2019 was performed. Demographic, clinical baseline, and radiographic parameters were recorded. The primary outcome of interest was perioperative complications (surgical, neurological, and medical). Secondary outcomes of interest included case length, blood loss, and length of stay. Multivariate analysis was used to assess the risk of S1 PSO compared with 3CO at other levels.

RESULTS

A total of 405 patients underwent 3CO in the following locations: thoracic (n = 55), L1 (n = 25), L2 (n = 29), L3 (n = 141), L4 (n = 129), L5 (n = 17), and S1 (n = 9). After S1 PSO, there were significant improvements in the sagittal vertical axis (14.8 cm vs 6.7 cm, p = 0.004) and PI-LL mismatch (31.7° vs 9.6°, p = 0.025) due to decreased PI (80.3° vs 65.9°, p = 0.006). LL remained unchanged (48.7° vs 57.8°, p = 0.360). The overall complication rate was 27.4%; the surgical, neurological, and medical complication rates were 7.7%, 6.2%, and 20.0%, respectively. S1 PSO was associated with significantly higher rates of overall complications: thoracic (29.1%), L1 (32.0%), L2 (31.0%), L3 (19.9%), L4 (32.6%), L5 (11.8%), and S1 (66.7%) (p = 0.018). Similarly, an S1 PSO was associated with significantly higher rates of surgical (thoracic [9.1%], L1 [4.0%], L2 [6.9%], L3 [5.7%], L4 [10.9%], L5 [5.9%], and S1 [44.4%], p = 0.006) and neurological (thoracic [9.1%], L1 [0.0%], L2 [6.9%], L3 [2.8%], L4 [7.0%], L5 [5.9%], and S1 [44.4%], p < 0.001) complications. On multivariate analysis, S1 PSO was independently associated with higher odds of overall (OR 7.93, p = 0.013), surgical (OR 20.66, p = 0.010), and neurological (OR 14.75, p = 0.007) complications.

CONCLUSIONS

S1 PSO is a powerful technique for correction of rigid sagittal imbalance due to an artificially elevated PI in patients with rigid high-grade spondylolisthesis and chronic sacral fractures. However, the technique and intraoperative corrective maneuvers are challenging and associated with high surgical and neurological complications. Additional investigations into the learning curve associated with S1 PSO and complication prevention are needed.

ABBREVIATIONS ASD = adult spinal deformity; CVA = coronal vertical axis; EBL = estimated blood loss; LL = lumbar lordosis; LOS = length of stay; PI = pelvic incidence; PSIS = posterior superior iliac spine; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SVA = sagittal vertical axis; TK = thoracic kyphosis; UIV = upper instrumented vertebra; 3CO = 3-column osteotomy.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

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

USD  $600.00

Contributor Notes

Correspondence Darryl Lau: University of California, San Francisco, CA. darryl.lau@ucsf.edu.

INCLUDE WHEN CITING Published online June 19, 2020; DOI: 10.3171/2020.4.SPINE20239.

Disclosures Dr. Deviren: consultant for NuVasive, Biomet, SeaSpine, Medicrea, and Alphatec. Dr. Ames: employee of UCSF; consultant for DePuy Synthes, Medtronic, Medicrea, and K2M; royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; research support from Titan Spine, DePuy Synthes, and ISSG; editorial board of Operative Neurosurgery; grant funding from SRS; executive committee of ISSG; and director of Global Spinal Analytics.

  • 1

    Schwab FJ, Blondel B, Bess S, Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976). 2013;38(13):E803E812.

    • Search Google Scholar
    • Export Citation
  • 2

    Smith JS, Shaffrey CI, Fu KM, Clinical and radiographic evaluation of the adult spinal deformity patient. Neurosurg Clin N Am. 2013;24(2):143156.

    • Search Google Scholar
    • Export Citation
  • 3

    Smith JS, Singh M, Klineberg E, Surgical treatment of pathological loss of lumbar lordosis (flatback) in patients with normal sagittal vertical axis achieves similar clinical improvement as surgical treatment of elevated sagittal vertical axis: clinical article. J Neurosurg Spine. 2014;21(2):160170.

    • Search Google Scholar
    • Export Citation
  • 4

    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346353.

    • Search Google Scholar
    • Export Citation
  • 5

    Mummaneni PV, Shaffrey CI, Lenke LG, The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Neurosurg Focus. 2014;36(5):E6.

    • Search Google Scholar
    • Export Citation
  • 6

    Berven SH, Deviren V, Smith JA, Management of fixed sagittal plane deformity: outcome of combined anterior and posterior surgery. Spine (Phila Pa 1976). 2003;28(15):17101716.

    • Search Google Scholar
    • Export Citation
  • 7

    Bridwell KH, Lewis SJ, Lenke LG, Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am. 2003;85(3):454463.

    • Search Google Scholar
    • Export Citation
  • 8

    Kim YJ, Bridwell KH, Lenke LG, Results of lumbar pedicle subtraction osteotomies for fixed sagittal imbalance: a minimum 5-year follow-up study. Spine (Phila Pa 1976). 2007;32(20):21892197.

    • Search Google Scholar
    • Export Citation
  • 9

    Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral column resection for spinal deformity. Spine (Phila Pa 1976). 2006;31(19)(suppl):S171S178.

    • Search Google Scholar
    • Export Citation
  • 10

    Cogniet A, Aunoble S, Rigal J, Clinical and radiological outcomes of lumbar posterior subtraction osteotomies are correlated to pelvic incidence and FBI index: prospective series of 63 cases. Eur Spine J. 2016;25(8):26572667.

    • Search Google Scholar
    • Export Citation
  • 11

    Ozturk AK, Sullivan PZ, Arlet V. Sacral pedicle subtraction osteotomy for an extreme case of positive sagittal balance: case report. J Neurosurg Spine. 2018;28(5):532535.

    • Search Google Scholar
    • Export Citation
  • 12

    Hsieh PC, Ondra SL, Wienecke RJ, A novel approach to sagittal balance restoration following iatrogenic sacral fracture and resulting sacral kyphotic deformity. Technical note. J Neurosurg Spine. 2007;6(4):368372.

    • Search Google Scholar
    • Export Citation
  • 13

    Pennington Z, Ahmed AK, Goodwin CR, The use of sacral osteotomy in the correction of spinal deformity: technical report and systematic review of the literature. World Neurosurg. 2019;130:285292.

    • Search Google Scholar
    • Export Citation
  • 14

    Bronson WH, Dai A, Protopsaltis T. S1 pedicle subtraction osteotomy for fixed sagittal imbalance and lumbosacral kyphosis. Clin Spine Surg. 2019;32(6):233236.

    • Search Google Scholar
    • Export Citation
  • 15

    Lau D, Deviren V, Ames CP. The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve. J Neurosurg Spine. 2019;32(2):207220.

    • Search Google Scholar
    • Export Citation
  • 16

    Bodin A, Roussouly P. Sacral and pelvic osteotomies for correction of spinal deformities. Eur Spine J. 2015;24(suppl 1):S72S82.

  • 17

    Ames CP, Smith JS, Scheer JK, Impact of spinopelvic alignment on decision making in deformity surgery in adults: a review. J Neurosurg Spine. 2012;16(6):547564.

    • Search Google Scholar
    • Export Citation
  • 18

    Kuntz C IV, Levin LS, Ondra SL, Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature. J Neurosurg Spine. 2007;6(2):104112.

    • Search Google Scholar
    • Export Citation
  • 19

    Kuntz C IV, Shaffrey CI, Ondra SL, Spinal deformity: a new classification derived from neutral upright spinal alignment measurements in asymptomatic juvenile, adolescent, adult, and geriatric individuals. Neurosurgery. 2008;63(3)(suppl):2539.

    • Search Google Scholar
    • Export Citation
  • 20

    Roussouly P, Labelle H, Rouissi J, Bodin A. Pre- and post-operative sagittal balance in idiopathic scoliosis: a comparison over the ages of two cohorts of 132 adolescents and 52 adults. Eur Spine J. 2013;22(suppl 2):S203S215.

    • Search Google Scholar
    • Export Citation
  • 21

    Marty C, Boisaubert B, Descamps H, The sagittal anatomy of the sacrum among young adults, infants, and spondylolisthesis patients. Eur Spine J. 2002;11(2):119125.

    • Search Google Scholar
    • Export Citation
  • 22

    Jackson RP, Phipps T, Hales C, Surber J. Pelvic lordosis and alignment in spondylolisthesis. Spine (Phila Pa 1976). 2003;28(2):151160.

    • Search Google Scholar
    • Export Citation
  • 23

    Wilson PD Jr, Levine DB. Compensatory pelvic osteotomy for ankylosing spondylitis. A case report. J Bone Joint Surg Am. 1969;51(1):142148.

    • Search Google Scholar
    • Export Citation
  • 24

    Vanaclocha V, Vanaclocha-Saiz A, Rivera-Paz M, S1 pedicle subtraction osteotomy in sagittal balance correction. A feasibility study on human cadaveric specimens. World Neurosurg. 2019;123:e85e102.

    • Search Google Scholar
    • Export Citation
  • 25

    Dalle Ore CL, Ames CP, Deviren V, Lau D. Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis. J Neurosurg Spine. 2019;30(6):822832.

    • Search Google Scholar
    • Export Citation
  • 26

    Dalle Ore CL, Ames CP, Deviren V, Lau D. Outcomes following single-stage posterior vertebral column resection for severe thoracic kyphosis. World Neurosurg. 2018;119:e551e559.

    • Search Google Scholar
    • Export Citation
  • 27

    Lau D, Osorio JA, Deviren V, Ames CP. The relationship of older age and perioperative outcomes following thoracolumbar three-column osteotomy for adult spinal deformity: an analysis of 300 consecutive cases. J Neurosurg Spine. 2018;28(6):593606.

    • Search Google Scholar
    • Export Citation
  • 28

    Bianco K, Norton R, Schwab F, Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus. 2014;36(5):E18.

    • Search Google Scholar
    • Export Citation
  • 29

    Lau D, Dalle Ore CL, Reid P, Utility of neuromonitoring during lumbar pedicle subtraction osteotomy for adult spinal deformity. J Neurosurg Spine. 2019;31(3):397407.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 447 447 447
Full Text Views 36 36 36
PDF Downloads 19 19 19
EPUB Downloads 0 0 0