Asymmetrical pedicle subtraction osteotomy for correction of concurrent sagittal-coronal imbalance in adult spinal deformity: a comparative analysis

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  • 1 Departments of Neurological Surgery and
  • 2 Orthopaedic Surgery, University of California, San Francisco, California
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OBJECTIVE

Rigid multiplanar thoracolumbar adult spinal deformity (ASD) cases are challenging and many require a 3-column osteotomy (3CO), specifically asymmetrical pedicle subtraction osteotomy (APSO). The outcomes and additional risks of performing APSO for the correction of concurrent sagittal-coronal deformity have yet to be adequately studied.

METHODS

The authors performed a retrospective review of all ASD patients who underwent 3CO during the period from 2006 to 2019. All cases involved either isolated sagittal deformity (patients underwent standard PSO) or concurrent sagittal-coronal deformity (coronal vertical axis [CVA] ≥ 4.0 cm; patients underwent APSO). Perioperative and 2-year follow-up outcomes were compared between patients with isolated sagittal imbalance who underwent PSO and those with concurrent sagittal-coronal imbalance who underwent APSO.

RESULTS

A total of 390 patients were included: 338 who underwent PSO and 52 who underwent APSO. The mean patient age was 64.6 years, and 65.1% of patients were female. APSO patients required significantly more fusions with upper instrumented vertebrae (UIV) in the upper thoracic spine (63.5% vs 43.3%, p = 0.007). Radiographically, APSO patients had greater deformity with more severe preoperative sagittal and coronal imbalance: sagittal vertical axis (SVA) 13.0 versus 10.7 cm (p = 0.042) and CVA 6.1 versus 1.2 cm (p < 0.001). In APSO cases, significant correction and normalization were achieved (SVA 13.0–3.1 cm, CVA 6.1–2.0 cm, lumbar lordosis [LL] 26.3°–49.4°, pelvic tilt [PT] 38.0°–20.4°, and scoliosis 25.0°–10.4°, p < 0.001). The overall perioperative complication rate was 34.9%. There were no significant differences between PSO and APSO patients in rates of complications (overall 33.7% vs 42.3%, p = 0.227; neurological 5.9% vs 3.9%, p = 0.547; medical 20.7% vs 25.0%, p = 0.482; and surgical 6.5% vs 11.5%, p = 0.191, respectively). However, the APSO group required significantly longer stays in the ICU (3.1 vs 2.3 days, p = 0.047) and hospital (10.8 vs 8.3 days, p = 0.002). At the 2-year follow-up, there were no significant differences in mechanical complications, including proximal junctional kyphosis (p = 0.352), pseudarthrosis (p = 0.980), rod fracture (p = 0.852), and reoperation (p = 0.600).

CONCLUSIONS

ASD patients with significant coronal imbalance often have severe concurrent sagittal deformity. APSO is a powerful and effective technique to achieve multiplanar correction without higher risk of morbidity and complications compared with PSO for sagittal imbalance. However, APSO is associated with slightly longer ICU and hospital stays.

ABBREVIATIONS 3CO = 3-column osteotomy; ALIF = anterior lumbar interbody fusion; APSO = asymmetrical pedicle subtraction osteotomy; ASD = adult spinal deformity; CVA = coronal vertical axis; EBL = estimated blood loss; LL = lumbar lordosis; LOS = length of stay; ODI = Oswestry Disability Index; PI = pelvic incidence; PJK = proximal junctional kyphosis; PT = pelvic tilt; SVA = sagittal vertical axis; TK = thoracic kyphosis; TLIF = transforaminal lumbar interbody fusion; UIV = upper instrumented vertebrae; VCR = vertebral column resection.

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Contributor Notes

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

INCLUDE WHEN CITING Published online August 7, 2020; DOI: 10.3171/2020.5.SPINE20445.

Disclosures Dr. Deviren reports being a consultant for NuVasive, Seaspine, Medicrea, Alphatec, and Zimmer Biomet and receiving royalties from NuVasive. Dr. Ames reports being an employee of UCSF; receiving royalties from Stryker, Zimmer Biomet Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; being a consultant for DePuy Synthes, Medtronic, Medicrea, and K2M; performing research for Titan Spine, DePuy Synthes, and ISSG; serving as an editorial board member for Operative Neurosurgery; receiving grant funding from SRS; serving on the executive committee of ISSG; and serving as director of Global Spine Analytics.

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