Importance of the lumbar paraspinal muscles on the maintenance of global sagittal alignment after lumbar pedicle subtraction osteotomy

Thomas Caffard Spine Care Institute,
Department of Orthopedic Surgery, University of Ulm, Germany;

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Artine Arzani Spine Care Institute,

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Krizia Amoroso Spine Care Institute,

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Erika Chiapparelli Spine Care Institute,

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Samuel J. Medina Spine Care Institute,

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Lukas Schönnagel Spine Care Institute,
Center for Musculoskeletal Surgery, University of Berlin, Germany;

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Jiaqi Zhu Biostatistics Core, and

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Bruno Verna Spine Care Institute,

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Kyle Finos Spine Care Institute,

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Isaac Nathoo Spine Care Institute,

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Soji Tani Spine Care Institute,
Department of Orthopaedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan; and

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Gaston Camino-Willhuber Spine Care Institute,

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Ali E. Guven Spine Care Institute,

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Arman Zadeh Spine Care Institute,

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Ek Tsoon Tan Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York;

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John A. Carrino Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York;

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Jennifer Shue Spine Care Institute,

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Oliver Dobrindt Department of Orthopedic Surgery, University of Ulm, Germany;

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Timo Zippelius Department of Orthopedic Surgery, University of Ulm, Germany;

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David Dalton Spine Care Institute,
Department of Orthopedic Surgery, University Hospital Galway, Galway, Ireland

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Andrew A. Sama Spine Care Institute,

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Federico P. Girardi Spine Care Institute,

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Frank P. Cammisa Spine Care Institute,

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Alexander P. Hughes Spine Care Institute,

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OBJECTIVE

There are limited data about the influence of the lumbar paraspinal muscles on the maintenance of sagittal alignment after pedicle subtraction osteotomy (PSO) and the risk factors for sagittal realignment failure. The authors aimed to investigate the influence of preoperative lumbar paraspinal muscle quality on the postoperative maintenance of sagittal alignment after lumbar PSO.

METHODS

Patients who underwent lumbar PSO with preoperative lumbar MRI and pre- and postoperative whole-spine radiography in the standing position were included. Spinopelvic measurements included pelvic incidence, sacral slope, pelvic tilt, L1–S1 lordosis, T4–12 thoracic kyphosis, spinosacral angle, C7–S1 sagittal vertical axis (SVA), T1 pelvic angle, and mismatch between pelvic incidence and L1–S1 lordosis. Validated custom software was used to calculate the percent fat infiltration (FI) of the psoas major, as well as the erector spinae and multifidus (MF). A multivariable linear mixed model was applied to further examine the association between MF FI and the postoperative progression of SVA over time, accounting for repeated measures over time that were adjusted for age, sex, BMI, and length of follow-up.

RESULTS

Seventy-seven patients were recruited. The authors’ results demonstrated significant correlations between MF FI and the maintenance of corrected sagittal alignment after PSO. After adjustment for the aforementioned parameters, the model showed that the MF FI was significantly associated with the postoperative progression of positive SVA over time. A 1% increase from the preoperatively assessed total MF FI was correlated with an increase of 0.92 mm in SVA postoperatively (95% CI 0.42–1.41, p < 0.0001).

CONCLUSIONS

This study included a large patient cohort with midterm follow-up after PSO and emphasized the importance of the lumbar paraspinal muscles in the maintenance of sagittal alignment correction. Surgeons should assess the quality of the MF preoperatively in patients undergoing PSO to identify patients with severe FI, as they may be at higher risk for sagittal decompensation.

ABBREVIATIONS

ASA = American Society of Anesthesiologists Physical Status Classification System; CSA = cross-sectional area; ES = erector spinae; FAT = intramuscular fat; fCSA = functional CSA; FI = fat infiltration; LL = L1–S1 lordosis; MF = multifidus; PI = pelvic incidence; PI-LL = PI minus LL; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SS = sacral slope; SSA = spinosacral angle; SVA = C7–S1 sagittal vertical axis; TK = T4–12 thoracic kyphosis; TPA = T1 pelvic angle; VAS = visual analog scale.
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  • 1

    Le Huec JC, Thompson W, Mohsinaly Y, Barrey C, Faundez A. Sagittal balance of the spine. Eur Spine J. 2019;28(9):18891905.

  • 2

    Smith JS, Klineberg E, Schwab F. Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment. Spine (Phila Pa 1976). 2013;38(19):1663-1671.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Terran J, Schwab F, Shaffrey CI, et al. The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery. 2013;73(4):559568.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Elshamly M, Windhager R, Toegel S, Grohs JG. Long-term impact of sagittal malalignment on hardware after posterior fixation of the thoracolumbar spine: a retrospective study. BMC Musculoskelet Disord. 2020;21(1):387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Ochtman AEA, Kruyt MC, Jacobs WCH, et al. Surgical restoration of sagittal alignment of the spine: correlation with improved patient-reported outcomes: a systematic review and meta-analysis. JBJS Rev. 2020;8(8):e1900100.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Gupta MC, Gupta S, Kelly MP, Bridwell KH. Pedicle subtraction osteotomy. JBJS Essential Surg Tech. 2020;10(1):e0028.

  • 7

    Trobisch PD, Hwang SW, Drange S. PSO without neuromonitoring: analysis of peri-op complication rate after lumbar pedicle subtraction osteotomy in adults. Eur Spine J. 2016;25(8):26292632.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Qian BP, Huang JC, Qiu Y, et al. Complications of spinal osteotomy for thoracolumbar kyphosis secondary to ankylosing spondylitis in 342 patients: incidence and risk factors. J Neurosurg Spine. 2019;30(1):9198.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients: a long-term follow-up data. J Korean Neurosurg Soc. 2010;47(2):95101.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Schwab FJ, Patel A, Shaffrey CI, et al. Sagittal realignment failures following pedicle subtraction osteotomy surgery: are we doing enough?: Clinical article. J Neurosurg Spine. 2012;16(6):539546.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Lafage V, Ames C, Schwab F, et al. Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: a comprehensive radiographic analysis. Spine (Phila Pa 1976). 2012;37(3):E180E187.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Yagi M, Hosogane N, Watanabe K, Asazuma T, Matsumoto M. The paravertebral muscle and psoas for the maintenance of global spinal alignment in patient with degenerative lumbar scoliosis. Spine J. 2016;16(4):451458.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Muellner M, Haffer H, Moser M, et al. Paraspinal musculature impairment is associated with spinopelvic and spinal malalignment in patients undergoing lumbar fusion surgery. Spine J. 2022;22(12):20062016.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Han G, Wang W, Zhou S. Paraspinal muscle degeneration as an independent risk for loss of local alignment in degenerative lumbar scoliosis patients after corrective surgery. Global Spine J. 2023;13(5):11861193.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Legaye J, Duval-Beaupère G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J. 1998;7(2):99103.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Duval-Beaupère G, Schmidt C, Cosson P. A Barycentremetric study of the sagittal shape of spine and pelvis: the conditions required for an economic standing position. Ann Biomed Eng. 1992;20(4):451462.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Diebo BG, Ferrero E, Lafage R, et al. Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine (Phila Pa 1976). 2015;40(9):642649.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Barrey C, Jund J, Noseda O, Roussouly P. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Eur Spine J. 2007;16(9):14591467.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Protopsaltis T, Schwab F, Bronsard N, et al. The T1 pelvic angle, a novel radiographic measure of global sagittal deformity, accounts for both spinal inclination and pelvic tilt and correlates with health-related quality of life. J Bone Joint Surg Am. 2014;96(19):16311640.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Lafage V, Schwab F, Vira S, et al. Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction?. J Neurosurg Spine. 2011;14(2):184191.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Crawford RJ, Filli L, Elliott JM, et al. Age- and level-dependence of fatty infiltration in lumbar paravertebral muscles of healthy volunteers. AJNR Am J Neuroradiol. 2016;37(4):742748.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Faron A, Luetkens JA, Schmeel FC, Kuetting DLR, Thomas D, Sprinkart AM. Quantification of fat and skeletal muscle tissue at abdominal computed tomography: associations between single-slice measurements and total compartment volumes. Abdom Radiol (NY). 2019;44(5):19071916.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Yushkevich PA, Piven J, Hazlett HC, et al. User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage. 2006;31(3):11161128.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Moser M, Adl Amini D, Jones C, et al. The predictive value of psoas and paraspinal muscle parameters measured on MRI for severe cage subsidence after standalone lateral lumbar interbody fusion. Spine J. 2023;23(1):4253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Macintosh JE, Valencia F, Bogduk N, Munro RR. The morphology of the human lumbar multifidus. Clin Biomech (Bristol, Avon). 1986;1(4):196204.

  • 26

    Fidler MW, Jowett RL. Muscle imbalance in the aetiology of scoliosis. J Bone Joint Surg Br. 1976;58(2):200201.

  • 27

    Wang K, Deng Z, Chen X, et al. The role of multifidus in the biomechanics of lumbar spine: a musculoskeletal modeling study. Bioengineering (Basel). 2023;10(1):67.

  • 28

    Lorbergs AL, Allaire BT, Yang L, et al. A longitudinal study of trunk muscle properties and severity of thoracic kyphosis in women and men: the Framingham Study. J Gerontol A Biol Sci Med Sci. 2019;74(3):420427.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Babu JM, Wang KY, Jami M, Durand WM, Neuman BJ, Kebaish KM. Sarcopenia as a risk factor for complications following pedicle subtraction osteotomy. Clin Spine Surg. 2023;36(5):190194.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Xia W, Fu H, Zhu Z, et al. Association between back muscle degeneration and spinal-pelvic parameters in patients with degenerative spinal kyphosis. BMC Musculoskelet Disord. 2019;20(1):454.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Hansen L, de Zee M, Rasmussen J, Andersen TB, Wong C, Simonsen EB. Anatomy and biomechanics of the back muscles in the lumbar spine with reference to biomechanical modeling. Spine (Phila Pa 1976). 2006;31(17):18881899.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Macintosh JE, Bogduk N. The attachments of the lumbar erector spinae. Spine (Phila Pa 1976). 1991;16(7):783792.

  • 33

    Shaikh N, Zhang H, Brown SHM, et al. Synchronous imaging of pelvic geometry and muscle morphometry: a pilot study of pelvic retroversion using upright MRI. Sci Rep. 2021;11(1):20127.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Stradiotti P, Curti A, Castellazzi G, Zerbi A. Metal-related artifacts in instrumented spine. Techniques for reducing artifacts in CT and MRI: state of the art. Eur Spine J. 2009;18(Suppl 1):102108.

    • PubMed
    • Search Google Scholar
    • Export Citation

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