Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance

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OBJECTIVE

Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)–only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF).

METHODS

The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years’ follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were −1.2 (VAS back pain), −1.6 (VAS leg pain), −15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary).

RESULTS

A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence–lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence–LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score.

CONCLUSIONS

Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

ABBREVIATIONS ALIF = anterior LIF; ASD = adult spinal deformity; BMI = body mass index; HRQoL = health-related quality of life; LIF = lumbar interbody fusion; LL = lumbar lordosis; LLIF = lateral LIF; MCID = minimal clinically important difference; MCS = mental component summary; ODI = Oswestry Disability Index; PCS = physical component summary; PI = pelvic incidence; PJA = proximal junctional angle; PJK = proximal junctional kyphosis; PLIF = posterior LIF; PSF = posterior spinal fixation; PT = pelvic tilt; SF-36 = 36-Item Short Form Health Survey; SRS-22 = Scoliosis Research Society 22-question Questionnaire; SVA = sagittal vertical axis; TLIF = transforaminal LIF; UIV = upper instrumented vertebra; VAS = visual analog scale.

Abstract

OBJECTIVE

Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)–only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF).

METHODS

The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years’ follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were −1.2 (VAS back pain), −1.6 (VAS leg pain), −15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary).

RESULTS

A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence–lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence–LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score.

CONCLUSIONS

Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

Treatment options for adult spinal deformity (ASD) are varied according to the patient’s baseline condition. Patients with minimal pain and mild thoracolumbar coronal deformity might benefit from conservative treatment.18 The goal of surgical treatment for patients with ASD is to achieve sagittal and coronal balance, relieve axial and radiating pain, and achieve fusion. The surgical treatment of ASD is an effective endeavor that can be accomplished using a variety of surgical strategies. Interbody fusion has been advocated as an important surgical option in the treatment of ASD, because it can increase intervertebral disc height, provide indirect decompression of the neural foramen, enable circumferential fusion, and increase lumbar lordosis (LL).1,2,21 Lumbar interbody fusion (LIF) can be achieved via multiple approaches, including the posterior (PLIF), transforaminal (TLIF), lateral (LLIF), and anterior (ALIF) LIF approaches.

Although the surgical plan for achieving satisfactory balance depends on the type of deformity, the patient’s condition, and the surgeon’s experience, 3-column osteotomy is often required for decompensated rigid deformity with severe sagittal imbalance. For patients with ASD and mild to moderate global sagittal imbalance (sagittal vertical axis [SVA] less than 10 cm),26 surgical strategies are widely varied according to surgeon preference for interbody fusion, adaptation of minimally invasive surgical technique, and type of deformity.14,23,27

In an attempt to decrease blood loss, minimize soft-tissue dissection, and improve recovery times after ASD operations, minimally invasive surgical approaches have gained popularity in this arena. Although concerns have been raised regarding the ability of these approaches to correct sagittal plane deformity, the evolution of instrumentation for minimally invasive surgeries has broadened their applicability.10,20,29

To evaluate the effectiveness of different surgical strategies in the treatment of ASD with mild to moderate sagittal imbalance, we assessed and compared radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent surgery performed using 1 of 3 different techniques, a posterior spinal fixation (PSF)–only approach, a posterior approach combined with LLIF (LLIF+PSF), or a posterior approach combined with ALIF (ALIF+PSF).

Methods

Patient Population

The medical records of consecutive adults (aged > 18 years) who underwent surgery for ASD at a single institution between 2003 and 2013 were reviewed retrospectively. Included were patients who underwent posterior instrumentation from the pelvis to L-1 or above and had mild to moderate sagittal imbalance (SVA < 10 cm), a minimum of 2 years’ follow-up, and at least 1 of the following measurements of spinal deformity: coronal Cobb angle > 20°, pelvic tilt (PT) > 20°, and pelvic incidence (PI)–LL mismatch > 10°. Patients with severe sagittal imbalance (SVA > 10 cm) and those who underwent 3-column osteotomy, had a spinal deformity related to infection, or had malignant disease were excluded. Patients were categorized into 1 of 3 groups according to the surgical strategy implemented: LLIF+PSF, ALIF+PSF, or PSF only (Fig. 1). The LLIF+PSF group included patients who underwent TLIF at the L5–S1 level.

Fig. 1.
Fig. 1.

Lateral standing radiographs of patients after surgery. A: LLIF+PSF. B: ALIF+PSF. C: PSF only.

Surgical Procedures

We used no specific criteria for selecting one approach over another. Three approaches were used throughout the study period; LLIF was introduced later than the others. In general, the pairs of surgeries (in the LLIF+PSF and ALIF+PSF groups) were performed separately so that the remaining correction needed could be gauged. In the first stage, multilevel LLIF or ALIF was performed. For LLIF, the concave side was approached to maximize the number of interbody grafts and to restore foraminal height for indirect decompression in the coronal deformities. After docking on the lateral annulus and placing a tubular retractor via the transpsoas approach, discectomy and release of the far side of the annulus was performed, followed by implantation of the polyetheretherketone cage, which included cellular allograft. TLIF was performed at the L5–S1 level during the subsequent posterior approach. For ALIF, the patient was placed in the supine position. After fluoroscopic identification of the index level, a midline skin incision was made. A retroperitoneal approach to the appropriate disc space was achieved using a self-retaining retractor. After careful dissection and retraction of the abdominal vessels, the anterior longitudinal ligament, disc material, and posterior annulus were removed. A polyetheretherketone cage filled with cellular allograft was inserted. A plate was placed over the anterior vertebral body to protect against cage migration. For the posterior approach, the patient was placed on a Jackson table. After a midline skin incision and muscle dissection, interspinous ligament resection and multilevel Schwab Grade 1 or 2 osteotomies25 was performed. Segmental pedicle screws and iliac bolts were placed routinely. LL was restored using a rod cantilever and compression technique. Local autograft, iliac crest autograft, and corticocancellous chips were applied together with bone morphogenetic protein for fusion. For the PSF-only approach, a surgical procedure for ligament resection and osteotomies similar to that described for the posterior approach after ALIF or LLIF was performed in addition to multilevel TLIF in a single stage.

Clinical Data, Radiological Assessment, and HRQoL Scores

Demographic and clinical data included patient age, sex, body mass index (BMI), smoking status, comorbidities, location of upper instrumented vertebra (UIV) (upper thoracic [T1–T7] and lower thoracic [T8–L1]), number of interbody fusion and posterior levels, incidence of proximal junctional kyphosis (PJK), mechanism of PJK (screw pullout, fracture, or spondylolisthesis), revision surgery, pseudarthrosis, and other complications.

Full-length standing anteroposterior and lateral radiographs were analyzed on Surgimap software (Nemaris) at 3 time points—baseline, 6 weeks after surgery, and final follow-up. Radiographic spinal deformity parameter measurements included C7–S1 SVA (plumb line from the center of the C-7 vertebral body to the posterior sacral prominence on the lateral radiograph), thoracic kyphosis (sagittal Cobb angle from the superior endplate of T-5 to the inferior endplate of T-12), LL (sagittal Cobb angle of the inferior endplate of T-12 to the superior endplate of S-1), PI (angle between a line perpendicular to the superior endplate of S-1 and the line connecting the superior endplate of S-1 to the bicoxofemoral axis), sacral slope (angle between the superior endplate of S-1 and the horizontal line), PT (angle made between lines originating at the bicoxofemoral axis and extending vertically and to the middle of the superior endplate of S-1), PI-LL mismatch, proximal junctional angle (PJA) (sagittal Cobb angle between the UIV and the UIV plus 2 levels [UIV+2]), coronal Cobb angle of thoracic and lumbar curves, and coronal imbalance.

Standardized HRQoL measures included a visual analog scale (VAS) for back pain and leg pain (0 no pain, 10 most severe pain), the Oswestry Disability Index (ODI), the 36-Item Short Form Health Survey (SF-36), and the Scoliosis Research Society 22-question Questionnaire (SRS-22). Two standard summary scores, the physical component summary (PCS) and the mental component summary (MCS), were based on the SF-36.30 The SRS-22 provided a total score and scores on 5 subdomains, including pain, function, self-image, mental health, and satisfaction. To place HRQoL outcomes in a clinically relevant context, values for minimal clinically important differences (MCIDs) have been established. In this study, MCIDs were defined as the following according to previous reports5,7,8,11,24: −1.2 VAS back pain score, −1.6 VAS leg pain score, −15 ODI, 0.587/0.375/0.8/0.42 SRS-22 pain/function/self-image/mental health subdomain scores, and 5.2 SF-36 PCS score. Analyses of the differences in the proportions of patients whose HRQoL measures reached an MCID were performed.

Statistical Analyses

Continuous variables are presented as means ± SD. Frequency analysis was used for categorical variables. ANOVA and the Kruskal-Wallis test were used as appropriate for group comparisons. A p value < 0.05 defined statistical significance. All analyses were performed using SPSS 14.0 K (SPSS, Inc.).

Results

Two hundred twenty-one patients met the inclusion criteria. The cohort included 186 women and 35 men, and their mean age was 64 ± 9 years; the mean follow-up period was 34.5 ± 21.7 months. Fifty-eight patients underwent LLIF+PSF, 91 underwent ALIF+PSF, and 72 underwent PSF only. Preoperative SVA, LL, PI-LL mismatch, and lumbar and thoracic Cobb angles were similar among the 3 groups. Patients who underwent PSF only had more comorbidities. Patients who underwent ALIF+PSF were, on average, younger than those who underwent LLIF+PSF (62.6 vs 64.9 years, respectively) and had a lower BMI (26.1 vs 28.1 kg/m2, respectively). The LLIF+PSF group had a significantly higher mean number of interbody fusion levels (3.8 ± 1.2 levels) than the ALIF+PSF and PSF-only groups (2.7 ± 0.8 and 0.5 ± 0.7 levels, respectively). In terms of the date of surgery, patients in the ALIF+PSF and PSF-only groups underwent surgery, on average, 1 year later than those in the LLIF+PSF group, but the follow-up period did not differ among the 3 groups. Additional demographic data are presented in Table 1.

TABLE 1.

Demographic data

DemographicAll PatientsGroupp Value
LLIF+PSFALIF+PSFPSF-Only  
No. of patients221589172
Age in yrs (mean ± SD)64.2 ± 8.964.9 ± 7.862.6 ± 8.565.7 ± 9.80.063
Sex (female/male)186:3546:1276:1564:80.323
BMI in kg/m2 (mean ± SD)27.3 ± 5.428.1 ± 5.726.1 ± 4.528.1 ± 5.50.026
Smoker (%)39.129.84242.80.527
No. of comorbidities (mean ± SD)2.7 ± 1.82.4 ± 1.92.6 ± 1.63.2 ± 1.90.034
Follow-up in mos (mean ± SD)34.5 ± 21.728.9 ± 19.536.3 ± 21.836.8 ± 22.60.072
UIV (%)0.715
 Upper thoracic (T1–7)28.127.630.825.0
 Lower thoracic (T8–L1)71.972.469.275.0
Interbody fusion performed (%)72.910010016.70.000
No. of interbody fusion levels (mean ± SD)3.3 ± 1.23.8 ± 1.22.7 ± 0.80.5 ± 0.70.000
No. of posterior fusion levels (mean ± SD)6.5 ± 4.44.0 ± 3.37.1 ± 4.88.1 ± 2.90.077
SVA (%)0.602
 ≤5 cm6562.168.962.5
 >5 but <10 cm3537.931.137.5
PI-LL mismatch (%)0.534
 ≤10°41.637.941.245.1
 >10° but <20°27.124.125.931.0
 >20°31.337.932.923.9
PT (%)0.752
 ≤20°36.940.436.035.2
 >20° but <30°44.947.444.243.7
 ≥30°18.212.319.821.1

At final follow-up, all radiographic parameters were similar among the 3 groups (Table 2). The PJA between UIV and UIV+2 was highest in the PSF-only group (17.9° ± 12.9° vs 15.0° ± 10.9° [ALIF+PSF group] and 13.1° ± 9.8° [LLIF+PSF group]; p = 0.051). The percent change between the preoperative and final follow-up PJA was significantly lower in the LLIF+PSF group than in the other groups (148.3% ± 300.6% vs 258.1% ± 449.1% [ALIF+PSF] and 356.2% ± 575.3% [PSF-only group]; p = 0.047). The average numbers of complications were similar among the 3 groups. Compared with patients who underwent ALIF+PSF and PSF only, those who underwent LLIF+PSF had significantly fewer PJKs (41.8% vs 38.9% vs 22.4%, respectively), fewer UIV fractures (28.6% vs 31.9% vs 13.8%, respectively), and fewer UIV spondylolistheses (5.5% vs 6.9% vs 0%, respectively). Revision rates and the numbers of pseudarthrosis, hardware prominence, and other perioperative complications were similar among the 3 groups (Table 3).

TABLE 2.

Sagittal and coronal radiographic data

Radiographic DataAll PatientsGroupp Value
LLIF+PSFALIF+PSFPSF-Only  
SVA (mm)
 Preop36.5 ± 33.939.2 ± 36.432.2 ± 32.539.8 ± 33.40.287
 First postop25.3 ± 45.522.3 ± 46.624.6 ± 46.228.4 ± 43.90.74
 Final postop32.3 ± 45.326.2 ± 51.230.1 ± 46.739.9 ± 37.50.189
 (Final-pre)/pre (%)−44 ± 772−99.8 ± 755.855.7 ± 658.8−126 ± 9030.27
 p value (pre-final)0.1660.0460.650.969
Thoracic kyphosis (°)
 Preop33.5 ± 16.533.1 ± 14.831.5 ± 17.636.3 ± 15.70.182
 First postop39.5 ± 15.136.8 ± 12.439.7 ± 16.541.3 ± 15.10.248
 Final postop42.6 ± 16.540.6 ± 13.842.5 ± 17.944.4 ± 16.40.449
 (Final-pre)/pre (%)58.2 ± 169.640.6 ± 91.569.9 ± 148.957.2 ± 231.60.594
 p value (pre-final)<0.001<0.001<0.001<0.001
LL (°)
 Preop40.0 ± 15.939.1 ± 13.940.4 ± 18.140.3 ± 14.50.865
 First postop49.2 ± 13.951.8 ± 12.349.5 ± 14.846.6 ± 13.80.108
 Final postop48.4 ± 13.850.3 ± 12.348.8 ± 15.146.1 ± 12.90.225
 (Final-pre)/pre (%)46.7 ± 131.644.9 ± 84.258.5 ± 160.133.5 ± 123.50.484
 p value (pre-final)<0.001<0.001<0.001<0.001
PI-LL mismatch (°)
 Preop12.2 ± 15.714.3 ± 15.111.4 ± 17.311.3 ± 14.20.482
 First postop3.7 ± 14.32.3 ± 13.73.0 ± 14.55.5 ± 14.70.406
 Final postop4.6 ± 15.53.6 ± 16.93.2 ± 14.76.9 ± 14.90.262
 (Final-pre)/pre (%)−58.2 ± 269.6−91.8 ± 293.3−54.3 ± 306.6−36.9 ± 191.60.528
 p value (pre-final)<0.001<0.001<0.0010.038
PJA (UIV–UIV+2) (°)
 Preop6.8 ± 6.45.5 ± 5.27.2 ± 6.37.6 ± 7.10.147
 First postop10.3 ± 9.19.0 ± 6.39.8 ± 9.911.8 ± 9.60.2
 Final postop15.5 ± 11.313.1 ± 9.815.0 ± 10.917.9 ± 12.90.051
 (Final-pre)/pre (%)260.6 ± 467.1148.3 ± 300.6258.1 ± 449.1356.2 ± 575.30.047
 p value (pre-final)<0.001<0.001<0.001<0.001
PT (°)
 Preop21.9 ± 10.621.1 ± 9.522.4 ± 11.621.8 ± 10.20.787
 First postop18.2 ± 9.916.7 ± 7.917.4 ± 10.420.5 ± 10.20.053
 Final postop20.8 ± 9.020.0 ± 7.520.3 ± 9.822.0 ± 9.10.374
 (Final-pre)/pre (%)9.7 ± 135.6−7.8 ± 100.46.7 ± 99.927.3 ± 187.70.339
 p value (pre-final)0.0580.1170.080.907
PI (°)
 Preop52.5 ± 11.753.3 ± 9.952.6 ± 12.651.8 ± 12.20.755
 First postop53.0 ± 11.654.2 ± 9.352.7 ± 12.252.4 ± 12.50.659
 Final postop53.1 ± 11.654.0 ± 10.154.6 ± 12.352.7 ± 11.90.768
 (Final-pre)/pre (%)−1.1 ± 14.5−0.8 ± 13.9−1.1 ± 12.2−1.4 ± 17.40.963
 p value (pre-final)0.0660.1180.8720.230
Sacral slope (°)
 Preop30.5 ± 10.631.3 ± 10.730.1 ± 10.530.2 ± 10.50.765
 First postop34.5 ± 10.536.5 ± 9.135.4 ± 10.631.9 ± 11.10.025
 Final postop31.9 ± 9.833.3 ± 8.432.0 ± 10.230.8 ± 10.30.365
 (Final-pre)/pre (%)15.1 ± 108.213.3 ± 41.225.5 ± 161.43.7 ± 47.10.455
 p value (pre-final)0.0240.0460.1350.712
Thoracic Cobb angle (°)
 Preop17.9 ± 14.816.5 ± 15.218.7 ± 14.218.2 ± 15.50.655
 First postop9.9 ± 9.98.6 ± 9.210.7 ± 10.310.1 ± 10.10.457
 Final postop10.5 ± 9.88.9 ± 10.111.2 ± 10.010.8 ± 9.20.379
 (Final-pre)/pre (%)−6.7 ± 160.85.9 ± 263.8−11.9 ± 115.5−10.3 ± 88.70.792
 p value (pre-final)<0.001<0.001<0.001<0.001
Lumbar Cobb angle (°)
 Preop28.7 ± 17.330.0 ± 19.130.7 ± 16.525.0 ± 16.10.085
 First postop14.3 ± 11.213.0 ± 11.015.2 ± 11.114.2 ± 11.70.509
 Final postop14.9 ± 11.314.2 ± 12.515.8 ± 11.614.2 ± 9.80.559
 (Final-pre)/pre (%)−35.5 ± 68.1−42.7 ± 70.8−38.5 ± 50.2−25.7 ± 83.80.324
 p value (pre-final)<0.001<0.001<0.001<0.001
Coronal imbalance (mm)
 Preop10.1 ± 30.77.6 ± 39.612.7 ± 25.48.8 ± 28.50.555
 First postop8.6 ± 24.610.3 ± 24.711.1 ± 21.93.8 ± 27.30.150
 Final postop7.2 ± 25.410.7 ± 25.29.1 ± 25.51.9 ± 24.80.098
 (Final-pre)/pre (%)−29.6 ± 301.8−40.4 ± 351.1−10.6 ± 318.6−44.3 ± 235.10.753
 p value (pre-final)0.1740.6060.2010.051

(Final-pre)/pre = percent difference calculated by (final postoperative value − preoperative value)/preoperative value; p value (pre-final) = p value of paired t-test between the preoperative value and the final postoperative value.

Values are means ± SD. Boldface type indicates statistical significance.

TABLE 3.

Summary of complications

ComplicationAll PatientsGroupp Value
LLIF+PSFALIF+PSFPSF-Only  
PJK (%)35.722.441.838.90.045
PJK mechanism (%)
 Screw pullout1415.515.411.10.687
 UIV fracture25.813.828.631.90.047
 Spondylolisthesis4.50.05.56.90.142
Revision due to PJK (%)12.78.613.215.30.517
Revision due to non-PJK (%)25.324.118.734.70.064
Pseudarthrosis (%)10.98.68.815.30.342
Hardware prominence, failure (%)8.16.95.512.50.248
Complications (%)
 Implant4.53.44.45.60.846
 Infection18.615.520.918.10.709
 Neurological8.210.37.77.00.775
 Cardiopulmonary14.517.217.68.30.197
 Vascular1.43.41.10.00.233
 Gastrointestinal10.06.99.912.50.571
 Renal4.58.63.32.80.216
 Anemia57.755.265.650.00.125
 Operative4.15.25.51.40.374
Total complications (mean ± SD)1.5 ± 1.11.6 ± 1.11.6 ± 1.21.3 ± 0.90.082

Boldface type indicates statistical significance.

Table 4 shows comparisons of preoperative and postoperative HRQoL data. All preoperative HRQoL scores were similar among the 3 groups. After surgery, patients in the LLIF+PSF group had a significantly lower ODI, higher SRS-22 self-image/total scores, and greater percent improvement in the total SRS-22 score. Patients in the LLIF+PSF group had greater achievement of the MCID in the SRS-22 pain score than those in the ALIF+PSF and PSF-only groups (88.9% vs 60.4% vs 42.3%, respectively; p = 0.002) (Table 5).

TABLE 4.

Summary of HRQoL measures

HRQoL MeasureTotalGroupp Value
LLIF+PSFALIF+PSFPSF-Only  
VAS back score
 Preop6.2 ± 2.76.3 ± 2.96.3 ± 2.65.9 ± 3.10.761
 First postop3.4 ± 2.73.4 ± 2.33.5 ± 2.93.4 ± 2.90.989
 Final postop3.3 ± 2.93.2 ± 2.93.1 ± 2.93.8 ± 3.20.398
 (Final-pre)/pre (%)−46.4 ± 54.5−57.3 ± 37.6−45.3 ± 63.9−36.3 ± 48.60.361
 p value (pre-final)<0.001<0.001<0.0010.011
VAS leg score
 Preop3.9 ± 3.64.8 ± 3.63.5 ± 3.53.7 ± 3.70.215
 First postop1.6 ± 2.42.1 ± 2.51.2 ± 2.01.9 ± 2.90.294
 Final postop2.1 ± 2.82.1 ± 2.92.2 ± 2.71.9 ± 2.80.924
 (Final-pre)/pre (%)−60.8 ± 49.5−61.4 ± 47.2−61.5 ± 55.2−58.7 ± 41.40.981
 p value (pre-final)<0.001<0.0010.0060.004
ODI
 Preop46.1 ± 14.547.2 ± 15.145.3 ± 14.846.2 ± 13.50.834
 First postop50.3 ± 15.950.0 ± 18.149.6 ± 15.051.9 ± 15.20.35
 Final postop34.3 ± 17.930.2 ± 16.033.2 ± 18.539.2 ± 17.70.058
 (Final-pre)/pre (%)−26.6 ± 39.0−38.2 ± 25.9−26.1 ± 43.8−15.7 ± 39.80.065
 p value (pre-final)<0.001<0.001<0.0010.011
SRS-22, function score
 Preop2.8 ± 0.62.8 ± 0.72.8 ± 0.62.8 ± 0.50.748
 First postop2.8 ± 0.52.8 ± 0.52.8 ± 0.42.8 ± 0.50.855
 Final postop3.3 ± 0.63.5 ± 0.53.2 ± 0.73.2 ± 0.70.082
 (Final-pre)/pre (%)26.3 ± 24.235.6 ± 35.825.1 ± 38.021.3 ± 24.20.287
 p value (pre-final)<0.001<0.001<0.001<0.001
SRS-22, pain score
 Preop2.4 ± 0.62.3 ± 0.72.5 ± 0.62.4 ± 0.70.496
 First postop2.5 ± 0.62.5 ± 0.82.5 ± 0.52.5 ± 0.70.974
 Final postop3.0 ± 0.93.2 ± 0.93.0 ± 0.82.8 ± 0.80.162
 (Final-pre)/pre (%)39.2 ± 47.360.1 ± 53.532.7 ± 38.729.5 ± 49.90.025
 p value (pre-final)<0.001<0.001<0.0010.005
SRS-22, self-image score
 Preop2.7 ± 0.62.7 ± 0.72.6 ± 0.62.9 ± 0.70.08
 First postop3.6 ± 0.53.5 ± 0.53.6 ± 0.53.6 ± 0.60.894
 Final postop3.5 ± 0.73.7 ± 0.63.4 ± 0.83.3 ± 0.70.043
 (Final-pre)/pre (%)41.3 ± 46.349.5 ± 44.943.5 ± 48.128.7 ± 42.90.236
 p value (pre-final)<0.001<0.001<0.0010.001
SRS-22, mental health score
 Preop3.6 ± 0.93.6 ± 0.93.6 ± 0.93.6 ± 0.80.998
 First postop3.8 ± 0.73.6 ± 0.83.9 ± 0.73.7 ± 0.80.209
 Final postop3.8 ± 0.83.8 ± 0.83.8 ± 0.93.8 ± 0.80.95
 (Final-pre)/pre (%)15.3 ± 35.715.9 ± 28.814.8 ± 38.315.8 ± 38.30.988
 p value (pre-final)0.010.0230.0430.079
SRS-22, subtotal score
 Preop2.9 ± 0.52.8 ± 0.52.8 ± 0.52.9 ± 0.40.389
 First postop3.1 ± 0.42.9 ± 0.43.2 ± 0.43.2 ± 0.50.105
 Final postop3.4 ± 0.63.6 ± 0.53.3 ± 0.63.3 ± 0.60.119
 (Final-pre)/pre (%)25.9 ± 26.936.6 ± 24.824.6 ± 27.718.7 ± 25.50.061
 p value (pre-final)<0.001<0.001<0.0010.001
SRS-22, satisfaction score
 Preop2.9 ± 0.92.9 ± 0.92.9 ± 0.92.7 ± 0.80.532
 First postop4.0 ± 0.73.9 ± 0.74.1 ± 0.64.1 ± 0.60.712
 Final postop3.9 ± 0.84.1 ± 0.73.9 ± 0.93.8 ± 0.80.358
 (Final-pre)/pre (%)50.1 ± 62.357.3 ± 55.345.8 ± 65.450.1 ± 72.50.774
 p value (pre-final)<0.001<0.001<0.0010.001
SRS-22, total score
 Preop2.9 ± 0.52.7 ± 0.62.8 ± 0.52.9 ± 0.40.545
 First postop3.4 ± 0.63.5 ± 0.83.3 ± 0.43.3 ± 0.50.43
 Final postop3.5 ± 0.73.8 ± 0.73.4 ± 0.63.3 ± 0.60.003
 (Final-pre)/pre (%)29.9 ± 33.146.3 ± 40.825.9 ± 28.620.3 ± 26.10.008
 p value (pre-final)<0.001<0.001<0.0010.001
SF-36/PCS score
 Preop29.8 ± 8.528.1 ± 9.231.1 ± 8.429.1 ± 8.10.314
 First postop28.7 ± 7.329.5 ± 7.128.3 ± 7.228.2 ± 8.20.775
 Final postop34.7 ± 9.735.1 ± 9.735.8 ± 10.632.9 ± 8.70.292
 (Final-pre)/pre (%)24.2 ± 34.128.6 ± 37.025.1 ± 36.819.9 ± 27.80.629
 p value (pre-final)<0.0010.003<0.0010.001
SF-36/MCS score
 Preop46.6 ± 13.444.2 ± 15.247.7 ± 13.746.7 ± 11.70.57
 First postop47.9 ± 12.946.5 ± 14.649.0 ± 12.147.5 ± 12.70.756
 Final postop48.8 ± 13.349.7 ± 13.349.1 ± 13.147.7 ± 13.70.769
 (Final-pre)/pre (%)18.4 ± 51.436.5 ± 73.311.5 ± 36.915.1 ± 48.90.138
 p value (pre-final)0.0020.0040.1940.183

Values are means ± SD. Boldface type indicates statistical significance.

TABLE 5.

MCID achievement

HRQoL MeasureAll Patients (%)Group (%)p Value
LLIF+PSFALIF+PSFPSF-Only  
VAS
 Back pain60.771.962.544.80.092
 Leg pain47.050.046.444.80.916
ODI45.857.644.236.40.217
SRS-22
 Pain63.488.960.442.30.002
 Function63.474.160.457.70.395
 Self-image51.563.052.138.50.205
 Mental health42.644.441.742.30.973
SF-36/PCS50.554.254.242.40.539

Boldface type indicates statistical significance.

Discussion

The ideal surgical treatment for ASD is a topic of much interest and debate. In this study, we assessed and compared radiographic data, complications, and HRQoL scores among patients with ASD and moderate sagittal deformity who underwent a PSF-only, LLIF+PSF, or ALIF+PSF. The major findings of our study are that satisfactory radiographic outcomes for patients with ASD can be achieved similarly and adequately with these 3 different surgical approaches and that patients who underwent LLIF+PSF experienced lower rates of PJK and mechanical failure at the UIV as well as less back pain, less disability, and better SRS-22 scores than those treated with the ALIF+PSF or PSF-only surgical strategy.

Posterior release, posterior interbody fusion, and reduction via a PSF-only approach have been shown to provide satisfactory multiplanar correction for adult scoliosis.17 Although effective, the PSF-only approach has a higher reported rate of morbidity3,6 and enables less access to the anterior vertebral body, which might compromise its ability to result in adequate spinal realignment and/or fusion. In addition, the posterior approach and placement of interbody cages via the posterior approach can be difficult when performing revision surgery in patients in whom significant scarring and bone grafting have altered the anatomy. The lower percentage of interbody fusion (16.7%) in the PSF-only group highlights this limitation of PSF-only approaches. As such, alternative approaches (i.e., anterior and lateral) offer unique advantages in the setting of ASD when combined with the posterior approach.

Both ALIF and LLIF are viable options for the treatment of ASD. ALIF offers several advantages over LLIF, including enabling direct decompression of neural foramina, providing accessibility to L5–S1, requiring less mobilization of the psoas muscle (which lowers the risk of lumbar plexus injury), and enabling resection of the anterior longitudinal ligament, wide discectomies, and insertion of wedge-shaped lordotic grafts. However, it does carry risks related to mobilization of the abdominal viscera and large vessels.15,19,31 In contrast, LLIF can restore intervertebral disc height, which results in indirect decompression of neural foramina without jeopardizing segmental stability because it retains the anterior and posterior longitudinal ligaments.1,4,9,12,16,21 Furthermore, wide interbody cages that support the lateral rims of the endplate can be placed via the lateral approach, which might translate into preventing subsidence and subsequent loss of deformity correction.

In our study, LLIF+PSF resulted in significantly fewer incidences of radiographic PJK than the ALIF+PSF and PSF-only approaches (22.4%, 41.8%, and 38.9%, respectively), although the rates of revision performed because of PJK were not different among the 3 groups. The PSF-only group had a higher PJA at final follow-up than the hybrid groups and a higher incidence of fracture at the UIV. Patients in the PSF-only group also experienced a higher incidence of spondylolisthesis at the proximal junction (6.9% vs 0%, respectively), more revision surgeries (15.3% vs 8.6%, respectively), and more pseudarthroses (15.3% vs 8.6%, respectively) than those in the LLIF+PSF group (differences not statistically significant), which might explain why our LLIF+PSF group showed significant improvement in SRS-22 total and self-image scores over those of the ALIF+PSF and PSF-only groups; HRQoL scores are reportedly associated with improvement in radiographic alignment and negatively affected by complications that necessitate revision surgery.22 Uribe et al.28 reported that total complication rates were not different between their hybrid and open PSF-only groups (47% and 63%, respectively). We also found that complication rates were similar among our 3 groups. In addition, Hamilton et al.13 compared reoperation rates in their hybrid (minimally invasive LLIF+PSF) and PSF-only groups and found that the rate of revision surgery was higher among patients in the hybrid group (27%) than those in the PSF-only group (12%). Interesting to note is that neurological deficit and PJK were the most common reasons for reoperation in the hybrid and PSF-only groups; the rates of revision surgery performed because of PJK were 9.5% in the hybrid group and 4.8% in the PSF-only group.13 In contrast, our PSF-only group was found to have higher rates of revision surgery and incidence of radiographic PJK, but this difference was not significant in comparison with the other groups.

In addition, we found that all 3 surgical techniques (PSF only, ALIF+PSF, and LLIF+PSF) resulted in significant improvements in sagittal radiographic deformity parameters and HRQoL scores. Although Haque et al.14 also found that LLIF+PSF resulted in greater restoration of PI-LL mismatch and SVA than did their PSF-only group, Hamilton et al.13 found that the SVA was improved after surgery for patients in their PSF-only group but not for those in their LLIF+PSF group (53 mm [before surgery] vs 53.1 mm [after surgery]). These discrepancies highlight the heterogeneity of this disorder and the need for prospective studies to assess the efficacy of different surgical techniques among more homogeneous populations of people with ASD.

The findings of this study should be considered in the context of its limitations. One of its major limitations is its retrospective nature and that the choice of surgery was based mainly on surgeon preference. In addition, because the surgeries were performed by various surgeons over 10 years, it is difficult to differentiate between results of the different surgeries and the effects of individual differences and accumulation of experience among those surgeons. However, we found no difference between baseline deformity parameters, UIV, and postoperative deformity parameters, which represent the surgical goals, and achievements were constant even though the surgical strategies were different. Because the study included patients with various degrees of freedom in choosing their surgical procedure, it is difficult to extend the analysis to patients with severe deformity. Although this was a study of a large cohort from a single institution, it is necessary to confirm the results through a multicenter prospective study.

Conclusions

In adults with mild to moderate sagittal plane deformity, satisfactory radiographic outcomes can be achieved similarly and adequately with different surgical approaches. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of PJK and mechanical failure at the UIV as well as less back pain, less disability, and better SRS-22 scores.

Disclosures

Dr. Ames has served as a consultant to DePuy, Stryker, and Medtronic, is a patent holder for Fish & Richardson, P.C., and has received royalties from Stryker and Biomet Spine. Dr. Berven reports being a consultant for Medtronic, Stryker, Globus Medical, and RTI, and he holds patents with Medtronic, Stryker, and CoorsTek Medical. Dr. Burch has served as a consultant for Medtronic and Lily, Inc. Dr. Chou has served as a consultant for Medtronic, Globus, and Orthofix. Dr. Deviren has served as a consultant for NuVasive and Guidepoint. Dr. Mummaneni has served as a consultant for DePuy Spine, has direct ownership in Spinicity/ISD, has received honoraria from AOSpine, and has received royalties from DePuy Spine, Thieme Publishing, and Springer Publishing. Dr. Tay has served as a consultant for Stryker Spine, DePuy Synthes, and Biomet and has received research support from AOSpine North America, NuVasive, and Globus.

Author Contributions

Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Bae. Statistical analysis: Bae. Administrative/technical/material support: Theologis. Study supervision: Deviren.

References

  • 1

    Acosta FLLiu JSlimack NMoller DFessler RKoski T: Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine 15:92962011

  • 2

    Benglis DMElhammady MSLevi ADVanni S: Minimally invasive anterolateral approaches for the treatment of back pain and adult degenerative deformity. Neurosurgery 63 (3 Suppl):1911962008

  • 3

    Bhagat SVozar VLutchman LCrawford RJRai AS: Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience. Eur Spine J 22 (Suppl 1):S42S462013

  • 4

    Caputo AMMichael KWChapman TMJennings JMHubbard EWIsaacs RE: Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis. J Clin Neurosci 20:155815632013

  • 5

    Carreon LYSanders JODiab MSucato DJSturm PFGlassman SD: The minimum clinically important difference in Scoliosis Research Society-22 Appearance, Activity, and Pain domains after surgical correction of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) ':207920832010

  • 6

    Cho SKBridwell KHLenke LGYi JSPahys JMZebala LP: Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976) 37:4895002012

  • 7

    Copay AGGlassman SDSubach BRBerven SSchuler TCCarreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:9689742008

  • 8

    Crawford CH IIIGlassman SDBridwell KHBerven SHCarreon LY: The minimum clinically important difference in SRS-22R total score, appearance, activity and pain domains after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 40:3773812015

  • 9

    Dahdaleh NSSmith ZASnyder LAGraham RBFessler RGKoski TR: Lateral transpsoas lumbar interbody fusion: outcomes and deformity correction. Neurosurg Clin N Am 25:3533602014

  • 10

    Dakwar ECardona RFSmith DAUribe JS: Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis. Neurosurg Focus 28(3):E82010

  • 11

    Fakurnejad SScheer JKLafage VSmith JSDeviren VHostin R: The likelihood of reaching minimum clinically important difference and substantial clinical benefit at 2 years following a 3-column osteotomy: analysis of 140 patients. J Neurosurg Spine 23:3403482015

  • 12

    Guérin PObeid IBourghli AMasquefa TLuc SGille O: The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach. Surg Radiol Anat 34:1511572012

  • 13

    Hamilton DKKanter ASBolinger BDMundis GM JrNguyen SMummaneni PV: Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up. Eur Spine J 25:260526112016

  • 14

    Haque RMMundis GM JrAhmed YEl Ahmadieh TYWang MYMummaneni PV: Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients. Neurosurg Focus 36(5):E132014

  • 15

    Hsieh MKChen LHNiu CCFu TSLai PLChen WJ: Combined anterior lumbar interbody fusion and instrumented posterolateral fusion for degenerative lumbar scoliosis: indication and surgical outcomes. BMC Surg 15:262015

  • 16

    Isaacs REHyde JGoodrich JARodgers WBPhillips FM: A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976) 35 (26 Suppl):S322S3302010

  • 17

    Lippman CRSpence CAYoussef ASCahill DW: Correction of adult scoliosis via a posterior-only approach. Neurosurg Focus 14(1):e52003

  • 18

    Liu SDiebo BGHenry JKSmith JSHostin RCunningham ME: The benefit of nonoperative treatment for adult spinal deformity: identifying predictors for reaching a minimal clinically important difference. Spine J 16:2102182016

  • 19

    Lykissas MGAichmair AHughes APSama AALebl DRTaher F: Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:7497582014

  • 20

    Mummaneni PVShaffrey CILenke LGPark PWang MYLa Marca F: The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Neurosurg Focus 36(5):E62014

  • 21

    Mundis GMAkbarnia BAPhillips FM: Adult deformity correction through minimally invasive lateral approach techniques. Spine (Phila Pa 1976) 35 (26 Suppl):S312S3212010

  • 22

    O’Neill KRLenke LGBridwell KHNeuman BJKim HJArcher KR: Factors associated with long-term patient-reported outcomes after three-column osteotomies. Spine J 15:231223182015

  • 23

    Park PWang MYLafage VNguyen SZiewacz JOkonkwo DO: Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine 22:3743802015

  • 24

    Scheer JKLafage VSmith JSDeviren VHostin RMcCarthy IM: Impact of age on the likelihood of reaching a minimum clinically important difference in 374 three-column spinal osteotomies: clinical article. J Neurosurg Spine 20:3063122014

  • 25

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76 (Suppl 1):S33S412015

  • 26

    Schwab FUngar BBlondel BBuchowski JCoe JDeinlein D: Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976) 37:107710822012

  • 27

    Sembrano JNYson SCHorazdovsky RDSantos ERPolly DW Jr: Radiographic comparison of lateral lumbar interbody fusion versus traditional fusion approaches: analysis of sagittal contour change. Int J Spine Surg 9:162015

  • 28

    Uribe JSDeukmedjian ARMummaneni PVFu KMMundis GM JrOkonkwo DO: Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus 36(5):E152014

  • 29

    Wang MYMummaneni PV: Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes. Neurosurg Focus 28(3):E92010

  • 30

    Ware JE JrSherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 30:4734831992

  • 31

    Watkins RG IVHanna RChang DWatkins RG III: Sagittal alignment after lumbar interbody fusion: comparing anterior, lateral, and transforaminal approaches. J Spinal Disord Tech 27:2532562014

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Article Information

Correspondence Junseok Bae, Department of Neurological Surgery, Wooridul Spine Hospital, 445 Hakdong-ro, Gangnam-gu, Seoul 06068, South Korea. email: jsbaemd@gmail.com.

INCLUDE WHEN CITING Published online November 3, 2017; DOI: 10.3171/2017.5.SPINE161370.

Disclosures Dr. Ames has served as a consultant to DePuy, Stryker, and Medtronic, is a patent holder for Fish & Richardson, P.C., and has received royalties from Stryker and Biomet Spine. Dr. Berven reports being a consultant for Medtronic, Stryker, Globus Medical, and RTI, and he holds patents with Medtronic, Stryker, and CoorsTek Medical. Dr. Burch has served as a consultant for Medtronic and Lily, Inc. Dr. Chou has served as a consultant for Medtronic, Globus, and Orthofix. Dr. Deviren has served as a consultant for NuVasive and Guidepoint. Dr. Mummaneni has served as a consultant for DePuy Spine, has direct ownership in Spinicity/ISD, has received honoraria from AOSpine, and has received royalties from DePuy Spine, Thieme Publishing, and Springer Publishing. Dr. Tay has served as a consultant for Stryker Spine, DePuy Synthes, and Biomet and has received research support from AOSpine North America, NuVasive, and Globus.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Lateral standing radiographs of patients after surgery. A: LLIF+PSF. B: ALIF+PSF. C: PSF only.

References

1

Acosta FLLiu JSlimack NMoller DFessler RKoski T: Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine 15:92962011

2

Benglis DMElhammady MSLevi ADVanni S: Minimally invasive anterolateral approaches for the treatment of back pain and adult degenerative deformity. Neurosurgery 63 (3 Suppl):1911962008

3

Bhagat SVozar VLutchman LCrawford RJRai AS: Morbidity and mortality in adult spinal deformity surgery: Norwich Spinal Unit experience. Eur Spine J 22 (Suppl 1):S42S462013

4

Caputo AMMichael KWChapman TMJennings JMHubbard EWIsaacs RE: Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis. J Clin Neurosci 20:155815632013

5

Carreon LYSanders JODiab MSucato DJSturm PFGlassman SD: The minimum clinically important difference in Scoliosis Research Society-22 Appearance, Activity, and Pain domains after surgical correction of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) ':207920832010

6

Cho SKBridwell KHLenke LGYi JSPahys JMZebala LP: Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976) 37:4895002012

7

Copay AGGlassman SDSubach BRBerven SSchuler TCCarreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:9689742008

8

Crawford CH IIIGlassman SDBridwell KHBerven SHCarreon LY: The minimum clinically important difference in SRS-22R total score, appearance, activity and pain domains after surgical treatment of adult spinal deformity. Spine (Phila Pa 1976) 40:3773812015

9

Dahdaleh NSSmith ZASnyder LAGraham RBFessler RGKoski TR: Lateral transpsoas lumbar interbody fusion: outcomes and deformity correction. Neurosurg Clin N Am 25:3533602014

10

Dakwar ECardona RFSmith DAUribe JS: Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis. Neurosurg Focus 28(3):E82010

11

Fakurnejad SScheer JKLafage VSmith JSDeviren VHostin R: The likelihood of reaching minimum clinically important difference and substantial clinical benefit at 2 years following a 3-column osteotomy: analysis of 140 patients. J Neurosurg Spine 23:3403482015

12

Guérin PObeid IBourghli AMasquefa TLuc SGille O: The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach. Surg Radiol Anat 34:1511572012

13

Hamilton DKKanter ASBolinger BDMundis GM JrNguyen SMummaneni PV: Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up. Eur Spine J 25:260526112016

14

Haque RMMundis GM JrAhmed YEl Ahmadieh TYWang MYMummaneni PV: Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients. Neurosurg Focus 36(5):E132014

15

Hsieh MKChen LHNiu CCFu TSLai PLChen WJ: Combined anterior lumbar interbody fusion and instrumented posterolateral fusion for degenerative lumbar scoliosis: indication and surgical outcomes. BMC Surg 15:262015

16

Isaacs REHyde JGoodrich JARodgers WBPhillips FM: A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976) 35 (26 Suppl):S322S3302010

17

Lippman CRSpence CAYoussef ASCahill DW: Correction of adult scoliosis via a posterior-only approach. Neurosurg Focus 14(1):e52003

18

Liu SDiebo BGHenry JKSmith JSHostin RCunningham ME: The benefit of nonoperative treatment for adult spinal deformity: identifying predictors for reaching a minimal clinically important difference. Spine J 16:2102182016

19

Lykissas MGAichmair AHughes APSama AALebl DRTaher F: Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:7497582014

20

Mummaneni PVShaffrey CILenke LGPark PWang MYLa Marca F: The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Neurosurg Focus 36(5):E62014

21

Mundis GMAkbarnia BAPhillips FM: Adult deformity correction through minimally invasive lateral approach techniques. Spine (Phila Pa 1976) 35 (26 Suppl):S312S3212010

22

O’Neill KRLenke LGBridwell KHNeuman BJKim HJArcher KR: Factors associated with long-term patient-reported outcomes after three-column osteotomies. Spine J 15:231223182015

23

Park PWang MYLafage VNguyen SZiewacz JOkonkwo DO: Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine 22:3743802015

24

Scheer JKLafage VSmith JSDeviren VHostin RMcCarthy IM: Impact of age on the likelihood of reaching a minimum clinically important difference in 374 three-column spinal osteotomies: clinical article. J Neurosurg Spine 20:3063122014

25

Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76 (Suppl 1):S33S412015

26

Schwab FUngar BBlondel BBuchowski JCoe JDeinlein D: Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976) 37:107710822012

27

Sembrano JNYson SCHorazdovsky RDSantos ERPolly DW Jr: Radiographic comparison of lateral lumbar interbody fusion versus traditional fusion approaches: analysis of sagittal contour change. Int J Spine Surg 9:162015

28

Uribe JSDeukmedjian ARMummaneni PVFu KMMundis GM JrOkonkwo DO: Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus 36(5):E152014

29

Wang MYMummaneni PV: Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes. Neurosurg Focus 28(3):E92010

30

Ware JE JrSherbourne CD: The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 30:4734831992

31

Watkins RG IVHanna RChang DWatkins RG III: Sagittal alignment after lumbar interbody fusion: comparing anterior, lateral, and transforaminal approaches. J Spinal Disord Tech 27:2532562014

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