Treatment of only the fractional curve for radiculopathy in adult scoliosis: comparison to lower thoracic and upper thoracic fusions

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OBJECTIVE

Many options exist for the surgical management of adult spinal deformity. Radiculopathy and lumbosacral pain from the fractional curve (FC), typically from L4 to S1, is frequently a reason for scoliosis patients to pursue surgical intervention. The purpose of this study was to evaluate the outcomes of limited fusion of the FC only versus treatment of the entire deformity with long fusions.

METHODS

All adult scoliosis patients treated at the authors’ institution in the period from 2006 to 2016 were retrospectively analyzed. Patients with FCs from L4 to S1 > 10° and radiculopathy ipsilateral to the concavity of the FC were eligible for study inclusion and had undergone three categories of surgery: 1) FC only (FC group), 2) lower thoracic to sacrum (LT group), or 3) upper thoracic to sacrum (UT group). Primary outcomes were the rates of revision surgery and complications. Secondary outcomes were estimated blood loss, length of hospital stay, and discharge destination. Spinopelvic parameters were measured, and patients were stratified accordingly.

RESULTS

Of the 99 patients eligible for inclusion in the study, 27 were in the FC group, 46 in the LT group, and 26 in the UT group. There were no significant preoperative differences in age, sex, smoking status, prior operation, FC magnitude, pelvic tilt (PT), sagittal vertical axis (SVA), coronal balance, pelvic incidence–lumbar lordosis (PI-LL) mismatch, or proportion of well-aligned spines (SVA < 5 cm, PI-LL mismatch < 10°, and PT < 20°) among the three treatment groups. Mean follow-up was 30 (range 12–112) months, with a minimum 1-year follow-up. The FC group had a lower medical complication rate (22% [FC] vs 57% [LT] vs 58% [UT], p = 0.009) but a higher rate of extension surgery (26% [FC] vs 13% [LT] vs 4% [UT], p = 0.068). The respective average estimated blood loss (592 vs 1950 vs 2634 ml, p < 0.001), length of hospital stay (5.5 vs 8.3 vs 8.3 days, p < 0.001), and rate of discharge to acute rehabilitation (30% vs 46% vs 85%, p < 0.001) were all lower for FC and highest for UT.

CONCLUSIONS

Treatment of the FC only is associated with a lower complication rate, shorter hospital stay, and less blood loss than complete scoliosis treatment. However, there is a higher associated rate of extension of the construct to the lower or upper thoracic levels, and patients should be counseled when considering their options.

ABBREVIATIONS ASA = American Society of Anesthesiologists; CVA = coronal vertical axis; FC = fractional curve; HRQOL = health-related quality of life; LC = lower thoracic; LL = lumbar lordosis; PI = pelvic incidence; PI-LL = pelvic incidence–lumbar lordosis; PJK = proximal junctional kyphosis; PT = pelvic tilt; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion; UT = upper thoracic.

Article Information

Correspondence Dominic Amara: UCSF Spine Center, University of California, San Francisco, CA. dominic.amara@ucsf.edu.

INCLUDE WHEN CITING Published online February 1, 2019; DOI: 10.3171/2018.9.SPINE18505.

Disclosures Dr. Ames has served as a consultant to DePuy Synthes, Medicrea, K2M, Stryker, and Medtronic and has received royalties from Stryker, DePuy Synthes, NuVasive, and Biomet Spine. Dr. Berven reports being a consultant for Medtronic Spine, Stryker Spine, Globus Medical, Innovasis, and RTI; has ownership in Providence Medical and Green Sun Medical; and holds patents with Medtronic, Stryker, and CoorsTek Medical. Dr. Burch has served as a consultant for Medtronic and has received research support from Lilly Inc. Dr. Chou has served as a consultant for Medtronic and Globus and has received royalties from Globus. Dr. Deviren has served as a consultant for NuVasive, Biomet, Alphatec, Pfizer, Medicrea, Seaspine, and Guidepoint and has received royalties from NuVasive. Dr. Mummaneni has served as a consultant for DePuy Synthes, has direct ownership in Spinicity/ISD, has received honoraria from AOSpine, and has received royalties from DePuy Synthes, Thieme Publishing, and Springer Publishing. Dr. Tay has served as a consultant for Lumetra, 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.

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Figures

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    Left: Anteroposterior radiograph obtained in a patient with an FC > 10° and left-sided radiculopathy. Right: Anteroposterior radiograph obtained in the same patient after FC surgery with instrumentation from L4 to S1.

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    Illustrations showing FC-only fusion (L4–S1, A), sacrum to lower thoracic fusion (T10, B) and sacrum to upper thoracic fusion (T3, C). Illustration by Kenneth Xavier Probst. Copyright UCSF. Published with permission. Figure is available in color online only.

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