The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery

Restricted access

OBJECTIVE

Minimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.

METHODS

A modified algorithm was developed that incorporates a patient’s preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.

RESULTS

Over a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.

CONCLUSIONS

The MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.

ABBREVIATIONS ACR = anterior column realignment; ASD = adult spinal deformity; LL-PI = lumbar lordosis–pelvic incidence; LLIF = lateral lumbar interbody fusion; MIS = minimally invasive surgery; MISDEF = MIS deformity; MISDEF2 = MISDEF revision 2; PT = pelvic tilt; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion.
Article Information

Contributor Notes

Correspondence Kai-Ming Fu: Cornell Medical Center, New York, NY. kaimingfu@gmail.com.INCLUDE WHEN CITING Published online October 25, 2019; DOI: 10.3171/2019.7.SPINE181104.Disclosures All authors: grant for this study from ISSG. Praveen Mummaneni: consultant for DePuy Spine, Stryker, and Globus; direct stock ownership in Spinicity/ISD; clinical or research support from NREF; royalties from DePuy Spine, Thieme Publishers, and Springer Publishing; honoraria from Spineart; and grant from AOSpine. Paul Park: consultant for Globus, NuVasive, Zimmer Biomet, Medtronic, and Allosource; and royalties from Globus. Christopher Shaffrey: consultant for and patent holder with Medtronic, NuVasive, and Zimmer Biomet. Michael Wang: consultant for DePuy Synthes, K2M, Spineology, and Stryker; direct stock ownership in Spinicity/ISD and Medical Device Partners; and medical advisory board of Vallum. Juan Uribe: consultant for NuVasive, Si Bone, and Misonix; and direct stock ownership in and royalties from NuVasive. Richard Fessler: consultant for and royalties from DePuy Synthes, teaching and education for Benvenue, and ownership in InQ Innovations. Dean Chou: consultant for Globus and Medtronic, and royalties from Globus. Adam Kanter: consultant for and royalties from NuVasive and Zimmer Biomet. David Okonkwo: consultant for Stryker and royalties from NuVasive and Zimmer Biomet. Greg Mundis: consultant for NuVasive, K2M, Viseon, Seaspine, and Allosource; direct stock ownership in NuVasive and Viseon; royalties from K2M; and board member of Global Spine Outreach and San Diego Spine Foundation. Robert Eastlack: consultant for NuVasive, Aesculap, K2M, SI Bone, Stryker, Seaspine, Baxter, Titan, and Carevature; direct stock ownership in NuVasive, Seaspine, Alphatec Spine, Invuity, and Spine Innovation; ownership in Spine Innovation; royalties from Globus, NuVasive, and Aesulap; patent holder with Invuity, Spine Innovation, and NuTech; research support from NuVasive, Alphatec Spine, and Seaspine; and board member/committee appointments to Nocimed, Matrisys, San Diego Spine Foundation, and Society of Lateral Access Surgery and Scoliosis Research Society. Pierce Nunley: consultant for Spineology, K2M, Centinel Spine, Zimmer Spine, Vertiflex, Camber, and Integrity; direct stock ownership in Amedica, Paradigm, Spineology, and Camber; patent holder with Camber; and patent holder with and royalties from K2M, Zimmer Spine, and Safewire. Neel Anand: consultant for Medtronic, Globus, GYS Tech, TheraCell, and Spinal Balance; direct stock ownership in Medtronic, Globus, GYS Tech, TheraCell, Atlas Spine, AF Cell, Bonovo, Paradigm Spine, and Spinal Balance; royalties from Medtronic, Globus, and Elsevier; scientific advisory board for Globus, GYS Tech, TheraCell, and Spinal Balance; speaker for DePuy Synthes and Stryker; and editor of Gray’s Anatomy. Lawrence Lenke: consultant for Medtronic, K2M, and DePuy Synthes; royalties from Medtronic; reimbursement for airfare/hotel from AOSpine, Broadwater, Seattle Science Foundation, Scoliosis Research Society, Stryker Spine, and The Spinal Research Foundation; royalties from Medtronic and Quality Medical Publishing; philanthropic research funding from Evans Family Donation and Fox Family Foundation; grant support to institution from DePuy Synthes, Scoliosis Research Society, EOS, and Setting Scoliosis Straight Foundation; fellowship support to institution from AOSpine; and expert witness in a patent infringement case for Fox Rothschild, LLC. Khoi Than: consultant for Bioventus and past consultant for Medtronic. Kai- Ming Fu: consultant for SI-BONE, Johnson and Johnson, and Globus.
Headings
References
  • 1

    Anand NBaron EMKhandehroo BKahwaty S: Long-term 2- to 5-year clinical and functional outcomes of minimally invasive surgery for adult scoliosis. Spine (Phila Pa 1976) 38:156615752013

    • Search Google Scholar
    • Export Citation
  • 2

    Anand NBaron EMThaiyananthan GKhalsa KGoldstein TB: Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 21:4594672008

    • Search Google Scholar
    • Export Citation
  • 3

    Anand NCohen RBCohen JKahndehroo BKahwaty SBaron E: The influence of lordotic cages on creating sagittal balance in the CMIS treatment of adult spinal deformity. Int J Spine Surg 11:232017

    • Search Google Scholar
    • Export Citation
  • 4

    Choy WMiller CAChan AKFu KMPark PMummaneni PV: Evolution of the minimally invasive spinal deformity surgery algorithm: an evidence-based approach to surgical strategies for deformity correction. Neurosurg Clin N Am 29:3994062018

    • Search Google Scholar
    • Export Citation
  • 5

    Hawasli AHKhalifeh JMChatrath AYarbrough CKRay WZ: Minimally invasive transforaminal lumbar interbody fusion with expandable versus static interbody devices: radiographic assessment of sagittal segmental and pelvic parameters. Neurosurg Focus 43(2):E102017

    • Search Google Scholar
    • Export Citation
  • 6

    Kanter ASTempel ZJOzpinar AOkonkwo DO: A review of minimally invasive procedures for the treatment of adult spinal deformity. Spine (Phila Pa 1976) 41 (Suppl 8):S59S652016

    • Search Google Scholar
    • Export Citation
  • 7

    Manwaring JCBach KAhmadian AADeukmedjian ARSmith DAUribe JS: Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study. J Neurosurg Spine 20:5155222014

    • Search Google Scholar
    • Export Citation
  • 8

    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

    • Search Google Scholar
    • Export Citation
  • 9

    Park POkonkwo DONguyen SMundis GM JrThan KDDeviren V: Can a minimal clinically important difference be achieved in elderly patients with adult spinal deformity who undergo minimally invasive spinal surgery? World Neurosurg 86:1681722016

    • Search Google Scholar
    • Export Citation
  • 10

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

    • Search Google Scholar
    • Export Citation
  • 11

    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

    • Search Google Scholar
    • Export Citation
  • 12

    Turner JDAkbarnia BAEastlack RKBagheri RNguyen SPimenta L: Radiographic outcomes of anterior column realignment for adult sagittal plane deformity: a multicenter analysis. Eur Spine J 24 (Suppl 3):4274322015

    • Search Google Scholar
    • Export Citation
  • 13

    Wang MYBordon G: Mini-open pedicle subtraction osteotomy as a treatment for severe adult spinal deformities: case series with initial clinical and radiographic outcomes. J Neurosurg Spine 24:7697762016

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 260 260 260
Full Text Views 49 49 49
PDF Downloads 40 40 40
EPUB Downloads 0 0 0
PubMed
Google Scholar