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Measurement of Spinopelvic Angles on Prone Intraoperative Long-Cassette Lateral Radiographs Predicts Postoperative Standing Global Alignment in Adult Spinal Deformity Surgery

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Abstract

Study Design

Retrospective review from a single institution.

Objectives

To evaluate intraoperative T1-pelvic angle (TPA), T4PA, and T9PA as predictors of postoperative global alignment after adult spinal deformity (ASD) surgery.

Summary of Background Data

Malalignment following adult spinal surgery is associated with disability and correlates with health-related quality of life. Preoperative planning and intraoperative verification are crucial for optimal postoperative outcomes. Currently, only pelvic incidence minus lumbar lordosis (PI-LL) mismatch has been used to assess intraoperative correction.

Methods

Patients undergoing ≥4-level spinal fusion with full-length pre-, intra-, and first postoperative calibrated radiographs were included from a single institution. Alignment measurements were obtained for sagittal vertical axis (SVA), PI-LL, TPA, T4PA, and T9PA. The whole cohort was divided into upper thoracic (UT: UIV > T7) and lower thoracic fusions (LT: UIV < T7). Change was assessed between phases, and a subanalysis was included for UT and LT groups to compare alignment changes for differing extent of proximal fusion in the sagittal plane.

Results

Eighty patients (mean 63.4 years, 70% female, mean levels fused 11.9) underwent significant ASD correction (ΔPI-LL = 22.1°; ΔTPA = 13.8°). For all, intraoperative TPA, T4PA, and T9PA correlated with postoperative SVA (range, r = 0.41-0.59), whereas intraoperative PI-LL correlated less (r = 0.38). For UT (n = 49), all spinopelvic angles and LL were similar intraoperative to postoperatively (p > .09). For LT (n = 31), intraoperative and postoperative T9PA and LL were similar (p > .10) but TPA and T4PA differed (p < .02). For UT, all intraoperative and postoperative spinopelvic angles strongly correlated (r = 0.8–0.9). For LT, intraoperative to postoperative T9PA strongly correlated (r = 0.83) and TPA, T4PA, and LL correlated moderately (r = 0.65–0.70). LT trended toward more reciprocal kyphosis postoperatively (8.1° vs. 2.6°; p = .059).

Conclusions

Intraoperative measurements of TPA, T4PA, and T9PA correlated better with postoperative global alignment than PI-LL, demonstrating their utility in confirming alignment goals. When comparing intraoperative to postoperative films, only T9PA was similar in LT whereas all spinopelvic angles were similar in UT. Reciprocal kyphosis in unfused segments of LT fusions may account for difference in TPA and T4PA from intraoperative to postoperative films.

Level of Evidence

Level III.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 15th St, New York, NY, 10016, USA

    Jonathan H. Oren MD, Jared C. Tishelman BA, Louis M. Day BS, Joseph F. Baker MD, Norah Foster MD, Subaraman Ramchandran MD, Cyrus Jalai BS, Gregory Poorman BS, Ryan Cassilly MD, Aaron Buckland MD, Peter G. Passias MD, Thomas J. Errico MD & Themistocles S. Protopsaltis MD

  2. Department of Orthopaedic Surgery, Denver International Spine Center, 1601 E 19th Ave #6250, Denver, CO, 80218, USA

    Shay Bess MD

Authors
  1. Jonathan H. Oren MD
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  2. Jared C. Tishelman BA
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  3. Louis M. Day BS
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  4. Joseph F. Baker MD
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  5. Norah Foster MD
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  6. Subaraman Ramchandran MD
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  7. Cyrus Jalai BS
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  8. Gregory Poorman BS
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  9. Ryan Cassilly MD
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  10. Aaron Buckland MD
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  11. Peter G. Passias MD
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  12. Shay Bess MD
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  13. Thomas J. Errico MD
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  14. Themistocles S. Protopsaltis MD
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Corresponding author

Correspondence to Themistocles S. Protopsaltis MD.

Additional information

Author disclosures: JHO (none), JCT (none), LMD (none), JFB (none), NF (none), SR (none), CJ (none), GP (none), RC (none), AB (none), PGP (grants from DePuy Synthes, personal fees from Medicrea and SpineWave, nonfinancial support from Zimmer-Biomet, grants from CSRS, outside the submitted work), Shay Bess (grants and personal fees from K2 Medical; personal fees from Pioneer and AlloSource; grants from DePuy-Synthes, Medtronic, and NuVasive, outside the submitted work), TJE (other from Fastenetix, K2M, Pfizer, Paradigm Spine, and ISSGF, outside the submitted work), TSP (personal fees from Medicrea, personal NuVasive, Globus, and Innovasis; grants from Zimmer Spine and Cervical Spine Research Society, outside the submitted work).

IRB approval was obtained before initiation of this study.

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Oren, J.H., Tishelman, J.C., Day, L.M. et al. Measurement of Spinopelvic Angles on Prone Intraoperative Long-Cassette Lateral Radiographs Predicts Postoperative Standing Global Alignment in Adult Spinal Deformity Surgery. Spine Deform 7, 325–330 (2019). https://doi.org/10.1016/j.jspd.2018.07.007

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  • DOI: https://doi.org/10.1016/j.jspd.2018.07.007

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