Surgical management of coronal and sagittal imbalance of the spine without PSO: a multicentric cohort study on compensated adult degenerative deformities

  • Alessandro Ramieri
  • Massimo Miscusi
  • Maurizio Domenicucci
  • Antonino Raco
  • Giuseppe Costanzo
Original Article

Abstract

Purpose

Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative thoracolumbar and lumbar kyphoscoliosis by a non posterior subtraction osteotomy technique.

Methods

We operated 22 painful thoracolumbar and lumbar compensated degenerative deformities by anterior (ALIF), extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion and grade 2 osteotomy (SPO) to restore lumbar lordosis and mobilize the coronal curve. Two-stage surgery, first anterior and after 2 or 3 weeks posterior, was proposed when the Oswestry Disability Index (ODI) was equal to or greater than 50% and VAS more than 5. All patients were submitted to X-ray and clinical screening during pre, post-operative and follow-up periods.

Results

We performed 5 ALIFs, 39 XLIFs, 8 TLIFs, 32 SPOs. No major complications were recorded and complication rate was 18% after lateral fusion and 22.7% after posterior approach. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p < 0.05). Clinical follow-up (mean 20.5; range 18–24) was satisfactory in all cases, except for two due to sacroiliac pain. Mean preoperative VAS was 7.7 (range 6–10), while ODI was 67% on average (range 50–78). After two-stage surgery, VAS and ODI decreased, respectively, to 2.4 (range 2–4) and 31% (range 25–45), while their values were 4 (range 2-6) and 35% (range 20–55) at the final follow-up.

Conclusion

Current follow-up does not allow definitive conclusions. However, the surgical approach adopted in this study seems promising, improving balance and clinical condition of adult patients with a compensated sagittal degenerative imbalance of the thoracolumbar spine.

Keywords

Scoliosis Kyphosis Adult degenerative spine Osteotomy Interbody fusion 

References

  1. 1.
    Aebi M (2005) The adult scoliosis. Eur Spine J 14:925–948CrossRefPubMedGoogle Scholar
  2. 2.
    Glassman SD, Bridwell K, Dimar JR et al (2005) The impact of positive sagittal balance in adult spine deformity. Spine 30:2024–2029CrossRefPubMedGoogle Scholar
  3. 3.
    Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2010) Sagittal parameters of global spinal balance: normative values from a prospective cohort of seven hundred nine Caucasian asymptomatic adults. Spine 35:E1193–E1198CrossRefPubMedGoogle Scholar
  4. 4.
    Glassman SD, Berven S, Bridwell K et al (2005) Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine 30:682–688CrossRefPubMedGoogle Scholar
  5. 5.
    Bridwell KH, Lewis SJ, Rinella A et al (2004) Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance, surgical technique. J Bone Joint Surg 86A(Suppl 1):44–50CrossRefGoogle Scholar
  6. 6.
    Suk SI, Chung ER, Lee SM et al (2005) Posterior vertebral column resection in fixed lumbosacral deformity. Spine 30:E703–E710CrossRefPubMedGoogle Scholar
  7. 7.
    Charosky S, Guigui P, Blamoutier A et al (2012) Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine 37:693–700CrossRefPubMedGoogle Scholar
  8. 8.
    Blondel B, Schwab F, Bess S et al (2013) Posterior global malalignment after osteotomy for sagittal plane deformity: it happens and here is why. Spine 38:E394–E401CrossRefPubMedGoogle Scholar
  9. 9.
    Maier S, Smith JS, Schwab F et al (2014) Revision surgery after three-column osteotomy in 335 adult spinal deformity patients: inter-center variability and risk factors. Spine Feb 27 (Epub ahead of print) Google Scholar
  10. 10.
    Berjano P, Cecchinato R, Sinigaglia A et al (2015) Anterior column realignment from a lateral approach for the treatment of severe sagittal imbalance: a retrospective radiographic study. Eur Spine J 24(Suppl 3):433–438CrossRefPubMedGoogle Scholar
  11. 11.
    Turner JD, Akbarnia BA, Eastlack RK et al (2015) Radiographic outcomes of anterior column realignment for adult sagittal plane deformity: a multicenter analysis. Eur Spine J 24(Suppl 3):427–432CrossRefPubMedGoogle Scholar
  12. 12.
    Berjano P, Lamartina C (2014) Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J 23:1815–1824CrossRefPubMedGoogle Scholar
  13. 13.
    Barrey C, Roussouly P, Le Huec JC et al (2013) Compensatory mechanisms contributing to keep the sagittal balance of the spine. Eur Spine J 22:S834–S841CrossRefPubMedGoogle Scholar
  14. 14.
    Schwab F, Blondel B, Chay E et al (2014) The comprehensive anatomical spinal osteotomy classification. Neurosurgery 74:112–120CrossRefPubMedGoogle Scholar
  15. 15.
    Schwab F, Ungar B, Blondel B et al (2012) Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine 37:1077–1082CrossRefPubMedGoogle Scholar
  16. 16.
    Berjano P, Bundy J, Balsano M (2013) Spinal alignment and correction in adults. In: Goodrich A, Volcan IJ, 2nd ed. Extreme lateral interbody fusion (XLIF), 91–115Google Scholar
  17. 17.
    Savage JW, Patel AA (2014) Fixed sagittal plane imbalance. Global Spine J. 4:287–296CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Dubousset J (1994) Three-dimensional analysis of the scoliotic deformity. In: Weinsteid SL (ed) The pediatric spine: principles and practice. New York Raven Press, New YorkGoogle Scholar
  19. 19.
    Heary RF, Kumar S, Bono CM (2008) Decision making in adult deformity. Neurosurgery 63(Suppl 3):69–77CrossRefPubMedGoogle Scholar
  20. 20.
    Birknes JK, White AP, Albert TJ et al (2008) Adult degenerative scoliosis: a review. Neurosurgery 63(Suppl 3):94–103CrossRefPubMedGoogle Scholar
  21. 21.
    Smith J, Singh M, Klineberg E et al (2013) Surgical treatment of pathological loss of lumbar lordosis (flatback)in the setting of normal SVA achieves similar clinical improvement as surgical treatment for elevated SVA. 20th IMAST, Vancouver, July 10–13Google Scholar
  22. 22.
    Phillips FM, Isaacs RE, Rodgers WB et al (2013) Adult degenerative scoliosis treated with XLIF. Spine 21:1853–1861CrossRefGoogle Scholar
  23. 23.
    Isaacs R, Hyde J, Goodrich JA et al (2010) A prospective, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine 35:S322–S330CrossRefPubMedGoogle Scholar
  24. 24.
    Hsieh MK, Chen LH, Niu CC et al (2015) Combined anterior lumbar interbody fusion and instrumented posterolateral fusion for degenerative lumbar scoliosis: indication and surgical outcomes. BMC Surg 15:26CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Bao H, He S, Liu Z et al (2015) Will immediate postoperative imbalance improve in patients with thoracolumbar/lumbar degenerative kyphoscoliosis? A comparison between Smith-Petersen osteotomy and pedicle subtraction osteotomy with an average 4 years of follow-up. Spine 40:E293–E300CrossRefPubMedGoogle Scholar
  26. 26.
    Cho KJ, Bridwell KH, Lenke LG et al (2005) Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance. Spine 30:2030–2037CrossRefPubMedGoogle Scholar
  27. 27.
    Kim HJ, Boachie-Adjei O, Shaffrey CI et al (2014) Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis. Spine 39:E795–E799CrossRefPubMedGoogle Scholar
  28. 28.
    Scheer JK, Smith JS, Clark AJ et al (2015) Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. J Neurosurg Spine 22:540–553CrossRefPubMedGoogle Scholar
  29. 29.
    Fakurnejad S, Scheer JK, Lafage V et al (2015) 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 23:340–348CrossRefPubMedGoogle Scholar
  30. 30.
    Bridwell KH (1996) Where to stop the fusion distally in adult scoliosis: L4, L5, or the sacrum? Instr Course Lect 45:101–107PubMedGoogle Scholar
  31. 31.
    Edwards CC 2nd, Bridwell KH, Patel A et al (2004) Long adult deformity fusions to L5 and the sacrum. A matched cohort analysis. Spine 29:1996–2005CrossRefPubMedGoogle Scholar
  32. 32.
    Kuhns CA, Bridwell KH, Lenke LG et al (2007) Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up. Spine 32:2771–2776CrossRefPubMedGoogle Scholar
  33. 33.
    Koller H, Pfanz C, Meier O et al (2015) Factors influencing radiographic and clinical outcomes in adult scoliosis surgery: a study of 448 European patients. Eur Spine J (Epub ahead of print) Google Scholar
  34. 34.
    Guler UO, Cetin E, Yaman O et al (2015) Sacropelvic fixation in adult spinal deformity (ASD); a very high rate of mechanical failure. Eur Spine J 24:1085–1091CrossRefPubMedGoogle Scholar
  35. 35.
    Wang G, Hu J, Liu X, Cao Y (2015) Surgical treatment for degenerative lumbar scoliosis: a meta analysis. Eur Spine J 24:1792–1799CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Alessandro Ramieri
    • 1
    • 5
  • Massimo Miscusi
    • 2
  • Maurizio Domenicucci
    • 3
  • Antonino Raco
    • 2
  • Giuseppe Costanzo
    • 4
  1. 1.OrthopaedicsDon Gnocchi Foundation, ONLUSMilanItaly
  2. 2.NeurosurgeryS. Andrea HospitalRomeItaly
  3. 3.Department Neurology and PsychiatryNeurosurgery, Sapienza Rome UniversityRomeItaly
  4. 4.OrthopaedicsPolo Pontino Sapienza Rome UniversityLatinaItaly
  5. 5.RomeItaly

Personalised recommendations