Four-rod instrumentation and interbody fusion may reduce mechanical complications in degenerative scoliosis surgery compared to 2-rod instrumentation. The purpose was to compare clinical results, sagittal alignment and mechanical complications with both techniques.
Full spine radiographs were analysed in 97 patients instrumented to the pelvis: 58 2-rod constructs (2R) and 39 4-rod constructs (4R). Clinical scores (VAS, ODI, SRS-22, EQ-5D-3L) were assessed preoperatively, at 3 months, 1 year and last follow-up (average 4.2 years). Radiographic measurements were: thoracic kyphosis, lumbar lordosis, spinopelvic parameters, segmental lordosis distribution. The incidence of non-union and PJK were investigated.
All clinical scores improved significantly in both groups between preoperative and last follow-up. In the 2R-group, lumbar lordosis increased to 52.8° postoperatively and decreased to 47.0° at follow-up (p = 0.008). In the 4R-group, lumbar lordosis increased from 46.4 to 52.5° postoperatively and remained at 53.4° at follow-up. There were 8 (13.8%) PJK in the 2R-group versus 6 (15.4%) in the 4R-group, with a mismatch between lumbar apex and theoretic lumbar shape according to pelvic incidence. Non-union requiring revision surgery occurred on average at 26.9 months in 28 patients (48.3%) of the 2R-group. No rod fracture was diagnosed in the 4R-group.
Multi-level interbody fusion combined with 4-rod instrumentation decreased risk for non-union and revision surgery compared to select interbody fusion and 2-rod instrumentation. The role of additional rods on load sharing still needs to be determined when multiple cages are used. Despite revision surgery in the 2R group, final clinical outcomes were similar in both groups.
Level of evidence
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price includes VAT (USA)
Tax calculation will be finalised during checkout.
Chen PG-C, Daubs MD, Berven S et al (2016) Surgery for degenerative lumbar scoliosis: the development of appropriateness criteria. Spine 41:910–918. https://doi.org/10.1097/BRS.0000000000001392
Kyrölä K, Kautiainen H, Pekkanen L et al (2019) Long-term clinical and radiographic outcomes and patient satisfaction after adult spinal deformity correction. Scand J Surg SJS Off Organ Finn Surg Soc Scand Surg Soc 108:343–351. https://doi.org/10.1177/1457496918812201
Sebaaly A, Riouallon G, Obeid I et al (2018) Proximal junctional kyphosis in adult scoliosis: comparison of four radiological predictor models. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 27:613–621. https://doi.org/10.1007/s00586-017-5172-x
Blamoutier A, Guigui P, Charosky S et al (2012) Surgery of lumbar and thoracolumbar scolioses in adults over 50. Morbidity and survival in a multicenter retrospective cohort of 180 patients with a mean follow-up of 4.5 years. Orthop Traumatol Surg Res OTSR 98:528–535. https://doi.org/10.1016/j.otsr.2012.04.014
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 37:693–700. https://doi.org/10.1097/BRS.0b013e31822ff5c1
Sebaaly A, Gehrchen M, Silvestre C et al (2019) Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. https://doi.org/10.1007/s00586-019-06253-1
Riouallon G, Bouyer B, Wolff S (2016) Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25 years. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 25:2527–2534. https://doi.org/10.1007/s00586-016-4505-5
Yamato Y, Hasegawa T, Kobayashi S et al (2018) Treatment strategy for rod fractures following corrective fusion surgery in adult spinal deformity depends on symptoms and local alignment change. J Neurosurg Spine 29:59–67. https://doi.org/10.3171/2017.9.SPINE17525
Cho SK, Bridwell KH, Lenke LG et al (2012) Comparative analysis of clinical outcome and complications in primary versus revision adult scoliosis surgery. Spine 37:393–401. https://doi.org/10.1097/BRS.0b013e31821f0126
Lertudomphonwanit T, Kelly MP, Bridwell KH et al (2018) Rod fracture in adult spinal deformity surgery fused to the sacrum: prevalence, risk factors, and impact on health-related quality of life in 526 patients. Spine J Off J North Am Spine Soc 18:1612–1624. https://doi.org/10.1016/j.spinee.2018.02.008
Soroceanu A, Diebo BG, Burton D et al (2015) Radiographical and implant-related complications in adult spinal deformity surgery: incidence, patient risk factors, and impact on health-related quality of life. Spine 40:1414–1421. https://doi.org/10.1097/BRS.0000000000001020
Godzik J, Hlubek RJ, Newcomb AGUS et al (2019) Supplemental rods are needed to maximally reduce rod strain across the lumbosacral junction with TLIF but not ALIF in long constructs. Spine J Off J North Am Spine Soc 19:1121–1131. https://doi.org/10.1016/j.spinee.2019.01.005
Palumbo MA, Shah KN, Eberson CP et al (2015) Outrigger rod technique for supplemental support of posterior spinal arthrodesis. Spine J Off J North Am Spine Soc 15:1409–1414. https://doi.org/10.1016/j.spinee.2015.03.004
Hyun S-J, Lenke LG, Kim Y-C et al (2014) Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine 39:1899–1904. https://doi.org/10.1097/BRS.0000000000000556
Merrill RK, Kim JS, Leven DM et al (2017) Multi-Rod constructs can prevent rod breakage and pseudarthrosis at the lumbosacral junction in adult spinal deformity. Glob Spine J 7:514–520. https://doi.org/10.1177/2192568217699392
Gupta S, Eksi MS, Ames CP et al (2018) A Novel 4-rod technique offers potential to reduce rod breakage and pseudarthrosis in pedicle subtraction osteotomies for adult spinal deformity correction. Oper Neurosurg Hagerstown Md 14:449–456. https://doi.org/10.1093/ons/opx151
Shen FH, Qureshi R, Tyger R et al (2018) Use of the “dual construct” for the management of complex spinal reconstructions. Spine J Off J North Am Spine Soc 18:482–490. https://doi.org/10.1016/j.spinee.2017.08.235
Sebaaly A, Sylvestre C, El Quehtani Y et al (2018) Incidence and risk factors for proximal junctional kyphosis: results of a multicentric study of adult scoliosis. Clin Spine Surg 31:E178–E183. https://doi.org/10.1097/BSD.0000000000000630
Pizones J, Martin MB, Perez-Grueso FJS et al (2019) Impact of adult scoliosis on roussouly sagittal shape classification. Spine 44:270–279. https://doi.org/10.1097/BRS.0000000000002800
Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30:346–353. https://doi.org/10.1097/01.brs.0000152379.54463.65
Lafage R, Schwab F, Glassman S et al (2017) Age-adjusted alignment goals have the potential to reduce PJK. Spine 42:1275–1282. https://doi.org/10.1097/BRS.0000000000002146
Yilgor C, Sogunmez N, Boissiere L et al (2017) Global alignment and proportion (gap) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am 99:1661–1672. https://doi.org/10.2106/JBJS.16.01594
Maillot C, Ferrero E, Fort D et al (2015) Reproducibility and repeatability of a new computerized software for sagittal spinopelvic and scoliosis curvature radiologic measurements: Keops(®). Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 24:1574–1581. https://doi.org/10.1007/s00586-015-3817-1
Sebaaly A, Grobost P, Mallam L, Roussouly P (2018) Description of the sagittal alignment of the degenerative human spine. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 27:489–496. https://doi.org/10.1007/s00586-017-5404-0
Glattes RC, Bridwell KH, Lenke LG et al (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine 30:1643–1649. https://doi.org/10.1097/01.brs.0000169451.76359.49
Guevara-Villazón F, Boissiere L, Hayashi K et al (2020) Multiple-rod constructs in adult spinal deformity surgery for pelvic-fixated long instrumentations: an integral matched cohort analysis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 29:886–895. https://doi.org/10.1007/s00586-020-06311-z
Sugawara R, Takeshita K, Inomata Y et al (2019) The japanese scoliosis society morbidity and mortality survey in 2014: the complication trends of spinal deformity surgery from 2012 to 2014. Spine Surg Relat Res 3:214–221. https://doi.org/10.22603/ssrr.2018-00677
Kelly MP, Lenke LG, Bridwell KH et al (2013) Fate of the adult revision spinal deformity patient: a single institution experience. Spine 38:E1196-E1200. https://doi.org/10.1097/BRS.0b013e31829e764b
Zhu F, Bao H, Liu Z et al (2014) Unanticipated revision surgery in adult spinal deformity: an experience with 815 cases at one institution. Spine 39:B36-44. https://doi.org/10.1097/BRS.0000000000000463
Pizones J, Pérez Martin-Buitrago M, Perez-Grueso FJS et al (2017) Function and clinical symptoms are the main factors that motivate thoracolumbar adult scoliosis patients to pursue surgery. Spine 42:E31–E36. https://doi.org/10.1097/BRS.0000000000001694
Wang G, Hu J, Liu X, Cao Y (2015) Surgical treatments for degenerative lumbar scoliosis: a meta analysis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 24:1792–1799. https://doi.org/10.1007/s00586-015-3942-x
Hu X, Lieberman IH (2019) Revision adult spinal deformity surgery: does the number of previous operations have a negative impact on outcome? Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 28:155–160. https://doi.org/10.1007/s00586-018-5747-1
Yagi M, Akilah KB, Boachie-Adjei O (2011) Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine 36:E60-E68. https://doi.org/10.1097/BRS.0b013e3181eeaee2
Kim YJ, Bridwell KH, Lenke LG et al (2008) Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine 33:2179–2184. https://doi.org/10.1097/BRS.0b013e31817c0428
Zou L, Liu J, Lu H (2019) Characteristics and risk factors for proximal junctional kyphosis in adult spinal deformity after correction surgery: a systematic review and meta-analysis. Neurosurg Rev 42:671–682. https://doi.org/10.1007/s10143-018-1004-7
Kim DK, Kim JY, Kim DY et al (2017) Risk factors of proximal junctional kyphosis after multilevel fusion surgery: more than 2 years follow-up data. J Korean Neurosurg Soc 60:174–180. https://doi.org/10.3340/jkns.2016.0707.014
Hlubek RJ, Godzik J, Newcomb AGUS et al (2019) Iliac screws may not be necessary in long-segment constructs with L5–S1 anterior lumbar interbody fusion: cadaveric study of stability and instrumentation strain. Spine J Off J North Am Spine Soc 19:942–950. https://doi.org/10.1016/j.spinee.2018.11.004
Ntilikina Y, Charles YP, Persohn S, Skalli W (2020) Influence of double rods and interbody cages on quasistatic range of motion of the spine after lumbopelvic instrumentation. Eur Spine J. https://doi.org/10.1007/s00586-020-06594-2
Theologis AA, Safaee M, Scheer JK et al (2017) Magnitude, location, and factors related to regional and global sagittal alignment change in long adult deformity constructs: report of 183 patients with 2-year follow-up. Clin Spine Surg 30:E948–E953. https://doi.org/10.1097/BSD.0000000000000503
Smith JS, Shaffrey CI, Sansur CA et al (2011) Rates of infection after spine surgery based on 108,419 procedures: a report from the scoliosis research society morbidity and mortality committee. Spine 36:556–563. https://doi.org/10.1097/BRS.0b013e3181eadd41
All the authors participated in the study with no study funding involved.
Conflict of interest
Vincent Lamas has no conflict of interest. Yann Philippe Charles is a consultant for Stryker, Clariance and Ceraver; he received royalties and grants unrelated to this study from Stryker and Clariance. Nicolas Tuzin has no conflict of interest. Jean-Paul Steib is a consultant for Clariance and Zimmer-Biomet; he received royalties from Clariance, Zimmer-Biomet and Medtronic.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Communicated by FRANCE.
About this article
Cite this article
Lamas, V., Charles, Y.P., Tuzin, N. et al. Comparison of degenerative lumbar scoliosis correction and risk for mechanical failure using posterior 2-rod instrumentation versus 4-rod instrumentation and interbody fusion. Eur Spine J 30, 1965–1977 (2021). https://doi.org/10.1007/s00586-021-06870-9
- Adult spinal deformity
- Degenerative scoliosis
- Four-rod instrumentation
- Sagittal alignment
- Proximal junctional kyphosis