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Comparison of degenerative lumbar scoliosis correction and risk for mechanical failure using posterior 2-rod instrumentation versus 4-rod instrumentation and interbody fusion

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusion

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

III.

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References

  1. 1.

    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

    Article  PubMed  Google Scholar 

  2. 2.

    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

    Article  Google Scholar 

  3. 3.

    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

    Article  Google Scholar 

  4. 4.

    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

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    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

    Article  PubMed  Google Scholar 

  6. 6.

    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

    Article  Google Scholar 

  7. 7.

    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

    Article  Google Scholar 

  8. 8.

    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

    Article  PubMed  Google Scholar 

  9. 9.

    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

    Article  PubMed  Google Scholar 

  10. 10.

    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

    Article  Google Scholar 

  11. 11.

    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

    Article  PubMed  Google Scholar 

  12. 12.

    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

    Article  Google Scholar 

  13. 13.

    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

    Article  Google Scholar 

  14. 14.

    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

    Article  PubMed  Google Scholar 

  15. 15.

    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

    Article  Google Scholar 

  16. 16.

    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

    Article  Google Scholar 

  17. 17.

    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

    Article  Google Scholar 

  18. 18.

    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

    Article  PubMed  Google Scholar 

  19. 19.

    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

    Article  PubMed  Google Scholar 

  20. 20.

    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

    Article  PubMed  Google Scholar 

  21. 21.

    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

    Article  PubMed  Google Scholar 

  22. 22.

    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

    Article  PubMed  Google Scholar 

  23. 23.

    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

    CAS  Article  Google Scholar 

  24. 24.

    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

    Article  Google Scholar 

  25. 25.

    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

    Article  PubMed  Google Scholar 

  26. 26.

    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

    Article  Google Scholar 

  27. 27.

    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

    Article  PubMed  Google Scholar 

  28. 28.

    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

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    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

    Article  PubMed  Google Scholar 

  30. 30.

    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

    Article  PubMed  Google Scholar 

  31. 31.

    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

    Article  Google Scholar 

  32. 32.

    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

    Article  Google Scholar 

  33. 33.

    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

    Article  PubMed  Google Scholar 

  34. 34.

    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

    Article  PubMed  Google Scholar 

  35. 35.

    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

    Article  PubMed  Google Scholar 

  36. 36.

    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

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    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

    Article  Google Scholar 

  38. 38.

    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

    Article  PubMed  Google Scholar 

  39. 39.

    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

    Article  PubMed  Google Scholar 

  40. 40.

    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

    Article  PubMed  Google Scholar 

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Funding

All the authors participated in the study with no study funding involved.

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Correspondence to Vincent Lamas.

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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.

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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

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Keywords

  • Adult spinal deformity
  • Degenerative scoliosis
  • Four-rod instrumentation
  • Sagittal alignment
  • Non-union
  • Proximal junctional kyphosis