Advances in Spinal Fusion Strategies in Adult Deformity Surgery

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Abstract

Background

As the frequency of adult deformity surgery (ADS) continues to increase, our understanding of techniques that enhance fusion must continue to evolve because pseudarthrosis can be a serious and costly event.

Purposes/Questions

We sought to conduct a review of the literature investigating techniques that can enhance outcomes of ADS.

Methods

Two databases were searched for keywords such as “advances in spinal fusion,” “new technology in adult spinal deformity,” “interbody devices for adult spinal deformity,” “adult spinal deformity rods,” and “screw design in adult spinal deformity” to examine recent literature and trends in ADS.

Results

We identified 45 articles for our review. Topics studied include the use of multiple rods, interbody fusion, distal fixation techniques, and bone morphogenetic protein or iliac crest bone graft.

Conclusions

Many recent innovations in treatments to enhance fusion in ADS have been studied, some more controversial than others. Further research into the efficacy of these techniques may increase fusion rates in ADS.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Ackerman SJ, Mafilios MS, Polly DW Jr. Economic evaluation of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion: an evidence-based modeling approach. Spine (Phila Pa 1976). 2002;27:S94–S99.

    Article  Google Scholar 

  2. 2.

    Ames CP, Scheer JK, Lafage V, et al. Adult spinal deformity: epidemiology, health impact, evaluation, and management. Spine Deformity. 2016;4:310–322.

    PubMed  Article  Google Scholar 

  3. 3.

    Annis P, Brodke DS, Spiker WR, Daubs MD, Lawrence BD. The fate of L5-S1 with low-dose BMP-2 and pelvic fixation, with or without interbody fusion, in adult deformity surgery. Spine (Phila Pa 1976). 2015;40:e634–e639.

    Article  Google Scholar 

  4. 4.

    Arutyunyan GG, Angevine PD, Berven S. Cost-effectiveness in adult spinal deformity surgery. Neurosurgery. 2018;83:597–601.

    PubMed  Article  Google Scholar 

  5. 5.

    Bodenheimer T. High and rising health care costs. Part 1: seeking an explanation. Ann Intern Med. 2005;142:847–854.

    PubMed  Article  Google Scholar 

  6. 6.

    Buell TJ, Bess S, Xu M, et al. Optimal tether configurations and preload tensioning to prevent proximal junctional kyphosis: a finite element analysis. J Neurosurg Spine. 2019:1–11.

  7. 7.

    Cho SK, Shin JI, Kim YJ. Proximal junctional kyphosis following adult spinal deformity surgery. Euro Spine J. 2014;23:2726–2736.

    Article  Google Scholar 

  8. 8.

    Cutler DM. Rising medical costs mean more rough times ahead. JAMA. 2017;318:508–509.

    PubMed  Article  Google Scholar 

  9. 9.

    Daniels AH, DePasse JM, Durand W. Rod fracture after apparently solid radiographic fusion in adult spinal deformity patients. World Neurosurg. 2018;117:e530–e537.

    PubMed  Article  Google Scholar 

  10. 10.

    Dimitriou R, Mataliotakis GI, Angoules AG, Kanakaris NK, Giannoudis PV. Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review. Injury. 2011;42 Suppl 2:s3–s15.

    PubMed  Article  Google Scholar 

  11. 11.

    Ebata S, Ohba T, Oba H, Haro H. Bilateral dual iliac screws in spinal deformity correction surgery. J Orthop Surg Res. 2018;13:260.

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005;30:2024–2029.

    Article  Google Scholar 

  13. 13.

    Glassman SD, Carreon LY, Campbell MJ, et al. The perioperative cost of Infuse bone graft in posterolateral lumbar spine fusion. Spine J. 2008;8:443–448.

    PubMed  Article  Google Scholar 

  14. 14.

    Gupta S, Eksi MS, Ames CP, Deviren V, Durbin-Johnson B, Smith JS, Gupta MC. 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). 2018;14:449–456.

    PubMed  Article  Google Scholar 

  15. 15.

    Han S, Hyun SJ, Kim KJ, Jahng TA, Kim HJ. Comparative study between cobalt chrome and titanium alloy rods for multilevel spinal fusion: proximal junctional kyphosis more frequently occurred in patients having cobalt chrome rods. World Neurosurg. 2017;103:404–409.

    PubMed  Article  Google Scholar 

  16. 16.

    Han S, Hyun SJ, Kim KJ, Jahng TA, Lee S, Rhim SC. Rod stiffness as a risk factor of proximal junctional kyphosis after adult spinal deformity surgery: comparative study between cobalt chrome multiple-rod constructs and titanium alloy two-rod constructs. Spine J. 2017;17:962–968.

    PubMed  Article  Google Scholar 

  17. 17.

    Harimaya K, Mishiro T, Lenke LG, Bridwell KH, Koester LA, Sides BA. Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs. Spine (Phila Pa 1976). 2011;36:1701–1710.

    Article  Google Scholar 

  18. 18.

    Harrop JS, Jeyamohan SB, Sharan A, Ratliff J, Vaccaro AR. Iliac bolt fixation: an anatomic approach. J Spinal Disord Tech. 2009;22:541–544.

    PubMed  Article  Google Scholar 

  19. 19.

    Hyun SJ, Lenke LG, Kim YC, Koester LA, Blanke KM. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976). 2014;39:1899–1904.

    Article  Google Scholar 

  20. 20.

    Januszewski J, Beckman JM, Harris JE, Turner AW, Yen CP, Uribe JS. Biomechanical study of rod stress after pedicle subtraction osteotomy versus anterior column reconstruction: a finite element study. Surg Neurol Int. 2017;8:207.

    PubMed  PubMed Central  Article  Google Scholar 

  21. 21.

    Kelly MP, Lenke LG, Bridwell KH, Agarwal R, Godzik J, Koester L. Fate of the adult revision spinal deformity patient: a single institution experience. Spine (Phila Pa 1976). 2013;38:e1196–e1200.

    Article  Google Scholar 

  22. 22.

    Kelly MP, Kim HJ, Ames CP, et al. Minimum detectable measurement difference for health-related quality of life measures varies with age and disability in adult spinal deformity: implications for calculating minimal clinically important difference. Spine (Phila Pa 1976). 2018;43:e790–e795.

    Article  Google Scholar 

  23. 23.

    Kim HJ, Iyer S. Proximal junctional kyphosis. J Am Acad Orthop Surg. 2016;24:318–326.

    PubMed  Article  Google Scholar 

  24. 24.

    Kim YJ, Bridwell KH, Lenke LG, Rinella AS, Edwards C 2nd. Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis. Spine (Phila Pa 1976). 2005;30:468–474.

    Article  Google Scholar 

  25. 25.

    Kim YJ, Bridwell KH, Lenke LG, Cho KJ, Edwards CC 2nd, Rinella AS. Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis. J Bone Joint Surg Am. 2006;88:721–728.

    PubMed  Google Scholar 

  26. 26.

    Kim HJ, Buchowski JM, Zebala LP, Dickson DD, Koester L, Bridwell KH. RhBMP-2 is superior to iliac crest bone graft for long fusions to the sacrum in adult spinal deformity: 4- to 14-year follow-up. Spine (Phila Pa 1976). 2013;38:1209–1215.

    Article  Google Scholar 

  27. 27.

    Kuklo TR, Bridwell KH, Lewis SJ, Baldus C, Blanke K, Iffrig TM, Lenke LG. Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine (Phila Pa 1976). 2001;26:1976–1983.

    CAS  Article  Google Scholar 

  28. 28.

    Lafage R, Schwab F, Glassman S, et al. Age-adjusted alignment goals have the potential to reduce PJK. Spine (Phila Pa 1976). 2017;42:1275–1282.

    Article  Google Scholar 

  29. 29.

    Luhmann SJ, Bridwell KH, Cheng I, Imamura T, Lenke LG, Schootman M. Use of bone morphogenetic protein-2 for adult spinal deformity. Spine (Phila Pa 1976). 2005;30:s110–s117.

    Article  Google Scholar 

  30. 30.

    Martin-Buitrago MP, Pizones J, Sanchez Perez-Grueso FJ, et al. Impact of iliac instrumentation on the quality of life of patients with adult spine deformity. Spine (Phila Pa 1976). 2018;43:913–918.

    Article  Google Scholar 

  31. 31.

    McClellan JW, Mulconrey DS, Forbes RJ, Fullmer N. Vertebral bone resorption after transforaminal lumbar interbody fusion with bone morphogenetic protein (rhBMP-2). J Spinal Disord Tech. 2006;19:483–486.

    PubMed  Article  Google Scholar 

  32. 32.

    McKay B, Sandhu HS. Use of recombinant human bone morphogenetic protein-2 in spinal fusion applications. Spine (Phila Pa 1976). 2002;27:s66–s85.

    Article  Google Scholar 

  33. 33.

    Merrill RK, Kim JS, Leven DM, Kim JH, Cho SK. Multi-rod constructs can prevent rod breakage and pseudarthrosis at the lumbosacral junction in adult spinal deformity. Global Spine J. 2017;7:514–520.

    PubMed  PubMed Central  Article  Google Scholar 

  34. 34.

    O’Brien JR, Yu WD, Bhatnagar R, Sponseller P, Kebaish KM. An anatomic study of the S2 iliac technique for lumbopelvic screw placement. Spine (Phila Pa 1976). 2009;34:e439–e442.

    Article  Google Scholar 

  35. 35.

    O’Brien JR, Yu W, Kaufman BE, Bucklen B, Salloum K, Khalil S, Gudipally M. Biomechanical evaluation of S2 alar-iliac screws: effect of length and quad-cortical purchase as compared with iliac fixation. Spine (Phila Pa 1976). 2013;38:e1250–e1255.

    Article  Google Scholar 

  36. 36.

    O’Shaughnessy BA, Bridwell KH, Lenke LG, et al. Does a long-fusion “T3-sacrum” portend a worse outcome than a short-fusion “T10-sacrum” in primary surgery for adult scoliosis? Spine (Phila Pa 1976). 2012;37:884–890.

    Article  Google Scholar 

  37. 37.

    Peelle MW, Lenke LG, Bridwell KH, Sides B. Comparison of pelvic fixation techniques in neuromuscular spinal deformity correction: Galveston rod versus iliac and lumbosacral screws. Spine (Phila Pa 1976). 2006;31:2392–2398; discussion 2399.

    Article  Google Scholar 

  38. 38.

    Poorman GW, Jalai CM, Boniello A, Worley N, McClelland S, 3rd, Passias PG. Bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis. European Spine J. 2017;26:2094–2102.

    Article  Google Scholar 

  39. 39.

    Rahman RK, Buchowski JM, Stephens B, Dorward IG, Koester LA, Bridwell KH. Comparison of TLIF with rhBMP-2 versus no TLIF and higher posterolateral rhBMP-2 dose at L5-S1 for long fusions to the sacrum with sacropelvic fixation in patients with primary adult deformity. Spine (Phila Pa 1976). 2013;38:2264–2271.

    Article  Google Scholar 

  40. 40.

    Raman T, Nayar SK, Liu S, Skolasky RL, Kebaish KM. Cost-effectiveness of primary and revision surgery for adult spinal deformity. Spine (Phila Pa 1976). 2018;43:791–797.

    Article  Google Scholar 

  41. 41.

    Scheer JK, Lafage R, Schwab FJ, et al. Under correction of sagittal deformities based on age-adjusted alignment thresholds leads to worse health-related quality of life whereas over correction provides no additional benefit. Spine (Phila Pa 1976). 2018;43:388–393.

    Article  Google Scholar 

  42. 42.

    Scheer JK, Oh T, Smith JS, et al. Development of a validated computer-based preoperative predictive model for pseudarthrosis with 91% accuracy in 336 adult spinal deformity patients. Neurosurg Focus. 2018;45:e11.

    PubMed  Article  Google Scholar 

  43. 43.

    Schwab FJ, Blondel B, Bess S, et al. Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976). 2013;38:e803–e812.

    Article  Google Scholar 

  44. 44.

    Shen FH, Harper M, Foster WC, Marks I, Arlet V. A novel “four-rod technique” for lumbo-pelvic reconstruction: theory and technical considerations. Spine (Phila Pa 1976). 2006;31:1395–1401.

    Article  Google Scholar 

  45. 45.

    Solla F, Barrey CY, Burger E, Kleck CJ, Fière VJ. Patient-specific rods for surgical correction of sagittal imbalance in adults. Clin Spine Surg. 2019;32:80–86.

    PubMed  Article  Google Scholar 

  46. 46.

    Sponseller PD, Zimmerman RM, Ko PS, et al. Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up. Spine (Phila Pa 1976). 2010;35:1887–1892.

    Article  Google Scholar 

  47. 47.

    Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976). 2006;31:303–308.

    Article  Google Scholar 

  48. 48.

    Wang C, Bell K, McClincy M, Jacobs L, Dede O, Roach J, Bosch P. Biomechanical comparison of ponte osteotomy and discectomy. Spine (Phila Pa 1976). 2015;40:e141–e145.

    Article  Google Scholar 

  49. 49.

    Yeramaneni S, Ames CP, Bess S, et al. Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database. Spine J. 2018;18:1829–1836.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Han Jo Kim MD.

Ethics declarations

Conflict of Interest

Jeremy Steinberger, MD, Philip York, MD, and Sohrab Virk MD, MBA, declare that they have no conflicts of interest. Han Jo Kim, MD, reports personal fees from K2M and Zimmer Biomet and advisory board membership from AOSpine, outside the submitted work.

Human/Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Informed Consent

N/A

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Additional information

This study was a review of previously published literature. It is exempt from any IRB or IACUC requirements.

Electronic supplementary material

ESM 1

(PDF 541 kb)

ESM 2

(PDF 538 kb)

ESM 3

(PDF 1.19 mb)

ESM 4

(PDF 576 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Steinberger, J., York, P., Virk, S. et al. Advances in Spinal Fusion Strategies in Adult Deformity Surgery. HSS Jrnl 16, 195–199 (2020). https://doi.org/10.1007/s11420-020-09751-x

Download citation

Keywords

  • adult spinal deformity
  • spinal rod
  • fusion
  • spinal osteotomy
  • interbody fusion
  • iliac fixation