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Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients.
J Neurosurg Spine. 2017 Feb; 26(2):208-219.JN

Abstract

OBJECTIVE

The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD).

METHODS

Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed.

RESULTS

Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes.

CONCLUSIONS

Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.

Authors+Show Affiliations

Department of Orthopaedic Surgery, University of California, San Francisco.Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California.Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California.Department of Neurological Surgery, University of Pittsburgh, Pennsylvania.Department of Neurologic Surgery, University of California, San Francisco, California.Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois.Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado.Department of Orthopedic Surgery, NYU Hospital for Joint Diseases.Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York.Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and.Department of Orthopedic Surgery, Oregon Health & Science University, Portland, Oregon.Department of Orthopaedic Surgery, University of California, San Francisco.Department of Neurologic Surgery, University of California, San Francisco, California.No affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

27767682

Citation

Theologis, Alexander A., et al. "Utility of Multilevel Lateral Interbody Fusion of the Thoracolumbar Coronal Curve Apex in Adult Deformity Surgery in Combination With Open Posterior Instrumentation and L5-S1 Interbody Fusion: a Case-matched Evaluation of 32 Patients." Journal of Neurosurgery. Spine, vol. 26, no. 2, 2017, pp. 208-219.
Theologis AA, Mundis GM, Nguyen S, et al. Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients. J Neurosurg Spine. 2017;26(2):208-219.
Theologis, A. A., Mundis, G. M., Nguyen, S., Okonkwo, D. O., Mummaneni, P. V., Smith, J. S., Shaffrey, C. I., Fessler, R., Bess, S., Schwab, F., Diebo, B. G., Burton, D., Hart, R., Deviren, V., & Ames, C. (2017). Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients. Journal of Neurosurgery. Spine, 26(2), 208-219. https://doi.org/10.3171/2016.8.SPINE151543
Theologis AA, et al. Utility of Multilevel Lateral Interbody Fusion of the Thoracolumbar Coronal Curve Apex in Adult Deformity Surgery in Combination With Open Posterior Instrumentation and L5-S1 Interbody Fusion: a Case-matched Evaluation of 32 Patients. J Neurosurg Spine. 2017;26(2):208-219. PubMed PMID: 27767682.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients. AU - Theologis,Alexander A, AU - Mundis,Gregory M,Jr AU - Nguyen,Stacie, AU - Okonkwo,David O, AU - Mummaneni,Praveen V, AU - Smith,Justin S, AU - Shaffrey,Christopher I, AU - Fessler,Richard, AU - Bess,Shay, AU - Schwab,Frank, AU - Diebo,Bassel G, AU - Burton,Douglas, AU - Hart,Robert, AU - Deviren,Vedat, AU - Ames,Christopher, AU - ,, Y1 - 2016/10/21/ PY - 2016/10/22/pubmed PY - 2017/2/23/medline PY - 2016/10/22/entrez KW - 3CO = 3-column osteotomy KW - ALIF = anterior lumbar interbody fusion KW - ASA = American Society of Anesthesiologists KW - ASD = adult spinal deformity KW - BMI = body mass index KW - CCI = Charlson Comorbidity Index KW - EBL = estimated blood loss KW - HRQoL = health-related quality of life KW - LIF = lateral interbody fusion KW - LL = lumbar lordosis KW - LOS = length of stay KW - ODI = Oswestry Disability Index KW - PI = pelvic incidence KW - PI-LL = mismatch between PI and LL (lumbopelvic mismatch) KW - PSF = posterior instrumented spinal fusion KW - PT = pelvic tilt KW - SVA = sagittal vertical axis KW - TK = thoracic kyphosis KW - TLIF = transforaminal lumbar interbody fusion KW - VAS = visual analog scale KW - adult spinal deformity KW - complications KW - health-related quality of life KW - lateral interbody fusion KW - lumbosacral interbody fusion KW - minimally invasive SP - 208 EP - 219 JF - Journal of neurosurgery. Spine JO - J Neurosurg Spine VL - 26 IS - 2 N2 - OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion. SN - 1547-5646 UR - https://www.unboundmedicine.com/medline/citation/27767682/Utility_of_multilevel_lateral_interbody_fusion_of_the_thoracolumbar_coronal_curve_apex_in_adult_deformity_surgery_in_combination_with_open_posterior_instrumentation_and_L5_S1_interbody_fusion:_a_case_matched_evaluation_of_32_patients_ L2 - https://thejns.org/doi/10.3171/2016.8.SPINE151543 DB - PRIME DP - Unbound Medicine ER -