Case SeriesComparison of a Newer Versus Older Protocol for Circumferential Minimally Invasive Surgical (CMIS) Correction of Adult Spinal Deformity (ASD)—Evolution Over a 10-Year Experience
Introduction
Circumferential minimally invasive surgery (CMIS) for the correction of adult spinal deformity (ASD) has evolved significantly throughout the years. Laparoscopic surgery was advocated in the early nineties. These keyhole methods, though, have been hampered by a steep learning curve, excessive costs, and a high complications rate [1], [2].
In 2003 we started lateral lumbar interbody fusion (LLIF) with open posterior instrumentation on 1 or 2 spinal levels. In 2004, the presacral axial lumbar interbody fusion (AxiaLIF) approach was introduced to address L5–S1 interbody fusion in a minimally invasive surgical (MIS) manner. In 2005, multilevel percutaneous posterior instrumentation technologies for spinal trauma became available. It became a natural extension to use this technology for ASD posterior instrumentation, which in turn enabled ASD correction in a purely circumferential MIS fashion. The culmination gave rise to our original staged surgical protocol [3] in late 2006.
Reflecting on our early experiences, in 2011, we implemented numerous changes to our methodology, forming the basis of our new protocol for CMIS correction of ASD. We transitioned to a mini–anterior lumbar interbody fusion (mini-ALIF) approach to L5–S1 to obtain optimal sagittal balance [4] and increase union rates.
We transitioned away from the transpsoas approach to a more anterior oblique trajectory to the disc space. Furthermore, we started using local dexamethasone directly in the area of the LLIF around the same time.
To address the limitations in obtaining optimal sagittal balance [4], [5], [6], we started using 12-degree lordotic cages in 2011 at multiple levels. We also obtained routine intervening radiographs to assess alignment in between stages. Furthermore, we refined our posterior fixation techniques, allowing for the passage of hypercontoured rods with aggressive reduction techniques.
In this study, we describe our original and new protocols. We compare clinical, functional, and radiologic outcomes of patients treated according to the respective protocols. The study objectively documents how changes in our protocol, based on our experience and improvements in the technical learning curve, may have contributed to improved functional outcomes in patients undergoing CMIS correction of ASD.
Section snippets
Materials and Methods
We queried our prospectively collected database for all patients who underwent CMIS correction of ASD at 3 or more levels. The study period was November 2006 to April 2014. Data were collected with internal review board approval. Patients in the study all had clinically significant ASD characterized by severe back pain, progressively worsening with or without radicular pain. The back pain was far worse than leg pain and had failed all attempts at conservative therapy for well over 6 months. In
Results
Data comparing baseline demographic, surgical, and radiographic factors are shown in Table 2. The new protocol had more operated levels and lower follow-up beyond 2 years (p < .05).
Table 3 compares the original and new protocols based on radiographic outcomes. Delta-Cobb angle was 14.5 in the original and 20.0 in the new protocol (p < .05). The new protocol had a latest SVA and PI-LL mismatch of 30.6 and 9.0 mm compared with 42.9 and 15.5 mm in the old protocol. The EBL and the operative times
Discussion
There is a growing body of evidence supporting the use of CMIS techniques for treatment of ASD [3], [20], [21]. Early reports have suggested that CMIS techniques are limited by the lack of correction afforded in the sagittal plane [22], [23]. Haque et al. reported clinical and radiologic outcomes of 184 patients divided into three groups based on surgical approaching including 42 MIS, 33 hybrid, and 109 open. The authors show a significant improvement in postoperative SVA in the open group
References (42)
- et al.
Evaluation of hip flexion strength following lateral lumbar interbody fusion
Spine J
(2013) - et al.
Benefits of the paraspinal muscle-sparing approach versus the conventional midline approach for posterior nonfusion stabilization: comparative analysis of clinical and functional outcomes
SAS J
(2007) - et al.
Operative management of degenerative scoliosis: an evidence-based approach to surgical strategies based on clinical and radiographic outcomes
Neurosurg Clin N Am
(2007) - et al.
The economics of minimally invasive spine surgery: the value perspective
Spine
(2010) - et al.
Comparison of the mini-open versus laparoscopic approach for anterior lumbar interbody fusion: a retrospective review
Neurosurgery
(2002) - et al.
Minimally invasive approaches for the correction of adult spinal deformity
Eur Spine J
(2013) - et al.
Limitations and ceiling effects with circumferential minimally invasive correction techniques for adult scoliosis: analysis of radiological outcomes over a 7-year experience
Neurosurg Focus
(2014) - et al.
Minimally invasive anterior column reconstruction for sagittal plane deformities
- et al.
Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients
Neurosurg Focus
(2014) - et al.
Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis
Neurosurgi Focus
(2010)
Motor nerve injuries following the minimally invasive lateral transpsoas approach
J Neurosurg Spine
Lateral lumbar interbody fusion: indications, outcomes, and complications
J Am Acad Orthop Surg
Neurologic deficit following lateral lumbar interbody fusion
Eur Spine J
Does minimally invasive transsacral fixation provide anterior column support in adult scoliosis?
Clin Orthop Relat Res
Axial lumbar interbody fusion (AxiaLIF) approach for adult scoliosis
Eur Spine J
The axial transsacral approach to interbody fusion at L5-S1
Neurosurgi Focus
AxiaLIF system: minimally invasive device for presacral lumbar interbody spinal fusion
Med Devices
Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes
Spine
Dexamethasone—a helpful adjunct in management after lumbar discectomy
Neurosurgery
The use of dexamethasone in primary lumbar disc surgery. A prospective, randomized, double-blind study
Spine
The impact of perioperative complications on clinical outcome in adult deformity surgery
Spine
Cited by (24)
Assessing outcomes of surgical treatment in adult spinal deformity: a critical approach
2021, Orthopaedics and TraumaCitation Excerpt :The second stage posterior instrumentation is performed a few days later, when the patient has been re-evaluated and is medically stable, with addition of posterior column or partial facetectomies as required. The use of hyperlordotic interbody cage devices and aggressive contouring of definitive rods can result in satisfactory correction of ASD.51 If staged procedures are selected, the interval period should allow for replenishment of nutritional status which often requires supplemental nutrition.52
Lateral lumbar interbody fusion in adult spine deformity – A review of literature
2021, Journal of Clinical Orthopaedics and TraumaIncidence and risk factors of lateral cage migration occurred after the first-stage lateral lumbar interbody fusion surgery
2021, Orthopaedics and Traumatology: Surgery and ResearchCitation Excerpt :In MUTLI-level degenerative disc diseases, LLIF can be performed in the first-stage, and then a second-stage posterior fixation will be performed via percutaneous or paraspinal muscle sparing approach in case of the resolution of neurologic symptom [8,9]. The meanings of strategic staged manner in MUTLI-level degenerative disc disease include (1) the interval of the staged surgery give us clinical documentation of relief of radicular symptoms and claudication pain, which provide the information for whether decompression should be performed and the decompression level in the second stage [9,10]; (2) reassessment of the sagittal and coronal balance for spinal deformities, which provides the information for fine-tune and correct for any imbalance, and fixation levels in the second stage [10,11]. However, cage migration might occur during the interval of the staged surgery, which is usually diagnosed as movement of the cage that exceeds 3 mm or extends beyond the wall of the vertebral body [12].
Minimally invasive osteotomies for adult deformity
2021, Seminars in Spine SurgeryAnalysis of Spino-Pelvic Parameters and Segmental Lordosis with L5-S1 Oblique Lateral Interbody Fusion at the Bottom of a Long Construct in Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity
2019, World NeurosurgeryCitation Excerpt :We believe that the key to successful surgery is diligent patient selection, choosing patients in whom the vessels are well bifurcated at L5-S1 and little or no mobilization is needed. Our staged protocol has been published previously.30,31 We achieved robust correction of LL, SL at L5-S1, PI–LL mismatch, pelvic tilt, and SVA with this technique.
The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016
2019, Spine DeformityCitation Excerpt :In the past decade, minimally invasive surgery has rapidly evolved and is being increasingly used in the treatment of complex spinal pathologies. Recent literature has cited its multiple advantages include reduced blood loss, shorter operative time, quicker recovery, and improved cosmetics [1-6]. Because MIS is a developing field with a steep learning curve, there is little consensus on how to exploit different approaches.
Author disclosures: NA (other from Globus Medical, Theracell, Medtronic, DePuy Synthes, Stryker Spine, Paradigm Spine, NuVasive, and Elsevier, outside the submitted work); JEC (none); RBC (none); BK (none); SK (none); EB (other from Elsevier and McGraw-Hill, outside the submitted work).