Elsevier

Spine Deformity

Volume 5, Issue 3, May 2017, Pages 213-223
Spine Deformity

Case Series
Comparison of a Newer Versus Older Protocol for Circumferential Minimally Invasive Surgical (CMIS) Correction of Adult Spinal Deformity (ASD)—Evolution Over a 10-Year Experience

https://doi.org/10.1016/j.jspd.2016.12.005Get rights and content

Abstract

Study Design

Retrospective.

Objectives

Compare circumferential minimally invasive surgical (CMIS) correction outcomes of patients treated for adult spinal deformity (ASD) with a newer versus older protocol

Summary of Background Data

CMIS techniques have become increasingly popular. Increasing experience and learning curve may help improve outcomes.

Methods

A prospectively collected database was queried for all patients who underwent CMIS correction of ASD (Cobb angle >20° or sagittal vertical axis [SVA] >50 mm or pelvic incidence–lumbar lordosis mismatch >10) at 3+ levels. Those without a full-length radiograph or 2-year follow-up were excluded. Patients were compared based on treatment using our original or newer protocol.

Results

The original protocol had 76 patients with an average age of 66.99 years (range 46–81, standard deviation [SD] 9.03), and the new protocol had 53 patients with average age of 65.85 years (range 48–85, SD 8.08). Preoperative and latest visual analog scale (VAS) scores in the original were 6.85 and 3.45 (p = .001) and in the new were 6.19 and 2.27 (p = .004). Delta-VAS scores were 3.27 and 4.27. The Oswestry disability index (ODI) reduced from 45.84 to 32.91 (p = .041) in the original and from 44.21 to 25.39 (p = .017) in the new. Average delta-ODIs were 22.25 and 24.01. Preoperative, latest, and delta-SF physical component scores for the original were 35.38, 42.42, and 10.06 and for the new, 30.89, 39.49, and 11.93. SF mental component scores were 50.96, 55.19, and 12.84 and 50.12, 52.99, and 8.85. The original and new protocols had latest Cobb angles of 11.54° and 11.12° (p = .789), delta-Cobb angles of 14.51° and 20.03° (p < .05), latest SVAs of 42.85 and 30.58 mm (p < .05) and latest PI–LL mismatch of 15.49 and 9.00 mm (p < .05). In the original and the new, the average preoperative SVAs that reliably achieved a postoperative SVA of 50 mm or less were 84 and 119 mm, respectively, and the maximum delta-SVAs were 89 and 120 mm. The new protocol had fewer surgical complications (p < .05).

Conclusion

Improvements in radiographic scores, functional outcomes, and limits of SVA correction and lower complication rates suggest that the new protocol may help improve outcomes. These findings may be a reflection of our 10-year experience and advances in the learning curve.

Level of Evidence

Level IV.

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

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    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).

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