Elsevier

World Neurosurgery

Volume 127, July 2019, Pages e649-e655
World Neurosurgery

Original Article
Minimally Invasive Surgery for Mild-to-Moderate Adult Spinal Deformities: Impact on Intensive Care Unit and Hospital Stay

https://doi.org/10.1016/j.wneu.2019.03.237Get rights and content

Objective

To compare circumferential minimally invasive (cMIS) versus open surgeries for mild-to-moderate adult spinal deformity (ASD) with regard to intensive care unit (ICU) and hospital lengths of stay (LOS).

Methods

A retrospective review of 2 multicenter ASD databases with 426 ASD (sagittal vertical axis <6 cm) surgery patients with 4 or more fusion levels and 2-year follow-up was conducted. ICU stay, LOS, and estimated blood loss (EBL) were compared between open and cMIS surgeries.

Results

Propensity matching resulted in 88 patients (44 cMIS, 44 open). cMIS were older (61 vs. 53 years, P = 0.005). Mean levels fused were 6.5 in cMIS and 7.1 in open (P = 0.368). Preoperative lordosis was higher in open than in cMIS (42.7° vs. 40.9°, P = 0.016), and preoperative visual analog score back pain was greater in open than in cMIS (7 vs. 6.2, P = 0.033). Preoperative and postoperative spinopelvic parameters and coronal Cobb angles were not different. EBL was 534 cc in cMIS and 1211 cc in open (P < 0.001). Transfusions were less in cMIS (27.3% vs. 70.5%, P < 0.001). ICU stay was 0.6 days for cMIS and 1.2 days for open (P = 0.009). Hospital LOS was 7.9 days for cMIS versus 9.6 for open (P = 0.804).

Conclusions

For patients with mild-to-moderate ASD, cMIS surgery had a significantly lower EBL and shorter ICU stay. Major and minor complication rates were lower in cMIS patients than open patients. Overall LOS was shorter in cMIS patients, but did not reach statistical significance.

Introduction

As more knowledge is gained about adult spinal deformity (ASD) surgery, patient outcomes have improved in terms of quality of life and alleviation of disability.1, 2, 3 Although the morbidity has decreased in the era of modern surgery compared with historical controls, the magnitude of ASD surgery nonetheless still has a significant impact on the patient.4, 5, 6, 7 Multilevel fusions, osteotomies, significant blood loss with subsequent fluid shifts, large areas of muscle dissection, and open anterior surgery all disrupt a patient's homeostasis and demand a more intense recovery.6, 8, 9, 10 Moreover, many patients with ASD go to the intensive care unit (ICU) after their surgery for pain control, blood volume resuscitation, blood pressure management, and airway precaution.6, 8, 9, 10 Concomitantly, the cost of such surgeries is in part increased because of the increased cost of ICU stay.11, 12 Thus, the “intensity of stay”—as characterized by the length of hospitalization and the length of ICU stay—is a major factor in ASD surgery. Trying to decrease this intensity of stay can potentially decrease the morbidity, complication rate, and costs.

It has been shown that minimally invasive spine (MIS) surgery can decrease morbidity by decreasing blood loss, hospital stay, infection, and cost compared with open surgery.13, 14, 15 As MIS surgery has made technical advances, its application has gone beyond routine, straightforward conditions into the realm of complex ASD correction. With this advance in MIS, the potential to significantly decrease the intensity of stay in ASD surgery has become promising. We wished to compare the intensity of stay during open ASD surgery with circumferentially MIS (cMIS) surgery to see if there is a difference with regard to the intensity of stay.

The purpose of this study was to evaluate the impact of minimally invasive surgery on patients undergoing ASD corrective surgery compared with open surgery.

Section snippets

Methods

A retrospective review of 2 multicenter ASD databases with similar inclusion criteria was conducted. The first database included patients with ASD from 11 institutions in the United States who underwent traditional, open posterior-only, or anterior-posterior spine surgery (open) and were enrolled into a prospective registry.

The second database is a retrospective registry of patients from 10 institutions in the United States who underwent minimally invasive spinal deformity surgery that includes

Results

There were 44 patients in the cMIS group and 44 in the open group from a total of 88 patients. Mean age was 61 years in the cMIS group and 53 years in the open group (P = 0.005). Mean levels fused were 6.5 in the cMIS group and 7.1 in the open group (P = 0.368). Preoperative spinopelvic parameters were not different between groups. The preoperative PI-LL difference was 11.3° for the cMIS group and 15.3° for the open group (P = 0.444); the postoperative PI-LL difference was 8.2° and 7°,

Discussion

There have been significant advances in assessing outcome variables in ASD, and such advances must be incorporated into planning MIS adult deformity surgery. Early data showed the importance of the SVA, but spinopelvic parameters were not accounted for.1, 16 The PI-LL mismatch and PT have become critical when planning ASD surgery.2, 17 Moreover, lateral listhesis and spondylolisthesis have also been associated with increased disability as a result of the radiculopathy secondary to stenosis.2 As

Conclusions

For patients undergoing surgical correction of mild-to-moderate spinal deformity, patients undergoing cMIS surgery had a significantly lower estimated blood loss, shorter ICU stay, and fewer major and minor complications. However, it is important to keep in mind that these are not severe sagittal plane deformities, and as such, this must be taken into consideration when interpreting the data.

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      With the use of innovative instrumentation methods and surgical techniques, MIS minimizes paraspinal injury. It is well documented that MIS techniques result in decreased blood loss, postoperative pain, wound infection, length of hospital stay, long-term disability, and narcotic dependence when compared to open techniques.7-15,21-31 Conversely, open surgery for ASD correction leads to greater blood loss, necessitating increased fluid resuscitation and transfusion.

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      Briefly, single-blinded and unblinded, level II RCTs have demonstrated MIS techniques to reduce intraoperative blood loss in the following operations: lumbar diskectomy [57], lumbar laminectomy [56], lumbar laminectomy and fusion [58], and transforaminal lumbar interbody fusion [59–61] There is also level II data suggesting MIS approaches reduce intraoperative blood loss when applied to separation surgery for spinal metastases [62]. Similarly, level III evidence suggests MIS strategies can reduce intraoperative blood loss in surgeries for adult spinal deformity [63,64], adolescent idiopathic scoliosis [65], thoracolumbar spine fractures [66], and intradural-extramedullary tumors [67,68]. Suffice to say, we believe that minimally invasive strategies should always be employed where they can be safely reconciled with the goals of surgery.

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    Conflict of interest statement: Dean Chou reports other from International Spine Study Group, during the conduct of the study; personal fees and other from Medtronic; and personal fees and other from Globus, outside the submitted work.

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