A combination of 3 novel MIS techniques allows comparable correction of adult spinal deformity, with low pseudarthrosis rates, significantly improved functional outcomes, and excellent clinical and radiological improvement, but considerably lowers morbidity and complication rates at early and long-term follow-up.

No abstract

Level IV.

BackgroundOutcomes for minimally invasive scoliosis correction surgery have been reported for mild adult scoliosis. Larger curves historically have been treated with open surgical procedures including facet resections or posterior column osteotomies, which have been associated with high-volume blood loss. Further, minimally invasive techniques have been largely reported in the setting of degenerative scoliosis.Questions/purposesWe describe the effects of circumferential minimally invasive surgery (cMIS) for moderate to severe scoliosis in terms of (1) operative time and blood loss, (2) overall health and disease-specific patient-reported outcomes, (3) deformity correction and fusion rate, and (4) frequency and types of complications.MethodsBetween January 2007 and January 2012, we performed 50 cMIS adult idiopathic scoliosis corrections in patients with a Cobb angle of greater than 30° but less than 75° who did not have prior thoracolumbar fusion surgery; this series represented all patients we treated surgically during that time meeting those indications. Our general indications for this approach during that period were increasing back pain unresponsive to nonoperative therapy with cosmetic and radiographic worsening of curves. Surgical times and estimated blood loss were recorded. Functional clinical outcomes including VAS pain score, Oswestry Disability Index (ODI), and SF-36 were recorded preoperatively and postoperatively. Patients’ deformity correction was assessed on pre- and postoperative 36-inch (91-cm) standing films and fusion was assessed on CT scan. Minimum followup was 24 months (mean, 48 months; range, 24–77 months).ResultsMean blood loss was 613 mL for one-stage surgery and 763 mL for two-stage surgery. Mean operative time was 351 minutes for one-stage surgery and 482 minutes for two-stage surgery. At last followup, mean VAS and ODI scores decreased from 5.7 and 44 preoperatively to 2.9 and 22 (p < 0.001 and 0.03, respectively) and mean SF-36 score increased from 48 preoperatively to 74 (p = 0.026). Mean Cobb angle and sagittal vertical axis decreased from 42° and 51 mm preoperatively to 16° and 27 mm postoperatively (both p < 0.001). An 88% fusion rate was confirmed on CT scan. Perioperative complications occurred in 11 of the 50 patients (22%), with delayed complications needing further surgery in 10 more patients at last followup.ConclusionscMIS provides for good clinical and radiographic outcomes for moderate (30°–75°) adult idiopathic scoliosis. Patients undergoing cMIS should be carefully selected to avoid fixed, rigid deformities and a preoperative sagittal vertical axis of greater than 10 cm; surgeons should consider alternative techniques in those patients.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

BackgroundSpinal fusion to the sacrum, especially in the setting of deformity and long constructs, is associated with high complication and pseudarthrosis rates. Transsacral discectomy, fusion, and fixation is a minimally invasive spine surgery technique that provides very rigid fixation. To date, this has been minimally studied in the setting of spinal deformity correction.Questions/purposesWe determined (1) the fusion rate of long-segment arthrodeses, (2) heath-related quality-of-life (HRQOL) outcomes (VAS pain score, Oswestry Disability Index [ODI], SF-36), and (3) the common complications and their frequency in adult patients with scoliosis undergoing transsacral fixation without supplemental pelvic fixation.MethodsBetween April 2007 and May 2011, 92 patients had fusion of three or more segments extending to the sacrum for spinal deformity. Transsacral L5-S1 fusion without supplemental pelvic fixation was performed in 56 patients. Of these, 46 with complete data points and a minimum of 2 years of followup (mean, 48 months; range, 24–72 months; 18% of patients lost to followup) were included in this study. Nineteen of the 46 (41%) had fusions extending above the thoracolumbar junction, with one patient having fusion into the proximal thoracic spine (T3-S1). General indications for the use of transsacral fixation were situations where the fusion needed to be extended to the sacrum, such as spondylolisthesis, prior laminectomy, stenosis, oblique take-off, and disc degeneration at L5-S1. Contraindications included anatomic variations in the sacrum, vascular anomalies, prior intrapelvic surgery, and rectal fistulas or abscesses. Fusion rates were assessed by full-length radiographs and CT scanning. HRQOL data, including VAS pain score, ODI, and SF-36 scores, were assessed at all pre- and postoperative visits. Intraoperative and postoperative complications were noted.ResultsForty-one of 46 patients (89%) developed a solid fusion at L5-S1. There were significant improvements in all HRQOL parameters. Eight patients had complications related to the transsacral fusion, including five pseudarthroses and three superficial wound dehiscences. Three patients underwent revision surgery with iliac fixation. There were no bowel injuries, sacral hematomas, or sacral fractures.ConclusionsTranssacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in the setting of long-segment constructs in carefully selected patients. This study was retrospective and suffered from some loss to followup; future prospective trials are called for to compare this technique to other, more established approaches.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.