A Pilot Study on Posterior Polyethylene Tethers to Prevent Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity

Buell, Thomas J.; Buchholz, Avery L.; Quinn, John C.; Bess, Shay; Line, Breton; Ames, Christopher P.; Schwab, Frank J.; Lafage, Virginie; Shaffrey, Christopher I.; Smith, Justin S.

doi:10.1093/ons/opy065

Cited by 57 publications

(61 citation statements)

References 31 publications

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“…The effect of tethers may be lessened when the UIV is at the mid-to-upper thoracic spine. Furthermore, Buell et al 38 attached the tether to a crosslink at the UIV for some of their patients, which was associated with an even lower rate of PJK in a pilot study by the same authors. Thus, the efficacy of the surgical technique, with regard to level placement, use of crosslinks, and method of tensioning, will require continued investigation.…”

Section: Discussionmentioning

confidence: 99%

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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Study Design: Retrospective cohort study.Objectives: Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year. Methods: A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIVÀ1 with a surgical nylon tape while PLSÀ patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts. Results: A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLSÀ (28.6%) were similar (P ¼ .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P ¼ .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK. Conclusion: Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.

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Section: Discussionmentioning

confidence: 99%

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Iyer

Lovecchio

Elysée

et al. 2019

Global Spine Journal

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“…Surgical management of ASD is often associated with high blood loss and transfusion requirements. 2,4,5,25,[36][37][38] The significant blood loss and transfusions may be related to several factors, such as the relatively advanced age of many patients with ASD, their high rate of associated comorbidities, as well as surgically related factors (i.e., posterior approach, pelvic fixation, osteotomy, and longer operative duration). 26,42 The need for blood transfusions to compensate for these losses is associated with perioperative complications such as infections, thromboembolic events, and hemolytic transfusion reactions.…”

Section: Discussionmentioning

confidence: 99%

Rotational thromboelastometry–guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study

Buell¹,

Taylor²,

Chen³

et al. 2019

Neurosurgical Focus

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OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen’s d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen’s d = 0.66). This difference was no longer significant after adjusting for TXA (β = −0.18, 95% confidence interval [CI] −1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = −0.41, 95% CI −772.55 to −76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.

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“…A finite element analysis by Bess and colleagues suggested that tethers are effective in dissipating the forces at the uppermost instrumented vertebra (UIV), 3 and recent case series support their clinical effectiveness in reducing PJK. 7,8 The magnitude and location of correction of LL also appear to be important factors in PJK development. It is important to apply age-adjusted alignment objectives when planning ASD surgery to reduce the risk of overcorrection of LL, which may produce excessive compensatory junctional kyphosis.…”

Section: Pseudarthrosis and Instrumentation Failurementioning

confidence: 99%

Treatment of adult thoracolumbar spinal deformity: past, present, and future

Smith

Shaffrey

Ames

et al. 2019

Journal of Neurosurgery: Spine

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Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.

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A Pilot Study on Posterior Polyethylene Tethers to Prevent Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity

Abstract: Junctional tethers significantly reduced occurrence of PJK. This difference was progressive from NT to TO to TC, but only reached pairwise significance for NT vs TC. This suggests potential benefit of tethers to reduce PJK, and that future prospective studies are warranted.

Cited by 57 publications

References 31 publications

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Posterior Ligamentous Reinforcement of the Upper Instrumented Vertebrae +1 Does Not Decrease Proximal Junctional Kyphosis in Adult Spinal Deformity

Rotational thromboelastometry–guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study

Treatment of adult thoracolumbar spinal deformity: past, present, and future

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