Does a Long-Fusion “T3-Sacrum” Portend a Worse Outcome Than a Short-Fusion “T10-Sacrum” in Primary Surgery for Adult Scoliosis?

OʼShaughnessy, Brian A.; Bridwell, Keith H.; Lenke, Lawrence G.; Cho, Woojin; Baldus, Christy; Chang, Michael S.; Auerbach, Joshua D.; Crawford, Charles H.

doi:10.1097/brs.0b013e3182376414

Cited by 126 publications

(94 citation statements)

References 15 publications

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“…1,14,15 Higher rates of perioperative complications and revision surgery create a challenge for the management of adult spinal deformity. 1,14,15,19 Older age, medical comorbidities, and surgical invasiveness have been considered significant risk factors for perioperative complications after spinal surgery. 14,15 Although PT UIV is a more invasive procedure than DT UIV, we found no clear difference in the incidence of revision surgery between the 2 groups.…”

Section: Discussionmentioning

confidence: 99%

“…3,12,18 Proximal thoracic UIV has also been associated with a higher prevalence of pseudarthrosis, a longer operative time, greater blood loss, and a longer hospital stay. 19 However, there is little available information to guide informed decision making in the choice of UIV fusion with respect to PJK, postoperative sagittal plane change, and prevalence of revision surgery after long instrumented fusion to the sacrum in adults.…”

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confidence: 99%

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Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Maruo

Racine

et al. 2013

SPI

141

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Object Proximal junctional kyphosis (PJK) is a common and significant complication after corrective spinal deformity surgery. The object of this study was to compare—based on clinical outcomes, postoperative proximal junctional kyphosis rates, and prevalence of revision surgery—proximal thoracic (PT) and distal thoracic (DT) upper instrumented vertebra (UIV) in adults who underwent spine fusion to the sacrum for the treatment of spinal deformity. Methods In this retrospective study the authors evaluated clinical and radiographic data from consecutive adults (age > 21 years) with a deformity treated using long instrumented posterior spinal fusion to the sacrum in the period from 2007 to 2009. The PT group included patients in whom the UIV was between T-2 and T-5, whereas the DT group included patients in whom the UIV level was between T-9 and L-1. Perioperative surgical data were compared between the PT and DT groups. Additionally, segmental, regional, and global spinal alignments, as well as the sagittal Cobb angle at the proximal junction, were analyzed on preoperative, early postoperative, and final standing 36-in. radiographs. Patient-reported outcome measurements (visual analog scale, Scoliosis Research Society Patient Questionnaire-22, Oswestry Disability Index, and the 36-Item Short-Form Health Survey) were compared. Results Eighty-nine patients, 22 males and 67 females, had a minimum follow-up of 2 years, and thus were eligible for participation in this study. Sixty-seven patients were in the DT group and 22 were in the PT group. Operative time (p = 0.387) and estimated blood loss (p < 0.05) were slightly higher in the PT group. The overall rate of revision surgery was 48.0% and 54.5% in the DT and PT groups, respectively (p = 0.629). The prevalence of PJK according to radiological criteria was 34% in the DT group and 27% in the PT group (p = 0.609). The percent of patients with PJK that required surgical correction (surgical PJK) was 11.9% (8 of 67) in the DT group and 9.1% (2 of 22) in the PT group (p = 1.0). The onset of surgical PJK was significantly earlier than radiological PJK in the DT group (p < 0.01). The types of PJK were different in the PT and DT groups. Compression fracture at the UIV was more prevalent in the DT group, whereas subluxation was more prevalent in the PT group. Postoperatively, the PT group had less thoracic kyphosis (p = 0.02), less sagittal imbalance (p < 0.01), and less pelvic tilt (p = 0.04). In the DT group, early postoperative radiographs demonstrated that the proximal junctional angle of patients with surgical PJK was greater than in those without PJK and those with radiological PJK (p < 0.01). Clinical outcomes were significantly improved in both groups, and there was no significant difference between the groups. Conclusions Both PT and DT UIVs improve segmental and global sagittal plane alignment as well as patient-reported quality of life in those treated for adult spinal deformity. The prevalence of PJK was not different in the PT and DT groups. However, compression fracture was the mechanism more frequently observed with DT PJK, and subluxation was the mechanism more frequently observed in PT PJK. Strategies to avoid PJK may include vertebral augmentation to prevent fracture at the DT spine and mechanical means to prevent vertebral subluxation at the PT spine.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Maruo

Racine

et al. 2013

SPI

141

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“…1,4,8,17,18,35,36,38 Both 3CO procedures are technically challenging and are associated with significant morbidity rates, but have resulted in significant improvements in clinical and radiographic outcomes for patients with ASD. 1,4,6,8,11,12,14,17,21,26 Despite these improvements, suboptimal spinal correction has been reported in 22%-42% of patients undergoing 3COs for ASD. 3,20,33 To properly assess spinopelvic alignment, radiographic thresholds indicating severe disability have been established.…”

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confidence: 99%

“…An uppermost instrumented vertebra (UIV) in the upper thoracic region is often used for correcting large coronal curves in the thoracic region, for thoracolumbar kyphosis, and for sagittal malalignment. 9,18,26 Alternatively, in cases with well-balanced curves, a UIV in the thoracolumbar region is often used. 9,18,26 A proximal termination in the upper thoracic region may maintain postoperative alignment, but longer operation times and a risk for more complications with this procedure may offset its benefits.…”

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confidence: 99%

The likelihood of reaching minimum clinically important difference and substantial clinical benefit at 2 years following a 3-column osteotomy: analysis of 140 patients

Fakurnejad

Lafage

Smith

et al. 2015

SPI

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OBJECT Three-column osteotomies (3COs) are technically challenging techniques for correcting severe rigid spinal deformities. The impact of these interventions on outcomes reaching minimum clinically important difference (MCID) or substantial clinical benefit (SCB) is unclear. The objective of this study was to determine the rates of MCID and SCB in standard health-related quality of life (HRQOL) measures after 3COs in patients with adult spinal deformity (ASD). The impacts of location of the uppermost instrumented vertebra (UIV) on clinical outcomes and of maintenance on sagittal correction at 2 years postoperatively were also examined. METHODS The authors conducted a retrospective multicenter analysis of the records from adult patients who underwent 3CO with complete 2-year radiographic and clinical follow-ups. Cases were categorized according to established radiographic thresholds for pelvic tilt (> 22°), sagittal vertical axis (> 4.7 cm), and the mismatch between pelvic incidence and lumbar lordosis (> 11°). The cases were also analyzed on the basis of a UIV in the upper thoracic (T1–6) or thoracolumbar (T9–L1) region. Patient-reported outcome measures evaluated preoperatively and 2 years postoperatively included Oswestry Disability Index (ODI) scores, the Physical Component Summary and Mental Component Summary (MCS) scores of the 36-Item Short Form Health Survey, and Scoliosis Research Society-22 questionnaire (SRS-22) scores. The percentages of patients whose outcomes for these measures met MCID and SCB were compared among the groups. RESULTS Data from 140 patients (101 women and 39 men) were included in the analysis; the average patient age was 57.3 ± 12.4 years (range 20–82 years). Of these patients, 94 had undergone only pedicle subtraction osteotomy (PSO) and 42 only vertebral column resection (VCR); 113 patients had a UIV in the upper thoracic (n = 63) orthoracolumbar region (n = 50). On average, 2 years postoperatively the patients had significantly improved in all HRQOL measures except the MCS score. For the entire patient cohort, the improvements ranged from 57.6% for the SRS-22 pain score MCID to 24.4% for the ODI score SCB. For patients undergoing PSO or VCR, the likelihood of their outcomes reaching MCID or SCB ranged from 24.3% to 62.3% and from 16.2% to 47.8%, respectively. The SRS-22 self-image score of patients who had a UIV in the upper thoracic region reached MCID significantly more than that of patients who had a UIV in the thoracolumbar region (70.6% vs 41.9%, p = 0.0281). All other outcomes were similar for UIVs of upper thoracic and thoracolumbar regions. Comparison of patients whose spines were above or below the radiographic thresholds associated with disability indicated similar rates of meeting MCID and SCB for HRQOL at the 2-year follow-up. CONCLUSIONS Outcomes for patients having UIVs in the upper thoracic region were no more likely to meet MCID or SCB than for those having UIVs in the thoracolumbar region, except for the MCID in the SRS-22 self-image measure. The HRQOL outcomes in patients who had optimal sagittal correction according to radiographic thresholds determined preoperatively were not significantly more likely to reach MCID or SCB at the 2-year follow-up. Future work needs to determine whether the Schwab preoperative radiographic thresholds for severe disability apply in postoperative settings.

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“…For example, if the dissection of the posterior muscular attachments to transverse processes of the upper thoracic vertebrae plays a pivotal role in the development of PJK, studies should consistently show upper instrumented vertebrae of T1-T6 having a higher incidence of PJK [1]. More recent literature comparing PJK rates in those with upper thoracic (T1-T3) versus lower thoracic (T10-T12) instrumented vertebrae [4,8] have determined that upper instrumented vertebrae in the lower thoracic spine had a higher PJK rate. In addition, some studies [4][5][6][7][8] have failed to show a difference in PJK rates between different upper instrumented vertebrae.…”

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Reply to Letter to the Editor: Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

Kim

2013

Clinical Orthopaedics &Amp; Related Research

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Does a Long-Fusion “T3-Sacrum” Portend a Worse Outcome Than a Short-Fusion “T10-Sacrum” in Primary Surgery for Adult Scoliosis?

Abstract: With long fusions to the sacrum, one should anticipate more perioperative complications, a higher pseudarthrosis rate, and perhaps more revision surgery than short fusions. Short fusions may result in a more proximal junctional kyphosis, only rarely requiring revision surgery.

Cited by 126 publications

References 15 publications

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum: a comparison of proximal and distal upper instrumented vertebrae

The likelihood of reaching minimum clinically important difference and substantial clinical benefit at 2 years following a 3-column osteotomy: analysis of 140 patients

Reply to Letter to the Editor: Combined Anterior-Posterior Surgery is the Most Important Risk Factor for Developing Proximal Junctional Kyphosis in Idiopathic Scoliosis

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