Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Lafage, Renaud; Obeid, Ibrahim; Liabaud, Barthélemy; Bess, Shay; Burton, Douglas C.; Smith, Justin S.; Jalai, Cyrus M.; Hostin, Richard A.; Shaffrey, Christopher I.; Ames, Christopher P.; Kim, Hee Jin; Klineberg, Eric O.; Schwab, Frank J.; Lafage, Virginie

doi:10.3171/2018.6.spine161468

Cited by 40 publications

(15 citation statements)

References 39 publications

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“…In the context of our findings, this is a very important observation, as the distribution of lordosis is increasingly recognized as a factor associated with outcomes. 28 - 30 Other than supine LL, our model also found that PI was an independent predictor of lumbar lordosis. Given that the cases in this study were performed within the past 5 years, this relationship is likely attributable to the clinical application of the past decade of ASD research, which has repeatedly demonstrated the intimate associations between pelvic parameters and LL.…”

Section: Discussionmentioning

confidence: 53%

“… 37 , 38 This has led researchers to propose that elderly patients should be fused with more thoracic kyphosis compared with their younger counterparts, a strategy recommended as a method to reduce mechanical complications. 13 , 28 The relationship between postoperative TK and supine LL is similar—research has shown that reciprocity between curves is necessary to restore the spine’s anatomic alignment. 39 Clinically, severe mismatch between TK and LL has been associated with poor outcomes.…”

Section: Discussionmentioning

confidence: 99%

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Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Elysée

Lovecchio

Lafage

et al. 2020

Global Spine Journal

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Study Design: Retrospective cohort study. Objective: To investigate correlations between preoperative supine imaging and postoperative alignment. Methods: A retrospective review was conducted of a single-institution database of patients with adult spinal deformity (ASD). Patients were stratified by fusion location in the lumbar or thoracic spine. Outcomes of interest were postoperative lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal alignment parameters were compared and correlation analyses were performed. Multilinear stepwise regression was conducted to identify independent predictors of postoperative LL or TK. Regression analyses were repeated within the lumbar and thoracic fusion cohorts. Results: A total of 99 patients were included (mean age 63.2 years, 83.1% female, mean body mass index 27.3 kg/m2). Scoliosis Research Society classification demonstrated moderate to severe sagittal and/or coronal deformity (pelvic tile modifier, 18.2% ++; sagittal vertical axis, 27.3% ++, pelvic incidence minus lumbar lordosis mismatch, 29.3% ++, SRS type, 29.3% N type curve and 68.7% L or D type curve). A total of 73 patients (73.7%) underwent lumbar fusion and 50 (50.5%) underwent thoracic fusion. Correlation analyses demonstrated a significant association between pre- and postoperative LL and TK. Multilinear regression demonstrated that LL supine and pelvic incidence were significant predictors of postoperative LL ( r 2 = 0.568, P < .001). LL supine, TK supine, and age were significant predictors of postoperative TK ( r 2 = 0.490, P < .001). Conclusion: Preoperative supine films are superior to standing in predicting postoperative alignment at 1-year follow-up. Anticipation of undesired alignment changes through supine imaging may be useful in mitigating the risk of iatrogenic malalignment.

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Section: Discussionmentioning

confidence: 53%

Section: Discussionmentioning

confidence: 99%

Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Elysée

Lovecchio

Lafage

et al. 2020

Global Spine Journal

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“…As a whole, these results suggest that the loss of lumbar lordosis mainly occurs in the L4-S1 DLL. As a consequence, failure to restore DLL is correlated with an increased risk of proximal junctional failure [ 21 ], and DLL should be preserved or restored around 36° [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Optimal Correction of Adult Spinal Deformities Requires Restoration of Distal Lumbar Lordosis

Pesenti

Prost

McCausland

et al. 2021

Advances in Orthopedics

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Purpose. The aim of this study is to analyze results according to postoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch in the management of adult spine deformity (ASD) patients. Recently, it has been reported that in addition to lumbar lordosis amount, lordosis repartition between its proximal and distal parts was crucial. Methods. We enrolled 77 consecutive ASD patients who underwent posterior spinal fusion and deformity correction between 2015 and 2018. On preoperative and 1-year follow-up radiographs, we analyzed different parameters such as L1-S1 lumbar lordosis, L1-L4 proximal lordosis (PLL), L4-S1 distal lordosis (DLL), pelvic tilt (PT), sagittal vertical axis (SVA), and PI-LL mismatch. Comparisons were performed according to postoperative PI-LL mismatch (defined as “aligned” when PI-LL was <10°). The relationship between lordosis distribution and postoperative alignment status was investigated. Results. On the whole series, average lumbar lordosis, SVA, and PI-LL improved (28.2° vs.43.5°, 82 vs. 51 mm, and 26°vs. 14°, all p < 0.001 , respectively). On the other hand, PT remained unchanged (30° vs. 28°, p > 0.05 ). 35 patients were classified as “aligned” and 42 as “not aligned.” Patients from the “aligned” group had a significantly lower PI than patients from the “not aligned” group (52° vs. 61°, p = 0.009 ). Postoperative PLL was not different between groups (18° vs. 16° p > 0.05 ), whereas DLL was significantly higher in the “aligned” group (31° vs. 22°, p = 0.003 ). PI-LL was significantly correlated to DLL (rho = 0.407, p < 0.001 ) but not with PLL (rho = 0.110, p = 0.342 ). Conclusions. Our results revealed that in ASD patients, postoperative malalignment was associated with a lack of DLL restoration. “Not aligned” patients had also a significantly higher pelvic incidence. Specific attention must be paid to restore optimal distal lumbar lordosis in order to set the amount and the distribution of optimal postoperative lumbar lordosis.

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“…36,62 Although historically L3 has been the most common level for lordosis restoration via PSO, emerging evidence suggests that restoring lordosis in a more physiological location (i.e., L4-S1) may be protective against PJK. 35 Orientation of the UIV and terminal rod contouring also appear to be important factors in PJK development.…”

Section: Pseudarthrosis and Instrumentation Failurementioning

confidence: 99%

“…Preplanned machine-bent rods may reduce junctional failures by helping to ensure that desired alignment corrections are achieved, including overall magnitudes of thoracic and lumbar curves, location of LL restoration (e.g., in the lower lumbar levels), and appropriate contouring of the proximal end of the rod. 34,35,84 An overall better definition of individualized alignment objectives, beyond simple age-adjusted objectives, could markedly reduce PJK. 32,36 In the future, more aggressive attention to bone optimization may also reduce junctional fractures.…”

Section: Advances To Further Reduce Complicationsmentioning

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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Location of correction within the lumbar spine impacts acute adjacent-segment kyphosis

Cited by 40 publications

References 39 publications

Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery

Optimal Correction of Adult Spinal Deformities Requires Restoration of Distal Lumbar Lordosis

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

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