Disclosures UCSF Techniques in Complex Spine Surgery Course Las Vegas, 2019 • Zimmer Biomet: consultant, honoraria, royalties Three-Column Osteotomy • Nuvasive: consultant, honoraria, royalties versus Interbody for Major • K2M: consultant, honoraria • Alphatec: stock ownership Sagittal Malalignment • AlloSource: consultant • Cerapedics: consultant Justin S. Smith, MD, PhD • DePuy: research study group support • NREF: fellowship funding Harrison Distinguished Professor • AO: research support, fellowship funding Vice Chair for Research Chief of Spine Division • Editorial Boards: Journal of Neurosurgery Department of Neurosurgery Spine , Neurosurgery , Operative Neurosurgery , University of Virginia Spine Deformity Factors Influencing Deformity tors Influencing ng Deform Assessment of Curve Stiffness Correction Strategy • Supine films • Deformity magnitude • Bending films • Location • Films over a bolster • Focal vs. Global • Fused segments • Helps determine • Prior surgical properties of coronal approaches and sagittal deformities • Flexible vs. Rigid
Osteotomies (low- to high-grade) and discectomies/ interbody fusion are key tools for correction of spinal deformity. • Retrospective review of ALIF (32) vs TLIF 25) in patients undergoing fusion of <3 levels • Excluded patients if >25% spondylolisthesis or fixed spinal deformities • Compared foraminal height, local disc angle, and lumbar lordosis • ALIF increased local Cobb angle (8.3 o ) and increased LL (6.2 o ) • TLIF decreased local Cobb angle (-0.1 o ) • ALIF example case. and decreased LL (-2.1 o ) Hseih et al. JNS Spine 2007;7:379-86. Hseih et al. JNS Spine 2007;7:379-86.
• Retrospective review of 45 patients treated with single-level TLIF for single-level degenerative condition • Mean follow-up 21 months • TLIF example case. Unilateral facetectomy, • Assessed LL, disc height, VAS oblique cage placement. Hseih et al. JNS Spine 2007;7:379-86. How good are modern ALIF techniques for achieving lumbar lordosis and sagittal alignment? • Disc height increased by 4.5 mm Hyperlordotic ALIF spacers? • Only gained 3.6 o of lumbar lordosis • “Less lordosis was associated with worse back and leg pain as assessed by VAS.” • “Patients with persistent leg pain at final follow-up had less lumbar lordosis and intervertebral height than patients without leg pain.” Kepler et al. Orthop Surg 2012;4:15-20.
Majority were deformity cases Majority placed • Retrospective review of 69 hyperlordotic at L4-5 or L5-S1 ALIFs (20 o or 30 o ) in 41 patients with adult degenerative spinal disease (all had staged ant/post procedures) Most also had long-segment • Mean age 55 yrs (23-76 yrs) posterior fusion • Average follow-up 10 mos (2-28 mos) Saville et al. JNS Spine . 2016;25:713-19. Results • For 30 o HLCs (+/- SPO), mean segmental lordosis Case examples in which ALIF achieved was 29 o (26 o -34 o ) can be key in correction of • For 20 o HLCs (+/- SPO), mild to moderate sagittal mean segmental lordosis alignment. achieved was 19 o (16 o -22 o ) • Mean SVA decreased from 113 mm (38-320 mm) to 43 mm (-13 to 112 mm) Saville et al. JNS Spine . 2016;25:713-19.
Supine CT Scout 72 y/o woman PI=82° LL=32° Decrease of C7-S1 SVA PI-LL=50° PT=50° Lumbar spine remains rigid and markedly kyphotic (PI= 82°) +10 cm +10 cm Management? • Fixed sagittal spino-pelvic malalignment in patient with high PI • L5-S1 disc space open • Stenosis at L1-2 • Surgery: - L5-S1 ALIF (25 o ) PI=82 ° - T11-ilium screws LL=32 ° PI-LL=50 ° - L1-2 PCO + TLIF PT=50 °
65 y/o man PI=62° LL=26° PI-LL=36° PT=25° +7 cm Management? • Fixed sagittal spino-pelvic malalignment • Solid fusion L3-5 • L5-S1 disc space open • Stenosis at L2-3 • Surgery: - L5-S1 ALIF (25 o , 20 mm ht) PI=62 ° Vacuum disc at L5-S1 - T11-ilium screws LL=26 ° PI-LL=36 ° - L2-3, L3-4, L5-S1 SPO PT=25 ° Left Parasagittal Mid-Sagittal Right Parasagittal - L3-4 TLIF
Following ALIF 74 y/o man Case example in which ALIF can be key in correction of major sagittal alignment. PI=59° LL=+6° >+30 cm PI-LL=65° PT=32°
Air in L5-S1 disc Left Parasagittal Mid-Sagittal Right Parasagittal Pre-op standing Pre-op supine Management? • Severe sagittal spino- pelvic malalignment • Previous multi-level lumbar decompression but no fusion • L5-S1 disc space open • Surgery: PI=59 ° - L4-S1 ALIFs (15 o ) LL=+6 ° PI-LL=65 ° - T10-ilium screws Pre-op standing Supine post ALIFs PT=32 ° - T12-L5 PCOs Pre-op supine
How good are modern TLIF techniques for achieving lumbar lordosis and sagittal alignment? Considerations to Optimize PCO + TLIF TLIF Carpentry • Surgical technique � Sufficiently distract across disc space � Use a large (>10mm), lordotic cage (especially at L5-S1)
Considerations to Optimize TLIF Carpentry • Surgical technique � Meticulous disc removal, including contralateral side and anterior � Position cage in anterior third of body (not oblique) Takahashi et al. Neuro Med Chir. 2014;54:692. • Retrospective review of 80 patients who underwent TLIF ( 107 levels ) • Excluded patients treated with a PSO • Minimum 2-year follow-up • Assessed standing x-rays for: � Changes in segmental lordosis � Changes in regional lordosis (L1-S1) � Global sagittal alignment ( SVA ) Jagannathan et al. Neurosurgery. 2009;64:055-64.
• Change in segmental lordosis at TLIF level at minimum two-year follow-up • Lumbar lordosis improved for 1-, 2-, or � L1-2: 5.9 o 3-level TLIF cases � L2-3: 4.3 o � L3-4: 8.5 o • Increase in lumbar lordosis was greater with a 2-level (29 o ) or 3-level TLIF (30 o ) � L4-5: 11.3 o � L5-S1: 22.2 o Jagannathan et al. Neurosurgery. 2009;64:055-64. Jagannathan et al. Neurosurgery. 2009;64:055-64. Hyperlordotic ALIF +/- SPO � For 30 o HLCs , mean segmental lordosis achieved Case example in which TLIF was 29 o (range: 26 o -34 o ) with PCO can be key in Saville et al. JNS Spine . 2016;25:713-19. correction of mild to moderate PCO / TLIF sagittal alignment. � L5-S1: 22.2 o � Increase in lumbar lordosis was greater with a 2-level (29 o ) or 3-level TLIF (30 o ) Jagannathan et al. Neurosurgery. 2009;64:055-64.
74 y/o woman PI=73° LL=+5° • Canal stenosis PI-LL=78° - Moderate at L1-2 PT=44° - Severe at L2-3 • Foramenal stenosis - Severe bilat L1-2 20° - Severe bilat L2-3 - Severe bilat L4-5 +22 cm -8 cm Standing Supine
CB = -2 cm CB = -8 cm Management Cobb T12-L5 = 0° Cobb T12-L5 = 20° • Removal of prior instrumentation • Pedicle screws T10-S1 • Bilateral iliac bolts • T12-L3 and L4-5 PCOs C7-S1 SVA = +22 cm • L2-3 and L4-5 TLIFs TK = 70 o • No complications T12-L5 Coronal Cobb = 20 o PI-LL = 78 o PT = 44 o SVA = +22 cm SVA = +4 cm PT = 44° PT = 26° LL = -5° LL = 55° PI-LL = 78° PI-LL = 18° LL = 55° LL = -5°
Case Example • 67 y/o woman p/w progressive back pain and radiation to L>>R LEs (posterolateral Case example in which leg and foot) TLIF with PCO can be key • Also c/o positive sagittal imbalance, in correction of major subjective leg weakness, and inability to walk >1 block (limited by pain and sagittal alignment. weakness) • PMH: pulmonary HTN, cardiac arrhythmia, RA, SLE, DM Type 2, obesity, osteoporosis (femoral neck T-score = -2.5), previous smoker = 11 o L L = 48 o PI- L L = 37 o PT = 37 o PT SVA = +19c m PI = 59 o C7- CSVL ~0c m
Supine/Bolster X-rays Management • T4-S1 PSI/PSF • Bilateral iliac bolts TK = 58 o TK = 60 o • T8-S1 PCOs PI-LL = 8 o PI-LL = 48 o PT = 12 o PT = 37 o • L4-5 TLIF • Post-op screening SVA = +4cm SVA = +19cm C7-S1 SVA = +19cm ultrasound -> RLE T4-T12 Sag Cobb = 58 o femoral DVT -> IVC filter L2-5 Coronal Cobb = 31 o placed (o/w no peri-op complications) PI-LL = 48 o PT = 37 o
Surgical Options for Major Sagittal cal Options for r Major Sa Alignment Correction • Pedicle Subtraction Osteotomy - Aggressive segmental correction - Stiff or fixed deformities • Objective: Assess utilization trends of PSO based - Associated with high on commercially available database with private payor and 5% of Medicare claims from 2008-2011 complication rates • 3.2-fold increase in utilization of PSOs while - Anterior column prohibitively fused to diagnosis of ASD, fusion for spine deformity, and enable sufficient correction otherwise posterior spine fusion had minimal to no increase 68 y/o woman PI=66° Are PSOs being over-utilized? LL=+8° PI-LL=74° PT=51° There are situations where PSO remains necessary in order to 44° correct the deformity. +10 cm +6.6 cm
Supine CT Scout Supine CT Scout Some global coronal correction Significant decrease Rigid coronal curve of C7-S1 SVA Lumbar spine remains rigid and kyphotic 37° 44° +10 cm +6.6 cm Flexion Extension Left Parasagittal Mid-Sagittal Right Parasagittal
Management? • Severe fixed sagittal spino-pelvic malalignment • Anterior/lateral fusion L1-2, L2-3, L4-5 • Solid posterolateral fusion L1-L5 • Surgery: - T10-ilium screws PI=66 ° - T12-L1, L5-S1 PCOs LL=+8 ° PI-LL=74 ° - L5-S1 TLIF PT=51 ° - L3 asym ePSO Sometimes need to combine 3CO with interbodies to correct major sagittal malalignment
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