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Complications and Radiographic Correction in Adult Scoliosis

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Complications and Radiographic Correction in Adult Scoliosis Neurosurg Focus 28 (3):E7, 2010 Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation MATTHEW J. TOR M ENTI , M.D., MATTHEW B. MASERATI , M.D., CHRISTOPHER M. BONFIEL D , M.D., DAVI D O. OKONKWO , M.D., PH.D., AN D AD A M S. KANTER , M.D. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Object. The authors recently used a combined approach of minimally invasive transpsoas extreme lateral in- terbody fusion (XLIF) and open posterior segmental pedicle screw instrumentation with transforaminal lumbar in- terbody fusion (TLIF) for the correction of coronal deformity. The complications and radiographic outcomes were compared with a posterior-only approach for scoliosis correction. Methods. The authors retrospectively reviewed all deformity cases that were surgically corrected at the Uni- versity of Pittsburgh Medical Center Presbyterian Hospital between June 2007 and August 2009. Eight patients underwent combined transpsoas and posterior approaches for adult degenerative thoracolumbar scoliosis. The com- parison group consisted of 4 adult patients who underwent a posterior-only scoliosis correction. Data on intra- and postoperative complications were collected. The pre- and postoperative posterior-anterior and lateral scoliosis series radiographic films were reviewed, and comparisons were made for coronal deformity, apical vertebral translation (AVT), and lumbar lordosis. Clinical outcomes were evaluated by comparing pre- and postoperative visual analog scale scores. Results. The median preoperative coronal Cobb angle in the combined approach was 38.5° (range 18–80°). Fol- lowing surgery, the median Cobb angle was 10° (p < 0.0001). The mean preoperative AVT was 3.6 cm, improving to 1.8 cm postoperatively (p = 0.031). The mean preoperative lumbar lordosis in this group was 47.3°, and the mean postoperative lordosis was 40.4°. Compared with posterior-only deformity corrections, the mean values for curve correction were higher for the combined approach than for the posterior-only approach. Conversely, the mean AVT correction was higher in the posterior-only group. One patient in the posterior-only group required revision of the instrumentation. One patient who underwent the transpsoas XLIF approach suffered an intraoperative bowel injury necessitating laparotomy and segmental bowel resection; this patient later underwent an uneventful posterior-only correction of her scoliotic deformity. Two patients (25%) in the XLIF group sustained motor radiculopathies, and 6 of 8 patients (75%) experienced postoperative thigh paresthesias or dysesthesias. Motor radiculopathy resolved in 1 patient, but persisted 3 months postsurgery in the other. Sensory symptoms persisted in 5 of 6 patients at the most recent follow-up evaluation. The mean clinical follow-up time was 10.5 months for the XLIF group and 11.5 months for the posterior-only group. The mean visual analog scale score decreased from 8.8 to 3.5 in the XLIF group, and it decreased from 9.5 to 4 in the posterior-only group. Conclusions. Radiographic outcomes such as the Cobb angle and AVT were significantly improved in patients who underwent a combined transpsoas and posterior approach. Lumbar lordosis was maintained in all patients under- going the combined approach. The combination of XLIF and TLIF/posterior segmental instrumentation techniques may lead to less blood loss and to radiographic outcomes that are comparable to traditional posterior-only approaches. However, the surgical technique carries significant risks that require further evaluation and proper informed consent. (DOI: 10.3171/2010.1.FOCUS09263) KEY WOR D S • adult scoliosis • extreme lateral interbody fusion • spinal deformity • Cobb angle HE benefits of anterior approaches for arthrodesis when compared with posterior-only fusion constructs. in deformity correction surgery are well known The application of anterior interbody fusion—initially and include load sharing and increased fusion rates developed for the treatment of spinal tuberculosis— T to the treatment of spondylolisthesis was first reported by Burns in 1933.3 Lane and Moore13 first described its Abbreviations used in this paper: A/P = anterior/posterior; AVT = apical vertebral translation; CSVL = center sacral vertebral line; use in the treatment of intervertebral disc degeneration PA = posterior-anterior; PLIF = posterior lumbar interbody fusion; in 1948, and interbody arthrodesis has seen increasingly TLIF = transforaminal lumbar interbody fusion; VAS = visual ana- widespread use ever since. log scale; VB = vertebral body; XLIF = extreme lateral interbody Cloward4 introduced the technique of posterior inter- fusion. body fusion in 1953, in his classic paper arguing for the Neurosurg Focus / Volume 28 / March 2010 1 Unauthenticated | Downloaded 09/29/21 02:06 PM UTC M. J. Tormenti et al. TABLE 1: Patients undergoing combined XLIF and posterior instrumentation* Posterior Case No. XLIF Levels Interbody Levels Instrumented Levels XLIF Allograft TLIF Graft 1 L2–4 L5–S1 T10–ilium AF IC, BMP 2 L1– 4 L5–S1 T10–ilium AF IC, BMP 3 L2–5 L5–S1 T9–ilium AF IC 4 L1– 4 L4–S1 T8–ilium AF BMP 5 L1– 4 L5–S1 T11–ilium AF IC 6 L1–5 L5–S1 T10–ilium DBM IC, BMP 7 L1–3 L5–S1 T6–ilium DBM IC, BMP 8 L2–5 L5–S1 L1–S1 DBM local bone only * AF = Actifuse bone graft; BMP = bone morphogenetic protein; DBM = demineralized bone matrix; IC = autologous iliac crest. superiority of an approach that offered the spine surgeon Methods the ability to accomplish decompression of the neural ele- Study Design ments and circumferential arthrodesis, all from a single, posterior approach, and without the inherent risk to the We retrospectively reviewed all deformity correc- abdominal viscera and retroperitoneal structures incurred tions performed at the University of Pittsburgh Medical by a transperitoneal approach. Center Presbyterian Hospital between June 2007 and In 2001, Pimenta17 introduced a novel approach to August 2009. The purpose of the study was to evaluate the anterior lumbar spine, using a lateral, transpsoas ap- radiographic deformity correction parameters and peri- proach that was later popularized by Ozgur et al.15 in 2006 operative complications following posterior instrumented as “extreme lateral interbody fusion.” The extreme lateral fusion supplemented with transpsoas interbody fusion, approach offers several advantages over traditional inter- and to compare these results to those achieved following body approaches. It obviates the need for mobilization of posterior-only correction in which TLIF or PLIF tech- the great vessels—thereby avoiding the associated risk of niques were used. Eight patients underwent deformity cor- sexual dysfunction—and does not require the assistance rection via a combined A/P approach. Anterior interbody of a general surgeon. Similarly, it avoids transgression of fusion was performed via an extreme lateral transpsoas the nerve roots and thecal sac and, therefore, places these approach, and 4 patients underwent deformity correction structures at a lower theoretical risk. The extreme lateral via a posterior-only approach. Laterally placed interbody approach has also been reported to decrease operating spacers contained either Actifuse synthetic bone graft time when compared with other approaches to the anterior material (ApaTech, Inc.) or demineralized bone matrix lumbar spine, including even mini-open and laparoscopic (Table 1). All posterior instrumentation was placed via an techniques. The lateral approach also offers the advan- open posterior approach. Posterior arthrodesis was per- formed at all instrumented levels by using a combination tage of decreased blood loss, both through the avoidance of decortication, local autograft, autologous iliac crest, of the epidural venous plexus, and through shorter operat- and bone morphogenetic protein (Tables 1 and 2). In all ing times. For these reasons, transpsoas XLIF is a prom- patients, both pre- and postoperative standing PA and lat- ising alternative to traditional interbody techniques in the eral long-cassette scoliosis series plain radiographs were treatment of adult degenerative scoliosis, because those available for review in our computerized radiographic ar- affected by this condition are often more advanced in age chives. Medical records and patient interviews conducted and suffer from multiple medical comorbidities that make at follow-up evaluations were used to document intra- them less ideal candidates for traditional, “open” multi- and postoperative complications and to establish the VAS level interbody fusions. score in each treatment group. The application of transpsoas XLIF to adult lumbar TABLE 2: Patients undergoing posterior-only correction degenerative scoliosis was first reported by Pimenta in 17 2001, and thus is still in its infancy, with a dearth of Case Posterior Instrumented published results on the effectiveness of the technique No. Interbody Levels Levels Interbody Allograft for this indication. Over the past 18 months at our insti- tution, we have applied the extreme lateral approach to 1 L2–5 L1–5 AF the treatment of adult degenerative scoliosis. Herein we 2 L5–S1 T9–ilium BMP report our initial radiographic results and perioperative 3 none L1–S1 BMP complications, and compare them to those achieved using 4 L3–4 T7–ilium IC, BMP traditional interbody techniques for the same indication during the same time period.
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