Deformity correction techniques in adult spinal deformity

This review focuses on the surgical techniques that are used to effectively correct thoracolumbar adult spinal deformity. Preoperative considerations and planning for selecting the appropriate correction technique, level selection, patient positioning, open correction techniques, and minimally invasive correction maneuvers are discussed.     

Lateral lumbar deformity correction and outcomes

Minimally invasive surgery for adult spinal deformity has become an increasingly popular technique to treat this complex patient population.  The use of lateral lumbar interbodies fusion has become the most valuable technique to achieve deformity correction by manipulating the anterior column.  The LLIF technique allows for both coronal and sagittal plane deformity correction while providing a large load bearing surface for stability and an optimal environment for fusion.  If severe sagittal plane deformities are encountered then the anterior column realignment technique with release of the anterior longitudinal ligament can be used in carefully selected patients to achieve the desired alignment goals.  Ultimately patient selection and surgeon experience will play an important role in the successful completion of minimally invasive LLIF for adult spinal deformity     

Minimally invasive surgical techniques for adult spinal deformity

Minimally invasive surgery has become increasingly popular, utilizing smaller incisions in an effort to reduce morbidity associated with traditional approaches. Traditional correction of adult degenerative scoliosis is associated with significant risks and prolonged recovery. Surgeons should be cognizant of patient selection factors, approaches, risks, and outcomes of minimally invasive procedures, because they can be effective and desirable for the patient. Minimally invasive spinal deformity correction and hybrid constructs are viable alternatives to traditional open surgery.     

Minimally invasive anterior column realignment for the treatment of adult spinal deformity: A review of the literature

Surgical treatment of adult spine deformity requires correction in multiple planes. Currently employed open and minimally invasive techniques and instrumentation allow for robust rotational and coronal-plane correction. However, large sagittal deformities frequently require vertebral osteotomies, which can increase morbidity and complications, particularly in an elderly population. Anterior column realignment has emerged as a technique that can provide significant sagittal plane correction through a minimally invasive approach. We will provide an overview of this procedure, technical challenges, risks, outcomes, and review the recent literature on anterior column realignment for the treatment of adult spine deformity.     

The role of minimally invasive lateral lumbar interbody fusion in sagittal balance correction and spinal deformity

Purpose

The recent proliferation of minimally invasive lateral lumbar interbody fusion (LLIF) techniques has drawn attention to potential for these techniques to control or correct sagittal misalignment in adult spinal deformity. We systemically reviewed published studies related to LLIF use in adult spinal deformity treatment with emphasis on radiographic assessment of sagittal balance.

Methods

A literature review was conducted to examine studies focusing on sagittal balance restoration in adult degenerative scoliosis with the LLIF approach.

Results

Fourteen publications, 12 retrospective and 2 prospective, reported data regarding lumbar lordosis correction (1,266 levels in 476 patients) but only two measured global sagittal alignment.

Conclusion

LLIF appears to be especially effective when the lumbar lordosis and sagittal balance correction goals are less than 10° and 5 cm, respectively. However, the review demonstrated a lack of consistent reporting on sagittal balance restoration with the MIS LLIF techniques.

     

Lateral lumbar interbody fusion in adult spine deformity – A review of literature

IntroductionSurgery for adult spine deformity presents a challenging issue for spinal surgeons with high morbidity rates reported in the literature. The minimally invasive lateral approach aims at reducing these complications while maintaining similar outcomes as associated with open spinal surgeries. The aim of this paper is to review the literature on the use of lateral lumbar interbody fusion in the cases of adult spinal deformity.MethodsA literature review was done using the healthcare database Advanced Research on NICE and NHS website using Medline. Search terms were “XLIF” or “LLIF” or “DLIF” or “lateral lumbar interbody fusion” or “minimal invasive lateral fusion” and “adult spinal deformity” or “spinal deformity”.ResultsA total of 417 studies were considered for the review and 44 studies were shortlisted after going through the selection criteria. The data of 1722 patients and 4057 fusion levels were analysed for this review. The mean age of the patients was 65.18 years with L4/5 being the most common level fused in this review. We found significant improvement in the radiological parameters (lordosis, scoliosis, and disk height) in the pooled data. Transient neurological symptoms and cage subsidence were the two most common complications reported.ConclusionLLIF is a safe and effective approach in managing adult spinal deformity with low morbidity and acceptable complication rates. It can be used alone for lower grades of deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities.     

Pain after adult deformity surgery

Adult spinal deformity is a broad spectrum of disorders that are becoming more prevalent with an ageing population. In those with moderate to severe deformity, surgical correction of spinal alignment is an increasingly common treatment and has demonstrated improvement in patients’ quality of life. Whilst continued research in risk stratification, advances in surgical techniques, and preoperative optimization has taken place, rates of adverse outcomes following surgery for adult spinal deformity are still frequent. Pain is a common complaint after spinal deformity correction; however, whether this pain is deemed a ‘normal’ amount, or a ‘pathological’ pain has not been well characterized in the literature. This paper aims to provide a framework for evaluating pain after spinal deformity correction surgery in order to guide clinical decision making.     

Osteoporotic spinal deformity: a biomechanical rationale for the clinical consequences and treatment of vertebral body compression fractures

This review article develops a biomechanical rationale for the clinical consequences and treatment of osteoporotic vertebral body compression fracture. In patients with osteoporotic vertebral fractures and spinal deformity, altered spinal biomechanics and global spinal imbalance are important factors in the increased morbidity and mortality reported in this population. Severe spinal deformity impairs physical functioning, health, and quality of life. The spinal deformity itself, independent of pain, is a significant cause of disability. Spinal deformity is also an independent risk factor for hip fracture. Treatments directed at osteoporotic vertebral compression fractures should ideally address spinal deformity as well as pain. Balloon kyphoplasty, the minimally invasive technique of reduction and internal fixation of osteopenic vertebral body compression fractures that addresses pain and spinal deformity, is discussed.     

Image guidance in spine tumor surgery

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.     

A Two-Stage Percutaneous Approach to Charcot Diabetic Foot Reconstruction

The goals of Charcot deformity correction are to restore osseous alignment, regain pedal stability, and prevent ulceration. Traditional reconstructive surgical approaches involve large, open incisions to remove bone and the use of internal fixation to attempt to fuse dislocated joints. Such operations can result in shortening of the foot and/or incomplete deformity correction, fixation failure, incision healing problems, infection, and the longterm use of casts or braces. We recommend a minimally invasive surgical technique for the treatment of Charcot deformity, which we performed on 11 feet in 8 patients. Osseous realignment was achieved through gradual distraction of the joints with external fixation, after which minimally invasive arthrodesis was performed with rigid internal fixation. Feet were operated on at various stages of Charcot deformity: Eichenholtz stage I (1 foot), Eichenholtz stage II (6 feet), and Eichenholtz stage III (4 feet). When comparing the average change in preoperative and postoperative radiographic angles, the transverse plane talar-first metatarsal angle (P = .02), sagittal plane talar-first metatarsal angle (P = .008), and calcaneal pitch angle (P = .001) were all found to be statistically significant. Complications included 3 operative adjustments of external or internal fixation, 4 broken wires or half-pins, 2 broken rings, and 11 pin tract infections. Most notably, no deep infection, no screw failure, and no recurrent ulcerations occurred and no amputations were necessary during an average follow-up of 22 months. Gradual Charcot foot correction with the Taylor spatial frame plus minimally invasive arthrodesis is an effective treatment.     

Pre-existing vertebral fracture is a risk factor for postoperative proximal junctional fracture after adult spinal deformity surgery: A propensity score-matched analysis

BackgroundCorrective surgery for adult spinal deformity has recently been increasingly performed because of aging populations and advances in minimally invasive surgery. Low bone mineral density is a major contributor to proximal junctional kyphosis after spinal long fusion. Assessment for low bone mineral density ideally involves both dual energy X-ray absorptiometry and identification of pre-existing vertebral fractures, the latter, requiring only standard equipment, being performed more frequently. We therefore aimed to examine the impact of pre-existing vertebral fractures on the incidence of type 2 proximal junctional kyphosis, including proximal junctional fracture and failure, after corrective surgery for adult spinal deformity.MethodsWe performed a retrospective, single institution study of 106 women aged over 50 years who had undergone corrective long spinal fusion for severely symptomatic spinal deformity from 2014 to 2017. We allocated them to three groups (with and without pre-existing vertebral fractures and with severe [Grades 2–3 according to Genant et al.‘s classification] preexisting vertebral fractures) and used propensity score matching to minimize bias. The primary outcome was postoperative proximal junctional fracture and the secondary outcome proximal junctional kyphosis/failure.ResultsThe primary and secondary endpoints were achieved significantly more often in the 28 patients with than in the 78 without preexisting vertebral fractures (total 41). The former group was also significantly older and had greater pelvic tilt and fewer fused segments than those without vertebral fractures. After propensity score matching, the incidences of the endpoints did not differ with pre-existing vertebral fracture status; however, patients with severe vertebral fractures more frequently had proximal junctional fractures postoperatively. Postoperative improvements in health-related quality of life scores did not differ with pre-existing vertebral fracture status.ConclusionsSevere pre-existing vertebral fractures are a risk factor for proximal junctional fracture after correction of adult spinal deformity.     

Emerging minimally invasive technologies for the management of scoliosis

Surgery for scoliosis has evolved dramatically over the past century -- from posterior surgery and casting that resulted in poor deformity correction and high pseudarthrosis rates and that required prolonged bed rest to anterior thoracoscopic and miniopen approaches that result in reproducible curve correction ranging from 55% to 70% with high fusion rates. The future of scoliosis surgery lies in the application of growth-modulation approaches by way of minimally invasive techniques, which will result in curve correction while maintaining spinal motion and disc and motion segment integrity. The optimal approach will use genetic testing to predict curve progression, thereby providing the clinical data required for determining the appropriate candidate for the use of this strategy.     

Der Taylor-spatial-frame-Fixateur

Despite adequate primary treatment many ankle fractures result in post-traumatic deformities and arthrosis. Revision mostly requires a multidirectional correction whereas internal fixation procedures are often not applicable due to soft tissue damage and the extent of deformity. The Taylor spatial frame enables simultaneous correction of multidirectional deformities through a virtual hinge using the same ideas of distraction osteogenesis as the Ilizarov fixator. The presented case demonstrates minimally invasive correction of a complex deformity of the ankle with the Taylor spatial frame fixator. Orthogonal alignment was achieved and a stabilizing tibiotalar arthrodesis was performed achieving a good functional and pain-free result.     

Minimally invasive osteotomies for adult deformity

Correction of adult spinal deformity is associated with substantial improvements in patient quality of life. However, traditional open osteotomy techniques are associated with notably high rates of morbidity particularly when utilizing larger, more powerful, 3-column osteotomies. Data exists that support the use of minimally invasive posterior column osteotomies in the context of transforaminal lumbar interbody fusion, but further research is warranted to confirm the clinical utility of mini-open 3-column osteotomies.     

Patient selection for minimally invasive spine surgery

Minimally invasive approaches to treat lumbar spine disease may carry many benefits over traditional open surgery with comparable patient outcomes. However, this advantage is conferred through appropriate patient selection. Not only do patient-specific anatomic factors influence the use of these techniques, but also surgeon familiarity with approaches. Adult spinal deformity surgery represents an area where minimally invasive spine (MIS) techniques have demonstrated significant impact in appropriately selected patients. Conversely, applying MIS techniques in patients inappropriate for minimally invasive surgery can result in complications, reoperations, and adverse outcomes. This chapter will highlight algorithms to guide patient and technique selection for MIS deformity surgery.     

Positioning considerations for lateral lumbar interbody surgery

Lateral Lumbar Interbody fusion has gained popularity as a minimally invasive approach to the thoracolumbar spine which provides indirect neurological decompression, increased fusion mass surface area, and provides coronal and sagittal plane correction of spinal deformity. The Lateral Lumbar Interbody Fusion is traditionally performed in the lateral decubitus position, however, concomitant pathologies in the spine often require ancillary procedures. The purpose of this paper is to describe standard Lateral Lumbar Interbody Fusion positioning considerations as well as to explore multi-position and single position surgeries when two separate approaches are required.     

Achskorrekturen und Pseudarthrosenbehandlung nach Unterschenkelfrakturen durch minimalinvasiven Zugang und Fixateur interne

One of the basic principles in the treatment of nonunion and malunion is gentle operative correction with minimal damage to the soft tissues, to avoid any further impairment of the already restricted blood flow. Eight tibial correction osteotomies and 36 stabilisations of tibial nonunion were performed by application of an internal fixator (locked screw-plate interface) that can be implanted by way of a minimally invasive approach; in one case an intramedullary nail with stable-angle locking screws was applied.Consolidation was achieved in all cases.Two cases of plate infection and one of osteitis were observed, all in patients who had had a primary infection associated with nonunion. In one case a residual deformity of 10° torsion remained. In our judgement, the combination of an internal fixator with stable-angle locking screws and a minimally invasive approach and also the stable-angle locking nail are successful methods of treatment for tibial malunion or nonunion.     

Minimally Invasive Surgical Techniques in Adult Degenerative Spinal Deformity: A Systematic Review

Background

Minimally invasive surgery (MIS) approaches have the potential to reduce procedure-related morbidity when compared with traditional approaches. However, the magnitude of radiographic correction and degree of clinical improvement with MIS techniques for adult spinal deformity remain undefined.

Question/purposes

In this systematic review, we sought to determine whether MIS approaches to adult spinal deformity correction (1) improve pain and function; (2) reliably correct deformity and result in fusion; and (3) are safe with respect to surgical and medical complications.

Methods

A systematic review of PubMed and Medline databases was performed for published articles from 1950 to August 2013. A total of 1053 papers were identified. Thirteen papers were selected based on prespecified criteria, including a total of 262 patients. Studies with limited short-term followup (mean, 12.1 months; range, 1.5–39 months) were included to capture early complications. All of the papers included in the review constituted Level IV evidence. Patient age ranged from 20 to 86 years with a mean of 65.8 years. Inclusion and exclusion criteria were variable, but all required at minimum a diagnosis of adult degenerative scoliosis.

Results

Four studies demonstrated improvement in leg/back visual analog scale, three demonstrated improvement in the Oswestry Disability Index, one demonstrated improvement in treatment intensity scale, and one improvement in SF-36. Reported fusion rates ranged from 71.4% to 100% 1 year postoperatively, but only two of 13 papers relied consistently on CT scan to assess fusion, and, interestingly, only four of 10 studies reporting radiographic results on deformity correction found the procedures effective in correcting deformity. There were 115 complications reported among the 258 patients (46%), including 37 neurological complications (14%).

Conclusions

The literature on these techniques is scanty; only two of the 13 studies that met inclusion criteria were considered high quality; CT scans were not generally used to evaluate fusion, deformity correction was inconsistent, and complication rates were high. Future directions for analysis must include comparative trials, longer-term followup, and consistent use of CT scans to assess for fusion to determine the role of MIS techniques for adult spinal deformity.     

小切口微创分期手术治疗早发型脊柱侧凸早期疗效观察

目的观察小切口微创分期手术治疗早发型小儿脊柱侧凸的早期疗效和安全性。方法对26例早发型小儿脊柱侧凸进行小切口微创分期手术治疗。其中男8例,女18例,年龄（8.5±1.2）岁。术前侧凸主弯冠状面Cobb角为（98.0°±15.4）°,矢状面后凸Cobb角为（38.8±14.7）°。Ⅰ期采用小切口微创手术,将脊柱侧凸矫正约55%左右,之后每隔6～12个月再进行一次生长矫形,至骨骼发育成熟后作终末矫形内固定,行剃刀背切除并植骨融合。结果所有病例均顺利完成手术,无严重并发症发生。16例完成初次手术,10例完成二次手术。初次小切口矫形术后侧凸主弯冠状面Cobb角为（42.2±10.1）°,平均矫正率56.9%;二次延长术后侧凸主弯冠状面Cobb角为（35.8±6.6）°,平均矫正率34.1%。总矫形率为65.4%。结论对早发型小儿脊柱侧凸行小切口微创分期手术治疗的研究初步证实,该术式可以提高畸形矫形效果,延缓脊柱融合时间,减轻早期融合对脊柱生长发育的影响。     

Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases

Modern concepts of treating thoracic diseases suggest more and more the use of minimally invasive thoracoscopic techniques to reduce morbidity and save costs. For treatment of specific lesions at the thoracic spine, several thoracoscopic procedures have been performed successfully. The present report examines the feasibility of thoracoscopic osteosynthesis in two patients with ventral hyperextension injuries and anterior instability of the thoracic spine. After initial correction of the anatomical deformity, autologous bone was harvested from the anterior iliac crest. Using a ventral, thoracoscopic approach, the main location of the ventral, damaged spinal segment was identified by the covering pleural haematoma. After endoscopic ventral bone grafting, osteosynthesis was performed, using dynamic compression plates, cardan drills and screw drivers. The perioperative course was uneventful, and follow up examinations after 3 years and 9 months, respectively, revealed an unchanged stable spinal segment. Our results show thoracoscopic osteosynthesis to be technically possible, with a potential for yielding satisfying long-term results.