Literature-based topic review.
To review the indications and techniques for different sacropelvic fixation methods and to outline important associated complications.
Despite all the advances and new ...developments in spinal instrumentation techniques, fixation at the lumbosacral junction continues to be one of the important challenges to spine surgeons. The poor bone quality of the sacrum, the complex regional anatomy, and the tremendous biomechanical forces at the lumbosacral junction contribute to the high rates of instrumentation-related problems. Although many techniques for sacropelvic fixation have been attempted, only a few are still widely used because of the high rate of complications associated with some of those techniques.
Review of literature and expert opinion.
There are many indications for sacropelvic fixation. Long fusions to the sacrum are the most common reasons for extending the instrumentation to the pelvis. Spinal surgeons performing complex spinal reconstruction should be familiar with the currently available techniques, including their potential risks and complications. Surgical treatment decisions should be based on an individual patient's anatomy and abnormalities, and on the surgeon's experience.
Abstract Background Context The incidence of proximal junctional kyphosis (PJK) ranges from 5-46% following adult spinal deformity (ASD) surgery. Approximately 66-76% of PJK occurs within 3 months of ...surgery. A subset of these patients, reportedly 26-47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK/PJF incidence at long term follow-up. Purpose The purpose of this study is to evaluate the long term radiographic and clinical outcomes, and incidence of PJK and PJF, after prophylactic vertebroplasty for long segment thoracolumbar posterior spinal fusion. Study Design Prospective cohort study. Patient Sample 39 patients, of whom 87 % were female, who underwent two level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF were included in this study. Outcome Measures Clinical outcomes were assessed using the Scoliosis Research Society-22, Short-Form (SF) 36, and ODI questionnaire. Radiographic parameters including PJK angle, and coronal and sagittal alignment, were calculated, along with relevant perioperative complications, and revision rates. Methods Of the 41 patients who received 2 level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF, and compromised a cohort with previously published two year follow up data, 39 (95%) completed 5 yr follow-up (average 67.6 months). PJK was defined as a change in the PJK angle ≥10° between the immediate post-operative and final follow-up radiograph. PJF was defined as acute proximal junctional fracture, fixation failure, or kyphosis requiring extension of fusion within the first 6 months postoperatively. Results 39 patients with a mean age of 65.6 (41-87) years were included in this study. Of the 39 patients, 28.2% developed PJK (11: 7.7% at 2 yrs, 20.5% between 2 to 5 yrs), and 5.1% developed acute PJF. Two of the 11 PJK patients required revision for progressive worsening of the PJK. There were no proximal junctional fractures. There was no significant difference in preoperative, immediate postoperative, and final follow-up measurements of thoracic kyphosis, lumbar lordosis, coronal, or sagittal alignment between patients who developed PJK, PJF, or neither (P>0.05). There was no significant difference in ODI, SRS-22, or SF-36 scores between those with and without PJK or PJF (P>0.05). Conclusions This long term follow up demonstrates that prophylactic vertebroplasty may minimize the risk for junctional failure in the early postoperative period. However, it did not appear to decrease the incidence of PJK at 5 years.
Three-dimensional computed tomography (CT) radiographic analysis.
To describe the parameters for a trajectory through a sacral starting point as a method of pelvic fixation in spinal deformity and to ...compare this technique with insertion from the posterior superior iliac spine (PSIS).
Long anchors projecting into the ilium provide optimal pelvic fixation. The traditional starting point in the PSIS requires muscle dissection and connectors or rod bends.
Twenty pelvic CTs of mature adolescents were analyzed using InSpace, a three-dimensional CT program, by 2 surgeons. Trajectory with maximal length and width through the sacral ala and iliac wing was obtained through CT imaging plane manipulation. Trajectory and starting-point parameters were measured. Parameters were evaluated and compared for insertion from the PSIS.
Based on the ideal trajectory, the mean starting point in S2 was 25 mm caudal to the superior endplate of S1 and 22 mm lateral to the sacral midline (S2 alar-iliac S2AI path). Maximal mean S2AI distance was 105 mm (range, 74-129 mm; SD = 11 mm). Maximal mean length for PSIS insertion was 118 mm (range, 99-147 mm; SD = 13 mm). Mean angulation was 40 degrees (SD = 6 degrees ) laterally in the transverse plane and 39 degrees (SD = 6 degrees ) caudally in the sagittal plane. The mean difference between surgeons in selecting the trajectory was 2 degrees and 1 degrees in the transverse and sagittal plane, respectively. The S2AI pathway traversed 35 mm of sacral ala. The narrowest mean width of the ilium along this path was 12 mm (range, 6-18 mm). The starting point for the S2AI was 19 mm deep to the PSIS. The distance from skin for S2AI versus PSIS techniques was 52 and 37 mm, respectively.
Iliac fixation through the S2 ala provides a reproducibly chosen starting point in line with S1 pedicle anchors. Implant prominence is minimized because the starting point is 15 mm deeper than the PSIS entry. It is less likely to be affected in cases using iliac crest bone graft harvest because of the more anterior position of the anchor in the ilium.
Objectives
To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery.
Design
Prospective observational study.
Setting
Academic medical center.
...Participants
Individuals aged 70 and older undergoing spine surgery (N = 89).
Measurements
Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale‐Revised‐98, and chart review. Hospital‐based outcomes were obtained from the medical record and hospital charges from data reported to the state.
Results
Thirty‐six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48–9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35–9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07–0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home.
Conclusion
Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.
Achieving solid osseous fusion across the lumbosacral junction has historically been, and continues to be, a challenge in spine surgery. Robust pelvic fixation plays an integral role in achieving ...this goal. The goals of this review are to describe the history of and indications for spinopelvic fixation, examine conventional spinopelvic fixation techniques, and review the newer S2-alar-iliac technique and its outcomes in adult and pediatric patients with spinal deformity. Since the introduction of Harrington rods in the 1960s, spinal instrumentation has evolved substantially. Indications for spinopelvic fixation as a means to achieve lumbosacral arthrodesis include a long arthrodesis (five or more vertebral levels) or use of three-column osteotomies in the lower thoracic or lumbar spine, surgical treatment of high-grade spondylolisthesis, and correction of lumbar deformity and pelvic obliquity. A variety of techniques have been described over the years, including Galveston iliac rods, Jackson intrasacral rods, the Kostuik transiliac bar, iliac screws, and S2-alar-iliac screws. Modern iliac screws and S2-alar-iliac screws are associated with relatively low rates of pseudarthrosis. S2-alar-iliac screws have the advantages of less implant prominence and inline placement with proximal spinal anchors. Collectively, these techniques provide powerful methods for obtaining control of the pelvis in facilitating lumbosacral arthrodesis.
Purpose
Three-column osteotomies at L5 or the sacrum (LS3COs) are technically challenging, yet they may be needed to treat lumbosacral kyphotic deformities. We investigated radiographic and clinical ...outcomes after LS3CO.
Methods
We analyzed 25 consecutive patients (mean age 56 years) who underwent LS3CO with minimum 2-year follow-up. Standing radiographs and health-related quality-of-life scores were evaluated. A new radiographic parameter “lumbosacral angle” (LSA) was introduced to evaluate sagittal alignment distal to the S1 segment.
Results
From preoperatively to the final follow-up, significant improvements occurred in lumbar lordosis (from − 34° to − 49°), LSA (from 0.5° to 22°), and sagittal vertical axis (SVA) (from 18 to 7.3 cm) (all,
p
< .01). Mean Scoliosis Research Society (SRS)-22r scores in activity, pain, self-image, and satisfaction (
p
< .05), and Oswestry Disability Index scores (
p
< .01) also improved significantly. Patients with SVA ≥ 5 cm at the final follow-up experienced less improvement in SRS-22r satisfaction scores than those with SVA < 5 cm. Patients with LSA < 20° at the final follow-up had significantly lower SRS-22r activity scores than those with LSA ≥ 20° (
p
= .014). Two patients had transient neurologic deficits, and 11 patients underwent revision for proximal junctional kyphosis (5), pseudarthrosis (3), junctional stenosis (2), or neurologic deficit (1).
Conclusions
LS3CO produced radiographic and clinical improvements. However, patients who remained sagittally imbalanced had less improvement in SRS-22r satisfaction score than those whose sagittal imbalance was corrected, and patients who maintained kyphotic deformity in the lumbosacral spine had lower SRS-22r activity scores than those whose lumbosacral kyphosis was corrected.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
Retrospective review.
To report and analyze the perioperative complications, radiographical results, and functional outcomes in elderly patients undergoing pedicle subtraction osteotomy (PSO) and/or ...vertebral column resection (VCR) procedures for spinal deformity correction.
To our knowledge, no studies have focused on 3-column osteotomies in the elderly.
We retrospectively reviewed prospectively collected data for 51 consecutive patients 60 years or older undergoing 3-column osteotomies for spinal deformity correction (PSO, 36 patients; VCR, 13 patients; PSO and VCR, 2 patients) and who had at least 2 years' follow-up. We analyzed the perioperative complications; the preoperative, postoperative, and final follow-up radiographical measurements; and the preoperative, postoperative, and final follow-up functional outcome scores (using the Scoliosis Research Society-22 questionnaire and Oswestry Disability Index). Hotelling's t2 test and the χ2 test were used for analysis (statistical significance, P < 0.05).
There were 9 (18%) major complications (5 with PSO and 4 with VCR) and 20 (39%) minor complications (14 with PSO and 6 with VCR). Compared with preoperative values, improvement at 6 weeks after surgery averaged 16° (range, 0°-42°) in thoracic scoliosis, 14° (range, 2°-25°) in lumbar scoliosis, 9° (range, 5°-35°) in thoracic kyphosis, -24° (range, -12° to -68°) in lumbar lordosis, 2.4 cm (range, 0-12 cm) in coronal balance, and 6.9 cm (range, -2 to 20 cm) in sagittal balance. At final follow-up, improvements in the coronal and sagittal balance were maintained. By final follow-up, compared with preoperative state, there were significant improvements in all 5 Scoliosis Research Society-22 domains and in the Oswestry Disability Index.
In the elderly patient, PSO and VCR can achieve significant restoration of sagittal and coronal balance and significant improvement in quality of life. However, both techniques can lead to serious complications and should be selectively used.
Abstract Background context Vertebral compression fractures at the proximal junction are common complications of long spinal fusion surgeries that can contribute to the development of proximal ...junctional kyphosis or proximal junctional failure. To our knowledge, no biomechanical studies have addressed the effect of vertebral augmentation at the proximal junction. Purpose To evaluate the effectiveness of prophylactic vertebroplasty in reducing the incidence of vertebral compression fractures at the proximal junction after a long spinal fusion in a cadaveric spine model. Study design Biomechanical cadaveric study. Methods We divided 18 cadaveric spine specimens into three groups of six spines each: a control group, a group treated with one-level prophylactic vertebroplasty at the upper instrumented vertebra, and a group treated with two-level prophylactic vertebroplasty at the upper instrumented vertebra and the supra-adjacent vertebra. In all spines, the pedicles were instrumented from L5 to T10. Using eccentric axial loading, the specimens were then compressed until failure. Failure was defined as a precipitous decrease in load with increasing compression. The effect of augmentation on load-to-failure was checked using linear regression. The effect of augmentation on incidence of adjacent fractures was checked using logistic regression. Differences at the level of p<.05 were considered significant. KyphX cement introducer was donated by Kyphon, and the pedicle screws were donated by DePuy. Results Fractures occurred in 12 of 18 specimens: five in the control group, six in the one-level group, and only one in the two-level group; these differences were statistically significant. Conclusions Prophylactic vertebroplasty at the upper instrumented level and its supra-adjacent vertebra reduced the incidence of junctional fractures after long posterior spinal instrumentation in this axially loaded cadaveric model. Additional studies are necessary to determine if these results are translatable to clinical practice.
Retrospective study.
To identify the prevalence of lumbar scoliosis in adults ≥ 40 years old; to investigate relationships between scoliosis prevalence and 3 parameters (age, race, gender); and to ...determine any effect of those parameters on curve severity.
As the population ages, the incidence of degenerative spine conditions increases. More patients are being diagnosed with and treated for spinal deformities, including scoliosis.
We examined dual-energy x-ray absorptiometry lumbar spine images of 3185 individuals ≥ 40 years old (average, 60.8 years; range, 40-97 years), obtained July 2002 to June 2005, to determine the presence of scoliosis (i.e., a curvature of ≥ 11.0°) by digitally measuring Cobb angles. Patients with a history of previous lumbar spinal surgery were excluded, leaving 2973 individuals for final evaluation. We used SAS system software, version 9.1 (SAS Institute, Inc., Cary, NC) to investigate the relationship between the prevalence of scoliosis and the variables of age, race, and gender, we then examined for any effect that these variables had on curve severity.
We identified scoliosis (i.e., a Cobb angle of ≥ 11°) in 263 of 2973 patients. Age was associated with an increased prevalence of scoliosis, e.g., 40 to 50 years old, 3.14%; ≥ 90 years old, 50%. Prevalence rates differed among races (e.g., 11.1% for whites and 6.5% for African Americans) but were similar for men and women. Most patients had mild curves (80.6%), there was no difference in the distribution of curve severity by gender or age, and African Americans were more likely to have mild curves (94.3%) than were other races.
The prevalence of scoliosis in our patients ≥ 40 years old was 8.85% and was associated with age and race, but not with gender. Most curves in our population were mild; curve severity was associated with race but not with age or gender.
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