title: Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study.
abstract: OBJECTIVE
  Minimally invasive (MI) fusion and instrumentation techniques are playing a new role in the treatment of adult spinal deformity. The open pedicle subtraction osteotomy (PSO) and Smith-Petersen osteotomy (SPO) are proven segmental methods for improving regional lordosis and global sagittal parameters. Recently the MI anterior column release (ACR) was introduced as a segmental method for treating sagittal imbalance. There is a paucity of data in the literature evaluating the alternatives to PSO and SPO for sagittal balance correction. Thus, the authors conducted a preliminary retrospective radiographic review of prospectively collected data from 2009 to 2012 at a single institution. The objectives of this study were to: 1) investigate the radiographic effect of MI-ACR on spinopelvic parameters, 2) compare the radiographic effect of MI-ACR with PSO and SPO for treatment of adult spinal deformity, and 3) investigate the radiographic effect of percutaneous posterior spinal instrumentation on spinopelvic parameters when combined with MI transpsoas lateral interbody fusion (LIF) for adult spinal deformity.
  
  
  METHODS
  Patient demographics and radiographic data were collected for 36 patients (9 patients who underwent MI-ACR and 27 patients who did not undergo MI-ACR). Patients included in the study were those who had undergone at least a 2-level MI-LIF procedure; adequate preoperative and postoperative 36-inch radiographs of the scoliotic curvature; a separate second-stage procedure for the placement of posterior spinal instrumentation; and a diagnosis of degenerative scoliosis (coronal Cobb angle > 10° and/or sagittal vertebral axis > 5 cm). Statistical analysis was performed for normality and significance testing.
  
  
  RESULTS
  Percutaneous transpedicular spinal instrumentation did not significantly alter any of the spinopelvic parameters in either the ACR group or the non-ACR group. Lateral MI-LIF alone significantly improved coronal Cobb angle by 16°, and the fractional curve significantly improved in a subgroup treated with L5-S1 transforaminal lumbar interbody fusion. Fifteen ACRs were performed in 9 patients and resulted in significant coronal Cobb angle correction, lumbar lordosis correction of 16.5°, and sagittal vertebral axis correction of 4.8 cm per patient. Segmental analysis revealed a 12° gain in segmental lumbar lordosis and a 3.1-cm correction of the sagittal vertebral axis per ACR level treated.
  
  
  CONCLUSIONS
  The lateral MI-LIF with ACR has the ability to powerfully restore lumbar lordosis and correct sagittal imbalance. This segmental MI surgical technique boasts equivalence to SPO correction of these global radiographic parameters while simultaneously creating additional disc height and correcting coronal imbalance. Addition of posterior percutaneous instrumentation without in situ manipulation or overcorrection does not alter radiographic parameters when combined with the lateral MI-LIF.
authors.affiliation: Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida.
authors.forename: Jotham C
authors.initials: JC
authors.lastname: Manwaring
authors.forename: Konrad
authors.initials: K
authors.lastname: Bach
authors.forename: Amir A
authors.initials: AA
authors.lastname: Ahmadian
authors.forename: Armen R
authors.initials: AR
authors.lastname: Deukmedjian
authors.forename: Donald A
authors.initials: DA
authors.lastname: Smith
authors.forename: Juan S
authors.initials: JS
authors.lastname: Uribe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008141:Lordosis / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D010027:Osteotomy / Q000379:methods; D011859:Radiography; D012189:Retrospective Studies; D012600:Scoliosis / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome