title: Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients.
abstract: OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.
authors: Department of Orthopaedic Surgery, University of California, San Francisco.
authors: Alexander A
authors: AA
authors: Theologis
authors: Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California.
authors: Gregory M
authors: GM
authors: Mundis
authors: Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California.
authors: Stacie
authors: S
authors: Nguyen
authors: Department of Neurological Surgery, University of Pittsburgh, Pennsylvania.
authors: David O
authors: DO
authors: Okonkwo
authors: Department of Neurologic Surgery, University of California, San Francisco, California.
authors: Praveen V
authors: PV
authors: Mummaneni
authors: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors: Justin S
authors: JS
authors: Smith
authors: Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia.
authors: Christopher I
authors: CI
authors: Shaffrey
authors: Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois.
authors: Richard
authors: R
authors: Fessler
authors: Department of Orthopaedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado.
authors: Shay
authors: S
authors: Bess
authors: Department of Orthopedic Surgery, NYU Hospital for Joint Diseases.
authors: Frank
authors: F
authors: Schwab
authors: Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York.
authors: Bassel G
authors: BG
authors: Diebo
authors: Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and.
authors: Douglas
authors: D
authors: Burton
authors: Department of Orthopedic Surgery, Oregon Health & Science University, Portland, Oregon.
authors: Robert
authors: R
authors: Hart
authors: Department of Orthopaedic Surgery, University of California, San Francisco.
authors: Vedat
authors: V
authors: Deviren
authors: Department of Neurologic Surgery, University of California, San Francisco, California.
authors: Christopher
authors: C
authors: Ames
mesh_terms: D000368:Aged; D001416:Back Pain / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D016208:Databases, Factual; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D011183:Postoperative Complications; D011446:Prospective Studies; D011788:Quality of Life; D012189:Retrospective Studies; D012447:Sacrum / Q000000981:diagnostic imaging / Q000601:surgery*; D012720:Severity of Illness Index; D013121:Spinal Curvatures / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome
keywords: 3CO = 3-column osteotomy; ALIF = anterior lumbar interbody fusion; ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; BMI = body mass index; CCI = Charlson Comorbidity Index; EBL = estimated blood loss; HRQoL = health-related quality of life; LIF = lateral interbody fusion; LL = lumbar lordosis; LOS = length of stay; ODI = Oswestry Disability Index; PI = pelvic incidence; PI-LL = mismatch between PI and LL (lumbopelvic mismatch); PSF = posterior instrumented spinal fusion; PT = pelvic tilt; SVA = sagittal vertical axis; TK = thoracic kyphosis; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale; adult spinal deformity; complications; health-related quality of life; lateral interbody fusion; lumbosacral interbody fusion; minimally invasive