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Justin S. Smith, MD, PhDHarrison Distinguished Professor
Vice Chair for ResearchChief of Spine Division
Department of NeurosurgeryUniversity of Virginia
Three-Column Osteotomy versus Interbody for Major
Sagittal Malalignment
UCSF Techniques in Complex Spine Surgery CourseLas Vegas, 2019
Disclosures• Zimmer Biomet: consultant, honoraria, royalties
• DePuy: research study group support
• K2M: consultant, honoraria• Nuvasive: consultant, honoraria, royalties
• Cerapedics: consultant
• NREF: fellowship funding• AO: research support, fellowship funding
• AlloSource: consultant
• Editorial Boards: Journal of Neurosurgery Spine, Neurosurgery, Operative Neurosurgery,Spine Deformity
• Alphatec: stock ownership
• Deformity magnitude• Location• Focal vs. Global• Fused segments• Prior surgical
approaches• Flexible vs. Rigid
Factors Influencing Deformity tors Influencingng DeformCorrection Strategy
•Supine films•Bending films•Films over a bolster•Helps determine
properties of coronal and sagittal deformities
Assessment of Curve Stiffness
Osteotomies (low- to high-grade) and discectomies/ interbody fusion
are key tools for correction of spinal deformity. • Retrospective review of ALIF (32) vs TLIF
25) in patients undergoing fusion of <3 levels• Excluded patients if >25% spondylolisthesis
or fixed spinal deformities• Compared foraminal height, local disc angle,
and lumbar lordosis
Hseih et al. JNS Spine 2007;7:379-86.
• ALIF increased local Cobb angle (8.3o) and increased LL (6.2o)
• TLIF decreased local Cobb angle (-0.1o)and decreased LL (-2.1o)
Hseih et al. JNS Spine 2007;7:379-86.
• ALIF example case.
Hseih et al. JNS Spine 2007;7:379-86.
• TLIF example case. Unilateral facetectomy,oblique cage placement.
• Retrospective review of 45 patients treated with single-level TLIF for single-level degenerative condition
• Mean follow-up 21 months
• Assessed LL, disc height, VAS
Kepler et al. Orthop Surg 2012;4:15-20.
• Only gained 3.6o of lumbar lordosis• Disc height increased by 4.5 mm
• “Less lordosis was associated with worse back and leg pain as assessed by VAS.”
• “Patients with persistent leg pain at final follow-up had less lumbar lordosis and intervertebral height than patients without leg pain.”
How good are modern ALIF techniques for achieving lumbar lordosis and sagittal alignment?
Hyperlordotic ALIF spacers?
• Retrospective review of 69 hyperlordoticALIFs (20o or 30o) in 41 patients with adult degenerative spinal disease (all had staged ant/post procedures)
• Mean age 55 yrs (23-76 yrs)
• Average follow-up 10 mos (2-28 mos)Saville et al. JNS Spine. 2016;25:713-19.
Majority were deformity cases
Majority placed at L4-5 or L5-S1
Most also had long-segment posterior fusion
Saville et al. JNS Spine. 2016;25:713-19.
• For 30o HLCs (+/- SPO), mean segmental lordosis achieved was 29o (26o-34o)
Results
• For 20o HLCs (+/- SPO),mean segmental lordosis achieved was 19o (16o-22o)
• Mean SVA decreased from 113 mm (38-320 mm) to 43 mm (-13 to 112 mm)
Case examples in which ALIFcan be key in correction of mild to moderate sagittal
alignment.
+10 cm
LL=32°PI=82°
PT=50°PI-LL=50°
72 y/o woman
+10 cm
Supine CT Scout
Decrease of C7-S1 SVA
Lumbar spine remains rigid and markedly kyphotic (PI= 82°)
• Fixed sagittal spino-pelvic malalignment in patient with high PI
Management?
PI=82°LL=32°PT=50°
PI-LL=50°
• L5-S1 disc space open
• Surgery: - L5-S1 ALIF (25o)- T11-ilium screws- L1-2 PCO + TLIF
• Stenosis at L1-2
+7 cm
LL=26°PI=62°
PT=25°PI-LL=36°
65 y/o man
Mid-SagittalLeft Parasagittal Right Parasagittal
Vacuum disc at L5-S1
• Fixed sagittal spino-pelvic malalignment
Management?
PI=62°LL=26°PT=25°
PI-LL=36°
• L5-S1 disc space open
• Surgery: - L5-S1 ALIF (25o, 20 mm ht)- T11-ilium screws- L2-3, L3-4, L5-S1 SPO - L3-4 TLIF
• Stenosis at L2-3
• Solid fusion L3-5
Following ALIF
Case example in which ALIF can be key in correction of major sagittal alignment.
>+30 cmPI=59°
PT=32°PI-LL=65°
74 y/o man
LL=+6°
Pre-op standing Pre-op supineMid-SagittalLeft Parasagittal Right Parasagittal
Air in L5-S1 disc
• Severe sagittal spino-pelvic malalignment
Management?
PI=59°LL=+6°PT=32°
PI-LL=65°
• L5-S1 disc space open• Surgery:
- L4-S1 ALIFs (15o)- T10-ilium screws- T12-L5 PCOs
• Previous multi-level lumbar decompression but no fusion
Pre-op standingPre-op supine Supine post ALIFs
How good are modern TLIF techniques for achieving lumbar lordosis and sagittal alignment?
PCO + TLIF Considerations to Optimize TLIF Carpentry
• Surgical techniqueSufficiently distract across disc spaceUse a large (>10mm), lordoticcage (especially at L5-S1)
Considerations to Optimize TLIF Carpentry
• Surgical techniqueMeticulous disc removal, including contralateral side and anteriorPosition cage in anterior third of body (not oblique)
Takahashi et al. Neuro Med Chir. 2014;54:692.
Jagannathan et al. Neurosurgery. 2009;64:055-64.
• Retrospective review of 80 patients who underwent TLIF (107 levels)
• Minimum 2-year follow-up
• Assessed standing x-rays for:
Changes in regional lordosis (L1-S1)Global sagittal alignment (SVA)
Changes in segmental lordosis
• Excluded patients treated with a PSO
Jagannathan et al. Neurosurgery. 2009;64:055-64.
• Change in segmental lordosis at TLIF level at minimum two-year follow-up
L1-2: 5.9o
L2-3: 4.3o
L3-4: 8.5o
L4-5: 11.3o
L5-S1: 22.2o
Jagannathan et al. Neurosurgery. 2009;64:055-64.
• Increase in lumbar lordosis was greater with a 2-level (29o) or 3-level TLIF (30o)
• Lumbar lordosis improved for 1-, 2-, or 3-level TLIF cases
Saville et al. JNS Spine. 2016;25:713-19.
For 30o HLCs , mean segmental lordosis achieved was 29o (range: 26o-34o)
Hyperlordotic ALIF +/- SPO
Jagannathan et al. Neurosurgery. 2009;64:055-64.
Increase in lumbar lordosis was greater with a 2-level (29o) or 3-level TLIF (30o)
L5-S1: 22.2o
PCO / TLIF
Case example in which TLIF with PCO can be key in correction of mild to moderate sagittal alignment.
LL=+5°PI=73°
PT=44°PI-LL=78°
74 y/o woman
-8 cm+22 cm
20°
• Canal stenosis- Moderate at L1-2- Severe at L2-3
• Foramenal stenosis- Severe bilat L1-2- Severe bilat L2-3- Severe bilat L4-5
Standing Supine
• Removal of prior instrumentation
• Pedicle screws T10-S1
• Bilateral iliac bolts
• T12-L3 and L4-5 PCOs
• L2-3 and L4-5 TLIFs
• No complicationsPI-LL = 78o PT = 44o
C7-S1 SVA = +22 cm
T12-L5 Coronal Cobb = 20o
TK = 70o
Management CB = -8 cmCobb T12-L5 = 20°
CB = -2 cmCobb T12-L5 = 0°
SVA = +22 cmPT = 44°LL = -5°PI-LL = 78°
SVA = +4 cmPT = 26°LL = 55°PI-LL = 18°
LL = -5°LL = 55°
Case example in which TLIF with PCO can be key in correction of major sagittal alignment.
• 67 y/o woman p/w progressive back pain and radiation to L>>R LEs (posterolateral leg and foot)
• Also c/o positive sagittal imbalance,subjective leg weakness, and inability to walk >1 block (limited by pain and weakness)
• PMH: pulmonary HTN, cardiac arrhythmia, RA, SLE, DM Type 2, obesity, osteoporosis (femoral neck T-score = -2.5), previous smoker
Case Example
SVA = +19cm
C7-CSVL ~0cm
LL = 11o
PI = 59o
PT = 37o
PI-LL = 48o
PT = 37o
Supine/Bolster X-rays
• T4-S1 PSI/PSF
• Bilateral iliac bolts
• T8-S1 PCOs
• L4-5 TLIF
PI-LL = 48o PT = 37o
C7-S1 SVA = +19cm
L2-5 Coronal Cobb = 31oT4-T12 Sag Cobb = 58o
• Post-op screening ultrasound -> RLE femoral DVT -> IVC filter placed (o/w no peri-op complications)
Management
SVA = +19cm SVA = +4cm
PI-LL = 48o
PT = 37o
TK = 60o
PI-LL = 8o
PT = 12o
TK = 58o
Surgical Options for Major Sagittal cal Options for r Major SaAlignment Correction
- Aggressive segmental correction
• Pedicle Subtraction Osteotomy
- Stiff or fixed deformities
- Anterior column prohibitively fused to enable sufficient correction otherwise
- Associated with high complication rates
• Objective: Assess utilization trends of PSO based on commercially available database with private payor and 5% of Medicare claims from 2008-2011
• 3.2-fold increase in utilization of PSOs while diagnosis of ASD, fusion for spine deformity, and posterior spine fusion had minimal to no increase
There are situations where PSO remains necessary in order to correct the deformity.
Are PSOs being over-utilized?
44°
+6.6 cm
+10 cm
LL=+8°PI=66°
PT=51°PI-LL=74°
68 y/o woman
+10 cm
Supine CT Scout
Significant decrease of C7-S1 SVA
Lumbar spine remains rigid and kyphotic
44°
+6.6 cm
37°
Supine CT Scout
Rigid coronal curve
Some global coronal correction
Flexion Extension Mid-SagittalLeft Parasagittal Right Parasagittal
• Severe fixed sagittal spino-pelvic malalignment
Management?
PI=66°LL=+8°PT=51°
PI-LL=74°
• Anterior/lateral fusion L1-2, L2-3, L4-5
• Surgery: - T10-ilium screws- T12-L1, L5-S1 PCOs- L5-S1 TLIF- L3 asym ePSO
• Solid posterolateral fusion L1-L5
Sometimes need to combine 3CO with interbodies to correct major sagittal malalignment
36°
>+20 cm
LL=+15°PI=80°
PT=62°PI-LL=95°
70 y/o woman
36°
Supine CT ScoutMinimal change
>+20 cm
Supine CT Scout
Some decrease of C7-S1 SVA
Lumbar spine remains rigid and kyphotic
Solid fusion throughout thoracic and lumbar spine (T5-L5)
• Severe fixed sagittal spino-pelvic malalignment
Management?
PI=80°LL=+15°PT=62°
PI-LL=95°
• L5-S1 disc space open
• Surgery: - L5-S1 ALIF (15o)- T10-ilium screws- L5-S1 PCO- L4 ePSO
• Very solid posterolateral fusion T5-L5
ePSO Technique Video
Conclusions
• PSOs should be reserved for severe deformities with anterior column prohibitively fused for correction otherwise
• Flexibility assessment is important (supine, over a bolster, CT scout)
• If flexible, even severe sagittal malalignment can often be corrected with PCOs and TLIFs
• Newer hyperlordotic ALIF spacers provide powerful segmental lordosis correction and may obviate need for 3-column osteotomy Thank You