J Korean Neurosurg Soc.  2016 Nov;59(6):615-621. 10.3340/jkns.2016.59.6.615.

Surgical Outcomes of Post-Fusion Lumbar Flatback Deformity with Sagittal Imbalance

Affiliations
  • 1Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea. spinekim@khu.ac.kr

Abstract


OBJECTIVES
To review surgical results of post-fusion lumbar flatback treated with pedicle subtraction osteotomy (PSO) or Smith-Petersen osteotomies (SPOs).
METHODS
Twenty-eight patients underwent osteotomies. Radiological outcomes by sagittal vertical axis (SVA), and pelvic tilt (PT), T1 pelvic angle (T1PA), and pelvic incidence (PI)-lumbar lordosis (LL) at preoperative, postoperative 1 month, and final were evaluated. Oswestry Disability Index (ODI), visual analog scale (VAS) score of back pain/leg pain, and Scoliosis Research Society-22 score (SRS-22r) were analyzed and compared. Patients were divided into 2 groups (SVA ≤5 cm : normal, SVA >5 cm : positive) at final and compared outcomes.
RESULTS
Nineteen patients (68%) had PSO and the other 9 patients had SPOs with anterior lumbar interbody fusions (ALIFs) (Mean age : 65 years, follow-up : 31 months). The PT, PI-LL, SVA, T1PA were significantly improved at 1 month and at final (p<0.01). VAS score, ODI, and SRS-22r were also significantly improved at the final (p<0.01). 23 patients were restored with normal SVA and the rest 5 patients demonstrated to positive SVA. SVA and T1PA at 1 month and SVA, PI-LL, and T1PA at final were significantly different (p<0.05) while the ODI, VAS, and SRS-22r did not differ significantly between the groups (p>0.05). Common reoperations were early 4 proximal junctional failures (14%) and late four rod fractures.
CONCLUSION
Our results demonstrate that PSO and SPOs with ALIFs at the lower lumbar are significantly improves sagittal balance. For maintenance of normal SVA, PI-LL might be made negative value and T1PA might be less than 11° even though positive SVA group was also significantly improved clinical outcomes.

Keyword

Post-fusion flatback deformity; Pedicle subtraction osteotomy; Smith-Petersen osteotomy; Anterior lumbar interbody fusion

MeSH Terms

Animals
Congenital Abnormalities*
Follow-Up Studies
Humans
Incidence
Lordosis
Osteotomy
Scoliosis
Visual Analog Scale

Figure

  • Fig. 1 L4 pedicle subtraction osteotomy (PSO) in a 56-year-old woman with post-fusion lumbar flatback deformity. A : Preoperative lumbar lateral X-ray. B : lumbar MRI showing hypolordotic fusion from L2 to S1 and severe adjacent segment degeneration with sclerosis at L2–3 level. There was also paraspinal and psoas muscle atrophy and fatty infiltration around L4–5 level. The patient underwent L4 PSO with L2–3 TLIF. C and D : The patient was improved and well maintained spinal and spinopelvic balance at 31 months postoperatively : PI-LL, -15°; SVA, -27 mm; PT, 7°; achieved angle by L4 PSO of 36°. SVA : sagittal vertical axis, PT : pelvic tilt, PI : pelvic incidence, LL : lumbar lordosis, TLIF : transforaminal lumbar interbody fusion.

  • Fig. 2 Lower lumbar SPOs with ALIFs were performed in a 54-year-old woman with post-fusion lumbar flatback deformity. A : Preoperative lumbar and whole spine lateral X-ray. B : Lumbar MRI. Very positive sagittal imbalance with nonunion and rod fracture at the lower lumbar was detected. MRI showed multilevel lower lumbar disc degeneration with severe paraspinal and psoas muscle atrophy. C and D : The patient underwent lower lumbar SPOs with ALIFs at L3–4–5 and PLIF at L2–3 by the P-AP approaches. The patient was very satisfied with well maintained global spinal balance at 32 months postoperatively : PI-LL, -12°; SVA, -17 mm; PT, 11° at the postoperative 32-month lumbar, whole spine X-ray. SPO : Smith-Petersen osteotomy, ALIF : anterior lumbar interbody fusion, P-AP : posterior-anteriorposterior, SVA : sagittal vertical axis, PT : pelvic tilt, PI : pelvic incidence, LL : lumbar lordosis, PLIF : posterior lumbar interbody fusion.


Cited by  1 articles

Radiographic and Clinical Outcomes Following Pedicle Subtraction Osteotomy : Minimum 2-Year Follow-Up Data
Ho Yong Choi, Seung-Jae Hyun, Ki-Jeong Kim, Tae-Ahn Jahng, Hyun-Jib Kim
J Korean Neurosurg Soc. 2020;63(1):99-107.    doi: 10.3340/jkns.2018.0170.


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