Yonsei Med J.  2017 Nov;58(6):1177-1185. 10.3349/ymj.2017.58.6.1177.

Effect of Sagittal Balance on Risk of Falling after Lateral Lumbar Interbody Fusion Surgery Combined with Posterior Surgery

• Lee BH
• Yang JH
• Kim HS
• Suk KS
• Lee HM
• Park JO
• Moon SH

• KMID: 2418900
• DOI: http://doi.org/10.3349/ymj.2017.58.6.1177

Abstract

PURPOSE
To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach.
MATERIALS AND METHODS
From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes.
RESULTS
The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016).
CONCLUSION
Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

Keyword

Lumbar spinal stenosis; surgery; actual falls; sagittal balance; outcome; lateral lumbar interbody fusion

MeSH Terms

Accidental Falls/*statistics & numerical data
Aged
Aged, 80 and over
Decompression, Surgical/*methods
Exercise Test
Female
Humans
Incidence
Lumbar Vertebrae/*diagnostic imaging/*surgery
Male
Middle Aged
Outcome Assessment (Health Care)
Postoperative Period
Postural Balance
Quality of Life
Radiography
Risk
Spinal Fusion/*methods
Spinal Stenosis/*surgery

Figure

• 

  Fig. 1 Enrollment and follow-up of the study participants. SB, sagittal balance; SI, sagittal imbalance; PLF, postero-lateral fusion; LLIF, lateral lumbar interbody fusion; LSS, lumbar spinl stenosis; EQ-5D, Euro-QoL 5 dimension.

• 

  Fig. 2 Comparison of pre- and postoperative sagittal balance status depending on surgical treatment. Both (A) sagittal balance PLF patient and (B) sagittal imbalance PLF patient demonstrated no change on the sagittal profile postoperatively. However (C) sagittal imbalnce LLIF patient presented with considerable change of lumbar lordosis and other sagittal profiles after surgery. PLF, postero-lateral fusion; LLIF, lateral lumbar interbody fusion.

• 

  Fig. 3 Postoperative changes in functional mobility test results, reflecting risk of falling in the SB PLF group, SI PLF group, and LLIF group (unit: seconds). In the post-hoc analysis, the Bonferroni method was utilized to demonstrate statistical differences between groups for each measure. *p<0.05. AST, alternate-step test; SMT, six-meter-walk test; STS, sit-to-stand test; TUGT, timed-up-and-go test; SB, sagittal balance; SI, sagittal imbalance; LLIF, lateral lumbar interbody fusion; PLF, postero-lateral fusion.

• 

  Fig. 4 Postoperative changes in the values of the EQ-5D questionnaire, EQ-VAS, and ODI in the SB PLF group, SI PLF group, and LLIF group. SB, sagittal balance; SI, sagittal imbalance; PLF, postero-lateral fusion; LLIF, lateral lumbar interbody fusion; EQ-5D, Euro-QoL 5-dimension; VAS, visual analogue scale; ODI, oswestry disability index.

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