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Pedicle Subtraction Osteotomy: Maximizing correction and reducing - - PDF document
Pedicle Subtraction Osteotomy: Maximizing correction and reducing - - PDF document
11/13/2015 Pedicle Subtraction Osteotomy: Maximizing correction and reducing complications Munish C. Gupta, MD Chief of Pediatric and Adult Spine Surgery Mildred B. Simon Distinguished Professor of Orthopedics Professor of Neurological Surgery
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Surgical Plan ?
Anterior release/resectio n and Posterior Fusion Pedicle subtraction
- steotomy
Vertebral Column Resection
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PSO Pedicle Subtraction Osteotomies
First Described by Leong then Thomasen Charles Heinig used it with Decancellation of the vertebral Body Resection
– Spinous process – Lamina – Facet joint – Pedicle
CORR vol 194 April 1985
Indications for Pedicle Subtraction Osteotomies
Sagittal plane deformity Minimal coronal plane deformity Multiple surgeries anterior or posterior
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Grade III - Partial body resection
Most suited when >20° segmental correction needed Appropriate even through fusion All levels of spine possible
Preferable below conus
Frank Schwab, MD Virginie Lafage, PhD
Pathologic Behavior
Increasing pelvic tilt with increasing kyphosis
Sagittal plane interpretation and management deformity PierreRoussouly • Colin Nnadi
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Aims of Sagittal Plane Realignment
Gravity line at least through femoral heads Lumbar lordosis and Pelvic incidence within 10 degrees Pelvic tilt less than 25
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Positioning
Table that can bend Abdomen free Pad all the pressure points
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Decompression
Midline laminectomy extending above and below Pedicle to pedicle posterior element bony resection Follow the nerve roots out
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Osteotomy
Dissect outside the body Ronguer the the body Hollow out the body with curettes Use the table for closing the osteotomy Use temporary rods to control the correction
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Place the retractors outside the vertebral body Hollow out the vertebral body
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Remove the pedicle Remove the lateral part of the vertebral body
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Remove from superior and then inferior After removal of the vertebral body
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Removal
- f the
posterior wall Bony resection complete Closure of the
- steotomy
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2002 2013
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T1 to L5 anterior and posterior spinal fusion
64 yo male Severe back pain Hard to stand and walk
Fused in flat back position
Flat lumbar spine Discectomy at L5-S1 Disc degeneration L5- S1
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Flatback
Anterior fusion with femoral ring allograft Pedicle subtraction
- steotomy
Extension of instrumentation to the pelvis
Anterior L5-S1 fusion and Pedicle subtraction osteotomy
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67 yo female Multiple Surgeries
Severe Low back pain Decompensated coronally and sagittaly Normal neurology Smoker Morphine pump
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Surgical Plan ?
Anterior release/resectio n and Posterior Fusion Pedicle subtraction
- steotomy
Vertebral Column Resection
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Pedicle Subtraction Osteotomy
Addressing the coronal and saggital planes Four rods for ease
- f osteotomy
correction and placement of the long rods
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Pedicle Subtraction Osteotomy
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Anterior L5-S1 and L4-5 femoral ring PSO L3
Correction of Lumbar Lordosis
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Pedicle Subtraction Osteotomies Blood loss Neurologic Compromise Nonunion Proximal Junctional Failure
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Neurologic Complications of Lumbar Pedicle Subtraction Osteotomy A 10-Year Assessment 11.1% (12 of 108 pts) Permanent deficit of 2.8% (3 of 108 pts). Always unilateral and distal to the level of the osteotomy. Combination of subluxation, residual dorsal impingement, and dural buckling. Neuromonitoring did not detect any of the deficits.
Buchowski et al. SPINE Volume 32, Number 20, pp 2245–2252
Neurologic Complications of Lumbar Pedicle Subtraction Osteotomy A 10-Year Assessment
Buchowski et al SPINE Volume 32, Number 20, pp 2245–2252
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Pedicle Subtraction Osteotomy (PSO) in the Revision versus Primary Adult Spinal Deformity (ASD) Patient: Is there a difference in correction and complications?
- Gupta. Terran, Mundis, Smith, Shaffrey, Han,
Boachie-Adjei, Lafage, Bess, Hostin, Burton, Ames, Kebaish, Klineberg. International Spine Study Group
Materials and Methods
A retrospective review of a large multi-center database of 353 adult spinal deformity
– The inclusion criteria
age >18 ,either SVA > 5cm, pelvic tilt > 25 deg, scoliosis >20 deg ,thoracic kyphosis > 60 deg
Study Population
– PSO in the lumbar spine – complete peri-operative complications data – one year follow-up radiographic and clinical data
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Results
260 pts out of 353 pts met the inclusion criteria. 37 patients underwent Primary PSO 223 patients underwent Revision PSO Minimum 1 yr Follow –up
Demographic Results
Primary Revision t-test Mean SD Mean SD p Age (years) 60.1 13.6 58.9 10.9 0.549 BMI (kg/m2) 26.1 7.2 27.9 6.8 0.184 OR time (mn)
404
127
455
145
0.114
Blood Loss (ml)
2654
2742
2696
1945
0.924
# levels fused 10.5 4.0 10.7 3.9 0.802
The OR time and blood loss was not statistically different
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Primary PSO
Pre-op Post Δ pre to post t-test Mean SD Mean SD Mean SD p Thoracic Kyphosis T2- T12
30.1 22.0 47.6 14.9 17.4 16.6 .0000
Thoracic Kyphosis T4- T12
28.8 21.5 41.5 13.5 12.7 19.4 .0003
Lumbar Lordosis L1-S1
- 24.0
25.1
- 53.3
11.9
- 29.3
26.0 .0000
Sagittal Vertical Axis
127.9 78.4 30.8 52.9 97.2 80.1 .0000
T1 Spino-Pelvic Inclination
3.6 7.0
- 4.3
4.8 8.0 7.0 .0000
Pelvic Tilt
31.2 12.2 23.2 9.6 7.9 10.5 .0001
PI minus LL
30.8 25.8 1.9 12.4 28.9 25.8 .0000
Statistical improvement in sagittal parameters
Revision PSO
Pre-op Post Δ pre to post t-test Mean SD Mean SD Mean SD p Thoracic Kyphosis T2-T12
30.2 19.1 44.6 17.3 14.4 14.6 .0000
Thoracic Kyphosis T4-T12
27.2 17.7 37.4 16.8 10.1 14.7 .0000
Lumbar Lordosis L1-S1
- 23.2
19.1
- 52.6
14.7
- 29.3
16.7 .0000
Sagittal Vertical Axis
141.8 76.5 40.9 59.8 100.9 74.2 .0000
T1 Spino-Pelvic Inclination
4.4 7.2
- 3.4
5.5 7.8 7.0 .0000
Pelvic Tilt
32.3 10.6 24.5 11.0 7.8 8.6 .0000
PI minus LL
36.3 18.4 7.0 16.8 29.2 16.6 .0000
Statistical improvement in sagittal parameters
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Intra-operative Complications
Complication ALL Primary Revision Intra-op Bleeding > 4L
20.3% 27.6% 19.1%
Intra-op Cardiac Arrest 0.5% 0.0% 0.5% Intra-op Cord Deficit 2.4% 3.4% 2.2% Intra-op Unplanned Stage 1.4% 0.0% 1.6% Intra-op Vessel / OrganI njury 0.5% 0.0% 0.5%
High blood loss in PSO’s
Postoperative complications
Complication ALL Primary Revision Post-op Acute Respiratory Distress/Failure 2.8% 0.0% 3.3% Post-op Arrhythmia 1.5% 0.0% 1.7% Post-op Bowel Bladder Dysfunction
14.0% 10.3% 14.6%
Post-op Cauda Equina Deficit 1.0% 0.0% 1.1% Post-op Deep Infection 4.3% 6.9% 3.9% Post-op DVT 1.9% 0.0% 2.2% Post-op Motor Deficit
10.2% 6.9% 10.7%
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Postoperative complications
Complication ALL Primary Revision Post-op Optic Deficit 0.5% 3.4% 0.0% Post-op PE 2.4% 3.4% 2.2% Post-op Pneumonia 1.5% 0.0% 1.7% Post-op Reintubation 0.5% 0.0% 0.6% Post-op Sepsis 1.0% 0.0% 1.1% Post-op Tracheotomy 0.5% 0.0% 0.6% Post-op Unplanned Return OR
14.0% 17.2% 13.5%
High rate of return to OR within the first year
Revision Rates
Primary PSO and Revision PSO groups
– implant failure no statistical difference – (R=4.48%, P=5.41%) – non-union no statistical difference (R=3.59%. P=5.41%).
ALL Primary Revision Odds ratio 95% CI 3M 8.1% 2.7% 9% 3.5 [0.46;27.26] Between 3M and 1Y 6.5% 5.4% 6.7% 1.3 [0.25;5.76] Before 1Y
14.2%
8.1% 15.2% 2 [0.59;7.01]
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Discussion
PSO were primarily performed for sagittal plane deformity in Revision and Primary cases as Hedlund reported The operative time , blood loss and infection rate was not statistically different and similar to other reports The most common level was L3 Angular Correction in Primary 27 deg and Revision 24 deg was similar to reports of 25-30 range in the literature
Discussion
Pelvic Mismatch to 0 postoperatively
– Primary PSO 81.1% – Revision PSO 58.8%
Better ability to correct pelvic tilt in a primary situation than the revision situation with a previous lumbo-sacral fusion
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Discussion
The motor deficits not statistically different
– Primary PSO 6.9% – Revision PSO 10.7% – The neurologic complication rate has been reported to be 11% by Buchowski et al.
Revision Rates High up to 14 % in the first year
– needs more detailed analysis
Conclusion
Pedicle Subtraction Osteotomy may be performed in a Primary and Revision adult spinal deformity patient
– Similar sagittal correction and complication rates. – Primary PSO patients are more likely to achieve better spino-pelvic realignment.
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Four Rods Prevent Rod Breakage and Pseudarthrosis in Pedicle Subtraction Osteotomies
Sachin Gupta, Murat Sakir Eksi, Christopher Ames, Vedat Deviren, Blythe Durbin-Johnson Ph.D., Munish C. Gupta, M.D. University of California Davis, Department of Orthopedics
Purpose
Current Rod Breakage Rate in PSO’s: 16% (Smith 2012) Compare 4 rod “Gupta” technique to dual rods in PSO’s
Example of Four-Rod “Gupta” Technique Example of Two-Rod Technique
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Methods
Retrospective review of consecutive PSO’s Major difference was the number of rods used between centers Center 1
– 29 patients – 4 rod technique
Center 2
– 20 patients – Dual rods
Radiographic and Clinical results analyzed Two-sample t-tests and Fisher’s exact Test
Results
Greater Mean TK, SVA, CSVL, PI+TK+LL
– pre-op and post-op for Center 1
Change in sagittal plane parameters was not statistically significant Similar mean PSO angular correction 39 and 37 deg Center 1:
– 1 Pseudarthrosis (infection, rod removal) – 0 Rod Breakages
Center 2
– 5 Pseudarthroses – 5 Rod Breakages
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Discussion and Conclusion
Four Rods Better than Two Rods
– Center 1 Four rods
2 small rods across
- steotomy
2 long rods
– not attached at location
- f small rods
– Center 2 Dual rods
- nly 2 long rods across
- steotomy site
No acute bend on the Long Rods producing less stress
Ankylosing Spondylitis
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Biomechanics
REDUCING ROD BREAKAGE AND PSEUDOARTHROSIS
IN PEDICLE SUBTRACTION OSTEOTOMY: THE
IMPORTANCE OF ROD NUMBER AND CONFIGURATION IN 264 PATIENTS WITH 2-YEAR FOLLOW-UP
Munish Gupta, Jensen K. Henry, Frank Schwab, Christopher P. Ames, Eric Klineberg, Justin S. Smith, Vedat Deviren, Christopher I Shaffrey, Robert Hart, Richard Hostin, Gregory Mundis, Han Jo Kim, Douglas
- C. Burton, Virginie Lafage, ISSG
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Retrospective review of multicenter, consecutive database
- f ASD patients undergoing 3CO
– ≥1 PSO in the lumbar spine – Baseline, post-op, and 2+ year radiographs
Demographic, operative (including rod material & diameter), revision, radiographic data Each radiograph assessed for:
– Number, configuration (if >2) of rods spanning the PSO site
Accessory (A): attached to primary rods Satellite (S): independently anchored
– Fusion above/below PSO site – Instrumentation failure, timing, and location
Methods Methods
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Revisions (Total): P=0.105 Revisions (Pseudo or Instr. Failure): P=0.035 PSO Site Failure: P=0.128
2 Rods
(n=190)
28% 26% 41%
3 Rods
(n=36)
29% 17% 42%
4 Rods
(n=38)
18% 13% 28%
Results
N=264 62±11yrs BMI 29.3 72% female
(all P>0.05) Revisions (Total): P<0.001 Revisions (Pseudo or Instr. Failure): P=0.009 PSO Site Failure: P=0.038
Results
Accessory (n=45)
31% 23% 50%
Satellite (n=29)
10% 0% 8%
Rod Configuration
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Results
Overall: 27% 2R: 25%
Small (≤5.5):
26%
Cobalt Chrom e (n=79)
Overall: 19% 2R: 24%
Small (≤5.5):
28%
Stainless Steel (n=62)
Overall: 39% 2R: 44%
Small (≤5.5):
43%
Titanium (n=87)
Failures/Non-Union at PSO Site by Rod Material
P=0.027 (Overall) P=0.037 (2R) No significant differences in failure rates among materials for 3-4R (P=0.127) or larger (>5.5mm) diameter (P=0.319); otherwise consistent P=0.068
(Diameter <5.5mm)
Results
Failures/Non-Union at PSO Site by Rod Diameter
Overall: 30% 3-4R: 33%
Small [≤5.5mm] n=195
Overall: 18% 3-4R: 5%
Large [>5.5mm] n=55
P=0.052 (Overall) P=0.009 (3-4 Rods) No significant differences in failure rates between diameters for 2R (P=0.463); trend otherwise consistent
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Overall: 21% Satellite: 0% Accessory: 24% 2 Rods: 23%
IBF (n=182)
Overall: 33% Satellite: 27% Accessory: 40% 2 Rods: 34%
No IBF (n=54)
Results
Failures/Non-Union at PSO Site by Interbody Fusion
P=0.046 (Overall) P=0.050 (Satellite) P=0.396 (Accessory) P=0.112 (2 Rods)
High rate of non-union and rod breakage (n=72/264; 27%) in first 2 years after PSO Lower rates of instrumentation failure in:
– 4 rod constructs – Satellite constructs – Larger diameter (6.0-6.35mm) rods – Avoidance of titanium – Interbody fusion
Bottom line: 21 4S constructs with
- nly 2 failures in 2 years…
– 4S + IBF = 100% success at 2 years (n=11)
Rod Results
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