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 Disclosures Stock: Johnson & Johnson, Pfizer, Proctor & Gamble, Pioneer Consultant: DePuy, Medtronic, Orthofix Royalties: DePuy 1

11/13/2015 67 yo female Multiple Surgeries Severe Low back pain Decompensated coronally and sagittaly Normal neurology Smoker Morphine pump 2

11/13/2015 Surgical Plan ? Anterior release/resectio n and Posterior Fusion Pedicle subtraction osteotomy Vertebral Column Resection 3

11/13/2015 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 4

11/13/2015 Grade III - Partial body resection Most suited when >20° segmental correction needed Appropriate even through fusion All levels of spine possible Frank Schwab, MD Preferable below conus Virginie Lafage, PhD Pathologic Behavior Increasing pelvic tilt with increasing kyphosis Sagittal plane interpretation and management deformity PierreRoussouly • Colin Nnadi 5

11/13/2015 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 6

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11/13/2015 Positioning Table that can bend Abdomen free Pad all the pressure points 9

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11/13/2015 Decompression Midline laminectomy extending above and below Pedicle to pedicle posterior element bony resection Follow the nerve roots out 12

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11/13/2015 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 14

11/13/2015 Place the retractors outside the vertebral body Hollow out the vertebral body 15

11/13/2015 Remove the pedicle Remove the lateral part of the vertebral body 16

11/13/2015 Remove from superior and then inferior After removal of the vertebral body 17

11/13/2015 Removal of the posterior wall Bony resection complete Closure of the osteotomy 18

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11/13/2015 2002 2013 22

11/13/2015 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 23

11/13/2015 Flatback Anterior fusion with femoral ring allograft Pedicle subtraction osteotomy Extension of instrumentation to the pelvis Anterior L5-S1 fusion and Pedicle subtraction osteotomy 24

11/13/2015 67 yo female Multiple Surgeries Severe Low back pain Decompensated coronally and sagittaly Normal neurology Smoker Morphine pump 25

11/13/2015 Surgical Plan ? Anterior release/resectio n and Posterior Fusion Pedicle subtraction osteotomy Vertebral Column Resection 26

11/13/2015 Pedicle Subtraction Osteotomy Addressing the coronal and saggital planes Four rods for ease of osteotomy correction and placement of the long rods 27

11/13/2015 Pedicle Subtraction Osteotomy 28

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11/13/2015 Anterior L5-S1 and L4-5 femoral ring PSO L3 Correction of Lumbar Lordosis 33

11/13/2015 Pedicle Subtraction Osteotomies Blood loss Neurologic Compromise Nonunion Proximal Junctional Failure 34

11/13/2015 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 35

11/13/2015 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 36

11/13/2015 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 The OR time and blood loss was not statistically different Primary Revision t-test Mean SD Mean SD p Age (years) 60.1 13.6 58.9 10.9 0.549 BMI 26.1 7.2 27.9 6.8 0.184 (kg/m 2 ) OR time 127 145 404 455 0.114 (mn) Blood Loss 2742 1945 2654 2696 0.924 (ml) # levels 10.5 4.0 10.7 3.9 0.802 fused 37

11/13/2015 Primary PSO Statistical improvement in sagittal parameters Δ pre to post Pre-op Post t-test Mean SD Mean SD Mean SD p Thoracic 30.1 22.0 47.6 14.9 17.4 16.6 .0000 Kyphosis T2- T12 Thoracic 28.8 21.5 41.5 13.5 12.7 19.4 .0003 Kyphosis T4- T12 Lumbar -24.0 25.1 -53.3 11.9 -29.3 26.0 .0000 Lordosis L1-S1 Sagittal Vertical 127.9 78.4 30.8 52.9 97.2 80.1 .0000 Axis T1 Spino-Pelvic 3.6 7.0 -4.3 4.8 8.0 7.0 .0000 Inclination 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 Revision PSO Statistical improvement in sagittal parameters Δ pre to post Pre-op Post t-test Mean SD Mean SD Mean SD p Thoracic 30.2 19.1 44.6 17.3 14.4 14.6 .0000 Kyphosis T2-T12 Thoracic 27.2 17.7 37.4 16.8 10.1 14.7 .0000 Kyphosis T4-T12 Lumbar Lordosis -23.2 19.1 -52.6 14.7 -29.3 16.7 .0000 L1-S1 Sagittal Vertical 141.8 76.5 40.9 59.8 100.9 74.2 .0000 Axis T1 Spino-Pelvic 4.4 7.2 -3.4 5.5 7.8 7.0 .0000 Inclination 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 38

11/13/2015 Intra-operative Complications High blood loss in PSO ’ s Complication ALL Primary Revision Intra-op 20.3% 27.6% 19.1% Bleeding > 4L Intra-op Cardiac 0.5% 0.0% 0.5% Arrest Intra-op Cord 2.4% 3.4% 2.2% Deficit Intra-op 1.4% 0.0% 1.6% Unplanned Stage Intra-op Vessel / 0.5% 0.0% 0.5% OrganI njury Postoperative complications Complication ALL Primary Revision Post-op Acute Respiratory 2.8% 0.0% 3.3% Distress/Failure Post-op Arrhythmia 1.5% 0.0% 1.7% Post-op Bowel Bladder 14.0% 10.3% 14.6% Dysfunction 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% 39

11/13/2015 Postoperative complications High rate of return to OR within the first year 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% Revision Rates ALL Primary Revision Odds ratio 95% CI 3M 8.1% 2.7% 9% 3.5 [0.46;27.26] Between 6.5% 5.4% 6.7% 1.3 [0.25;5.76] 3M and 1Y Before 1Y 8.1% 15.2% 2 [0.59;7.01] 14.2% 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%). 40

11/13/2015 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 41