The indications and outcomes for osteotomies in adult deformity - - PDF document

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The indications and outcomes for osteotomies in adult deformity - - PDF document

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11/13/2015 The indications and outcomes for osteotomies in adult deformity Michael Weber, MD, PhD, FRCSC McGill Orthopedic and Neurosurgery Spine and Scoliosis 5 th Annual UCSF Techniques in Complex Spine Surgery Course, November 6-7, 2015 A

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The indications and outcomes for

  • steotomies in adult deformity

Michael Weber, MD, PhD, FRCSC McGill Orthopedic and Neurosurgery Spine and Scoliosis

5th Annual UCSF Techniques in Complex Spine Surgery Course, November 6-7, 2015

A Case…

  • 64F with LBP
  • PMH
  • Hypertension, hyperlipidemia
  • L3/L4 fusion (1970)
  • Habits
  • Non-smoker, occasional EtOH
  • HPI
  • Increasing LBP over past 10 years
  • Heaviness in bilateral legs, walking tolerance > 5 minutes
  • Requires high doses of regular narcotics
  • No bowel/bladder dysfunction
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Physical Exam

  • Antalgic gait
  • Motor (R|L) Sensory (R|L)

L2 4+ 4+ 2 2 L3 4+ 4+ 2 2 L4 4+ 4+ 2 2 L5 4+ 4+ 1 1 S1 4+ 4+ 1 1

  • Patella reflex 1+ bilateral
  • Straight leg raise (-) bilateral

XR

SVA = 7.5cm PI = 50º PT = 38º SS = 12º LL = -2º

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Sagittal Balance

SVA should pass 3cm in front

  • f P-S corner of S1

15º 60º (30º-80º) 40º (20º-60º) 0º

Sagittal Balance

Sacral Slope Pelvic Tilt Pelvic Incidence

35º +/- 10º 15º +/- 5º 50º +/- 10º

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Flat Back Syndrome

  • Forward inclination of the trunk (i.e. positive

sagittal balance)

  • Compensatory posturing
  • Retroversion of the pelvis (SS, PT, PI)
  • Stooping = hip hyperextension + knee flexion
  • Fatigability and difficulty with gaze
  • Pain

Why is it Important?

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  • ↓ Lumbar lordosis and ↑L3 frontal obliquity correlate with

↓VAS and general health status

  • No such correlation with coronal Cobb angle

Why is it Important?

Realignment Objectives

  • Restore lumbar lordosis
  • LL = PI +/- 9º
  • LL = 0.8 x PI
  • Restore SVA to < 5cm
  • Restore pelvic tilt to <

20º

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  • Posterior opening wedge (Smith-Petersen)
  • Posterior closing wedge (Ponte)
  • Polysegmental wedges (Wilson &Turkell)
  • Three column closing wedge (Pedical

Subtraction Osteotom)

  • Vertebral column Resection (VCR)

Corrective Osteotomies

Schwab et al. Neurosurgery. 2015 Mar;76 Suppl 1

+ Large correction

  • High complication (vessels, bowel)
  • Pseudarthrosis

1º per 1mm resection

Opening Wedge Osteotomies

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  • Limited correction

10º per level

Closing Wedge Osteotomies

+ Large correction

  • High complication (vessels, bowel)
  • Pseudarthrosis

1º per 1mm resection + Can make huge correction + Can correct sagittal and coronal + less risk of pseudarthrosis up to 60º per level + Spread correction over several levels

  • Limited correction

10º per level + Large correction

  • High complication (vessels, bowel)
  • Pseudarthrosis

1º per 1mm resection

Three Column Osteotomy

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Three column closing wedge

Pedicle Subtraction Osteotomy (PSO)

Vertebral Column Resection (VCR)

Three column closing wedge

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  • ↑ Blood loss with closing wedge
  • ↑ Paralytic ileus with opening wedge
  • Comparable patient-reported & radiographic
  • utcomes
  • Equal dural tear, neurological injury, and reoperation

rates

Choice of osteotomy type

Lumbar Thoracic Sharp kyphosis PSO SPO VCR Smooth kyphosis Smooth kyphosis Sharp kyphosis

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  • Retrospective, 70 pts underwent lumbar PSO

Choice of osteotomy level

  • PSO correction correlated significantly with thoracic

kyphosis, LL, SS and PT

Choice of osteotomy level

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Back to the patient

SVA = 7.5cm PI = 50º PT = 38º SS = 12º LL = -2º

  • PSIF T10-pelvis
  • L3 PSO
  • TLIF L5-S1
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PSO

SVA = 7.5cm PI = 50º PT = 38º SS = 12º LL = -2º SVA = 3.5cm PI = 50º PT = 18º SS = 32º LL = 42º

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Six weeks Post-op

  • Retrospective
  • 140 patients
  • PSO for Sagittal imbalance
  • Multiple etiologies

Complications

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  • Correction with PSO

averaged 36.2°

  • Blood loss averaged 1515.6

mL

Complications

  • Scoliosis Research Society (SRS) Morbidity and Mortality Database

(2004 to 2007; N=578 patients):

  • ↑ complication rate with (34.8%) vs. without (17.0%, P < 0.001) an
  • steotomy
  • Progresive ↑ in complications from no osteotomy (17.0%), to

SPO (28.1%), to PSO (39.1%), to VCR (61.1%).

  • No difference associated with patient age (P = 0.68), surgeon

experience (P = 0.18), and history of prior surgery (P = 0.10).

Smith et al., Spine 2011

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Complications

  • Retrospective 41 patients, 43 TCTOs
  • IDEAL SPA (SVA< 4 cm, PT < 25°) VS FAIL
  • ↑ preoperative PT and SVA predicted failed post-operative SPA
  • ☞ Alternative correction procedures should be considered

when planning TCTO for patients with ↑ sagittal malalignment

Failure Predictors

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Take Home Points

  • Sagittal balance is important!
  • Functional outcomes are inversely related to SVA
  • Toolbox of osteotomies to restore spinopelvic aligmen
  • Posterior opening wedge
  • Posterior closing wedge
  • Three column closing wedge
  • The severity of impairment of LL and spinopelvic parameters

correlates with the post op PT and SVA after three column

  • steotomies

The indications and outcomes for

  • steotomies in adult deformity

5th Annual UCSF Techniques in Complex Spine Surgery Course, November 6-7, 2015

Michael Weber, MD, PhD, FRCSC McGill Orthopedic and Neurosurgery Spine and Scoliosis