Date Published: March 3, 2019
Author(s): Koichiro Ono, Kazuo Ohmori, Takeshi Hori.
Despite the accumulated knowledge of spinal alignment and clinical outcomes the full corrective surgery cannot be applied to all the deformity patients as it requires considerable surgical burden to the patients. The aim of this study was to investigate the clinical and radiological outcomes of the patients who have received short and long fusion for ASD. A total of 21 patients who received surgical reconstructive spinal fusion procedures and were followed up for at least one year were retrospectively reviewed. Sixteen cases have received spinal corrective surgery that upper instrumented vertebrate (UIV) was thoracic level (group T), or 5 cases were with UIV in lumbar level (group L). Group L had shorter operation time, smaller intraoperative estimated blood loss, and shorter postoperative hospitalization days. Group T tends to improve more in the magnitude of VAS of lumbar pain compared to group L. Improvement of spinal alignment revealed the advantage of long fusion compared to short fusion, in Cobb angle, sagittal vertical axis (SVA), lumbar lordosis (LL), PI-LL C7 plum line (C7PL), and center sacral vertebral line (CSVL). Pelvic tilt (PT) did not differ between the groups. Disc lordosis was the most acquired in XLIF compared to TLIF and PLF and maintained one year. There were 9 adverse events, 3 cases of pulmonary embolism (PE), one case of delirium, and 6 cases of proximal junctional kyphosis. Current study elucidated that long fusion, UIV, is thoracic and can achieve better spinal alignment compared to short fusion, UIV, in lumbar. XLIF demonstrated strong ability to reconstruct the deformity on intervertebral space that is better to apply as much intervertebral space as possible. For the ASD patients with complications, short fusion can be one of the options.
In world’s fastest aging society, one of the issues for quality of daily livings (QOL) of aging population in Japan is adult spinal deformity (ASD). ASD are associated with broad range of clinical and radiological findings such as progressive spinal deformity, chronic back pain, and neurological symptoms. Pathology of ASD includes primary degenerative scoliosis (“de novo” form), progressive idiopathic scoliosis in adult life, and scoliosis secondary to vertebral fracture and/or asymmetric arthritic disease . Among these, the number of degenerative and secondary scolioses is increasing in Japanese aging society. Advanced ASD presents loss of function, refractory to nonoperative treatment, and therefore requires the surgical intervention.
Eighty-six-year-old female (case no. 21) received staged spinal corrective surgery on her ASD (Figures 5(a) and 5(b)). XLIF was performed on L2/3,3/4,4/5 with 2 hours 29 min., estimated bleeding of 30 ml. Eight days later, open posterior surgery was conducted from T10 to S2 level with 7 hours and 27 min., estimated bleeding of 1100ml. Postoperative hospitalization days were 64 days. Clinical outcomes improved in magnitude of JOA score, VAS of lumbar pain and leg pain, ODI from 23, 64.8, 44.3, and 41.8, preoperatively to 23, 46, and 37, and no data at one month after the surgery, 25, 12, 20, and 17.8 at one year, respectively (Table 3(a)). C7PL-CSVL improved from 62 mm to 3 mm at one month after the surgery and 2 mm at one year. SVA decreased from 119 mm to 12 mm at one month after the surgery and 11 mm at one year (Table 3(b)). Cobb angle improved from 29° to 4° at one month after the surgery and 8° at one year. LL increased from 4° to 42° at one month and 45° at one year. In consequence, PI-LL improved from 50 to 12 at one month and 9 at one year. PT did not change during the course, from 24° to 21° at one month after the surgery and 27° at one year (Table 3(b)).
ASD are associated with broad range of clinical and radiological findings such as progressive spinal deformity, chronic back pain, and neurological symptoms. Previous studies have shown the spinal sagittal alignment and global balance is essential for patients QOL [9, 10, 12, 13]. To achieve proper spinopelvic alignment in the ASD patients, some of operative interventions require more surgical burden for the patient and more technical and physical demand on the spine surgeons. For advanced ASD, posterior-only procedure usually requires high volume osteotomies. Instead of osteotomies, anterior procedure predominantly utilized the disc space to reconstruct spinal alignment that also has large surgical burden . Recently introduced XLIF  can be alternative to the anterior procedure. Combined with XLIF and posterior correction and instrumentation, favorable clinical outcomes have been reported [12, 14, 15]. XLIF use the dedicated retractor which requires smaller incision than open anterior procedure and approach from lateral, abdominal, retroperitoneal, transpsoas approach to lateral portion of the intervertebral disc. Surgical field is bright with light source so that retroperitoneal organs and psoas are visible and surgeon can carefully approach the lateral aspect of the disc without bleeding or damaging vital organs. In this manner, XLIF extremely reduced surgical burden compared to the conventional anterior procedure. In addition to reduction of surgical burden, XLIF demonstrates strong ability to reconstruct the deformity on intervertebral space . It restores disc height and indirectly decompression spinal canal. Previous studies have reported XLIF is effective for coronal correction and only mild effect on improvement of sagittal alignment [16, 17]. Therefore, we perform conventional open surgery for posterior procedure to acquire adequate sagittal alignment. Sagittal correction is enhanced using facet osteotomies, rod rotation , and cantilever bending technique . Open conventional procedure requires a decent amount of surgical burden that the long fusion needs to consider for their application on the ASD patients with complications. According to our comparison study, group T had longer operation time, intraoperative estimated blood loss, and longer postoperative hospital stay (Table 2). As expected, this result indicated that surgical burden was higher in group T.