Complex Spinal Reconstruction Research Articles

Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis

Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P= 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P= 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

D45. Early Outcomes of Muscle Flap Closures in Complex Spine Surgeries: A Propensity-matched Cohort Analysis

PURPOSE: Plastic surgery closure with muscle flaps after complex spinal reconstruction has become popular. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complications between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious pathologies using a national database. METHOD: We performed a propensity-matched analysis using the 2010-2020 NSQIP dataset. RESULTS: Of 117,756 PTLFs meeting inclusion criteria, a higher proportion of flap closures had ASA Class III/IV than traditional closures (65.4% vs. 54.1%; p<0.001). 1,520 PTLFs (760 in each group) were included in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 3.0% for flap and 1.6% for traditional closure (p=0.09). Surgeries were longer with flap closure (p<0.001). After adjusting for operative time, flap closure was associated with lower wound complication odds (AOR, 0.98; p=0.041) and prolonged LOS (AOR, 1.05; p=0.001). Readmission, reoperation, home discharge, mortality, and non-wound complication were not associated with flap use. CONCLUSION: Plastic surgery closure was performed in patients with higher ASA classifications, suggesting consultation in sicker patients. Our propensity-matched cohort analysis of flap closure in PTLFs resulted in lower odds of wound complications than traditional closure. Sequelae of longer procedure time in flap closure may contribute to longer LOS. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case.

The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated. This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction. Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

Vascularized Rib Grafts to Augment Spinal Fusion: A Novel Approach

BACKGROUND: Pseudoarthrosis is a well-known complication following spinal fusion. Rates range from 5% to 40% and are influenced by both patient factors and technical factors. Patients with pseudoarthrosis may experience a return or worsening of their preoperative pain, which can significantly decrease quality of life. For patients with complex posterior column defects with either anterior or posterior columnar insufficiency, especially those receiving chemotherapy, radiation, predisposed to recurrent pseudarthrosis or infection, vascularized bone grafts (VBGs) have been shown to provide better outcomes than nonvascularized bone grafts (N-VBGs).1–5 The purpose of this study is to present an innovative pedicled rib VBG (R-VBG) that can be utilized to augment instrumented spinal fusion. METHODS: Following hardware placement for spinal fusion, an incision is made over the target rib. The intercostal muscle attachments to the superior border of the R-VBG are released, and the rib with its blood supply intact is bluntly dissected from the underlying pleura and inferior intercostal muscle attachments, protecting the subcostal vessels. Particular care is taken when separating the intercostal nerve from the subcostal vessels to prevent postoperative numbness and radicular pain. At the lateral limit of the dissection, the subcostal vessels were controlled, and the rib is cut distally and proximally. The R-VBG is then tunneled under the paraspinous muscles and placed along the posterolateral gutters of the spinal levels being augmented. The natural curvature of the rib is used to match the patients kyphosis/lordosis. The rib is cut down to size and fixated. RESULTS: To date, 7 R-VBGs have attempted. Of these 6 (86%) have been successfully harvested, all of which (100%) went on to achieve at least probable radiologic evidence of graft site fusion. CONCLUSION: The technique described for rotating a vascularized rib bone graft into the posterolateral space for spinal fusion as far as the L4/L5 joint space is an effective method for augmentation of spinal fusion in patients with complex spinal pathologies. Although additional data needs to be collected before true indications can be elucidated for this procedure, our preliminary prospective results suggest that this approach is relatively low risk, especially compared to free tissue transfer, and it has the benefit of providing well-vascularized, healthy bone to augment the fusion bed. REFERENCES: 1. Eastlack R, Dekutoski M, Bishop A, et al. Vascularized pedicled rib graft: a technique for posterior placement in spinal reconstruction. Spinal Disord Tech. 2007;20:610–615. 2. Bohl M, Mooney M, Catapano J, et al. Pedicled vascularized bone grafts for posterior occipitocervical and cervicothoracic fusion: a cadaveric feasibility study. Oper Neurosurg. 2018;15:318–324. 3. Bradford DS. Anterior vascular pedicle bone grafting for the treatment of kyphosis. Spine. 1980;5:318–323. 4. Bradford DS, Daher YH. Vascularised rib grafts for stabilisation of kyphosis. J Bone Joint Surg. 1986;68B:357–361. 5. Wilden JA, Moran SL, Dekutoski MB, et al. Results of vascularized rib grafts in complex spinal reconstruction. J Bone Joint Surg. 2006;88A:832–839.

P143. Efficacy of multi-rod constructs: comparison of two different 4-rod and 3-rod configurations in adult spinal deformity patients with long fusions to the sacrum

BACKGROUND CONTEXT Rod constructs in adult spinal deformity (ASD) surgery can be variable and modular, in many revision surgeries the new instrumentation is connected to the previous implants for extension of fusion or for junctional failure. Previous studies recently reported a lower rate of rod fractures and nonunion with the addition of extra rods and multi-rod constructs across 3CO site and complex spinal reconstructions. The high rate of rod failures in ASD lead to the adoption of various multi-rod constructs. The effect of rod configuration on the rate of implant failure in multi-rod constructs is unknown. Currently, no classification system exits to describe the different multi-rod constructs to allow comparison of rod configurations across data bases. There is no agreement on the terms used to describe multi-rod constructs. PURPOSE We present a new classification system that allows accurate description of various multi-rod constructs used in spine deformity in terms of rod configuration and density. Rod configurations in 110 ASD patients after long PSF to the sacrum with 4-rod and 3-rod constructs were classified according to the new classification system. Four-rod and 3-rod constructs were divided into two groups based on rod configuration: accessory rod group and satellite rod group. We compared rod failure rate (RF) between the two different groups, accessory vs satellite, to determine the effect or rod configuration on the rod fracture rate. STUDY DESIGN/SETTING Retrospective review of institutional database of ASD patients who underwent PSF to the sacrum with the use of multi-rod constructs, 3-rod and 4-rod constructs. The multi-rod constructs were classified according the new system based on the rod configurations (RC) of the additional rods. PATIENT SAMPLE ASD patients who underwent PSF to the sacrum with the use of multi-rod constructs, 3-rod and 4-rod constructs. OUTCOME MEASURES Radiographic evidence of rod failure, either unilateral or bilateral on follow up radiographs. METHODS Our institutional database of 526 ASD patients fused to sacrum was reviewed, 110 patients with multi-rod constructs were identified and divided into 4-rod or 3-rod constructs. Within the 4-rod or 3-rod groups, constructs were classified according to the rod configuration into either accessory group (A-group) with additional accessory rods or satellite group (S-group) with additional satellite rods. Accessory rods were defined as additional rods connected to the main construct but not attached to any anchors. Satellite rods were defined as shorter additional rods attached to screws or hooks, and either connected or not connected to the main construct. Most of the satellite rods were midline rod with hooks. Accessory and satellite rod configurations for 4-rod and 3-rod constructs were compared for fractures either unilateral or bilateral after a minimum of 2-year follow up. RESULTS The 4-rod constructs included 15 satellite (S-group) and 18 accessory (A-group) rod configurations. Average BMI and % primary to revision surgeries in both groups was not different p=0.38. Rod diameter (5.5 vs 6.35) in both groups was not different p=0.28. Median levels fused in S-group were 15 (13-17) vs A-group 12 (10-15) p=0.11. Interbody fusion was not different, S-group 12 (80%), A-group 15 (83%), p=0.81. Rod failures in S-group occurred in 2 (13.3%) vs 4 (22.2%) in A-group, p=0.47. Duration of time from surgery to rod failure was 27 months in the S-group compared to 14.5 months in A-group. The 3-rod constructs included 42 satellite and 29 accessory rod configurations. Average BMI was not different (p=0.83), the S-group had more revision cases 38 (90.5%) vs 17 (58.6%) for A-group p=0.03. In S-group 14 (33.3%) patients were 5.5 rods, 27 (64.3%) had 6.35 rods vs A-group: 26 (89.6%) 5.5 rods and 3(10.34%) had 6.35 rods, p=0.01. Median levels fused was not different between both groups, but A-group had more interbody fusions performed 12 (41.4%) vs 4 (9.52%) p=0.03. Rod failures in S-group were 7 (16.7%) vs 15 (51.7%) in the A-group, p=0.01. Duration of time from surgery to rod failure in satellite group was 41 months vs accessory group 31 months. CONCLUSIONS Multi-rod constructs with different rod configurations were compared using a new classification system, 4-rod constructs showed no difference in rate of rod failures. In the 3-rod constructs group, accessory rod configurations had more rod failures compared to satellite rod configurations. The multi-rod construct classification system is helpful in comparing different rod configurations in terms of implant complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Posterolateral corpectomy with pyramesh titanium cage reconstruction in dorsolumbar metastatic lesions

Background dataThe vertebral column represents the most common bony site for metastasis with an incidence ranged from 30% to 70% in patients with metastatic neoplasms. The dorsal spine carries the highest frequent site for metastasis all over the vertebral column followed by the lumber spine. These metastatic lesions are clinical entities that often necessitate a complex spinal decompression and anterior reconstruction. Posterolateral approaches alone allow for excellent decompression with transpedicular fixation and safe visualization of the neural elements for corpectomy and reconstruction so we can avoid the complications that can happen with the staged surgery.PurposeOur aim in the study is to report cases and evaluate our approach for fixation and assess the postoperative period regarding pain improvement and neurological deficit.Study designA retrospective study included 26 patients presented to the Neurosurgery Department at Sohag University Hospital within 3 years, between August 2014 and August 2017. Evaluation was made through using the Quebec Back Pain Disability Scale and muscle power grading scale.Material and methodsTwenty-six patients with metastatic dorsolumbar spine lesions underwent a single-stage surgery by midline posterior approach. Posterior decompression with transpedicular fixation above and below the affected segment was done for all patients. Unilateral facetectomies and pediculectomy followed by corpectomy were done. Insertion of pyramesh titanium cage filled with iliac bone graft with tightness of the screws bilateral. Follow-up period was 6–12 months postoperatively.ResultsThe average age was 58.36 ± 5.96 (range 33–67) years. More than two-thirds of them were males (69.2%). Majority of the lesions were dorsal (77%). Postoperative infection was observed in four patients (15.4%) who improved by IV antibiotics and frequent dressing while CSF (cerebrospinal fluid) leak occurred in three patients (11.5%) who stopped after daily dressing, and we made CSF lumbar tap in one patient. Twenty-two patients showed neurological improvement postoperatively (84.6%). The remaining four were paraplegic with no improvement. Back pain improved for all cases.ConclusionPosterolateral approach alone is efficient and safe for dorsolumbar decompression and reconstruction in the metastatic spine.Trial registrationIRB#3747 registered on August 27, 2017

Spinopelvic Fixation.

Fixation at the lumbosacral junction continues to be a challenge for spine surgeons despite advances in spinal instrumentation techniques. The poor bone quality of the sacrum, the complex regional anatomy, and the tremendous biomechanical forces at the lumbosacral junction contribute to the high rates of instrumentation-related complications. Although many spinopelvic fixation techniques have been reported, only a few are still widely used because of the high complication rates associated with previous techniques. Spinopelvic fixation has numerous indications. Long-segment lumbar and thoracolumbar fusions to the sacrum are the most common scenarios in which instrumentation is extended to the pelvis. Surgeons performing complex spinal reconstruction should be familiar with the available techniques, including their potential risks and complications.

Biomechanical comparison between titanium and cobalt chromium rods used in a pedicle subtraction osteotomy model.

Instrumentation failure is a common complication following complex spinal reconstruction and deformity correction. Rod fracture is the most frequent mode of hardware failure and often occurs at or near a 3-column osteotomy site. Titanium (Ti) rods are commonly utilized for spinal fixations, however, theoretically stiffer materials, such as cobalt-chrome (CoCr) rods are also available. Despite ongoing use in clinical practice, there is little biomechanical evidence that compares the construct ability to withstand fatigue stress for Ti and Co-Cr rods. Six models using 2 polyethylene blocks each were used to simulate a pedicle subtraction osteotomy. Within each block 6.0×45 mm polyaxial screws were placed and connected to another block using either two 6.0×100 mm Ti (3 models) or CoCr rods (3 models). The rods were bent to 40° using a French bender and were secured to the screws to give a vertical height of 1.5 cm between the blocks. The blocks were fatigue tested with 700N at 4 Hz until failure. The average number of cycles to failure for the Ti rod models was 12840 while the CoCr rod models failed at a significantly higher, 58351 cycles (P=0.003). All Ti models experienced rod fracture as the mode of failure. Two out of the three CoCr models had rod fractures while the last sample failed via screw fracture at the screw-tulip junction. The risk of rod failure is substantial in the setting of long segment spinal arthrodesis and corrective osteotomy. Efforts to increase the mechanical strength of posterior constructs may reduce the occurrence of this complication. Utilizing CoCr rods in patients with pedicle subtraction osteotomy may reduce the rate of device failure during maturation of the posterior fusion mass and limit the need for supplemental anterior column support

Use of the “dual construct” for the management of complex spinal reconstructions

Background ContextSurgical management of complex spinal reconstructions remains a clinical challenge, as pseudoarthrosis with subsequent rod breakage can occur. Increased rod density in the form of “satellite” or “outrigger” rods have been described; however, rod-fracture above or below satellite rods persist and can result in dissociation of the construct, loss of correction, and recurrence of deformity. The use of four distinct and mechanically independent rods (dual construct) reduces this concern. Since the original case description in 2006, there have been no other studies that use the dual construct for the surgical management of complex spinal reconstructions. PurposeThe purpose of this study is to review the long-term experience and surgical technique using the dual construct, and to present our complications, rod fracture rates, and outcomes for the surgical management of complex spinal reconstructions. Study DesignThis study used a surgical technique with case series outcomes. Patient SamplePatients were from a single-institute who underwent dual construct between 2010 and 2014 and who were available for 2-year follow-up. Outcome MeasuresRadiographic and functional outcomes, complications, rod fracture rates, and revision surgery rates were the outcome measures. MethodsA retrospective review was conducted from a single institution between 2010 and 2014, with a subsequent 2-year follow-up period. Extensive review of patients' medical record, radiographs, and advanced imaging where available was performed. Medical record was evaluated for patient demographics, surgical procedure, and complications. Radiographic measurements included presence or absence of implant failure and proximal junctional kyphosis or distal junctional kyphosis. ResultsA total of 36 patients underwent surgical reconstruction. The average estimated blood loss was 1,856 cc (range, 400–4,000 cc). The average length of stay was 7.3 days (range, 4–22 days). Clinical follow-up reported 21 patients (58.3%) with no or minimal pain. There were six deaths during the follow-up unrelated to the index procedure. Radiographic follow-up revealed three patients (8.3%) with rod fracture; one patient with one rod fracture, and two patients with two rod fractures. No patient had three or all four rod fractures. There were no screw fractures. None of the patients with rod fractures required revision surgery. ConclusionsThe biggest advantage of the dual construct is that rod breakage, although uncommon, is typically minimal, or asymptomatic, and more importantly does not result in loss of alignment, and therefore has not required revision surgery. The dual construct approach is a safe alternative to traditional two-rod constructs, with encouraging outcomes at follow-up.

Clinical Gait Analysis on a Patient Undergoing Surgical Correction of Kyphosis from Severe Ankylosing Spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton, including the sacroiliac joints, costovertebral joints, and the spine. Patients with AS found to have an alter gait pattern. The purpose of this study was to investigate biomechanical alterations in gait after surgical correction in a patient with severe kyphosis from AS. A case report in controlled laboratory study, a pretest-posttest design. A 20 year-old male presented with severe sagittal imbalance and inability to stand erect due to AS. He presented with thoracic kyphosis of 70°, lumbar kyphosis of 25°, and pelvic incidence of 43°. The patient had a complex spinal reconstruction with 84° of sagittal correction, normalizing his sagittal alignment. Gait analysis was performed the day before surgery and one month post surgery, including three-dimensional kinematics, ground reaction forces, and electromyography outcomes. Normalization of spinal alignment minimally increased walking speed and cadence. Lower extremity ranges of motion angles increased, but were not symmetrical even one month post surgery. Postoperatively, trunk flexion, neck extension and head orientation angles decreased compared with preoperative values, but was not symmetrical even one month post surgery. The trunk muscles were activated earlier in the post surgery condition compared to the pre surgery condition while lower extremity muscles presented later muscle activation. Surgical correction of spinal alignment improved spine function and efficiency. Changes in gait abnormality parameters observed imply that the patient used less energy to ambulate after surgery than before surgery. Although pre-surgery data showed compensation in the spine kinematics, post-surgery data supported significant changes in the spine and the lower extremity values. Formal gait and motion analysis can provide a method to assess the impact of severe spinal deformity on function and changes after treatment.

P171 - Novel “Dual Construct” for the Management of Complex Spinal Reconstructions: Evaluation of 57 Consecutive Patients

P171 - Novel “Dual Construct” for the Management of Complex Spinal Reconstructions: Evaluation of 57 Consecutive Patients

Defining Normative Quality Metrics in Complex High-Risk Deformity Cases: Results from the Scoli-Risk 1 Study

IntroductionQuality metrics are a component of the value calculation, and reflect the risk of care. There is significant variability in complication rates, and quality metric standards in spinal surgery. Case complexity or surgical invasiveness is an important predictor of perioperative complications, and normative standards for quality metrics should be stratified by case complexity. The purpose of this study is to define normative quality metrics for complex, high-risk spinal deformity cases, and to provide a standard and baseline data that may guide quality improvement in comparative research. Material and MethodsSecondary analysis of a prospective, international multicenter observational study (Scoli-Risk1) The study cohort included adults with spinal deformity in the cervicothoracic or thoracolumbar regions. Quality metrics include cumulative readmission and reoperation rates (30, 90, 180 days), wound infection, and DVT rates. Chi Square analysis is used to measure the relationship between osteotomy type and readmission and reoperation. Linear regression is used to determine the association of age and procedure with readmission and reoperation. Results273 patients from the Scoli-Risk 1 study were included in the analysis. Cumulative readmission rates were 7.7 (4.8;11.5), 13.2 (9.4;17.8), 16.5 (12.3;21.4) percent at 30, 90 and 180 days after index surgery. Reoperation rates were 14.7 (10.7;19.4), 17.6 (13.3;22.6), 20.1 (15.6;25.4) percent at 30, 90 and 180 days after index surgery. Age was a significant predictor of readmission during the first 180 days after surgery (OR1.388 (1.068;1.803)), but not a significant predictor of the need for reoperation (OR=1.109 (0.903;1.361)). Osteotomy type (PSO/VCR vs SPO) was not a significant predictor of the need for readmission (p = 0.986) or reoperation (p = 0.753). The overall infection rate was 7.0%, including 3.3% deep infections. The rate of DVT was 3.7%. ConclusionNormative quality metrics are not established for complex deformity surgery in adult patients. This paper demonstrates that readmissions and reoperations in complex spinal reconstruction in adults occur at a higher rate than expected rates in less complex spine procedures. Age is an important independent predictor of readmission, but not the need for reoperation. For each decade older, patients are 1.4 times more likely to be readmitted within 6 months of surgery. This data may be useful to provide normative data for comparative studies of surgical outcomes with similar magnitude of deformity treated with operations of comparable invasiveness.

A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes

Background ContextA variety of surgical approaches have been used for cage insertion in lumbar interbody fusion surgery. The direct anterior approach requires mobilization of the great vessels to access the intervertebral disc spaces cranial to L5/S1. With the lateral retroperitoneal transpsoas approach, it is difficult to access the L4/L5 intervertebral disc space due to the lumbar plexus and iliac crest, and L5/S1 is inaccessible. We describe a new anterolateral retroperitoneal approach, which is safe and reproducible to access the disc spaces from L1 to S1 inclusive, obviating the need for a separate direct anterior approach to access L5/S1. PurposeThis paper had the following objectives: first, to report a reproducible novel single-incision, muscle-splitting, anterolateral pre-psoas surgical approach to the lumbar spine from L1 to S1; second, to highlight the technical challenges of this approach and highlight approach-related complications; and third, to evaluate clinical outcomes using this surgical technique in a prospective series of L1 to S1 anterior lumbar interbody fusions (ALIFs) performed as part of a 360-degree fusion for adult spinal deformity correction. Study DesignThis report used a prospective cohort study. Patient SampleA prospective series of patients (n=64) having ALIF using porous tantalum cages as part of a two-stage complex spinal reconstruction from L1 to S1 were studied. Outcome MeasuresData collected included blood loss, operative time, incision size, technical challenges, perioperative complications, and secondary procedures. Clinical outcome measures used included visual analogue scale (VAS) Back Pain, VAS Leg Pain, EuroQoL-5 Dimensions (EQ-5D), EQ-5D VAS, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22). MethodsPre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 1.8 years. ResultsMean blood loss was 68±9.6 mL. The mean VAS Back Pain score improved from 7.5±1.25 preoperatively to 2.5±1.7 at 3 months (p=.02), 1.2±0.5 at 6 months (p=.01), and 1.4±0.6 at 1 year (p=.02). The mean ODI improved from 64.3±31.8 preoperatively to 16.6±14.7 at 3 months (p>.05), 10.7±6.0 at 6 months (p=.02), and 6.7±6.1 at 1 year (p=.01). There were no permanent neurologic, vascular, or visceral injuries. One revision anterior procedure was required on a patient with rheumatoid arthritis and advanced systemic disease that sustained a sacral fracture and required revision ALIF at L5/S1. ConclusionsThe technique described is a safe, new, muscle-splitting, psoas-preserving, one-incision approach to provide access from L1 to S1 for multilevel anterior or oblique lumbar interbody fusion surgery.

Outrigger rod technique for supplemental support of posterior spinal arthrodesis

Background contextInstrumentation failure is a recognized complication after complex spinal reconstruction and deformity correction. Rod fracture (RF) is the most frequent mode of hardware failure in long-segment spinal fusion surgery. This complication can negatively impact the clinical outcome by producing spinal pain, functional compromise, instability, and loss of deformity correction. PurposeTo describe the outrigger rod surgical technique. Study designReview of literature, case review, and surgical technique description. Patient sampleTwo clinical cases are presented. Outcome measuresRod fracture. MethodsOutrigger rod placement in posterior spinal arthrodesis is performed by supplementing primary spinal rods with outrigger rods attached with cranial and caudal side-by-side connectors providing a more robust construct. ResultsThis technique may be beneficial for preventing RF in patients undergoing surgery for three-column osteotomy for sagittal imbalance; pseudarthrosis surgery with previous hardware failure; transforaminal lumbar interbody cage placement at multiple levels in realignment procedures, long-segment spinal arthrodesis with impaired host fusion potential; long-segment instrumented fusions that span the cervicothoracic, thoracolumbar, or lumbosacral junction; and across spinal segments at high risk for RF (eg, after extensive resection of vertebral elements in the management of metastatic malignancy). ConclusionsThe risk of rod failure is substantial in the setting of long-segment spinal arthrodesis and corrective osteotomy. Efforts to increase the mechanical strength of posterior constructs may reduce the occurrence of this complication. The outrigger rod technique increases spinal construct stiffness and may improve the longevity of the construct. This technique should reduce the rate of device failure during maturation of posterior fusion mass and limit the need for supplemental anterior column support.

Clinical and radiologic outcome from 360-degree lumbar spondylodesis using porous tantalum cages in complex spinal reconstruction for degenerative lumbar spine deformity

Clinical and radiologic outcome from 360-degree lumbar spondylodesis using porous tantalum cages in complex spinal reconstruction for degenerative lumbar spine deformity

Clinical and Radiographic Outcomes After 3-Column Osteotomies With 5-Year Follow-up

Retrospective review of prospective database. To investigate long-term results after 3-column osteotomies (3-CO). Short-term studies have noted improved outcomes and alignment after 3-CO, but there is a paucity of long-term studies with a large group of patients. An analysis of 126 patients who underwent a 3-CO (pedicle subtraction osteotomy [N = 101]/vertebral column resection [N = 25]) with minimum 5-year follow-up was performed at a single institution. The mean age was 48 years (range, 8-79 yr) and average follow-up was for 7 years (range, 5-14 yr). Oswestry Disability Index and Scoliosis Research Society (SRS) scores and radiographical parameters were assessed at baseline, 6 weeks, and 1, 2, 3, and/or 5 years postoperatively and complications were recorded. Sagittal alignment improved at all postoperative time points from baseline (mean, 117 mm), but diminished from 6 weeks (mean, 24 mm) to 5 years (mean, 41 mm; P = 0.03). Average coronal alignment was improved from baseline (27 mm) at 6 weeks (18 mm; P = 0.003) and 5 years postoperatively (19 mm; P = 0.007), with no deterioration between 6 weeks and 5 years postoperatively (P = 0.9). Major surgical complications occurred in 36% (n = 45) and major repeat surgery was performed in 28% (n = 35). Significant improvements (P < 0.05) in Oswestry Disability Index and all SRS domain scores were found at each time point. All mean outcome scores at 5 years postoperatively exceeded minimal clinically important difference thresholds except the SRS function domain. Improvement in outcomes at 5 years postoperatively was similar in groups with major surgical complications versus those without and in those with reoperation versus those without. This study of 126 patients undergoing 3-CO found significant and sustained improvements in Oswestry Disability Index and SRS scores and sagittal alignment at a minimum 5 years postoperatively. This demonstrates the durability of these complex spinal reconstructions, even surprisingly in those patients having a major complication and/or revision surgery. 4.

The Seattle Spine Team Approach to Adult Deformity Surgery: A Systems-Based Approach to Perioperative Care and Subsequent Reduction in Perioperative Complication Rates

Study DesignRetrospective consecutive case review pre- and postintervention. ObjectivesCharacterize the effects of the intervention.Summary of Background Data: Complication rates in adult spinal deformity surgery are unacceptable. System approaches are necessary to increase patient safety. This group reported on the dual–attending surgeon approach, a live multidisciplinary preoperative screening conference, and the intraoperative protocol for the management of coagulopathy. The outcomes were demonstrated by complication rates before and after the institution of this protocol. MethodsForty consecutive patients in Group A were managed without the 3-pronged approach. A total of 124 consecutive patients in Group B had a dual–attending surgeon approach, were presented and cleared by a live multidisciplinary preoperative conference, and were managed according to the intraoperative protocol. ResultsGroup A had an average age of 62 years (range, 39–84 years). Group B had an average age of 64 years (range, 18–84 years). Most patients in both groups had fusions from 9 to 15 levels. Complication rates in Group B were significantly lower (16% vs. 52%) (p < .001). Group B showed significantly lower return rates to the operating room during the perioperative 90-day period (0.8% vs. 12.5%) (p < .001). Group B also had lower rates of wound infection requiring debridement (1.6% vs. 7.5%), lower rates of deep vein thrombosis/pulmonary embolism (3.2% vs. 10%), and lower rates of postoperative neurological complications (0.5% vs. 2.5%) (not significant). Group B had significantly lower rates of urinary tract infection requiring antibiotics (9.7% vs. 32.5%) (p < .001). ConclusionsThese data suggests that a team approach consisting of a dual–attending surgeon approach in the operating room, a live preoperative screening conference, and an intraoperative protocol for managing coagulopathy will significantly reduce perioperative complication rates and enhance patient safety in patients undergoing complex spinal reconstructions for adult spinal deformity.

The Role of the Minimally Invasive Extreme Lateral Interbody Fusion Procedure for Complex Spinal Reconstruction☆

Extreme lateral interbody fusion (XLIF) has gained popularity for use in degenerative stenosis and other conditions of the lumbar spine. The XLIF approach affords an ability to correct collapsed disc spaces and potentially aid in the correction of complex spinal deformities while minimizing blood loss and neurologic complications. Potential indications for the use of XLIF in complex deformities include adult degenerative scoliosis, adjacent segment disease, and infection. Complications include a high number of transient neurologic injuries to the lumbosacral plexus and rare permanent deficits. Although the technology remains in the early stages of adoption, XLIF can be a powerful tool for use in complex spinal deformities.

The Results of Vascularized-free Fibular Grafts in Complex Spinal Reconstruction

Retrospective review. To determine outcomes after anterior or posterior placement of vascularized-free fibular grafts in complex spinal reconstruction for tumor resection and osteomyelitis and to evaluate the results with respect to bony fusion, time to union, and complications. Biological reconstruction of segmental defects of the spinal column may be required when multiple vertebrae are resected for tumor or infection. Published series to date have not fully addressed surgical techniques or outcome and complications. A retrospective, Institutional Review Board-approved review was performed on the medical records and neuroimaging of all patients who underwent a vascularized-free fibular graft for a multisegmental spine reconstruction at a single institution over the last 10 years. Details regarding indications, the levels spanned, the graft length, and the time to union were evaluated. Seven patients (mean age, 43 y) underwent surgery using this technique, with an average follow-up of 38 months. Surgical indications included oncologic resection associated with radiation therapy (n=3) and surgical treatment of vertebral osteomyelitis (n=4). An average of 2.7 (median, 2) levels was fused with an average of 2.1 (median, 2) vertebral body excisions performed. Mean fibular length was 19.1 cm. Six of 7 patients achieved union at mean of 3.2 months. Complications specific to the fibular grafting procedure included 1 nonunion associated with pedicle thrombosis. Vascularized-free fibular grafts are effective in the treatment of complex spinal reconstruction after surgery for spinal tumors or osteomyelitis. The vascularized-free fibular graft adds structural support as well as living bone to the fusion site and is a reasonable alternative to nonvascularized grafts in locally compromised surgical beds.

Sacropelvic Fixation

Literature-based topic review. To review the indications and techniques for different sacropelvic fixation methods and to outline important associated complications. Despite all the advances and new developments in spinal instrumentation techniques, fixation at the lumbosacral junction continues to be one of the important challenges to spine surgeons. The poor bone quality of the sacrum, the complex regional anatomy, and the tremendous biomechanical forces at the lumbosacral junction contribute to the high rates of instrumentation-related problems. Although many techniques for sacropelvic fixation have been attempted, only a few are still widely used because of the high rate of complications associated with some of those techniques. Review of literature and expert opinion. There are many indications for sacropelvic fixation. Long fusions to the sacrum are the most common reasons for extending the instrumentation to the pelvis. Spinal surgeons performing complex spinal reconstruction should be familiar with the currently available techniques, including their potential risks and complications. Surgical treatment decisions should be based on an individual patient's anatomy and abnormalities, and on the surgeon's experience.