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10:14 63. Decompression and Instrumented Fusion for Management of Degenerative Lumbar Scoliosis
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Proceedings of the NASS 21st Annual Meeting / The Spine Journal 6 (2006) 1S–161S
RESULTS: Both hip pain VAS scores and Harris hip scores were significantly better after THR. Mean hip pain VAS scores were 7.08 before and 2.52 after THR surgery (p!.01). Harris hip scores were 45.74 before and 81.8 after the surgery (p!.01). Both low back pain VAS scores, as well as Oswestry spinal disability scores were significantly better after total hip replacement surgery. Mean low back pain VAS scores were 5.04 before and 3.68 after THR surgery (p5.013). Oswestry spinal disability scores were 36.72 before and 24.08 after total hip replacement surgery (p5.02). CONCLUSIONS: Low back pain was alleviated and spinal functional assessment indexes were significantly improved after total hip replacement surgery. This study, while pointing to the well known clinical association between hip and spine pathology, is among the first studies that demonstrates the clinical benefits total hip replacement surgery has upon back pain. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. CONFLICT OF INTEREST: No conflicts. doi: 10.1016/j.spinee.2006.06.085
10:14 63. Decompression and Instrumented Fusion for Management of Degenerative Lumbar Scoliosis Christopher Furey1, Sanford Emery2; 1Case Western Reserve University, Cleveland, OH, USA; 2West Virginia University School of Medicine, Morgantown, WV, USA BACKGROUND CONTEXT: Surgical management of adult degenerative scoliosis is a challenging problem with several different options available to the surgeon. PURPOSE: To assess the long-term efficacy of decompression and fusion employing pedicle screw instrumentation and iliac crest bone grafting in the treatment of degenerative scoliosis, with special attention to the nature and frequency of postoperative complications and the need for re-operation. STUDY DESIGN/SETTING: A retrospective analysis of clinical and radiographic outcomes. PATIENT SAMPLE: 42 adults (32 women and 10 men). Six patients had prior a lumbar decompression, although none had prior fusion. OUTCOME MEASURES: Specific queries regarding relief of back pain and leg pain, improvement in quality of life, satisfaction of preoperative expectations, and willingness to repeat the same procedure in hindsight. Plain radiograpghs in each case and CT scan if there was concern for pseudarthrosis. METHODS: All levels with spinal stenosis were decompressed including bilateral foraminotomies. All levels decompressed were fused as were any levels with lateral listhesis greater than 6 millimeters. The proximal extent of the fusion was at the lowest neutral vertebrae in the upper lumbar or lower thoracic spine. Fusion was extended to the sacrum only if an L5S1 spondylolisthesis was present (6 cases), but otherwise was stopped at L5. Average follow-up was 4.2 years (range 2.0–8.4 years). RESULTS: Relief of leg pain was excellent in 83%, good in 12%, fair or poor in 5%. Relief of back pain was excellent in 55%, good in 33%, fair or poor in 12%. 86% of patients felt there was improvement in their lifestyle postoperatively. 81% of patients felt their preoperative expectations had been met or exceeded. Posterolateral fusion was noted to be solid on plain radiographs by 6 months in 86% and marginal in 10%. There were two cases (4%) with pseudarthrosis. Positive outcomes were not significantly affected by number of levels fused or extension of fusion into the thoracic spine proximally or to the sacrum distally. Improvement in sagittal balance as measured on pre- and postoperative radiographs did not correlate with a favorable outcome. Presence of solid fusion did correlate with a favorable outcome. Eight patients (19%) required further surgery. Two patients (4%) with pseudarthrosis required revision instrumented fusion, two patients (4%) with early postoperative infections required surgical washouts with preservation of
instrumentation. Two patients (4%) had elective removal of painful instrumentation after 1 year. Two patients (4%) developed proximal junctional kyphosis requiring extension of fusion into the lower thoracic spine. CONCLUSIONS: Posterior decompression and fusion with pedicle screw instrumentation and iliac crest grafting is an effective treatment for adult degenerative scoliosis. Relief of leg pain is the most predictable outcome, although most patients achieve satisfactory relief of back pain as well. This surgical option is aggressive for older patients, with potential for significant complications and thus should be reserved for those patients who have failed conservative management and who are suitable medical candidates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. CONFLICT OF INTEREST: No conflicts. doi: 10.1016/j.spinee.2006.06.086
10:20 64. Neurologic Complications of Pedicle Subtraction Osteotomy: A Ten-Year Review Jacob Buchowski, MD, MS1, Craig Kuhns, MD1, Ronald Lehman, Jr., MD2, Yongjung Kim, MD1, Lawrence Lenke, MD1, Keith Bridwell, MD1; 1 Washington University in St. Louis, St. Louis, MO, USA; 2Walter Reed Army Medical Center, Washington, DC, USA BACKGROUND CONTEXT: Pedicle subtraction osteotomy (PSO), which is performed by resecting the posterior elements, pedicles, and vertebral body through a posterior approach, is frequently used to correct fixed sagittal imbalance creating approximately 30 of lordosis at the level of the osteotomy. This is a technically demanding procedure and can be fraught with complications. Nevertheless, no reports of neurologic complications after PSOs are available in the peer-reviewed literature. PURPOSE: The objectives of this study were to evaluate intra- and postoperative neurologic deficits after PSOs, to determine the risk factors associated with the development of a neurologic complication after PSO, to examine treatment strategies, and to analyze patient outcome. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Adult patients with fixed sagittal imbalance who underwent a pedicle subtraction osteotomy at a single tertiary referral spine center. OUTCOME MEASURES: Radiographic parameters and clinical outcome measures. METHODS: A total of 114 consecutive patients (84 women and 28 men) with an average age of 54.7613.9 years treated over a 10-year period (1995-2005) with a pedicle subtraction osteotomy for fixed sagittal imbalance were evaluated. The medical records were reviewed and intraoperative electrophysiologic data were analyzed. Radiographic analysis including assessment of thoracic kyphosis, lumbar lordosis, as well as sagittal and coronal balance was performed. RESULTS: A total of 114 pedicle subtraction osteotomies were performed. After surgery, thoracic kyphosis increased from 28.2618.6 to 35.4614.7 (p!.012). Similarly, lumbar lordosis increased from (-16.3)619.5 to (-50.2)615.2 (p!.001). Sagittal balance improved from 137672 mm preoperatively to 21652 mm postoperatively (p!.001). The incidence of intra- and postoperative neurologic deficit was 10.5% (12 of 114 patients). Neurologic deficits were found intraoperatively during a Stagnara wake-up test in three patients, immediately postoperatively in the operating room suite in four patients, and in a delayed manner in the remaining five patients. Although triggered EMGs were not used in all patients, electrophysiologic testing did not detect the deficit in any of the patients. Deficits were always unilateral and usually did not correspond to the level of the osteotomy. In nine patients surgical intervention consisting of central enlargement and further decompression was required. Four patients had weakness of multiple muscle groups. Neurologic deficits included weakness of: tibialis anterior (7 patients), quadriceps (5 patients), extensor hallucis longus (3 patients), flexor hallucis longus (1 patient), and cauda
Proceedings of the NASS 21st Annual Meeting / The Spine Journal 6 (2006) 1S–161S
RESULTS: Both hip pain VAS scores and Harris hip scores were significantly better after THR. Mean hip pain VAS scores were 7.08 before and 2.52 after THR surgery (p!.01). Harris hip scores were 45.74 before and 81.8 after the surgery (p!.01). Both low back pain VAS scores, as well as Oswestry spinal disability scores were significantly better after total hip replacement surgery. Mean low back pain VAS scores were 5.04 before and 3.68 after THR surgery (p5.013). Oswestry spinal disability scores were 36.72 before and 24.08 after total hip replacement surgery (p5.02). CONCLUSIONS: Low back pain was alleviated and spinal functional assessment indexes were significantly improved after total hip replacement surgery. This study, while pointing to the well known clinical association between hip and spine pathology, is among the first studies that demonstrates the clinical benefits total hip replacement surgery has upon back pain. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. CONFLICT OF INTEREST: No conflicts. doi: 10.1016/j.spinee.2006.06.085
10:14 63. Decompression and Instrumented Fusion for Management of Degenerative Lumbar Scoliosis Christopher Furey1, Sanford Emery2; 1Case Western Reserve University, Cleveland, OH, USA; 2West Virginia University School of Medicine, Morgantown, WV, USA BACKGROUND CONTEXT: Surgical management of adult degenerative scoliosis is a challenging problem with several different options available to the surgeon. PURPOSE: To assess the long-term efficacy of decompression and fusion employing pedicle screw instrumentation and iliac crest bone grafting in the treatment of degenerative scoliosis, with special attention to the nature and frequency of postoperative complications and the need for re-operation. STUDY DESIGN/SETTING: A retrospective analysis of clinical and radiographic outcomes. PATIENT SAMPLE: 42 adults (32 women and 10 men). Six patients had prior a lumbar decompression, although none had prior fusion. OUTCOME MEASURES: Specific queries regarding relief of back pain and leg pain, improvement in quality of life, satisfaction of preoperative expectations, and willingness to repeat the same procedure in hindsight. Plain radiograpghs in each case and CT scan if there was concern for pseudarthrosis. METHODS: All levels with spinal stenosis were decompressed including bilateral foraminotomies. All levels decompressed were fused as were any levels with lateral listhesis greater than 6 millimeters. The proximal extent of the fusion was at the lowest neutral vertebrae in the upper lumbar or lower thoracic spine. Fusion was extended to the sacrum only if an L5S1 spondylolisthesis was present (6 cases), but otherwise was stopped at L5. Average follow-up was 4.2 years (range 2.0–8.4 years). RESULTS: Relief of leg pain was excellent in 83%, good in 12%, fair or poor in 5%. Relief of back pain was excellent in 55%, good in 33%, fair or poor in 12%. 86% of patients felt there was improvement in their lifestyle postoperatively. 81% of patients felt their preoperative expectations had been met or exceeded. Posterolateral fusion was noted to be solid on plain radiographs by 6 months in 86% and marginal in 10%. There were two cases (4%) with pseudarthrosis. Positive outcomes were not significantly affected by number of levels fused or extension of fusion into the thoracic spine proximally or to the sacrum distally. Improvement in sagittal balance as measured on pre- and postoperative radiographs did not correlate with a favorable outcome. Presence of solid fusion did correlate with a favorable outcome. Eight patients (19%) required further surgery. Two patients (4%) with pseudarthrosis required revision instrumented fusion, two patients (4%) with early postoperative infections required surgical washouts with preservation of
instrumentation. Two patients (4%) had elective removal of painful instrumentation after 1 year. Two patients (4%) developed proximal junctional kyphosis requiring extension of fusion into the lower thoracic spine. CONCLUSIONS: Posterior decompression and fusion with pedicle screw instrumentation and iliac crest grafting is an effective treatment for adult degenerative scoliosis. Relief of leg pain is the most predictable outcome, although most patients achieve satisfactory relief of back pain as well. This surgical option is aggressive for older patients, with potential for significant complications and thus should be reserved for those patients who have failed conservative management and who are suitable medical candidates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. CONFLICT OF INTEREST: No conflicts. doi: 10.1016/j.spinee.2006.06.086
10:20 64. Neurologic Complications of Pedicle Subtraction Osteotomy: A Ten-Year Review Jacob Buchowski, MD, MS1, Craig Kuhns, MD1, Ronald Lehman, Jr., MD2, Yongjung Kim, MD1, Lawrence Lenke, MD1, Keith Bridwell, MD1; 1 Washington University in St. Louis, St. Louis, MO, USA; 2Walter Reed Army Medical Center, Washington, DC, USA BACKGROUND CONTEXT: Pedicle subtraction osteotomy (PSO), which is performed by resecting the posterior elements, pedicles, and vertebral body through a posterior approach, is frequently used to correct fixed sagittal imbalance creating approximately 30 of lordosis at the level of the osteotomy. This is a technically demanding procedure and can be fraught with complications. Nevertheless, no reports of neurologic complications after PSOs are available in the peer-reviewed literature. PURPOSE: The objectives of this study were to evaluate intra- and postoperative neurologic deficits after PSOs, to determine the risk factors associated with the development of a neurologic complication after PSO, to examine treatment strategies, and to analyze patient outcome. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Adult patients with fixed sagittal imbalance who underwent a pedicle subtraction osteotomy at a single tertiary referral spine center. OUTCOME MEASURES: Radiographic parameters and clinical outcome measures. METHODS: A total of 114 consecutive patients (84 women and 28 men) with an average age of 54.7613.9 years treated over a 10-year period (1995-2005) with a pedicle subtraction osteotomy for fixed sagittal imbalance were evaluated. The medical records were reviewed and intraoperative electrophysiologic data were analyzed. Radiographic analysis including assessment of thoracic kyphosis, lumbar lordosis, as well as sagittal and coronal balance was performed. RESULTS: A total of 114 pedicle subtraction osteotomies were performed. After surgery, thoracic kyphosis increased from 28.2618.6 to 35.4614.7 (p!.012). Similarly, lumbar lordosis increased from (-16.3)619.5 to (-50.2)615.2 (p!.001). Sagittal balance improved from 137672 mm preoperatively to 21652 mm postoperatively (p!.001). The incidence of intra- and postoperative neurologic deficit was 10.5% (12 of 114 patients). Neurologic deficits were found intraoperatively during a Stagnara wake-up test in three patients, immediately postoperatively in the operating room suite in four patients, and in a delayed manner in the remaining five patients. Although triggered EMGs were not used in all patients, electrophysiologic testing did not detect the deficit in any of the patients. Deficits were always unilateral and usually did not correspond to the level of the osteotomy. In nine patients surgical intervention consisting of central enlargement and further decompression was required. Four patients had weakness of multiple muscle groups. Neurologic deficits included weakness of: tibialis anterior (7 patients), quadriceps (5 patients), extensor hallucis longus (3 patients), flexor hallucis longus (1 patient), and cauda