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109. Radiographic and Clinical Results of L5 and S1 Pedicle Subtraction Osteotomies (PSO) for the Correction of Spinal Sagittal Imbalance
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S on 5 patients: improper screw placement (1), pseudoarthrosis proximal to L4 (2), junctional stenosis (1), residual deformity (1). Overall complication rate was 40.4% (7.7% minor, 34.6% major). Complications specific to S2iliac fixation: screw breakage 2, screw misplacement 1. There was stastically significant improvement in all SRS22 domains; (pre-/post; p-value): pain 1.1 (2.17/3.22; p!.001), self image 1.1 (2.12/3.19; p!.001), activity 0.8 (2.39/3.16; p!.001), mental 1.2 (1.89-3.07; p!.001), and satisfaction 0.9 (1.91/2.84; p!.001). The ODI showed a mean decrease 13.4 (40.16/ 26.79; p!.001), the SF-12 improvement of 12.3 (60.3/72.6; p5.005) in physical and 2.2 (59.9/69,4; p5.004) points in mental health. The VAS showed 5 patients with right SI-joint area pain (mean 4.8), 4 patients had left side pain (mean 5.5). There was one superficial and one deep wound infections. CONCLUSIONS: S2 Alar Iliac (S2AI) fixation is an easy, safe and effective method to achieve sacropelvic fixation in long posterior spinal fusions. Complications related to the technique are rare and the revision rate is low. FDA DEVICE/DRUG STATUS: Pedicle Screws: Approved for this indication.
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improvement; ODI score decreased from an average 66.5 613.1 (48, 84) to 40.2618.8 (24, 72) at last visit. The mean SRS-22 score was 2.3 (1.3, 2.9) prior to surgery, improving to 3.0 (2.2, 3.4) at last follow-up. CONCLUSIONS: L5 and S1 PSOs are technically challenging procedures, due to several factors including; 1- Unique anatomy of this area 2- Difficulty in achieving secure distal fixation 3- The reported higher rate of L5 nerve root injury. That has led to the reluctance of spine surgeons to consider PSO at these levels. However distal lumbosacral osteotomies can be very effective in the correction of sagittal imbalance, especially in patients with focal deformity distal to L4. In this relatively small series, yet the largest to date of L5 and S1 PSOs, we found that the clinical and radiographic outcomes are satisfactory with comparable complications to other levels PSOs and without an increased risk of neurologic injury or loss of fixation.
doi: 10.1016/j.spinee.2009.08.133
109. Radiographic and Clinical Results of L5 and S1 Pedicle Subtraction Osteotomies (PSO) for the Correction of Spinal Sagittal Imbalance Hassan Alosh1, Ahmed Salem2, Lee Riley, III, MD2, Khaled Kebaish, MD1; 1 Johns Hopkins University, Baltimore, MD, USA; 2Baltimore, MD, USA BACKGROUND CONTEXT: Pedicle subtraction osteotomy at L5 or S1 is rarely performed due to the difficulty in achieving distal fixation and to the concern about the potential for higher complications compared to PSO at a more proximal level. However L5 and S1 osteotomies can be more effective in correcting a focal deformity at the lumbosacral junction or the sacrum and in achieving a more physiologic spinal sagittal balance. PURPOSE: Little is known about the outcomes and complications associated with L5 and S1 PSOs. The potential advantages of this approach in correcting sagittal imbalance have yet to be reported. STUDY DESIGN/SETTING: Retrospective cohort of 14 consecutive patients who have undergone a PSO at L5 or S1 for the correction of sagittal imbalance at a single academic institution. PATIENT SAMPLE: 14 consecutive patients who have undergone a PSO at L5 or S1. OUTCOME MEASURES: Standard functional outcome tools, including the SRS 22, Oswestry Disability Index (ODI) and the visual analogue scale (VAS). Radiographic data and perioperative complications were collected. METHODS: Fourteen consecutive patients were retrospectively reviewed. Radiographic data included standard preoperative, postoperative and final follow-up 36 inch films. Radiographic measurements included, Lumbar lordosis cobb angles, in addition to the SVA and pelvic incidence. Functional outcome was determined with prospectively administered standard questionnaires. Post-operative complications were determined from a retrospective chart review. RESULTS: Fourteen patients underwent a PSO at L5 or S1 as part of multiple reconstructive procedures to correct a spinal deformity. Ten PSOs were performed at L5 and four at S1 for focal lumbosacral deformities. Preoperative diagnoses included; sacral fractures (n54), pseudoarthrosis (n52), congenital kyphoscoliosis (n51), ankylosing spondylitis (n51), Charcot’s spine (n51), and Lumbar flat back (n51). Complications included; two superficial wound infections and one L5 radiculopathy which resolved within 6 months. There was no pseudoarthrosis, loss of fixation or permanent neurologic deficit. Mean follow-up was 2.24 yrs (1.39, 3.15 yrs). Mean lumbar lordosis pre-operatively was -28.7 (5.8, -63.6), improving to -50.3 (-21.2, -73.8) at last follow-up. An overall 22.2 (8.3, 37.5) correction. At baseline, SVA was þ182.9 mm (þ103.9, þ303.4), decreasing to þ18.7 mm (-66.0, þ146.9), a mean 164.2 mm (73.1, 268.4) correction of sagittal imbalance. Patients also reported significant clinical
Figure. Preoperative radiograph (L) and postoperative (R) radiograph and CT of a 65 yo F s/p L5 PSO for severe sagittal imbalance after multiple prior surgeries including proximal levels PSOs.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.134
110. Restoration of Global Sagittal Balance with Thoracolumbar Osteotomy Results in Spontaneous Correction of Cervical Alignment in Patients who Maintain Horizontal Gaze Preoperatively John Rodriguez, MD1, Azadeh Farin, MD2, Vedat Deviren, MD1, Serena Hu, MD1, Christopher Ames, MD1; 1University of California, San Francisco, San Francisco, CA, USA; 2University of Southern California, Los Angeles, CA, USA Abstract text not published at authors’ request. doi: 10.1016/j.spinee.2009.08.135
111. Proximal Thoracic vs. Thoracolumbar Stop Following Pedicle Subtraction Osteotomy for Adult Patients with Sagittal Imbalance: Which One is Better? Yongjung Kim, MD1, Keith Bridwell, MD2, Lawrence Lenke, MD2, Oheneba Boachie-Adjei, MD3, Chris Hamill, MD4, Thomas Cha, MD5, Samuel Cho, MD5; 1Washington University in St. Louis, New York, NY, USA; 2Washington University in St. Louis, St. Louis, MO, USA; 3New York, NY, USA; 4University at Buffalo, Buffalo, NY, USA; 5Columbia University, New York, NY, USA BACKGROUND CONTEXT: No study on selection of proximal fusion level in pedicle subtraction osteotomy.
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improvement; ODI score decreased from an average 66.5 613.1 (48, 84) to 40.2618.8 (24, 72) at last visit. The mean SRS-22 score was 2.3 (1.3, 2.9) prior to surgery, improving to 3.0 (2.2, 3.4) at last follow-up. CONCLUSIONS: L5 and S1 PSOs are technically challenging procedures, due to several factors including; 1- Unique anatomy of this area 2- Difficulty in achieving secure distal fixation 3- The reported higher rate of L5 nerve root injury. That has led to the reluctance of spine surgeons to consider PSO at these levels. However distal lumbosacral osteotomies can be very effective in the correction of sagittal imbalance, especially in patients with focal deformity distal to L4. In this relatively small series, yet the largest to date of L5 and S1 PSOs, we found that the clinical and radiographic outcomes are satisfactory with comparable complications to other levels PSOs and without an increased risk of neurologic injury or loss of fixation.
doi: 10.1016/j.spinee.2009.08.133
109. Radiographic and Clinical Results of L5 and S1 Pedicle Subtraction Osteotomies (PSO) for the Correction of Spinal Sagittal Imbalance Hassan Alosh1, Ahmed Salem2, Lee Riley, III, MD2, Khaled Kebaish, MD1; 1 Johns Hopkins University, Baltimore, MD, USA; 2Baltimore, MD, USA BACKGROUND CONTEXT: Pedicle subtraction osteotomy at L5 or S1 is rarely performed due to the difficulty in achieving distal fixation and to the concern about the potential for higher complications compared to PSO at a more proximal level. However L5 and S1 osteotomies can be more effective in correcting a focal deformity at the lumbosacral junction or the sacrum and in achieving a more physiologic spinal sagittal balance. PURPOSE: Little is known about the outcomes and complications associated with L5 and S1 PSOs. The potential advantages of this approach in correcting sagittal imbalance have yet to be reported. STUDY DESIGN/SETTING: Retrospective cohort of 14 consecutive patients who have undergone a PSO at L5 or S1 for the correction of sagittal imbalance at a single academic institution. PATIENT SAMPLE: 14 consecutive patients who have undergone a PSO at L5 or S1. OUTCOME MEASURES: Standard functional outcome tools, including the SRS 22, Oswestry Disability Index (ODI) and the visual analogue scale (VAS). Radiographic data and perioperative complications were collected. METHODS: Fourteen consecutive patients were retrospectively reviewed. Radiographic data included standard preoperative, postoperative and final follow-up 36 inch films. Radiographic measurements included, Lumbar lordosis cobb angles, in addition to the SVA and pelvic incidence. Functional outcome was determined with prospectively administered standard questionnaires. Post-operative complications were determined from a retrospective chart review. RESULTS: Fourteen patients underwent a PSO at L5 or S1 as part of multiple reconstructive procedures to correct a spinal deformity. Ten PSOs were performed at L5 and four at S1 for focal lumbosacral deformities. Preoperative diagnoses included; sacral fractures (n54), pseudoarthrosis (n52), congenital kyphoscoliosis (n51), ankylosing spondylitis (n51), Charcot’s spine (n51), and Lumbar flat back (n51). Complications included; two superficial wound infections and one L5 radiculopathy which resolved within 6 months. There was no pseudoarthrosis, loss of fixation or permanent neurologic deficit. Mean follow-up was 2.24 yrs (1.39, 3.15 yrs). Mean lumbar lordosis pre-operatively was -28.7 (5.8, -63.6), improving to -50.3 (-21.2, -73.8) at last follow-up. An overall 22.2 (8.3, 37.5) correction. At baseline, SVA was þ182.9 mm (þ103.9, þ303.4), decreasing to þ18.7 mm (-66.0, þ146.9), a mean 164.2 mm (73.1, 268.4) correction of sagittal imbalance. Patients also reported significant clinical
Figure. Preoperative radiograph (L) and postoperative (R) radiograph and CT of a 65 yo F s/p L5 PSO for severe sagittal imbalance after multiple prior surgeries including proximal levels PSOs.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.134
110. Restoration of Global Sagittal Balance with Thoracolumbar Osteotomy Results in Spontaneous Correction of Cervical Alignment in Patients who Maintain Horizontal Gaze Preoperatively John Rodriguez, MD1, Azadeh Farin, MD2, Vedat Deviren, MD1, Serena Hu, MD1, Christopher Ames, MD1; 1University of California, San Francisco, San Francisco, CA, USA; 2University of Southern California, Los Angeles, CA, USA Abstract text not published at authors’ request. doi: 10.1016/j.spinee.2009.08.135
111. Proximal Thoracic vs. Thoracolumbar Stop Following Pedicle Subtraction Osteotomy for Adult Patients with Sagittal Imbalance: Which One is Better? Yongjung Kim, MD1, Keith Bridwell, MD2, Lawrence Lenke, MD2, Oheneba Boachie-Adjei, MD3, Chris Hamill, MD4, Thomas Cha, MD5, Samuel Cho, MD5; 1Washington University in St. Louis, New York, NY, USA; 2Washington University in St. Louis, St. Louis, MO, USA; 3New York, NY, USA; 4University at Buffalo, Buffalo, NY, USA; 5Columbia University, New York, NY, USA BACKGROUND CONTEXT: No study on selection of proximal fusion level in pedicle subtraction osteotomy.