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149. Sagittal Decompensation Following Pedicle Subtraction Osteotomy for Adult Patients with Sagittal Imbalance
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S and TLIF, structural bone and cage support were effective. BMP overgrowth occurred 1/250 discs. Nonunions only occurred at L5-S1 (5/49 discs, 10%) and had worse outcomes than patients achieving fusion. The stress across L5-S1 in long fusions, especially in severe sagittal imbalance, continues to challenge arthrodesis, despite improved fusion rates with rhBMP-2. FDA DEVICE/DRUG STATUS: rhBMP-2: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.183
149. Sagittal Decompensation Following Pedicle Subtraction Osteotomy for Adult Patients with Sagittal Imbalance Yongjung Kim, MD1, Keith Bridwell, MD2, Lawrence Lenke, MD2, Oheneba Boachie-Adjei, MD3, Chris Hamill, MD4, Samuel Cho, MD1, Thomas Cha, MD1; 1Columbia University, New York, NY, USA; 2 Washington University in St. Louis, St. Louis, MO, USA; 3Hospital for Special Surgery, New York, NY, USA; 4University at Buffalo, Buffalo, NY, USA BACKGROUND CONTEXT: No study on sagittal decompensation following lumbar pedicle subtraction osteotomy. PURPOSE: To determine postoperative sagittal decompensation (SD) following pedicle subtraction osteotomy (PSO) for adult patients with sagittal imbalance. STUDY DESIGN/SETTING: retrospective multicenter study. PATIENT SAMPLE: 141 patients with a minimum 2 years follow-up following pedicle subtraction osteotomy. OUTCOME MEASURES: radiographic and SRS outcome instrument. METHODS: A radiographic and clinical assessment of 141 adult patients (average 54.7 years) with sagittal imbalance who underwent PSO with a minimum 2-year follow-up (average 4.3 years, range 2-12 years) was performed. SD was defined as the sagittal vertical axis (SVA) O8 cm. RESULTS: The incidence was 29% (41/141), of which 16% (23) had early onset (!8 weeks postoperatively) and 15% had late onset SD. Comparing between SD and non-SD groups, age at surgery, co-morbidities, postoperative thoracic kyphosis (TK) Cobb angle (T5-T12), postoperative lumbar lordosis (LL) Cobb angle (T12-S1), the change in LL Cobb angle following PSO, and the sum of TK and LL Cobb angles were statistically different (p!0.05) between them (See Table 1). Associated risk factors were: immediate postoperative SVA O8 cm, the sum of TK, LL, and pelvic incidence Cobb angles O45, the sum of TK and LL Cobb angles ! -25, T12 horizontal angle O15, LL Cobb angle increase !40, associated co-morbidities, age at surgery O55 years, uppermost instrumented vertebra below T8, and preoperative SVA O15 cm. The total SRS outcomes scores were 3.22 and 3.59 for SD and non-SD groups, respectively (p50.025). The self-image subscale scores were 3.20 (for SD) and 3.72 (for non-SD) (p50.006). CONCLUSIONS: The incidence of SD following PSO for adult patients with sagittal imbalance was 29%. Multiple factors should be considered to achieve optimal correction while minimizing the risk of developing SD. Patients’ self-image seems to be affected the most with SD. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.184
150. Lower Doses of rhBMP-2 Appear Sufficient in Achieving Fusion in Adult Spinal Deformity Gaurav Abbi, MD, Jaspaul Gogia, MD, David Wright, Eric Klineberg, MD, Rolando Roberto, MD, Munish Gupta, MD; University Of California, Davis, Sacramento, CA, USA BACKGROUND CONTEXT: A large amount of bone graft is needed in achieving successful fusion in adult spinal deformity. Often, the amount of bone graft available is limited. Bone graft substitutes such as rhBMP-2 and
79S
allograft have aided in achieving long fusions for adult spinal deformity. Recent investigations of recombinant bone morphogenic protein have brought attention to its use in preventing pseudoarthrosis and avoiding complications associated with autogenous bone graft harvest. Previous studies have used large amounts of rhBMP-2 with satisfactory results. This is the first study to demonstrate low dose rhBMP use in adult spinal deformity with a minimum five vertebra fusion, with a total of 12-24 mg of rhBMP (1-2 large kits) per case. PURPOSE: To study use of lower dose rhBMP-2 in achieving spinal fusion for adult spinal deformity. STUDY DESIGN/SETTING: We performed a retrospective review of five hundred spinal procedures performed at one institution between January 2004 and February 2008. Forty-seven patients met the inclusion criteria of at least five vertebra fusion and use of rhBMP-2. PATIENT SAMPLE: Forty-seven patients with adult spinal deformity undergoing posterior or combined anterior and posterior fusion with rhBMP2 were identified. The average age was 60 years (range 31-85). Patients were followed for an average of 25 months (range 12-60). Diagnoses included degenerative scoliosis (38), adult scoliosis (6), Scheuermann’s kyphosis (1), kyphoscoliosis (2). OUTCOME MEASURES: Patients were evaluated for complications and clinical and radiographic evidence of fusion. METHODS: Chart review was performed for diagnosis, type of procedure, amount of rhBMP-2 used, comorbidities, and complications. Radiographic analysis included coronal and sagittal balance, and Cobb angle measurements of the major coronal and sagittal curves on pre-operative, immediate post-operative, and final follow-up films. RESULTS: Average major coronal curve was 29 degrees (range 9-51) preoperatively, 10 degrees postoperatively, and 9 degrees at final follow-up. Coronal balance correction averaged 9 mm after surgery with loss of 3 mm at final follow-up. Sagittal balance correction was 50 mm (range -10 to 171 mm) and loss of correction of 3 mm at final follow-up. Thirty patients had a total of 12 mg rhBMP-2 (1 large kit) used, fifteen had 24 mg (2 large kits) used, and two patients had 36 mg (3 large kits) used. Complications included pneumonia (2), junctional breakdown (3), infection (2), embolic stroke (1), pulmonary embolism (2), deep venous thrombosis (1), neuropraxia (1). One of the three patients with junctional breakdown required secondary procedures. One patient had instrumentation failure and pseudarthrosis at nine months, providing a pseudarthrosis rate of 1.8%. CONCLUSIONS: The surgical treatment of adult deformity is successful with low dose rhBMP-2 obviating the harvest of autogenous bone graft and its inherent limitations and morbidities. The use of rhBMP-2 in the range of 12-24 mg (1-2 large kits) total is drastically lower than previous investigations of 12 mg-22 mg per level. This translates to a measurable decrease in cost. FDA DEVICE/DRUG STATUS: INFUSE BMP: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.185
151. Scoliosis Surgery in Duchennes Muscular Dystrophy, Peri-Operative Medical and Surgical Considerations Anto Fritz, MD1, Rolando Roberto, MD1, Braden Boice2, Hwang Hosun, MD3, Andrew Skalsky, MD2, Yolanda Hagar, BS4, Laurel Beckett, PhD4, Munish Gupta, MD1, Craig McDonald, MD2; 1University of California, Davis, Sacramento, CA, USA; 2Sacramento, CA, USA; 3Houston, TX, USA; 4Davis, CA, USA BACKGROUND CONTEXT: Spine fusion has been advised in DMD once scoliosis exceeds 35 with occasional reports that fusion diminishes the rate of pulmonary function loss. We investigated changes in Cobb angle, pelvic obliquity (PO), forced vital capacity (FVC) and left ventricular fractional shortening (LVFS) in relation to surgical intervention. PURPOSE: We investigated changes in Cobb angle, pelvic obliquity (PO), forced vital capacity (FVC) and left ventricular fractional shortening
149. Sagittal Decompensation Following Pedicle Subtraction Osteotomy for Adult Patients with Sagittal Imbalance Yongjung Kim, MD1, Keith Bridwell, MD2, Lawrence Lenke, MD2, Oheneba Boachie-Adjei, MD3, Chris Hamill, MD4, Samuel Cho, MD1, Thomas Cha, MD1; 1Columbia University, New York, NY, USA; 2 Washington University in St. Louis, St. Louis, MO, USA; 3Hospital for Special Surgery, New York, NY, USA; 4University at Buffalo, Buffalo, NY, USA BACKGROUND CONTEXT: No study on sagittal decompensation following lumbar pedicle subtraction osteotomy. PURPOSE: To determine postoperative sagittal decompensation (SD) following pedicle subtraction osteotomy (PSO) for adult patients with sagittal imbalance. STUDY DESIGN/SETTING: retrospective multicenter study. PATIENT SAMPLE: 141 patients with a minimum 2 years follow-up following pedicle subtraction osteotomy. OUTCOME MEASURES: radiographic and SRS outcome instrument. METHODS: A radiographic and clinical assessment of 141 adult patients (average 54.7 years) with sagittal imbalance who underwent PSO with a minimum 2-year follow-up (average 4.3 years, range 2-12 years) was performed. SD was defined as the sagittal vertical axis (SVA) O8 cm. RESULTS: The incidence was 29% (41/141), of which 16% (23) had early onset (!8 weeks postoperatively) and 15% had late onset SD. Comparing between SD and non-SD groups, age at surgery, co-morbidities, postoperative thoracic kyphosis (TK) Cobb angle (T5-T12), postoperative lumbar lordosis (LL) Cobb angle (T12-S1), the change in LL Cobb angle following PSO, and the sum of TK and LL Cobb angles were statistically different (p!0.05) between them (See Table 1). Associated risk factors were: immediate postoperative SVA O8 cm, the sum of TK, LL, and pelvic incidence Cobb angles O45, the sum of TK and LL Cobb angles ! -25, T12 horizontal angle O15, LL Cobb angle increase !40, associated co-morbidities, age at surgery O55 years, uppermost instrumented vertebra below T8, and preoperative SVA O15 cm. The total SRS outcomes scores were 3.22 and 3.59 for SD and non-SD groups, respectively (p50.025). The self-image subscale scores were 3.20 (for SD) and 3.72 (for non-SD) (p50.006). CONCLUSIONS: The incidence of SD following PSO for adult patients with sagittal imbalance was 29%. Multiple factors should be considered to achieve optimal correction while minimizing the risk of developing SD. Patients’ self-image seems to be affected the most with SD. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.184
150. Lower Doses of rhBMP-2 Appear Sufficient in Achieving Fusion in Adult Spinal Deformity Gaurav Abbi, MD, Jaspaul Gogia, MD, David Wright, Eric Klineberg, MD, Rolando Roberto, MD, Munish Gupta, MD; University Of California, Davis, Sacramento, CA, USA BACKGROUND CONTEXT: A large amount of bone graft is needed in achieving successful fusion in adult spinal deformity. Often, the amount of bone graft available is limited. Bone graft substitutes such as rhBMP-2 and
79S
allograft have aided in achieving long fusions for adult spinal deformity. Recent investigations of recombinant bone morphogenic protein have brought attention to its use in preventing pseudoarthrosis and avoiding complications associated with autogenous bone graft harvest. Previous studies have used large amounts of rhBMP-2 with satisfactory results. This is the first study to demonstrate low dose rhBMP use in adult spinal deformity with a minimum five vertebra fusion, with a total of 12-24 mg of rhBMP (1-2 large kits) per case. PURPOSE: To study use of lower dose rhBMP-2 in achieving spinal fusion for adult spinal deformity. STUDY DESIGN/SETTING: We performed a retrospective review of five hundred spinal procedures performed at one institution between January 2004 and February 2008. Forty-seven patients met the inclusion criteria of at least five vertebra fusion and use of rhBMP-2. PATIENT SAMPLE: Forty-seven patients with adult spinal deformity undergoing posterior or combined anterior and posterior fusion with rhBMP2 were identified. The average age was 60 years (range 31-85). Patients were followed for an average of 25 months (range 12-60). Diagnoses included degenerative scoliosis (38), adult scoliosis (6), Scheuermann’s kyphosis (1), kyphoscoliosis (2). OUTCOME MEASURES: Patients were evaluated for complications and clinical and radiographic evidence of fusion. METHODS: Chart review was performed for diagnosis, type of procedure, amount of rhBMP-2 used, comorbidities, and complications. Radiographic analysis included coronal and sagittal balance, and Cobb angle measurements of the major coronal and sagittal curves on pre-operative, immediate post-operative, and final follow-up films. RESULTS: Average major coronal curve was 29 degrees (range 9-51) preoperatively, 10 degrees postoperatively, and 9 degrees at final follow-up. Coronal balance correction averaged 9 mm after surgery with loss of 3 mm at final follow-up. Sagittal balance correction was 50 mm (range -10 to 171 mm) and loss of correction of 3 mm at final follow-up. Thirty patients had a total of 12 mg rhBMP-2 (1 large kit) used, fifteen had 24 mg (2 large kits) used, and two patients had 36 mg (3 large kits) used. Complications included pneumonia (2), junctional breakdown (3), infection (2), embolic stroke (1), pulmonary embolism (2), deep venous thrombosis (1), neuropraxia (1). One of the three patients with junctional breakdown required secondary procedures. One patient had instrumentation failure and pseudarthrosis at nine months, providing a pseudarthrosis rate of 1.8%. CONCLUSIONS: The surgical treatment of adult deformity is successful with low dose rhBMP-2 obviating the harvest of autogenous bone graft and its inherent limitations and morbidities. The use of rhBMP-2 in the range of 12-24 mg (1-2 large kits) total is drastically lower than previous investigations of 12 mg-22 mg per level. This translates to a measurable decrease in cost. FDA DEVICE/DRUG STATUS: INFUSE BMP: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.185
151. Scoliosis Surgery in Duchennes Muscular Dystrophy, Peri-Operative Medical and Surgical Considerations Anto Fritz, MD1, Rolando Roberto, MD1, Braden Boice2, Hwang Hosun, MD3, Andrew Skalsky, MD2, Yolanda Hagar, BS4, Laurel Beckett, PhD4, Munish Gupta, MD1, Craig McDonald, MD2; 1University of California, Davis, Sacramento, CA, USA; 2Sacramento, CA, USA; 3Houston, TX, USA; 4Davis, CA, USA BACKGROUND CONTEXT: Spine fusion has been advised in DMD once scoliosis exceeds 35 with occasional reports that fusion diminishes the rate of pulmonary function loss. We investigated changes in Cobb angle, pelvic obliquity (PO), forced vital capacity (FVC) and left ventricular fractional shortening (LVFS) in relation to surgical intervention. PURPOSE: We investigated changes in Cobb angle, pelvic obliquity (PO), forced vital capacity (FVC) and left ventricular fractional shortening