Does Interbody Support at L5-S1 Matter in Long Fusions to the Pelvis?: A 5-year Analysis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine if the addition of L5-S1 interbody support in long fusion deformity constructs is associated with superior long-term clinical and radiographic outcomes. To compare the 5-year clinical and radiographic outcomes and complications between long fusion constructs with L5-S1 interbody support versus posterolateral fusion (PLF) alone. SUMMARY OF BACKGROUND DATA: Cadaveric biomechanical studies have suggested that an interbody fusion at L5-S1 is beneficial in long fusion constructs with sacropelvic fixation. However, there is limited data reflecting the superiority of interbody support augmentation in optimizing arthrodesis and deformity correction relative to PLF alone. METHODS: Eighty-eight consecutive adults with spinal deformity who underwent at minimum T11-pelvis posterior pedicle screw instrumentation with 5-year follow-up were included. Two cohorts were compared based on technique used at the lumbosacral junction (L5-S1): (A) no interbody (PLF; n = 23), or (B) interbody support at L5-S1 (IB; n = 65). Radiographic measurements and clinical outcome measures were compared at multiple time points. Complications were recorded and compared. RESULTS: No differences in baseline patient characteristics between cohorts. One nonunion occurred at L5-S1 in the PLF group (P = 0.091). Initial postop sagittal alignment was better in the IB group (PLF: 6.46 cm, IB: 2.48 cm, P = 0.007); however, this was not maintained over long-term follow-up. No significant differences in proximal junctional kyphosis (PLF: 7/23, IB: 9/65, P = 0.076). Proximal junctional failure was more frequent in the PLF group (PLF: 6/23, IB: 6/65, P = 0.043). No significant differences in complications were found. Both cohorts had improvement from baseline pain and functional scores. CONCLUSION: There is no absolute long-term advantage for lumbar interbody support in adult spinal deformity patients undergoing spinal arthrodesis to the pelvis.Level of Evidence: 3.

Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients. METHODS: Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study. RESULTS: A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 (P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 (P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts. CONCLUSIONS: The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer's recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.

Adult spine deformity surgery in elderly patients: are outcomes worse in patients 75 years and older?

STUDY DESIGN: Retrospective study of a prospectively collected database at one center. OBJECTIVES: Assess the outcomes and complications of adult spinal deformity (ASD) surgery in patients that are 75 years and older compared with patients of 65-75 years of age. With increasing amounts of ASD surgery being performed on elderly patients, it is important to assess how age plays a factor in corrective reconstruction surgery. METHODS: Inclusion criteria for the study were all patients ≥ 65 years of age that underwent thoracolumbar deformity correction involving ≥ four levels at a single institution by two surgeons. Patients were divided based on age into 65-74.9 or ≥ 75 groups. Radiographic parameters were measured preoperatively, postoperatively, and at 2 years. The Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) were collected preoperatively, at 1 year, and 2 years. Comorbidities included were based around the Charlson Comorbidity Index (CCI) and compared to the incidence of complications and need for further surgery. RESULTS: Both age groups had improvements in their radiographic parameters postoperatively which was maintained at 2 years. Comparing the different age groups with similar comorbidity burden in regard to complications and need for additional surgery yielded no statistically significant difference between groups. Both groups had comparable decreases in NRS and increases in ODI at 2 years. CONCLUSIONS: Analysis of our study population indicates that there is no difference between the outcomes and complications of deformity surgery in patients 75 years and older when compared to a younger elderly population. It also does not appear that a ≥ 3 comorbidity burden has a significant impact on the complications or need for additional surgery in our elderly spinal deformity surgery population. LEVEL OF EVIDENCE: Level IV.

Associations Between Body Mass and Revision Surgical Outcomes in Adult Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether an association exists between high body mass index (BMI>25 kg/m) and surgical outcomes in revision adult scoliosis patients. SUMMARY OF BACKGROUND DATA: Obesity is thought to be associated with increased surgical complications and inferior clinical outcomes in adults. There are no studies analyzing the effect of obesity on surgical outcomes in revision patients for adult scoliosis. METHODS: Forty-five consecutive revision adult scoliosis patients (35 women and 10 men; mean age, 62.7±9.3 y) with a minimum follow-up of 2 years were included in this study. Patients were divided into 2 groups according to BMI: overweight (BMI≥25 kg/m, n=27) and nonoverweight (<25 kg/m, n=18). Radiographic measures, Oswestry Disability Index (ODI), Visual Analog Scale (VAS), as well as comorbidities and complications were reviewed and compared at preoperative and 2-year follow-up. RESULTS: No significant differences in surgical methods, complication rates, or radiographic measures were found between the 2 groups except for the greater preoperative and final follow-up thoracic kyphosis in the overweight group (P<0.05). A higher comorbidity rate of circulatory disorders (33.3% vs. 0%, P=0.018) and diabetes (25.9% vs. 0%, P=0.053) was observed in the overweight group, as well as a higher preoperative VAS score (7.1±1.7 vs. 5.2±2.9, P=0.031). At 2-year follow-up, VAS and ODI improvements for both groups showed significant and similar improvement from preoperative (P<0.01). CONCLUSIONS: Overweight revision adult scoliosis patients had higher thoracic kyphosis and more significant preoperative pain compared with normal-weight individuals. Overweight patients also had significantly higher rates of medical comorbidities. However, BMI did not affect the functional outcome of surgical correction or perioperative complication rates. Overweight patients benefited from surgery just as much as nonoverweight patients at 2-year follow-up.

Does obesity affect surgical outcomes in degenerative scoliosis?

STUDY DESIGN: Retrospective cohort analysis of prospectively collected data. OBJECTIVE: To determine whether an association exists between body mass and surgical outcomes in patients with degenerative scoliosis after long instrumented spinal arthrodesis (≥ 4 discs). SUMMARY OF BACKGROUND DATA: Obesity is thought to be associated with increased surgical complications and inferior clinical outcomes in adults. There are no studies analyzing the effect of obesity on surgical outcomes in patients with degenerative scoliosis after long instrumented spinal arthrodesis. METHODS: Eighty-four consecutive patients with degenerative scoliosis (69 females and 15 males; mean age, 68.6 ± 8.0 yr) with a minimum follow-up of 2 years were included in this study. Patients were divided into 3 groups according to body mass index (BMI): obese (BMI ≥ 30 kg/m², n = 19), overweight (BMI = 25-29.9 kg/m², n = 35), and normal weight (BMI < 25 kg/m², n = 30). Radiographical measures, Oswestry Disability Index, visual analogue scale score, as well as comorbidities and complications were reviewed and analyzed for all patients preoperatively and at 1- and 2-year follow-ups. RESULTS: Compared with the normal weight group, no significant differences in surgical methods, comorbidities, complication rates, curve correction, or radiographical measures were found in the obese and overweight groups, except for a greater preoperative lumbar lordosis in the overweight group (-40.3° ± 13.8° vs. -26.0° ± 18.9°, P < 0.05). At 2-year follow-up, Oswestry Disability Index and visual analogue scalescores improved significantly in all groups compared with preoperatively (P < 0.01). The changes of Oswestry Disability Index and visual analogue scalescores from preoperatively to final follow-up were similar in the 3 groups (P > 0.05). CONCLUSION: Obesity did not affect the amount of deformity correction and did not increase comorbidities and postoperative complication rates. Overweight patients had a greater lumbar lordosis before surgery than normal weight patients. Obese and overweight patients benefited from surgery just as much as normal weight patients at 2-year follow-up.

Comparative analysis of clinical outcomes and complications in patients with degenerative scoliosis undergoing primary versus revision surgery.

STUDY DESIGN: Retrospective cohort analysis of prospectively collected data. OBJECTIVE: To compare clinical outcomes and postoperative complications in patients with lumbar degenerative scoliosis who underwent primary (P) versus revision (R) surgery. SUMMARY OF BACKGROUND DATA: Revision surgery for spinal deformity is technically challenging and may be associated with greater risks of complications and inferior clinical outcomes. There is a paucity of data in the literature comparing primary versus revision surgery in patients with degenerative scoliosis with respect to their clinical outcomes and complications. METHODS: An analysis of 84 consecutive patients with degenerative scoliosis who underwent primary versus revision surgery between 2002 and 2010 with a minimum 2-year follow-up was performed. RESULTS: There were 53 patients in the primary group and 31 in the revision group. The average number of previously operated levels in the revision group was 3.5 ± 2.6. Mean age at surgery, sex, and body mass index were similar between the 2 groups, as well as comorbidities and postoperative complication rates (P > 0.05). Although a greater preoperative coronal imbalance was noticed in the revision group (P: 2.5 cm vs. R: 4.8 cm, P = 0.022), the final radiographical measures were comparable between the 2 groups. At 2-year follow-up, Oswestry Disability Index and visual analogue scale scores improved significantly in both groups compared with preoperatively (P < 0.001). The improvement in scores of Oswestry Disability Index and visual analogue scale preoperatively to final follow-up was similar between the 2 groups (P > 0.05). CONCLUSION: Revision patients achieved the same radiographical and clinical outcomes as primary patients. The complication rates were similar between primary and revision patients. Revision patients benefit from surgery just as much as primary patients at 2-year follow-up.

Revision spinal fusion in patients older than 75: is it worth the risks?

STUDY DESIGN: Retrospective clinical study of a prospective database. OBJECTIVE: This study aims to determine whether revision spinal fusion surgery is worthwhile in patients older than 75 from a risk-benefit perspective. SUMMARY OF BACKGROUND DATA: The benefits of spinal fusion in patients older than 65 is well documented. However, the clinical benefit to patients older than 75 of revision surgery, which often yields worse outcomes with higher complication rates, is uncertain. METHODS: Ninety-nine consecutive patients older than 75 with minimum 2-year follow-up underwent spinal fusion as either a primary (n = 58) or revision (n = 41) operation. Diagnoses were spondylolisthesis (n = 43), scoliosis (n = 28), kyphosis (n = 5), and other degenerative spinal disorders (n = 26). Outcomes were obtained prospectively by visual analogue scale (VAS) and Oswestry Disability Index (ODI) at preoperative, 1-year, 2-year, and latest follow-up. RESULTS: Revision patients had significantly worse scores compared with primary patients at all time intervals, for both VAS (preoperative: 6.4 vs. 5.8, 1 yr: 3.6 vs. 2.4, 2 yr: 4.7 vs. 2.5) and ODI (preoperative: 52.2 vs. 44.1, 1 yr: 37.3 vs. 25.6, 2 yr: 47.0 vs. 25.0). Both groups improved significantly at 1 year postoperatively. At 2 years, the results of revision surgery deteriorated (ΔVAS: -1.7, ΔODI: -5.2), whereas the benefits of primary procedures were maintained (ΔVAS: -3.3, ΔODI: -19.1). Complications were generally greater in the revision group and included revision surgery (8[19.5%] vs. 7[12.1%]), nonunion (2[4.9%] vs. 3[5.2%]), adjacent level fracture (4[9.8%] vs. 6[10.3%]), infection (6[14.7%] vs. 2[3.4%]), foot drop (0[0.0%] vs. 4[6.9%]), imbalance (4[9.8%] vs. 1[1.7%]), pulmonary failure (1[2.4%] vs. 1[1.7%]), and death (0[0.0%] vs. 1[1.7%]). CONCLUSION: Despite having worse initial ODI and VAS scores, revision patients older than 75 initially benefit as much as patients older than 75 undergoing primary operations. However, at 2 years, revision patients do not have a sustained benefit despite a higher complication rate. LEVEL OF EVIDENCE: 4.

Transforaminal lumbar interbody fusion with rhBMP-2 in spinal deformity, spondylolisthesis, and degenerative disease--part 1: Large series diagnosis related outcomes and complications with 2- to 9-year follow-up.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To evaluate long-term clinical outcomes and complications of the transforaminal lumbar interbody fusion (TLIF) procedure from a large consecutive series, without industry funding. Clinical outcomes and complications are analyzed by diagnosis and primary versus revision surgery to assess whether TLIF with bone morphogenic protein (BMP) is appropriate for common use in deformity, spondylolisthesis, and degenerative disease. SUMMARY OF BACKGROUND DATA: A common method for achieving spinal arthrodesis includes TLIF with a cage and off-label interbody BMP-2, supported by posterior arthrodesis and a pedicle screw construct. There are no large studies analyzing outcomes and complications after TLIF in different diagnoses, for primary and revision surgery, leading some to question the widespread use of TLIF. METHODS: A total of 509 consecutive adults underwent open posterior instrumented fusion, augmented with TLIF at 872 discs using a cage and rhBMP-2, with minimum 2-year follow-up. Cohort diagnoses included 179 degenerative, 207 spondylolisthesis, and 123 deformity patients. Patient age averaged 61 years, 207 had undergone prior decompression or fusion surgery. All patients underwent posterior instrumented fusion and pedicle screw instrumentation at average 3.6 levels (range, 1-16); all patients had TLIF 1.7 levels (range, 1-4 levels) with BMP and autograft, stabilized with an interbody cage. RESULTS: At average 59 months follow-up, 12 patients developed pseudoarthrosis, 8 at TLIF levels (8/872 discs, 0.92%) most commonly at L5-S1 (6/8). Significant clinical improvement was noted in patients with deformity, spondylolisthesis, and degenerative disease undergoing primary and revision surgery. Overall, visual analogue scale preoperative score was 6.6, at 1 year 3.8, at 2 years 3.5 (P < 0.001) and the preoperative ODI was 50.9, at 1 year 36.1, and at 2 years 35.0 (P < 0 0.001). Pain medication requirements also declined. CONCLUSION: The efficacy of TLIF with BMP is supported in this large series with long-term follow-up, independent of industry. Reliable fusion and improved outcomes can be expected in adults undergoing TLIF for deformity, spondylolisthesis, and degenerative disease. Most complications occurred in patients with deformity. LEVEL OF EVIDENCE: 3.

Transforaminal lumbar interbody fusion with rhBMP-2 in spinal deformity, spondylolisthesis, and degenerative disease--part 2: BMP dosage-related complications and long-term outcomes in 509 patients.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: Without industry funding, the study evaluated short- and long-term complications related to off-label bone morphogenetic protein (BMP) used with transforaminal lumbar interbody fusion (TLIF) from a large consecutive series. Complications and results were analyzed by BMP dose, fusion length, and primary versus revision surgery. Based on the results, surgical technique and BMP dose recommendations were proposed. SUMMARY OF BACKGROUND DATA: Off-label use of BMP in TLIF, although common, has only been studied in small series and case reports using various techniques, cage types, and doses of BMP. Several of these studies have reported minimal complications. Others report problems related to BMP, which has led to questions regarding current widespread use of TLIF with BMP. METHOD: TLIF with rhBMP-2 was performed at 872 discs in 509 consecutive adults who underwent open posterior instrumented fusion and had minimum 2-year follow-up; diagnoses included degenerative disease (179), spondylolisthesis (207), deformity (123). Patient age averaged 61 years: 12% were smokers and 41% had revision surgery. TLIF was performed at 1.7 levels: single level: 229, 2 levels: 201, 3 levels: 74, 4 levels: 5. Local autograft was used for backfill around and behind each rectangular cage. Varying doses of interbody BMP were used at an average 7.3 mg per disc (range: 2-12 mg per disc). RESULTS: At 5 years average follow-up, 8 patients developed pseudoarthrosis at levels of TLIF (8 of 872 discs, 0.92%). Seroma (0.4%) and ectopic bone growth (0.6%) were too infrequent to be associated with a particular BMP dose. Deep infection was 2.6% overall (1.7% of the degenerative group). Symptomatic osteolysis or cage subsidence did not occur. Significant long-term improvement was noted in clinical and functional outcomes compared with preoperation. CONCLUSION: Five-year follow-up after TLIF with BMP, independent of industry, confirms effective arthrodesis in short and long fusions, both primary and revision. Most complications occurred in deformity patients. BMP-related complications (seroma, ectopic bone) were rare. LEVEL OF EVIDENCE: 3.

Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes.

STUDY DESIGN: Prospective, nonrandomized consecutive single surgeon series. OBJECTIVE: To compare the clinical and radiographic outcomes in degenerative lumbar scoliosis (DLS) patients treated with posterior instrumented correction and fusion with additional anterior lumbar interbody fusion (ALIF) versus transforaminal lumbar interbody fusion (TLIF) to help define whether anterior surgery should be routinely required in treating DLS. SUMMARY OF BACKGROUND DATA: The benefits of interbody support in promoting postoperative stability and arthrodesis are well established. Whether the interbody fusion is better performed from an anterior or posterior approach has not been studied for patients undergoing surgical correction for DLS. METHODS: Forty consecutive patients with DLS, stenosis, and olisthesis underwent posterior instrumented reduction/arthrodesis at average 7 levels (range: 4-9 levels). Additional ALIF was performed in 20 patients, TLIF in the other 20. Follow-up averaged 38 months (24-68 months). Oswestry Disability Index (ODI), visual analog pain scores (VAS) were evaluated preoperative, 1 and 2 years postoperative. Radiograph measurements included the scoliosis, T12 to S1 lordosis, coronal and sagittal balance, and pelvic incidence. CT evaluation of the fusion integrity was performed after 1 year. RESULTS: The ALIF group complications included 4 nonunions, 5 adjacent level fractures, 5 adjacent degeneration, 3 infections, and 1 footdrop. Revision surgery was performed in 8 of 20. Medical complications included 2 nonfatal pulmonary embolus, 1 ileus requiring colostomy, and 1 stroke. TLIF group complications included 3 adjacent segment degeneration, 2 adjacent fractures, 2 nonunions, and 1 infection and transient footdrop. Two of 20 required revision surgery. VAS and ODI improvements for both groups showed significant improvement from preoperative (P < 0.0019) but were not different. Deformity correction was also similar (70%) between ALIF and TLIF groups. CONCLUSION: With current deformity correction techniques, both ALIF and TLIF are effective in DLS surgery. Anterior surgery is not routinely required to treat all cases of DLS.