Posterior Spinal Osteotomy Prior to Anterior Column Realignment for Better Surgical Correction of Adult Spinal Deformity : Advantages and Indications|RISS 상세보기

다국어 초록 (Multilingual Abstract)

BACKGROUND
Combined anterior column realignment (ACR) with a posterior spinal osteotomy approach is being increasingly applied for the surgical treatment of adult spinal deformity (ASD). However, the traditional anterior-posterior (A-P) surgery has been shown to result in suboptimal postoperative sagittal alignment for certain severe rigid spinal deformities. The author hypothesized that posterior osteotomy prior to ACR would permit a potentially greater degree of lumbar lordosis (LL) for corrective surgery than the A-P approach. Currently, controversy remains regarding whether posterior osteotomy is performed prior to ACR in patients with sagittal imbalance.

OBJECTIVE
To determine the impact of posterior spinal osteotomy prior to the anterior approach (P-A) on the restoration of LL compared to the traditional A-P approach and identify the characteristics of patients who require this type of approach.

METHODS
Between January 2017 and December 2019, 260 consecutive patients with ASD who had undergone combined corrective surgery at a single institution were reviewed. This study included 178 patients who underwent posterior osteotomy prior to ACR procedure (P-A group) and 82 patients who underwent the traditional A-P procedure (A-P group). Meanwhile, the patients in the A-P group were divided into pelvic incidence (PI) minus lumbar lordosis (LL) mismatch < 10° group (n=62) and PI-LL mismatch ≥ 10° group (n=20) according to radiological evaluation. Sagittal spinopelvic parameters were determined from pre- and postoperative full-spine radiographs and compared between the groups. Multiple regression analysis was conducted to identify the risk factors for developing a postoperative PI-LL mismatch ≥ 10° in the A-P group.

RESULTS
Baseline demographics, clinical characteristics, and radiographic parameters were comparable between the groups. Except for PI, statistical improvements in other spinopelvic parameters were observed within each group (p<0.05). The P-A group showed a significantly higher change in LL (53.7 vs. 44.3 °, p<0.001), C7 sagittal vertical axis (SVA) (197.4 vs. 146.1 mm, p=0.021), segmental lordosis (SL) L2-3 (16.2 vs. 14.4 °, p=0.043), SL L3-4 (16.2 vs. 13.8 °, p=0.004), and SL L4-5 (15.1 vs. 11.3 °, p=0.001) as compared to the A-P group. At the final follow-up, PI-LL mismatch was significantly higher in the A-P group (13.4 vs. 2.9 °, p<0.001). Stepwise logistic regression analysis showed that age ≥ 75 years (odds ratio [OR]=2.151; 95% confidence interval [CI], 1.414-3.272; p<0.001), severe osteoporosis (OR=2.824; 95% CI, 1.481-5.381; p=0.002), rigid lumbar curve with dynamic changes in LL < 10° (OR=5.150; 95% CI, 2.296-11.548; p<0.001), and severe facet joint osteoarthritis (OR=4.513; 95% CI, 1.958-10.402; p<0.001) were independent risk factors for PI-LL mismatch ≥ 10° after traditional A-P surgery.

CONCLUSIONS
Posterior spinal osteotomy prior to ACR offers greater LL correction than the traditional combined anterior-posterior procedure. Indications of this approach procedure for ASD include patients aged ≥ 75 years, severe osteoporosis, rigid lumbar curve with dynamic change in LL < 10°, or more than four facet joints of Pathria G3 in the lumbar region.

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목차 (Table of Contents)

I. INTRODUCTION............................................................................................. 1
II. MATERIALS AND METHODS.......................................................................... 3
1. Patient recruitment.................................................................................... 3
2. Data collection........................................................................................... 3
3. Radiographic assessment........................................................................... 4

I. INTRODUCTION............................................................................................. 1
II. MATERIALS AND METHODS.......................................................................... 3
1. Patient recruitment.................................................................................... 3
2. Data collection........................................................................................... 3
3. Radiographic assessment........................................................................... 4
4. Assessment of facet joint osteoarthritis...................................................... 5
5. Surgical procedures.................................................................................... 6
6. Statistical analysis....................................................................................... 7
III. RESULTS........................................................................................................ 9
1. Baseline demographic data........................................................................ 9
2. Comparison of operative details and complications.................................... 9
3. Comparison of preoperative and postoperative spinopelvic parameters....... 10
4. Predictive risk factors for PI-LL mismatch ≥ 10°........................................... 10
5. Assessment of the reliability of radiographic measurements........................ 11
6. Illustrative cases......................................................................................... 12
IV. DISCUSSION.................................................................................................. 14
V. CONCLUSION................................................................................................ 19
VI. REFERENCES.................................................................................................. 20
VII. TABLES.......................................................................................................... 28
VIII. FIGURES........................................................................................................ 36

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