Justin S. Smith, MD, PhDHarrison Distinguished Professor

Vice Chair for ResearchChief of Spine Division

Department of NeurosurgeryUniversity of Virginia

Three-Column Osteotomy versus Interbody for Major

Sagittal Malalignment

UCSF Techniques in Complex Spine Surgery CourseLas Vegas, 2019

Disclosures• Zimmer Biomet: consultant, honoraria, royalties

• DePuy: research study group support

• K2M: consultant, honoraria• Nuvasive: consultant, honoraria, royalties

• Cerapedics: consultant

• NREF: fellowship funding• AO: research support, fellowship funding

• AlloSource: consultant

• Editorial Boards: Journal of Neurosurgery Spine, Neurosurgery, Operative Neurosurgery,Spine Deformity

• Alphatec: stock ownership

• Deformity magnitude• Location• Focal vs. Global• Fused segments• Prior surgical

approaches• Flexible vs. Rigid

Factors Influencing Deformity tors Influencingng DeformCorrection Strategy

•Supine films•Bending films•Films over a bolster•Helps determine

properties of coronal and sagittal deformities

Assessment of Curve Stiffness

Osteotomies (low- to high-grade) and discectomies/ interbody fusion

are key tools for correction of spinal deformity. • Retrospective review of ALIF (32) vs TLIF

25) in patients undergoing fusion of <3 levels• Excluded patients if >25% spondylolisthesis

or fixed spinal deformities• Compared foraminal height, local disc angle,

and lumbar lordosis

Hseih et al. JNS Spine 2007;7:379-86.

• ALIF increased local Cobb angle (8.3o) and increased LL (6.2o)

• TLIF decreased local Cobb angle (-0.1o)and decreased LL (-2.1o)

Hseih et al. JNS Spine 2007;7:379-86.

• ALIF example case.

Hseih et al. JNS Spine 2007;7:379-86.

• TLIF example case. Unilateral facetectomy,oblique cage placement.

• Retrospective review of 45 patients treated with single-level TLIF for single-level degenerative condition

• Mean follow-up 21 months

• Assessed LL, disc height, VAS

Kepler et al. Orthop Surg 2012;4:15-20.

• Only gained 3.6o of lumbar lordosis• Disc height increased by 4.5 mm

• “Less lordosis was associated with worse back and leg pain as assessed by VAS.”

• “Patients with persistent leg pain at final follow-up had less lumbar lordosis and intervertebral height than patients without leg pain.”

How good are modern ALIF techniques for achieving lumbar lordosis and sagittal alignment?

Hyperlordotic ALIF spacers?

• Retrospective review of 69 hyperlordoticALIFs (20o or 30o) in 41 patients with adult degenerative spinal disease (all had staged ant/post procedures)

• Mean age 55 yrs (23-76 yrs)

• Average follow-up 10 mos (2-28 mos)Saville et al. JNS Spine. 2016;25:713-19.

Majority were deformity cases

Majority placed at L4-5 or L5-S1

Most also had long-segment posterior fusion

Saville et al. JNS Spine. 2016;25:713-19.

• For 30o HLCs (+/- SPO), mean segmental lordosis achieved was 29o (26o-34o)

Results

• For 20o HLCs (+/- SPO),mean segmental lordosis achieved was 19o (16o-22o)

• Mean SVA decreased from 113 mm (38-320 mm) to 43 mm (-13 to 112 mm)

Case examples in which ALIFcan be key in correction of mild to moderate sagittal

alignment.

+10 cm

LL=32°PI=82°

PT=50°PI-LL=50°

72 y/o woman

+10 cm

Supine CT Scout

Decrease of C7-S1 SVA

Lumbar spine remains rigid and markedly kyphotic (PI= 82°)

• Fixed sagittal spino-pelvic malalignment in patient with high PI

Management?

PI=82°LL=32°PT=50°

PI-LL=50°

• L5-S1 disc space open

• Surgery: - L5-S1 ALIF (25o)- T11-ilium screws- L1-2 PCO + TLIF

• Stenosis at L1-2

+7 cm

LL=26°PI=62°

PT=25°PI-LL=36°

65 y/o man

Mid-SagittalLeft Parasagittal Right Parasagittal

Vacuum disc at L5-S1

• Fixed sagittal spino-pelvic malalignment

Management?

PI=62°LL=26°PT=25°

PI-LL=36°

• L5-S1 disc space open

• Surgery: - L5-S1 ALIF (25o, 20 mm ht)- T11-ilium screws- L2-3, L3-4, L5-S1 SPO - L3-4 TLIF

• Stenosis at L2-3

• Solid fusion L3-5

Following ALIF

Case example in which ALIF can be key in correction of major sagittal alignment.

>+30 cmPI=59°

PT=32°PI-LL=65°

74 y/o man

LL=+6°

Pre-op standing Pre-op supineMid-SagittalLeft Parasagittal Right Parasagittal

Air in L5-S1 disc

• Severe sagittal spino-pelvic malalignment

Management?

PI=59°LL=+6°PT=32°

PI-LL=65°

• L5-S1 disc space open• Surgery:

- L4-S1 ALIFs (15o)- T10-ilium screws- T12-L5 PCOs

• Previous multi-level lumbar decompression but no fusion

Pre-op standingPre-op supine Supine post ALIFs

How good are modern TLIF techniques for achieving lumbar lordosis and sagittal alignment?

PCO + TLIF Considerations to Optimize TLIF Carpentry

• Surgical techniqueSufficiently distract across disc spaceUse a large (>10mm), lordoticcage (especially at L5-S1)

Considerations to Optimize TLIF Carpentry

• Surgical techniqueMeticulous disc removal, including contralateral side and anteriorPosition cage in anterior third of body (not oblique)

Takahashi et al. Neuro Med Chir. 2014;54:692.

Jagannathan et al. Neurosurgery. 2009;64:055-64.

• Retrospective review of 80 patients who underwent TLIF (107 levels)

• Minimum 2-year follow-up

• Assessed standing x-rays for:

Changes in regional lordosis (L1-S1)Global sagittal alignment (SVA)

Changes in segmental lordosis

• Excluded patients treated with a PSO

Jagannathan et al. Neurosurgery. 2009;64:055-64.

• Change in segmental lordosis at TLIF level at minimum two-year follow-up

L1-2: 5.9o

L2-3: 4.3o

L3-4: 8.5o

L4-5: 11.3o

L5-S1: 22.2o

Jagannathan et al. Neurosurgery. 2009;64:055-64.

• Increase in lumbar lordosis was greater with a 2-level (29o) or 3-level TLIF (30o)

• Lumbar lordosis improved for 1-, 2-, or 3-level TLIF cases

Saville et al. JNS Spine. 2016;25:713-19.

For 30o HLCs , mean segmental lordosis achieved was 29o (range: 26o-34o)

Hyperlordotic ALIF +/- SPO

Jagannathan et al. Neurosurgery. 2009;64:055-64.

Increase in lumbar lordosis was greater with a 2-level (29o) or 3-level TLIF (30o)

L5-S1: 22.2o

PCO / TLIF

Case example in which TLIF with PCO can be key in correction of mild to moderate sagittal alignment.

LL=+5°PI=73°

PT=44°PI-LL=78°

74 y/o woman

-8 cm+22 cm

20°

• Canal stenosis- Moderate at L1-2- Severe at L2-3

• Foramenal stenosis- Severe bilat L1-2- Severe bilat L2-3- Severe bilat L4-5

Standing Supine

• Removal of prior instrumentation

• Pedicle screws T10-S1

• Bilateral iliac bolts

• T12-L3 and L4-5 PCOs

• L2-3 and L4-5 TLIFs

• No complicationsPI-LL = 78o PT = 44o

C7-S1 SVA = +22 cm

T12-L5 Coronal Cobb = 20o

TK = 70o

Management CB = -8 cmCobb T12-L5 = 20°

CB = -2 cmCobb T12-L5 = 0°

SVA = +22 cmPT = 44°LL = -5°PI-LL = 78°

SVA = +4 cmPT = 26°LL = 55°PI-LL = 18°

LL = -5°LL = 55°

Case example in which TLIF with PCO can be key in correction of major sagittal alignment.

• 67 y/o woman p/w progressive back pain and radiation to L>>R LEs (posterolateral leg and foot)

• Also c/o positive sagittal imbalance,subjective leg weakness, and inability to walk >1 block (limited by pain and weakness)

• PMH: pulmonary HTN, cardiac arrhythmia, RA, SLE, DM Type 2, obesity, osteoporosis (femoral neck T-score = -2.5), previous smoker

Case Example

SVA = +19cm

C7-CSVL ~0cm

LL = 11o

PI = 59o

PT = 37o

PI-LL = 48o

PT = 37o

Supine/Bolster X-rays

• T4-S1 PSI/PSF

• Bilateral iliac bolts

• T8-S1 PCOs

• L4-5 TLIF

PI-LL = 48o PT = 37o

C7-S1 SVA = +19cm

L2-5 Coronal Cobb = 31oT4-T12 Sag Cobb = 58o

• Post-op screening ultrasound -> RLE femoral DVT -> IVC filter placed (o/w no peri-op complications)

Management

SVA = +19cm SVA = +4cm

PI-LL = 48o

PT = 37o

TK = 60o

PI-LL = 8o

PT = 12o

TK = 58o

Surgical Options for Major Sagittal cal Options for r Major SaAlignment Correction

- Aggressive segmental correction

• Pedicle Subtraction Osteotomy

- Stiff or fixed deformities

- Anterior column prohibitively fused to enable sufficient correction otherwise

- Associated with high complication rates

• Objective: Assess utilization trends of PSO based on commercially available database with private payor and 5% of Medicare claims from 2008-2011

• 3.2-fold increase in utilization of PSOs while diagnosis of ASD, fusion for spine deformity, and posterior spine fusion had minimal to no increase

There are situations where PSO remains necessary in order to correct the deformity.

Are PSOs being over-utilized?

44°

+6.6 cm

+10 cm

LL=+8°PI=66°

PT=51°PI-LL=74°

68 y/o woman

+10 cm

Supine CT Scout

Significant decrease of C7-S1 SVA

Lumbar spine remains rigid and kyphotic

44°

+6.6 cm

37°

Supine CT Scout

Rigid coronal curve

Some global coronal correction

Flexion Extension Mid-SagittalLeft Parasagittal Right Parasagittal

• Severe fixed sagittal spino-pelvic malalignment

Management?

PI=66°LL=+8°PT=51°

PI-LL=74°

• Anterior/lateral fusion L1-2, L2-3, L4-5

• Surgery: - T10-ilium screws- T12-L1, L5-S1 PCOs- L5-S1 TLIF- L3 asym ePSO

• Solid posterolateral fusion L1-L5

Sometimes need to combine 3CO with interbodies to correct major sagittal malalignment

36°

>+20 cm

LL=+15°PI=80°

PT=62°PI-LL=95°

70 y/o woman

36°

Supine CT ScoutMinimal change

>+20 cm

Supine CT Scout

Some decrease of C7-S1 SVA

Lumbar spine remains rigid and kyphotic

Solid fusion throughout thoracic and lumbar spine (T5-L5)

• Severe fixed sagittal spino-pelvic malalignment

Management?

PI=80°LL=+15°PT=62°

PI-LL=95°

• L5-S1 disc space open

• Surgery: - L5-S1 ALIF (15o)- T10-ilium screws- L5-S1 PCO- L4 ePSO

• Very solid posterolateral fusion T5-L5

ePSO Technique Video

Conclusions

• PSOs should be reserved for severe deformities with anterior column prohibitively fused for correction otherwise

• Flexibility assessment is important (supine, over a bolster, CT scout)

• If flexible, even severe sagittal malalignment can often be corrected with PCOs and TLIFs

• Newer hyperlordotic ALIF spacers provide powerful segmental lordosis correction and may obviate need for 3-column osteotomy Thank You