Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: A comprehensive radiographic analysis

Virginie Lafage, Christopher Ames, Frank Schwab, Eric Otto Klineberg, Behrooz Akbarnia, Justin Smith, Oheneba Boachie-Adjei, Douglas Burton, Robert Hart, Richard Hostin, Christopher Shaffrey, Kirkham Wood, Shay Bess

Research output: Contribution to journalArticle

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Abstract

Study Design.: Consecutive, multicenter retrospective review. Objective.: To evaluate if change in thoracic kyphosis (TK) has a positive or negative impact on spinopelvic alignment after lumbar pedicle subtraction osteotomy (PSO) with short fusions. Summary of Background Data.: In the setting of sagittal malalignment, the effect of large vertebral resections can now be anticipated in long fusions, but their impact on unfused segments (reciprocal changes [RC]) remains poorly understood. Methods.: A total of 34 adult patients (mean age = 54 years; SD = 12) who underwent lumbar PSO with upper instrumented vertebra below T10 were included. Radiographic analysis included pre- and postassessment of TK, lumbar lordosis (LL), sagittal vertical axis (SVA), T1 spinopelvic inclination (T1SPI), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were analyzed to determine successful realignment. RC in the thoracic spine was designated favorable or unfavorable on the basis of impact on final SVA and PT. Results.: Mean PSO resection was 26°. LL increased from 20° to 49° (P < 0.001). SVA improved from 14 to 4 cm (P < 0.001), and PT improved from 33° to 25° (P < 0.001). Mean increase in TK was 13° (P = 0.002) but was unchanged in 11 patients. Five patients had a favorable RC, and 18 patients had an unfavorable RC. Unfavorable RC was attributed to junctional failure in 6 of 18 patients. Significant differences in the unfavorable RC group included age and greater preoperative PT, PI, SVA, and T1SPI. Conclusion.: Significant postoperative alignment changes can occur through unfused thoracic spinal segments after lumbar PSO. Unfavorable RC may limit optimal correction and lead to clinical failures. Risk factors for unfavorable thoracic RC include older patients, larger preoperative PI and PT, and worse preoperative T1SPI and are not simply due to junctional failure. Care should be taken with selective lumbar fusion and PSO in older patients and in those with severe preoperative spinopelvic parameters.

Original languageEnglish (US)
JournalSpine
Volume37
Issue number3
DOIs
StatePublished - Feb 1 2012

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Kyphosis
Osteotomy
Thorax
Lordosis
Incidence
Spine
Age Groups

Keywords

  • junctional failure
  • pelvic tilt
  • PSO
  • sagittal imbalance
  • selective fusion
  • spinopelvic alignment

ASJC Scopus subject areas

  • Clinical Neurology
  • Orthopedics and Sports Medicine

Cite this

Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy : A comprehensive radiographic analysis. / Lafage, Virginie; Ames, Christopher; Schwab, Frank; Klineberg, Eric Otto; Akbarnia, Behrooz; Smith, Justin; Boachie-Adjei, Oheneba; Burton, Douglas; Hart, Robert; Hostin, Richard; Shaffrey, Christopher; Wood, Kirkham; Bess, Shay.

In: Spine, Vol. 37, No. 3, 01.02.2012.

Research output: Contribution to journalArticle

Lafage, V, Ames, C, Schwab, F, Klineberg, EO, Akbarnia, B, Smith, J, Boachie-Adjei, O, Burton, D, Hart, R, Hostin, R, Shaffrey, C, Wood, K & Bess, S 2012, 'Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: A comprehensive radiographic analysis', Spine, vol. 37, no. 3. https://doi.org/10.1097/BRS.0b013e318225b926
Lafage, Virginie ; Ames, Christopher ; Schwab, Frank ; Klineberg, Eric Otto ; Akbarnia, Behrooz ; Smith, Justin ; Boachie-Adjei, Oheneba ; Burton, Douglas ; Hart, Robert ; Hostin, Richard ; Shaffrey, Christopher ; Wood, Kirkham ; Bess, Shay. / Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy : A comprehensive radiographic analysis. In: Spine. 2012 ; Vol. 37, No. 3.
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T2 - A comprehensive radiographic analysis

AU - Lafage, Virginie

AU - Ames, Christopher

AU - Schwab, Frank

AU - Klineberg, Eric Otto

AU - Akbarnia, Behrooz

AU - Smith, Justin

AU - Boachie-Adjei, Oheneba

AU - Burton, Douglas

AU - Hart, Robert

AU - Hostin, Richard

AU - Shaffrey, Christopher

AU - Wood, Kirkham

AU - Bess, Shay

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N2 - Study Design.: Consecutive, multicenter retrospective review. Objective.: To evaluate if change in thoracic kyphosis (TK) has a positive or negative impact on spinopelvic alignment after lumbar pedicle subtraction osteotomy (PSO) with short fusions. Summary of Background Data.: In the setting of sagittal malalignment, the effect of large vertebral resections can now be anticipated in long fusions, but their impact on unfused segments (reciprocal changes [RC]) remains poorly understood. Methods.: A total of 34 adult patients (mean age = 54 years; SD = 12) who underwent lumbar PSO with upper instrumented vertebra below T10 were included. Radiographic analysis included pre- and postassessment of TK, lumbar lordosis (LL), sagittal vertical axis (SVA), T1 spinopelvic inclination (T1SPI), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were analyzed to determine successful realignment. RC in the thoracic spine was designated favorable or unfavorable on the basis of impact on final SVA and PT. Results.: Mean PSO resection was 26°. LL increased from 20° to 49° (P < 0.001). SVA improved from 14 to 4 cm (P < 0.001), and PT improved from 33° to 25° (P < 0.001). Mean increase in TK was 13° (P = 0.002) but was unchanged in 11 patients. Five patients had a favorable RC, and 18 patients had an unfavorable RC. Unfavorable RC was attributed to junctional failure in 6 of 18 patients. Significant differences in the unfavorable RC group included age and greater preoperative PT, PI, SVA, and T1SPI. Conclusion.: Significant postoperative alignment changes can occur through unfused thoracic spinal segments after lumbar PSO. Unfavorable RC may limit optimal correction and lead to clinical failures. Risk factors for unfavorable thoracic RC include older patients, larger preoperative PI and PT, and worse preoperative T1SPI and are not simply due to junctional failure. Care should be taken with selective lumbar fusion and PSO in older patients and in those with severe preoperative spinopelvic parameters.

AB - Study Design.: Consecutive, multicenter retrospective review. Objective.: To evaluate if change in thoracic kyphosis (TK) has a positive or negative impact on spinopelvic alignment after lumbar pedicle subtraction osteotomy (PSO) with short fusions. Summary of Background Data.: In the setting of sagittal malalignment, the effect of large vertebral resections can now be anticipated in long fusions, but their impact on unfused segments (reciprocal changes [RC]) remains poorly understood. Methods.: A total of 34 adult patients (mean age = 54 years; SD = 12) who underwent lumbar PSO with upper instrumented vertebra below T10 were included. Radiographic analysis included pre- and postassessment of TK, lumbar lordosis (LL), sagittal vertical axis (SVA), T1 spinopelvic inclination (T1SPI), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were analyzed to determine successful realignment. RC in the thoracic spine was designated favorable or unfavorable on the basis of impact on final SVA and PT. Results.: Mean PSO resection was 26°. LL increased from 20° to 49° (P < 0.001). SVA improved from 14 to 4 cm (P < 0.001), and PT improved from 33° to 25° (P < 0.001). Mean increase in TK was 13° (P = 0.002) but was unchanged in 11 patients. Five patients had a favorable RC, and 18 patients had an unfavorable RC. Unfavorable RC was attributed to junctional failure in 6 of 18 patients. Significant differences in the unfavorable RC group included age and greater preoperative PT, PI, SVA, and T1SPI. Conclusion.: Significant postoperative alignment changes can occur through unfused thoracic spinal segments after lumbar PSO. Unfavorable RC may limit optimal correction and lead to clinical failures. Risk factors for unfavorable thoracic RC include older patients, larger preoperative PI and PT, and worse preoperative T1SPI and are not simply due to junctional failure. Care should be taken with selective lumbar fusion and PSO in older patients and in those with severe preoperative spinopelvic parameters.

KW - junctional failure

KW - pelvic tilt

KW - PSO

KW - sagittal imbalance

KW - selective fusion

KW - spinopelvic alignment

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