Sagittal spinal misalignment (SSM) is an established cause of pain and disability. Treating physicians must be familiar with the radiographic findings consistent with SSM. Additionally, the restoration or maintenance of physiological sagittal spinal alignment after reconstructive spinal procedures is imperative to achieve good clinical outcomes. The C-7 plumb line (sagittal vertical axis) has traditionally been used to evaluate sagittal spinal alignment; however, recent data indicate that the measurement of spinopelvic parameters provides a more comprehensive assessment of sagittal spinal alignment. In this review the authors describe the proper analysis of spinopelvic alignment for surgical planning. Online videos supplement the text to better illustrate the key concepts.
Introduction Surgical planning to address significant lumbar spine pathology, performed without appreciation of global spinal alignment, may have negative consequences. Our objective was to assess whether the extent of recommended surgery for lumbar pathology would significantly change with the addition of long-cassette standing X-rays. Materials and Methods This was an international online survey of spine surgeons. A series of 15 cases of lumbar spine pathology was presented with a brief clinical vignette and lumbar imaging (X-rays and MRI/CT). Surgeons were asked to select the most appropriate surgical plan, with five choices, ranging from least aggressive (decompression alone; 1 point) to the most aggressive (upper thoracic to sacrum/ilium fusion ± osteotomies/decompression/interbodies; 5 points). Cases were then reordered and presented with long-cassette standing X-rays and the same surgical planning question. Results were compared based on lumbar imaging only versus addition of long-cassette X-rays. Five cases (control group) had normal global alignment and 10 cases (study group) had global malalignment. Results A total of 316 surgeons completed the survey, predominantly (63%) from North America and Europe. Specialties included orthopedic surgery (65%) and neurosurgery (34%), 68% completed spine fellowship, and responders had a mean 13.4 years in practice that was a mean of 76% spine and included a mean of 123 fusions per year. For study cases, extent of recommended surgery increased significantly with the addition of long-cassette X-rays versus lumbar imaging only ( p = 0.002). For control cases with normal global alignment, no significant changes in surgery plans were identified with the addition of long-cassette X-rays ( p = 0.280). Conclusion Long-cassette standing X-rays can have a significant impact on surgical planning for lumbar pathology. Surgeons should maintain a relatively low threshold for obtaining long-cassette standing X-rays when contemplating surgical treatment for significant lumbar spine pathology.
Zygourakis, Corinna Clio MD; Scheer, Justin K MD; Yoon, Seungwon; Yeramaneni, Samrat MBBS, PhD; Hostin, Richard A MD; O’Brien, Michael F MD; Shaffrey, Christopher I MD, FACS; Smith, Justin S MD, PhD; Deviren, Vedat MD; Ames, Christopher P MD
An electronic survey administered to Scoliosis Research Society membership.To characterize surgeon views regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) management providing the framework in which a PJK/PJF classification system and treatment guidelines could be established.PJK/PJF are common complications of adult spinal deformity surgery. To date, there is no consensus on PJK/PJF definitions, classification, and indications for revision surgery. There is a paucity of data on deformity surgeon practice pattern variations and consensus opinion on treatment and prevention.An electronic 19-question survey regarding PJK/PJF was administered to members of the Scoliosis Research Society who treat adult spinal deformity. Determinants included the surgeons' type of practice, number of years in practice, agreement with given PJK/PJF definitions, importance of key factors influencing prevention and revision, prevention methods currently used, and the importance of developing a classification system.A total of 226 surgeons responded (38.8% response rate). Both 44.4% of surgeons selected "extremely important" and 40.8% selected "very important" that PJK in adult spinal deformity surgery is a very important issue and that a Scoliosis Research Society PJK/PJF classification system and guidelines for detection and prevention of PJK/PJF is a "must have" (18.1%) and "very likely helpful" (31.9%). Both 86.2% and 90.7% of surgeons agreed with the provided definitions of PJK and PJF, respectively. Top 5 revision indications included neurological deficit, severe focal pain, translation or subluxation fracture, a change in kyphosis angle of greater than 30°, chance fracture, spondylolisthesis greater than 6 mm, and instrumentation prominence. The majority of respondents use a PJK/PJF prevention strategy 60% of the time or more, the most common were terminal rod contour, preoperative bone mineral density testing, and frequent radiographical studies during first 3 months postoperative, preoperative bone mineral density medication for low bone mineral density.The results of this study provide insight from the practicing surgeons' perspective of the management of PJK and PJF that may aid in the validation of current definitions and consensus-based treatment decisions and prevention guidelines.5.
Failure of the posterior rods in long thoracolumbar deformity correction cases often requires revision surgery to treat the pseudoarthrosis and prevent loss of correction. While the entire rod can be replaced, this involves opening the entire incision which can lead to increased morbidity. Other clinically advantageous options include minimally invasive surgical approaches such as percutaneous insertion of connectors and additional rods.
