Staged Posterior Surgery for Severe Adult Deformity

Purpose: In order to avoid the physiologic insult associated with single stage, prolonged (>12 hour) posterior spinal surgery in complex adult deformity patients (requiring revisions, osteotomies, and/or long fusions), we developed an alternative approach in which one large posterior operation is divided into two smaller posterior procedures staged during one hospitalization.

Methods: 40 consecutive adults all with severe deformity and >2-year follow up were included. 31 of the patients presented for revision surgery and had prior posterior spinal instrumentation. During the first stage, existing implants were removed, decompressions were performed (if necessary) and new fixation points were established over the intended instrumentation levels. Temporary rods were placed across unstable segments to allow patient mobilization between stages. After 5-7 days of pulmonary and nutritional supplementation, patients were brought back to the operating room for reexposure of the posterior wound, osteotomies (if necessary), completion of instrumentation, and bone grafting. Anterior surgery was performed during either stage as necessary.

Results: Diagnoses included fixed sagittal imbalance (n=33), kyphosis (n=4), adult scoliosis (n=3), and ankylosing spondylitis (n=2). Average age at surgery was 47 years (range 18-68). Osteotomies were performed in 34 patients (pedicle subtraction in 25, Smith-Peterson in 9). Total anesthetic time averaged 10.2 hours for the first stage, 7.6 hours for the second stage (including associated anterior surgeries). An average of 4.8 levels were fused anteriorly (1-9) and 11.3 levels posteriorly (4-17). Estimated blood loss was 842cc (range 250cc–2800cc) for the first stage and 1176 cc (range 200cc–6000cc) for the second stage (including associated anterior surgeries). Only 5 patients required postoperative intubation: 4 were extubated within 24 hours and 1 within 48 hours. Wound complications occurred in 4 patients. Of these, 2 had deep infections (5%) - only 1 occurred perioperatively, whereas the other arose 13 months postop. One patient had a superficial infection (2.5%), and another had a sterile seroma evacuated without evidence of infection. Six patients (14%) have had evidence of pseudarthrosis. No major perioperative medical complications occurred (e.g., myocardial infarction, pneumonia, pulmonary embolus, death). Average postoperative SRS-24 questionnaire score was 90 out of a possible 120.Satisfaction, assessed by the last 3 questions on the SRS-24 questionnaire, was very high (average score 14 out of possible 15).

Conclusion: Staged posterior surgery can be performed safely with low rates of medical and wound complications as well as excellent functional outcomes in a patient population known to be at high risk. The approach can be useful in performing complex revision and osteotomy surgery while limiting physiologic stresses on the patient.