Minimally Invasive Lumbar Deformity Correction
The patient is a 70-year-old male with an eight year history of progressive back and leg pain. Right leg pain is greater than the left and he experiences severe neurogenic claudication when walking a distance of approximately one-half block.
His previous medical history includes hypertension, hypercholeserolemia, two previous lumbar laminectomy procedures with noninstrumentated posteriolateral fusion at L1-L2.
- Full strength in the bilateral lower extremities, except for left dorsiflexion
- Extensor Hallucis Longus: 4+/5
- Mildly positive straight leg raise on the right
- Forward flexed posture with development of left posterior thigh pain with forced hyperextension
- Trace reflexes bilateral patella and Achilles
Bracing, non-steroidal anti-inflammatory drugs, physical therapy, and epidural injections have not relieved the patient's symptoms.
Imaging shows loss of lumbar lordosis, multilevel bilateral foraminal stenosis, coronal deformity, and multilevel disc space collapse (Figs 1-4).
Standing x-rays (Figs. 1-2)
CT Scans (Figs. 3-4)
- Loss of lumbar lordosis
- Multilevel bilateral foraminal stenosis
- Coronal deformity
- Multilevel disc space collapse
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Minimally invasive oblique lateral interbody fusion L4-S1 with intrinsic screw/graft fixation (to prevent graft kick out), and a stand-alone direct lateral interbody fusion at L2-L4. The patient was braced following surgery.
Three days later, we performed a percutaneous pedicle screw and rod fixation at L2-S1.
Total blood loss for both stages was 150 cc. The patient did not require a stay in the Intensive Care Unit.
Surgeons' Treatment Rationale
- This elderly patient presented with multiple medical was at risk for being risk for infection.
- There was neurologic (claudication) and structural dysfunction (loss of sagittal/coronal balance).
- The combination of oblique and direct lateral interbody approaches permitted access to the entire lumbar spine through one incision in the lateral position.
- Multilevel interbody graft placement permitted powerful indirect decompression and deformity correction over a large surface area for fusion.
- Minimal blood loss.
- The staged approach permitted assessment of the potential need for direct decompression prior to Stage 2 internal fixation.
Intra-operative photography (Figs. 5-6)
Post-operative x-rays (Figs. 7-9)
The patient spent 5 days hospitalized in acute care, and 7 days in rehab. At the patient's 3-month post-op evaluation, he ambulates without an assistive device and reports good relief of his pre-operative back pain and claudication. His posture is more upright too.
The authors present a case of a 70-year-old male with progressive back pain and neurogenic claudication. Imaging shows multilevel disc collapse, loss of lumbar lordosis and coronal deformity. He was treated with the minimally invasive lateral approach via interbody indirect decompression and fusion, followed by a second stage, posterior percutaneous stabilization.
Adult degenerative deformity is a complex, multifaceted entity that poses clinical and technical challenges to the treating surgeon. As in this case, presentation includes both neurological and structural spinal dysfunction, typically in elderly patients with multiple comorbidities.
The authors are to be commended for applying minimally invasive spine (MIS) techniques to this case. The use of both the direct lateral and anterior oblique approaches permitted the surgeons to address all the lumbar levels with a single approach. Like many surgeons, I currently address L5-S1 with a separate anterior lumbar interbody fusion (ALIF) procedure or with a transforaminal lateral interbody fusion (TLIF) approach during the posterior stage. This patient appears to have enjoyed the benefits of an MIS approach, including short hospitalization, minimal tissue destruction and blood loss, and an excellent early clinical outcome.
There are critical points pertinent to adult degenerative deformity treatment that the authors undoubtedly considered, but are worth reviewing. Sagittal, coronal, and spinopelvic balance must be accurately assessed and addressed. On standing long-cassette films, the sagittal vertical axis (SVA), coronal sacral vertical line (CSVL), lumbar lordosis (LL), pelvic tilt (PT) and pelvic incidence (PI) must be measured. Surgical strategy should aim to correct sagittal imbalance and spinopelvic mismatch. Fractional curves at the lumbo-sacral junction similarly need to be considered and addressed. The degree of sagittal and spinopelvic imbalance often dictates the appropriate corrective technique.
In summary, the authors have nicely demonstrated the technical feasibility and short-term outcome after MIS treatment of adult degenerative deformity. Accurately assessing and addressing sagittal and spinopelvic imbalance is imperative for long-term success in these challenging cases.
Authors' Response to Case Discussion
We greatly appreciate Dr. Baaj's thoughtful commentary on our case presentation. We whole-heartedly agree that the short-term benefits of minimally invasive techniques in the management of lumbar degenerative deformity will need to be buttressed by solid long-term radiographic and clinical outcomes. As surgeons, we must consider the growing body of data regarding the role that regional and global measures of sagittal and pelvic alignment play in long-term clinical success for these patients.