Adding Lateral Interbody Fusion to Open Surgery Improves Outcomes in Adult Spinal Deformity

Commentary by lead author Russell G. Strom, MD, and Peer Discussion by Kevin R. O'Neill, MD, MS

Peer Reviewed

For adults with moderate spinal deformity, adding lateral interbody fusion (LIF) to open surgery using facet osteotomies and rod-cantilever technique to enhance lumbar lordosis is associated with faster recovery, fewer complications, and greater relief of pain and disability over open surgery alone, according to a retrospective review in the December issue of the Journal of Neurosurgery.

adult lumbar scoliosisThe investigators reviewed outcomes from all adults with thoracolumbar spinal deformity who underwent surgical correction.“Adult spinal deformity surgery involves significant treatment risk and recovery time,” explained lead author Russell G. Strom, MD, a neurosurgeon at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA, who completed the study as a fellow at University of California, San Francisco. “Lateral interbody fusion with percutaneous screw fixation carries low morbidity, but sagittal correction is limited. The goal of the study was to evaluate the combination of LIF and open posterior surgery with respect to deformity correction, recovery, complications, and outcomes.”

Retrospective Review
The investigators reviewed outcomes from all adults with thoracolumbar spinal deformity who underwent surgical correction between 2009 and 2014. Cases involving severe sagittal imbalance, <6 months follow-up, prior fusion, or involving ALIF were excluded from the analysis.

As shown in the Table, patients who received LIF+open surgery (n=32) had significantly less blood loss, lower durotomy rates, fewer days in the ICU, and were less likely to require inpatient rehabilitation after discharge compared to patients who received open surgery alone (n=60). While total surgery time was longer in the LIF+open surgery group (404 vs 304 minutes; P<0.001), posterior surgery time was shorter (263 vs 304 minutes; P=0.031).

At follow-up (average, 25-28 months), patients in the LIF+open surgery group had less pseudarthrosis, greater improvement in visual analog back pain, less disability, and greater lumbar coronal correction. Notably, the groups had similar baseline features and number of levels fused.

outcomes of lateral interbody fusion plus open surgery compared to open surgery along in adult spinal deformityThe findings illustrate that “LIF combined with open posterior surgery employing facet osteotomies and rod-cantilever technique is an effective strategy for adult spinal deformity of moderate severity,” Dr. Strom said. “Mean lumbar lordosis restoration was 22-degrees. Compared with our all-posterior operations, the combined approach yielded faster recovery, fewer complications, and greater relief of pain and disability.”

Dr. Strom noted that the hybrid approach is not appropriate for severe fixed sagittal deformities or patients with prior multilevel lumbar fusion. “In these situations, a posterior approach employing three column osteotomy should be considered,” Dr. Strom said.

Study Limitations
“The study is a retrospective review and prone to selection bias,” Dr. Strom concluded. “Prospective studies with matched cohorts are needed to corroborate our results.”

Commentary

Kevin R. O’Neill, MD, MS
Orthopaedic Spine Surgeon
OrthoIndy, Indianapolis, Indiana
Member of the SpineUniverse Editorial Board

This is an excellent study that demonstrates an effective approach to treating adult patients with mild-to-moderate spinal deformity and sagittal imbalance. Surgical correction of these deformities is complex and often plagued by relatively high complication rates. Previous studies investigating lateral interbody fusions often used minimally invasive posterior techniques, resulting in low perioperative complication rates but seemingly at the expense of affording less correction and/or having higher nonunion rates. This study describes a hybrid surgery, combining the minimally invasive lateral interbody approach with a more traditional open posterior approach to improve the amount of correction achieved and reduce the rates of nonunion. This may allow surgeons to avoid more aggressive posterior osteotomies and reduce overall complications.

Compared with the more traditional open posterior approach alone, the hybrid surgical technique used in the study resulted in less blood loss, fewer dural tears, and lower rates of nonunion. There was less need for both ICU and inpatient rehabilitation stays following surgery, and patients reported greater improvement in their outcomes.

The biggest strength of the study was that it attempts to answer a pertinent clinically important question. There is no question that we must try to minimize the relatively high complication rates associated with adult deformity surgery. While minimally invasive techniques are increasingly used for degenerative conditions, it remains unclear exactly how best to utilize these techniques to minimize perioperative complications while not impacting long-term results. This study is a significant contribution to our understanding.

The authors correctly point out limitations of the study. Because it was a retrospective study, patients were not randomized, which may introduce a selection bias. Also, it is important to recognize that this study only looks at a subset of the adult deformity population. More severe deformities (SVA>200mm, LL-PI>40 degrees) and patients with previous fusion surgeries were excluded. Finally, it is a single center study of 2 surgeons’ experience with a limited number of patients, which may limit the generalizability of the findings. It is possible that comparisons of their hybrid technique to an alternative posterior surgical strategy (ie, multilevel TLIF) may result in different conclusions.

The surgical correction of adult spinal deformities is among the most complex challenges facing surgeons. These surgeries are only performed by a subset of surgeons who generally have specialized training in dealing with such difficult cases. Best results are achieved by surgeons working within an established multidisciplinary system to minimize complications.

Updated on: 03/20/18
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Kevin R. O’Neill , MD, MS
Spine Surgeon
OrthoIndy, Inc.
Indianapolis, IN
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