All Posterior Treatment of Adult Spinal Deformity

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1 All Posterior Treatment of Adult Spinal Deformity Michael P. Kelly, MD, MS Washington University, Saint Louis, MO Spine Master s Course May 18, 2017

2 Disclosures Research Support Paid to Washington University Cervical Spine Research Society OREF AO Spine Barnes Jewish Foundation PCORI DepuySynthes Spine

3 Overview Adult Denovo Lumbar Scoliosis Heterogenous category of deformity Disability associated with ASLS Treatment Options Less invasive More invasive surgeries that work and have a track record Pros and Cons of Each Outcomes Potential Pitfalls Complications Associated with Each If you hate your psoas, the answer is clear..

4 Adult Denovo Lumbar Scoliosis Adult Symptomatic Lumbar Scoliosis A discrete subset of adult spinal deformity Lumbar curve > 30 Degrees Characterized by back pain, claudication, and/or radiculopathy

5 Adult Symptomatic Lumbar Scoliosis Associated with disability similar to cardiac disease, diabetes, and rheumatoid arthritis Given this pain, it is common to seek care The costs of care are rising due, in part, to increasing prevalence of ASLS

6 Adult Symptomatic Lumbar Scoliosis Average charge per hospital stay VERY high Likely unsustainable NIH RO1 Funded study underway to investigate predictors of success in ASLS Surgery

7 Adult Symptomatic Lumbar Scoliosis Historically treated with Anterior and Posterior Surgery Improve Lumbar Lordosis Improve Fusion Rates Anterior Scar Bothersome to Some (Including US!)

8 Adult Symptomatic Lumbar Scoliosis With improved instrumentation, techniques, and biologics a move towards All posterior, open surgery Single stage, single incision corrections Anesthetic protocols and anti-fibrinolytics can minimize EBL Transfusion medicine has evolved

9 Adult Symptomatic Lumbar Scoliosis Further evolution of surgical management to anterior + posterior via (some) muscle sparing approaches So what do we do?

10 Open, all-posterior spinal fusion surgery Ask the most important question first! Does it work? Dual-arm Randomized and Observational Cohort Study comparing Operative and Nonoperative Treatment of Adult Symptomatic Lumbar Scoliosis at Minimum 2-years followup Inclusion Criteria: Age Lumbar Coronal Cobb 30 Degrees or More ODI > 20 OR SRS Domain Score < 4.0 Primary Aims Examine effect of operative and nonoperative management on SRS-Subscore and ODI Examine impact of patient factors on 2-year outcomes

11 Adjusted Estimated Effect Oswestry Disability Index 3 Months 12 Months 24 Months NON OP TE NON OP TE NON OP TE P<0.001 P<0.001 P<0.001

12 Adjusted Estimated Effect SRS Subscore 3 Months 12 Months 24 Months NON OP TE NON OP TE NON OP TE P=0.435 P<0.001 P<0.001

13 What will Juan say? Too much destruction! Too much blood loss! So many complications! 30% Major Complications in 3 Column Osteotomies This isn t what we are discussing These are huge surgeries Depsite this, NO Change in HRQOL What about NIH Study? Complications related to surgery are COMMON Reoperation is troublesome, approaching 30% NO CHANGE IN HRQOL!

14 The goals of surgery Reliable relief of nerve root compression L-type curves most likely to improve with respect to both Back and Leg Pain Improvement to MCID or SCB most likely in L-type curves Translate to functional improvement? ASLS Study Improvements in Back Pain, Leg Pain, Distance

15 Value in Spinal Deformity Surgery Value is Cost per Outcome Outcome is perceived by the patient 20mg of rhbmp-2 at L-S junction in lieu of interbody with lower dose No difference in HRQOL No difference in Nonunions Low-dose at the L-S Junction without interbody device is effective We can offer reliable fusions without extra implant costs and similar HRQOL

16 Value in Spinal Deformity Surgery Results need to be reliable Comparison of Open vs MIS MIS Stays 7 days! Open 15! MIS had lower overall charges Open Had Better improvement in HRQOL Better deformity correction including SVA

17 Open Posterior High quality evidence shows HRQOL Benefits Adding extra things may not be necessary to achieve competitive fusion rates One incision, one trip to the OR The Future requires reliable, least expensive Need to treat as many as possible

18 If we can do it smaller, why not? Ante-psoas Trans-psoas MIS TLIFs

19 27% Rate of Sensory Deficits 10% Transient Neurological Deficits DO NOT THINK THESE ARE BENIGN 2.5% Permanent Deficits 20% Sensory 2% Transient Motor 1% Permanent

20 In the setting of reasonable alternatives, what is the role of trans-psoas? In addition to sensory deficits, motor deficits: Aorta injuries Bowel perforations Sympathectomies Shouldn t we, therefore, conclude that the cons of MIS XLIF outweigh its pros, and move to strike it from our surgical armamentarium?

21 Thank You Michael Kelly Assistant Professor