- Boulder Neurosurgical Associates, Boulder, Colorado, USA
- Justin Parker Neurological Institute, Boulder, Colorado, USA
Correspondence Address:
Sigita Burneikiene
Boulder Neurosurgical Associates, Boulder, Colorado, USA
DOI:10.4103/2152-7806.92933
Copyright: © 2012 Burneikiene S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Burneikiene S, Nelson EL, Mason A, Rajpal S, Serxner B, Villavicencio AT. Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis. Surg Neurol Int 15-Feb-2012;3:25
How to cite this URL: Burneikiene S, Nelson EL, Mason A, Rajpal S, Serxner B, Villavicencio AT. Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis. Surg Neurol Int 15-Feb-2012;3:25. Available from: http://sni.wpengine.com/surgicalint_articles/complications-in-patients-undergoing-combined-transforaminal-lumbar-interbody-fusion-and-posterior-instrumentation-with-deformity-correction-for-degenerative-scoliosis-and-spinal-stenosis/
Abstract
Background:Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction.
Methods:This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47).
Results:A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1).
Conclusion:This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.
Keywords: Adult scoliosis, complications, degenerative spine, lumbar stenosis, transforaminal lumbar interbody fusion
INTRODUCTION
The necessity to perform surgery for degenerative adult scoliosis continues to be a controversial issue and to this day no prospective controlled clinical trial exists comparing non-surgical to surgical treatment methods. In addition, this population tends to be elderly with multiple comorbidities, which can make major operations and the subsequent rehabilitation more complicated.
New and less invasive surgical techniques for scoliotic deformity correction are being investigated in clinical settings.[
MATERIALS AND METHODS
Patients
Twenty-nine patients who matched the defined criteria underwent surgery from February 2003 to October 2009. The mean follow-up time was 30 months (range, 15–47). Selected demographic patient parameters are presented in
All patients underwent TLIF procedure with posterior fixation. Selected surgical parameters are presented in
The safety of the TLIF approach was evaluated by prospectively recording all intraoperative and postoperative complications. Complications were defined as any adverse events that required symptomatic treatment or intervention and occurred intraoperatively and/or during a follow-up period and were related to surgery. All complications were further divided into systemic medical complications or hardware and surgical technique-related complications.
Clinical and radiographic outcomes
Pre- and postoperative anterior–posterior standing radiographs were used to measure alignment in the coronal plane and lateral neutral radiographs were used to measure lumbar lordosis in the sagittal plane using the Cobb method. The coronal plane deformities were measured using the endplates of maximally angled vertebrae cranially and caudally [Figure
Clinical outcomes were assessed using a combined back and lower extremity pain score measured on the Visual Analog Scale (VAS; 0–10). Overall clinical success was measured using postoperative questionnaires. Macnab criteria[
RESULTS
Complications
All complications are listed in
There were a total of 10 (35%) hardware and 4 (14%) surgical technique related complications, 8 (28%) of which required additional surgeries. Cerebrospinal fluid (CSF) leaks were all repaired intraoperatively under a high-power microscope with Prolene sutures followed by application of DuraGen Dural Graft Matrix (Integra LifeSciences, Plainsboro, NJ, USA) and DuraSeal (Covidien, Mansfield, MA, USA) with no subsequent postoperative intervention required. One patient developed increasing pain in legs and pain in posterior thighs with numbness and tingling and was diagnosed with a large subfascial fluid collection consistent with seroma or hematoma, and was taken back to surgery during the third postoperative week. The patient's incision was explored, the fluid was evacuated, and a subfascial drain was placed. Three patients had residual foraminal stenosis: two patients underwent exploration and foraminotomy and one patient was diagnosed with intractable neuropathic pain and was treated conservatively. Three months after the initial surgery, one patient underwent an additional surgery for adjacent level spondylolisthesis at the S1/S2 level. One patient had postoperative weakness and dysesthetic symptoms, which were potentially caused by nerve root irritation, and was treated conservatively with symptom resolution in 2.5 months. Another patient was reoperated on for hardware failure secondary to fracture at the top level of the construct (T12) and pseudoarthrosis 6 months after initial surgery. This patient's fusion was extended two levels and reinforced with bone cement.
A total of 5 (17%) patients developed pseudoarthrosis. Four patients had hardware-related complications, which included screw lucency (n = 3) and rod fracture (n = 1) associated with pseudoarthrosis (n =3), and three out of these four patients underwent redo surgeries.
Clinical and radiographic outcomes
Clinical outcomes were evaluated at an average time of 30 months (range, 15–47), and using Macnab criteria were determined to be excellent/good in 22 (76%) and fair in 7 (24%) out of 29 patients. We did not have any patients who rated the outcome of their surgical treatment as poor. The overall mean patient satisfaction rate was 77% (range, 42–100). The mean back and leg VAS scores decreased from 7.6 (range, 4–10) preoperatively to 3.6 (range, 0–8) postoperatively. This improvement in patients’ pain scores was statistically significant (P = 0.0001).
The mean preoperative coronal Cobb angle was 32.3° (range, 15°–55°) compared to the mean of 15.4° (range, 1°–49°) postoperatively, which was a statistically significant improvement (P = 0.0001). The graph [
The mean preoperative lumbar lordosis was 37.6° (range, 16°–55°) compared to the mean of 40.5° (range, 26°–59.2°) postoperatively. There were four patients who had a loss of lumbar lordosis of 7° on average (range, 4.3°–10.4°) postoperatively. Three of these four patients had preoperative lumbar lordosis ranging from 51.8° to 55.0°. Lumbar lordosis for this subgroup of patients was changed to a mean value of 42.5° (range, 32.1°–48.6°). Another group of patients (n = 4) that preoperatively had lumbar lordosis of less than 35° (mean 22.9°; range, 16°–30.5°) had an average of 34% improvement in their lumbar lordosis or 7.0° (range, 5.6°–10.3°) with an average postoperative lumbar lordosis of 30.0° (range, 26°–36.5°).
DISCUSSION
Traditionally, combined anterior-posterior reconstructive surgery has been associated with a high complication rate in patients undergoing surgery for painful degenerative disc disease,[
There are currently no published prospective clinical trials that report intra- and postoperative complications in patients undergoing TLIF surgery for degenerative scoliotic deformity correction. Although patients with degenerative scoliotic deformities tend to have smaller curves than those with idiopathic adolescent scoliosis, these curves are typically more rigid and can be very difficult to reduce. Patients also tend to be much older and often have associated comorbidities including osteoporosis. These two groups of patients and two distinct pathologies cannot be evaluated and compared as equals. A recent systematic review[
The complication rates found in our study were consistent with those reported in 2007 by Cho et al.[
A smaller group of similar patients was reported by Tormenti et al.[
Another study that evaluated 28 patients undergoing surgery for degenerative or idiopathic adult scoliosis was reported by Anand et al.[
Gupta,[
CONCLUSIONS
This study suggests that although the TLIF approach is feasible and effective in treating degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process that is very similar to anterior–posterior reconstructive surgery for degenerative scoliosis.
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