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What Degree of Malalignment Justifies Performance of Three Column Osteotomy in Revision Lumbar Spinal Fusion?

Friday, May 3, 2024

Presenting Author(s)

JM

Jamshaid Mir, MD

Research Fellow
NYU Langone Hospital
Paterson, NJ, US

Co-Author(s)

Christopher P. Ames, MD

Neurosurgeon
University of California, San Francisco
San Francisco, California, United States
SB

Shay Bess, MD

President of the ISSG/Orthopaedic Spine Surgeon
Denver International Spine Center, United States
Thomas Buell, MD (he/him/his)

Assistant Professor of Neurosurgery
University of Pittsburgh Medical Center
Pittsburgh, PA, US
Dean Chou, MD

Chief of the Spine Division, Professor, and Vice Chair of Neurosurgery
Columbia University
New York, New York, United States
AD

Alan H. Daniels, MD

Associate Professor of Orthopaedic Surgery/Chief, Adult Spinal Deformity Service
Alpert Medical School of Brown University
Providence, Rhode Island, United States
BD

Bassel Diebo, MD

Assistant Professor of Orthoepdic Surgery
Brown University
New York, New York, United States
RE

Robert K. Eastlack, MD

Orthopaedic Spine Surgeon
Scripps Clinic, United States
Jeffrey L. Gum, MD

Orthopaedic Spine Surgeon
Leatherman Spine Center, Kentucky, United States
D. Kojo Hamilton, MD

Attending Surgeon
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania, United States
RL

Renaud Lafage, MS

Biomedical engineer
Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
NYC, New York, United States
VL

Virginie Lafage, MD

Scientist
Lenox Hill Hospital
New York, New York, United States
BL

Breton G. Line, BS

Clinical Research Assistant
Denver International Spine Center, United States
Jeffrey Mullin, MD

Assistant Professor
University of Buffalo
Buffalo, New York, United States
Praveen V. Mummaneni, MD, MBA

Joan O'Reilly Endowed Professor and Vice Chair of Neurosurgery
Department of Neurological Surgery, University of California, San Francisco
San Francisco, CA, US
Gregory M. Mundis, Jr., MD (he/him/his)

Orthopaedic Spine Surgeon
San Diego Spine
Encinitas, California, United States
Paul Park, MD

Neurosurgeon
Semmes Murphey Clinic
MEMPHIS, Tennessee, United States
Peter G. Passias, MD

Assistant Clinical Professor of Orthopedic Surgery
New York University, Langone Medical Center
New Canaan, Connecticut, United States
JS

Justin Scheer, MD

Attending Surgeon
UCSF
San Francisco, California, United States
Christopher I. Shaffrey, MD

Professor of Spine Surgery
Duke University Medical Center
Durham, NC, US
Justin S. Smith, MD, PhD

Professor of Neurosurgery
Department of Neurosurgery, University of Virginia
Charlottesville, VA, US
AS

Alex Soroceanu, MD, FRCS(C), MPH

Clinical Associate Professor
University of Calgary, United States

Introduction: While the use of three column osteotomy(3CO) in complex spinal deformity is associated with improved outcomes and acceptable complication rates, we have yet to compare outcomes after 3CO based on varied degrees of preoperative malalignment and determine when 3CO is warranted.

Methods: Revision complex spinal deformity patients who were fused from at least L1 and proximal to S1 and below with available baseline and 1 year (1Y) follow-up were isolated. Patients were stratified by whether they had 3CO(3CO+) and those that did not(3CO-). 3CO- cohort was further assessed based on the development of complications and regional failure. Analysis controlled for age, gender, BMI, CCI, frailty, baseline deformity, and levels fused. Multivariable regression determined which sagittal parameters were predictive of good outcomes. Conditional-inference-tree(CIT) was used to determine thresholds.

Results: 132 patients met inclusion. Deformity at baseline was significantly worse in 3CO+. Despite fewer levels fused in 3CO+(10.7 vs 13.3, p<.05) cohort, there was higher EBL(2.2L vs 1.2L, p< 0.001), increased rates of massive blood loss(13% vs 1%, p=0.008), LOS(9.9 vs 6.6 days, p< 0.001), SICU admission(87% vs 60%,p=0.007), discharge to SNF or rehab. Differences amongst cohorts in 1Y radiographic alignment, with 3CO- cohort having worse PT(p=0.008) and TPA(p=0.01). Parameters predictive of mechanical complications were: increasing PT(OR: 1.325p=.048) and increasing TPA (OR: 1.064, p=.016). Thresholds values for baseline deformity associated with favorable outcomes in 3CO+ were: PT < 15.3°(p=0.047), PI-LL < 47.5°(p=0.026), TPA < 33.2°(p=0.047).

Conclusion : The use of three-column osteotomy in revision complex spinal deformity surgery is associated with worse perioperative outcomes, however by 1 year alignment parameters were improved relative to those that did not have a 3CO. Threshold values of radiographic parameters can guide surgical planning in those that may be considered for 3CO.