Patient assessment and planning lead to optimal sagittal plane correction  

NEW ORLEANS — Achieving optimal outcomes of sagittal plane correction in patients with adult spinal deformity depends on meticulous preoperative planning and careful intraoperative execution of that plan.  

Driven by an aging population, the incidence of adult spinal deformity is rapidly increasing, based on data from the International Spine Study Group. 

Frank J. Schwab

“We are at the beginning of a bit of an epidemic here,” Frank J. Schwab, MD, chief of the Spinal Deformity Service and clinical professor at New York University School of Medicine in New York, said in a presentation at the American Academy of Orthopaedic Surgeons Annual Meeting. “[We have] shifting demographics in our population; shifting expectations in our population. 

“We are operating on older and older patients and doing more significant realignment procedures,” Schwab said. Therefore, before operating when there is notable sagittal deformity, the surgeon needs a good plan, which starts with selecting the proper patient. The proper patient has a significant, treatable deformity, as defined by the Scoliosis Research Society classification system, the SF-36 and the Oswestry Disability Index. Their level of disability must correlate with what the surgeon sees on imaging. In addition, the patient must have appropriate post-surgical expectations, according to Schwab.  

Quantify surgical goals 

As a next step the surgeon should quantify the surgical goals. “Ideally, simulate the procedure, so you go into the OR with a plan,” Schwab said. “So that thinking almost stops in the OR; you just begin to execute. That has been helpful for us — to define very clearly and anticipate what we are going to do so that we focus more on the technical aspects once we are in the OR.”  

In the operating room, the surgeon needs to keep the plan simple, position the patient carefully and have a good team on hand. Mental flexibility is paramount; if plan A does not work, have plans B and C ready before entering the OR. “So you are not caught off guard when there’s a dural tear,” for example, Schwab said. “You may have to change your levels or the plan.” 

Multiple surgeons should be present. “Multiple surgeons bring down two things: blood loss and OR time,” Schwab said. “Those are major drivers of complications in adult deformity as we’ve seen from the International Spine Study Group data.” 

Multiple rods for stability 

In the interest of safety, the surgeon should use a stabilizing rod and perform a wide laminectomy, according to Schwab.  

A grade 4 resection, which includes the pedicle and the disc above, creates more instability. In these cases, it is also important to rasp the endplate, he said.  

To obtain more stability, Schwab suggested using a 4-rod technique. “There is a high fracture rate with single rods,” he said.  

As for intraoperative imaging, it can be done in several ways. “Flat plate is a more reliable measure of what you’ve obtained in terms of your alignment,” Schwab said. – by Colleen Owens  

Reference: 

Schwab FJ. Symposium D: Preoperative measurement & classification of sagittal deformity: Technical planning & intraoperative execution of sagittal plane correction. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans.  

For more information: 

Frank J. Schwab, MD, can be reached at the Center for Musculoskeletal Care, 333 E. 38th St., 6th Floor, New York, NY 10016; email: fschwab@att.net 
Disclosure: Schwab receives royalties from Medtronic Sofamor Danek, is part of the speakers bureau for K2M and Medtronic Sofamor Danek, is a paid consultant to K2M, Medtronic Sofamor Danek and DePuy, receives stock or stock options from Nemaris, and received research or institutional support from Medtronic Sofamor Danek and DePuy. 