One-third of patients undergoing lumbar fusion for degeneration had malalignment

Malalignment was also identified postoperatively in 28% of these patients who underwent fusion for degenerative conditions.

Among 578 patients who underwent one- or two-level degenerative lumbar fusion more than one-fourth of patients had malalignment preoperatively and postoperatively, highlighting the importance of measuring spinopelvic parameters in non-deformity cases, according to results that were published recently and presented at a meeting.

Perspective from Jeffrey L. Gum, MD

“Our data suggest that alignment assessment, preservation or restoration should be considered and incorporated into a surgical decision-making of all the spine fusions, not just in deformity cases,” Juan S. Uribe, MD, professor and vice chairman of neurological surgery and chief of the spinal division at Barrow Neurological Institute in Phoenix, told Orthopedics Today.

Uribe and his colleagues measured lumbar lordosis from L1 to S1, pelvic tilt and pelvic incidence in all patients included in the study. They defined alignment as pelvic incidence and lumbar lordosis less than 10° and they defined malalignment as pelvic incidence and lumbar lordosis greater than 10°.

“Out of the 578 patients, 30% of them were malaligned before the surgery and 28% of the patients were malaligned postop,” Uribe said.

He noted alignment preservation occurred in 53% of patients and alignment restoration occurred in 9% of patients.

“[The alignment] was not correct in 21% of patients,” Uribe said.

Results showed a worsened alignment in 7% of patients.

“We always had the suspicion that patients with degenerative spine conditions … do not have any kind of misalignment and we find out … that one-fourth of the patients with these degenerative conditions have some malalignment pre- or postoperative,” Uribe said. “So, the big message for all the community is that … you have to take into account when you are doing these cases that some of those patients need to have some surgical maneuvers to correct the misalignment, something that we did not think that happened with these one- or two-level surgeries.”

According to Uribe, this study can be used as a pilot study while prospective studies are performed to validate the results. Surgeons need to be aware of the possibility of malalignment in non-deformity cases, a condition that should be reviewed prior to surgery, he added,

“When surgeons are not deformity surgeons, they have to be concerned in terms of the need of knowing if the patient that is going to the OR, even [with] a simple one- or two-level fusion, … is not misaligned, because if that is the fact, you need to do a procedure that actually brings back or restores the alignment of the spine,” he said. – by Casey Tingle

Reference:

Leveque JC, et al. Spine (Phila Pa 1976). 2018;doi:10.1097/BRS.0000000000002500.

For more information:

Juan S. Uribe, MD, can be reached at 2910 N. 3rd Ave., Phoenix, AZ 85013.

Disclosure: Uribe reports he is a consultant for NuVasive.

Perspective

Jeffrey L. Gum, MD

A common saying among spine surgeons is, “We are all deformity surgeons, we either create or correct spinal deformity.” This multicenter study by Uribe and colleagues does a fantastic job of highlighting this attitude. Although spinopelvic alignment is routine for spinal deformity surgeons to evaluate and incorporate into the surgical plan, this study emphasizes the importance of this in smaller, one- and two-level lumbar fusions. With more than one-third of 619 patients (37% preoperatively and 35% postoperatively) s with spinopelvic malalignment, it is obvious that attention to these parameters is paramount. All spinal surgeons performing lumbar fusions, degenerative or deformity, need to incorporate the measurement of these parameters into their pre- and intra-operative plan to optimize the final alignment. The authors mention it has been well documented that optimal spinopelvic alignment correlates with health-related quality of life outcomes. Our next step is to illustrate that even for one- and two-level fusions for degenerative indications, optimizing the spinopelvic alignment will reduce adjacent segment pathology and subsequent revisions. I applaud the authors on their work and look forward to the full-length manuscript.

Jeffrey L. Gum, MD

Orthopedic spine surgeon Norton Leatherman Spine Center

Louisville, Kentucky

Disclosures: Gum reports he is a consultant for Medtronic, DePuy Synthes, Alphatec, Stryker, Acuity, PacMed, K2M and NuVasive; he receives royalties from Acuity; he is on the advisory/editorial board for American Journal of Orthopaedics; he receives grants from Fischer Owen Fund; he is a reviewer for The Spine Journal and American Journal of Orthopaedics; and he receives research support from Integra, Intellirod Spine Inc., Pfizer and International Spine Study Group Foundation.