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. 2014 Jun;472(6):1769-75.
doi: 10.1007/s11999-013-3335-6.

Does minimally invasive transsacral fixation provide anterior column support in adult scoliosis?

Neel Anand  1 , Eli M Baron, Babak Khandehroo
Affiliations

Does minimally invasive transsacral fixation provide anterior column support in adult scoliosis?

Neel Anand et al. Clin Orthop Relat Res. 2014 Jun.

Abstract

Background: Spinal fusion to the sacrum, especially in the setting of deformity and long constructs, is associated with high complication and pseudarthrosis rates. Transsacral discectomy, fusion, and fixation is a minimally invasive spine surgery technique that provides very rigid fixation. To date, this has been minimally studied in the setting of spinal deformity correction.

Questions/purposes: We determined (1) the fusion rate of long-segment arthrodeses, (2) heath-related quality-of-life (HRQOL) outcomes (VAS pain score, Oswestry Disability Index [ODI], SF-36), and (3) the common complications and their frequency in adult patients with scoliosis undergoing transsacral fixation without supplemental pelvic fixation.

Methods: Between April 2007 and May 2011, 92 patients had fusion of three or more segments extending to the sacrum for spinal deformity. Transsacral L5-S1 fusion without supplemental pelvic fixation was performed in 56 patients. Of these, 46 with complete data points and a minimum of 2 years of followup (mean, 48 months; range, 24-72 months; 18% of patients lost to followup) were included in this study. Nineteen of the 46 (41%) had fusions extending above the thoracolumbar junction, with one patient having fusion into the proximal thoracic spine (T3-S1). General indications for the use of transsacral fixation were situations where the fusion needed to be extended to the sacrum, such as spondylolisthesis, prior laminectomy, stenosis, oblique take-off, and disc degeneration at L5-S1. Contraindications included anatomic variations in the sacrum, vascular anomalies, prior intrapelvic surgery, and rectal fistulas or abscesses. Fusion rates were assessed by full-length radiographs and CT scanning. HRQOL data, including VAS pain score, ODI, and SF-36 scores, were assessed at all pre- and postoperative visits. Intraoperative and postoperative complications were noted.

Results: Forty-one of 46 patients (89%) developed a solid fusion at L5-S1. There were significant improvements in all HRQOL parameters. Eight patients had complications related to the transsacral fusion, including five pseudarthroses and three superficial wound dehiscences. Three patients underwent revision surgery with iliac fixation. There were no bowel injuries, sacral hematomas, or sacral fractures.

Conclusions: Transsacral fixation/fusion may allow for safe lumbosacral fusion without iliac fixation in the setting of long-segment constructs in carefully selected patients. This study was retrospective and suffered from some loss to followup; future prospective trials are called for to compare this technique to other, more established approaches.

Level of evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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Figures

Fig. 1A–B
Fig. 1A–B
These 36-inch (A) AP and (B) lateral standing radiographs show the spine of a 53-year-old woman complaining of back and leg pain. Workup revealed her to have adult idiopathic scoliosis. She has a left curve from T10-L4 measuring 58°, a right curve from T5-T10 of 34°, and a fractional curve of L4-S1 measuring 33°.
Fig. 2A–B
Fig. 2A–B
These 36-inch (A) AP and (B) lateral standing radiographs show the spine of the patient in Figure 1 at 3 years after lateral transpsoas discectomy and interbody fusion, percutaneous pedicle screw and rod placement, and L5-S1 transsacral discectomy and interbody fusion. A solid fusion was achieved at L5-S1 without iliac fixation.
Fig. 3A–B
Fig. 3A–B
Sagittal CT reconstructions 1 year after minimally invasive deformity reconstruction are shown. (A) A midsagittal cut shows some anterior interbody bone material. (B) An image through the L5-S1 facet shows a solid facet fusion (arrow) after use of BMP, local bone, and demineralized bone matrix for fusion.
See this image and copyright information in PMC

References

    1. Anand N, Baron EM. Minimally invasive approaches for the correction of adult spinal deformity. Eur Spine J. 2013;22(suppl 2):S232–S241. doi: 10.1007/s00586-012-2344-6. - DOI - PMC - PubMed
    1. Anand N, Baron EM. Presacral approaches for minimally invasive spinal fusion. In: Phillips FM, Lieberman I, Polly DW Jr, editors. Miimally Invasive Spine Surgery: Surgical Techniques & Disease Management. New York, NY: Springer; 2013.
    1. Anand N, Baron EM, Bray RS., Jr Benefits of the paraspinal muscle-sparing approach versus the conventional midline approach for posterior nonfusion stabilization: comparative analysis of clinical and functional outcomes. SAS J. 2007;1:93–99. doi: 10.1016/S1935-9810(07)70053-1. - DOI - PMC - PubMed
    1. Anand N, Baron EM, Khandehroo B, Kahwaty S. Long term 2 to 5 year clinical and functional outcomes of minimally invasive surgery (MIS) for adult scoliosis. Spine (Phila Pa 1976). 2013;38:1566–1575. doi: 10.1097/BRS.0b013e31829cb67a. - DOI - PubMed
    1. Anand N, Baron EM, Rosemann R, Hartl R, Kitchel S, Patel V. Safety and complication profile of percutaneous lumbosacral interbody fusion. Presented at Congress of Neurological Surgeons, New Orleans, LA, October 24 to 29, 2009.

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