Do the number of TLIF levels correlate with complications or long-term outcomes in degenerative scoliosis?

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2016

Summary

Eighty-one patients with degenerative lumbar scoliosis underwent posterior instrumented fusion with TLIF from 0-3 levels, and were prospectively followed an average 5 years to determine differences in complications, clinical outcomes, and radiographic alignment based on the number of TLIFs used. Long-term, all patients had significantly improved VAS, Oswestry, lumbar lordosis (T12-S1, L2-S1), sagittal balance, without difference based on the number of TLIFs. Complications were similar. A larger study is required to determine if subtle differences in sagittal alignment are significant.

Hypothesis

Two or 3 TLIF levels in degenerative lumbar scoliosis (DLS) have fewer better long-term sagittal alignment and fewer revision surgeries, but similar complications and clinical outcomes compared to 0-1 TLIF levels.

Design

Prospective nonrandomized comparison of consecutive DLS patients long-term after surgery using 0, 1, 2, and 3 TLIFs

Introduction

TLIF can provide enhanced lordosis and arthrodesis in DLS. Potential long-term improvements may be possible by increasing the number of TLIF’s used.

Methods

Multi-surgeon longitudinal database of complications, clinical and radiographic outcomes after Ponte osteotomies and instrumented fusion (PSF) of at least 6 levels for DLS from 2004-2014. All were fused to S1. Excluded: 3-column osteotomies, anterior and lateral fusions.

Results

Follow-up averaged 59 months (24-121mo) for 81 patients; age 68yrs (50-85yrs); 19 (23%) were revisions; Smokers-10. PSF averaged 8.4 levels (6-16). Based on TLIF number, there was no difference in PI, or pre-op lordosis, sagittal balance, or disc angles L2-S1. Long-term there was no difference in lordosis and sagittal balance based on TLIF number (p=0.09); no difference in infection (2), nonunion(11), or revision surgery(18). Individual disc spaces L3-S1 maintained similar long-term angles in the 0-TLIF and 3 TLIF groups: L3-4(-3°), L4-5(-10°), L5-S1 (-13°). VAS, ODI, pain med use were similar pre-op and improved with surgery for all groups (p<0.01), with pre-op scores best predicting long-term scores (p=.004).

Conclusions

Using current techniques in DLS surgery, there are no differences in long-term outcomes based on the number of TLIFs used. A larger study is needed to identify small radiographic differences, if they exist.

 0 TLIFs1 TLIFs2 TLIFs3 TLIFsTOTAL
Patients 14 23 28 26 81
Follow-up (mo) 43 38 64 79 59
Age 69 67 66 68 68
PSF levels 8.8 9.4 8.2 7.7 8.4
PI° 57 56 55 52 55
T12-S1° pre -33 -39 -37 -37 -37
latest -48 -47 -49 -49 -49
L2-S1° pre -35 -41 -41 -38 -39
latest -44 -44 -47 -47 -46
SVA cm pre 8.6 5.3 4.4 6.0 5.8
latest 7.7 4.9 2.8 4.5 4.6
VAS pre 6.7 7.0 6.4 6.0 6.5
latest 4.0 4.0 2.8 3.7 3.0
ODI pre 45 48 46 47 46
latest 31 28 25 31 26
Nonunion 2 6 1 2 11
Revision surg 2 7 3 6 18