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    Why Every Spine Fusion Can Be A Deformity?

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    PaulMcAfee
    This document discusses the importance of sagittal plane balance in spine surgery and how achieving proper balance can prevent deformity. It notes that every spine surgeon is effectively a deformity surgeon, as improper procedures can lead to deformity. It emphasizes that the lower down the spine an osteotomy is performed, the better the correction of sagittal vertical axis. It also discusses techniques for correcting adult spinal deformity including multi-level lumbar interbody fusions with osteotomies. Case examples are presented to illustrate pre-and post-operative sagittal alignment outcomes.

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    © All Rights Reserved
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    Why Every Spine Fusion Can Be A Deformity?

    Uploaded by

    PaulMcAfee
    115 views88 pages
    This document discusses the importance of sagittal plane balance in spine surgery and how achieving proper balance can prevent deformity. It notes that every spine surgeon is effectively a deformity surgeon, as improper procedures can lead to deformity. It emphasizes that the lower down the spine an osteotomy is performed, the better the correction of sagittal vertical axis. It also discusses techniques for correcting adult spinal deformity including multi-level lumbar interbody fusions with osteotomies. Case examples are presented to illustrate pre-and post-operative sagittal alignment outcomes.

    Original Description:

    McAfee Talk for Residents on Deformity October 2021

    Original Title

    McAfee Resident Deformity Talk 9.9.21

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    This document discusses the importance of sagittal plane balance in spine surgery and how achieving proper balance can prevent deformity. It notes that every spine surgeon is effectively a deformity surgeon, as improper procedures can lead to deformity. It emphasizes that the lower down the spine an osteotomy is performed, the better the correction of sagittal vertical axis. It also discusses techniques for correcting adult spinal deformity including multi-level lumbar interbody fusions with osteotomies. Case examples are presented to illustrate pre-and post-operative sagittal alignment outcomes.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    115 views88 pages

    Why Every Spine Fusion Can Be A Deformity?

    Uploaded by

    PaulMcAfee
    This document discusses the importance of sagittal plane balance in spine surgery and how achieving proper balance can prevent deformity. It notes that every spine surgeon is effectively a deformity surgeon, as improper procedures can lead to deformity. It emphasizes that the lower down the spine an osteotomy is performed, the better the correction of sagittal vertical axis. It also discusses techniques for correcting adult spinal deformity including multi-level lumbar interbody fusions with osteotomies. Case examples are presented to illustrate pre-and post-operative sagittal alignment outcomes.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 88

    Why Every Spine Fusion Can Be a

    Deformity?

    Paul C McAfee, MD
    Chief of Spinal Research
    MedStar
    Professor of Orthopedic Surgery at
    Georgetown School of Medicine
    Every Spine Surgeon is a
    Deformity Surgeon--

    “Either you study and focus on the treatment


    of Deformity or you are a surgeon who
    Causes Deformity”
    Jean Dubousset
    “Cone of Economy”
    “Four to the Floor”
    Sagittal Plane Balance
    SVA= Sagittal Vertical Axis > 4.7 cm
    PI – LL > 11 degrees
    PT > 22 degrees
    ODI >40
    As
    As you
    you increase
    increase Pelvic
    Pelvic Incidence
    Incidence (PI)
    (PI) you
    you must
    must
    increase
    increase Lumbar
    Lumbar Lordosis
    Lordosis ifif patient
    patient stays
    stays in
    in
    Balance
    Balance
    Chin Brow Vertical Angle
    CBVA More Perpendicular

    Inc Cervical Lordosis

    Increase T1 tilt Angle

    Increased Thoracic Kyphosis

    Increased Lumbar Lordosis

    Increase Sacral Tilt (SA)

    Increased Pelvic Incidence


    Case representative of a patient with good correction for SVA and PT.
    Preoperative lateral radiograph (left) showing an SVA of 119.73 mm,
    LL of 28°, SS of 30°, PT of 22°, and PI of 52°.
    Postoperative lateral radiograph (right) showing an
    SVA of 30.14 mm, LL of 60°, SS of 38°, PT of 9°, and PI of 47°.
    Case representative of high postoperative PT and poor correction of the SVA.
    Preoperative lateral radiograph (left) showing an SVA of 254.13 mm, LL of 32°,
    SS of 38°, PT of 40°, and PI of 78°. Postoperative lateral radiograph (right)
    showing an SVA of 150.42 mm, LL of 57°, SS of 40°, PT of 36°, and PI of 76°.
    Case representative of high postoperative PT with good correction of the SVA.
    Preoperative lateral radiograph (left) showing an SVA of 142.38 mm, LL of 20°,
    SS of 16°, PT of 40°, and PI of 56°. Postoperative lateral radiograph
    (right) showing an
    SVA of 24.79 mm, LL of 54°, SS of 26°, PT of 30°, and PI of 56°.
    HFC or
    Why SVA Failure? spinal and hip extensor weakness
    The Lower down the Spine You perform the osteotomy (More Cephalad)
    The better the correction of the SVA
    Cervical Sagittal Malalignment
    Difference between C2 and C7 Plumb line (1.5 cm is normal)
    Cervical SVA
    Cervical SVA– measure from Posterosuperior corner of C7 Vertebral Body
    Green line– C1 to C7 SVA
    Red Line– C2 to C7 SVA
    Yellow line—Gravity line, External auditory meatus (tragus) to C7

    Chin Brow Vertical Angle (CBVA)– (Should be Zero)


    Relationship between cervical SVA and T1 slope

    Larger T1 slope--- means more Displacement to Right so


    Cervical SVA goes up.
    Sacral Tilt and T1 tilt
    Always work together

    Thoracic Inlet Angle


    Analogous to
    Pelvic Incidence
    Easy to Get Confused
    Journal of Neurosurgery
    Aug 2013, Scheer et al
    FS- Femoral Shaft ?

    The spine functions as a global unit so that cervical alignment parameters influence
    and are influenced by, parameters in the lower regions.
    CL = cervical lordosis, COG = center of gravity,
    FS = femoral shaft, PI = pelvic incidence, PT = pelvic tilt. SS = sacral slope.
    OPLL or CSM with Cord Compression
    Only do Posterior Laminectomies if Cervical Spine is in Lordosis.

    A Spine Surgeon who Distracts against a Fixed Kyphosis is like


    A Professional Golfer Continuously Putting for Par…………
    HRQOL issues Worse for patient on the Right
    C2 SVA increased (Red Line)
    Overall Sagittal Imbalance would be higher (measure to posterosuperior
    S1 vertebral body) if these are standing 3 Foot Radiographs.
    Cotrel Traction-1960
    French
    French School
    School Children
    Children One
    One Year
    Year
    First Harrington Procedure done in Maryland 3/23/62
    6 months Cast
    XMAS– (9 months) Turn Loose
    13
    13 yryear
    old Lenkeold
    1C Lenke 1C Thoracic
    Thoracic Scoliosis
    Scoliosis
    Patient 1
    6 Weeks Post-op
    Cheerleader 14 yr
    old with 49 Degree
    Lenke Type 1B
    Thoracic Scoliosis
    Cheerleader
    6 Months Postop
    Deformity Outcome Instruments
    Instruments
    1. “The Doctor is Happy to See the Patient,
    and the Patient is Happy to See the Doctor ”
    ------------Frank Stinchfield, MD (1960)

    2. “The Scoliosis Patient can go away to


    College and Wear a T-Shirt and none of
    her friends Know that she has Scoliosis ”
    -----------Dennis Wenger, MD (1983)
    17 yr old Girl
    10/4/92
    Lenke 1B
    52 to 24
    35 to 3
    X-Axis
    Scoliosis
    Coronal plane Imbalance
    Large Numbers
    Easy to Measure
    HRQOL > 20mm
    Why Has this been Overlooked by Deformity Surgeons?
    The HRQOL Tolerances are Markedly Different Between the Three Axes of Spinal Stability—

    Occ to C2 3 mm

    Cervical 3.5mm

    Thoracic 2 mm

    Sagittal Plane Imbalance


    9 cm severe Lumbosacral 3 mm
    4.7 cm abnormal
    (Virginie Lafage 2012)
    Coronal Plane Imbalance
    > 2 cm
    All
    All of
    of the
    the Sagittal
    Sagittal and
    and Coronal
    Coronal Balance
    Balance Parameters
    Parameters would
    would
    be
    be WNL
    WNL in in these
    these two
    two dramatic
    dramatic Deformities–
    Deformities– PI,
    PI, SVL,
    SVL, PT,
    PT,
    SS,
    SS, etc.
    etc.

    !
    !
    !
    In!an!opposite!example!of!the!extreme!shortening!of!the!middle!column!is!Figure!67
    A!in!the!same!article!.!L3!is!dislocated!anterior!to!L4!but!the!patient!has!leg!
    This is an enhanced PDF from The Journal of Bone and Joint Surgery

    The PDF of the article you requested follows this cover page.

    The value of computed tomography in thoracolumbar fractures. An


    analysis of one hundred consecutive cases and a new classification
    PC McAfee, HA Yuan, BE Fredrickson and JP Lubicky
    J Bone Joint Surg Am. 1983;65:461-473.

    This information is current as of April 16, 2008

    Reprints and Permissions Click here to order reprints or request permission to use material from this
    article, or locate the article citation on jbjs.org and click on the [Reprints and
    Permissions] link.
    Publisher Information The Journal of Bone and Joint Surgery
    20 Pickering Street, Needham, MA 02492-3157
    www.jbjs.org
    17 year old Girl with 42 Degree, OOB 3 cm, Lenke 5C ,
    Best Scoliosis Outcome Instrument—
    Open Backed Wedding Dress
    17 year old Girl Ready for College
    50
    50 Degree
    Degree RR T/
    T/ 33
    33 Degree
    Degree L
    LLL

    50

    33
    Georgia Tech 6 Months Post –op
    Yellow Jacket Marching Band
    Lenke 1C
    Globus Employee
    Cobalt Chrome Rods
    February 1992– 6 Weeks Post-op
    Scoliosis Fusion T 4 to L1
    M.K.
    M.K. Washington
    Washington Ballet
    Ballet
    Nutcracker 6 months post-op
    21 Years S/P Selective Thoracic
    Scoliosis Fusion
    Residual 23
    Degrees
    21 years
    Multi-Level LLIF
    LLIF ++ Osteotomies
    Osteotomies
    for 3-D Deformity– 135 Levels
    Paul C McAfee, MD, MBA
    Chief of Spinal Research
    MedStar

    Professor Georgetown School of Medicine


    ADULT DEFORMITY

    HRQOL Correlates with


    SVA

    Sagittal Plane Balance


    Extreme 3 Dimensional Deformity
    1. Lumbar Scoliosis over 40 degrees (Mean 44, range 40 to
    55 degrees)
    2. Require Multiple level Osteotomies for Flat Back
    3. Usually 2 or more levels of Translation = anterior
    Spondylo and Lateral Listhesis (Two Planes), usually at
    multiple levels
    4. Soft tissue IntraCanal stenosis requiring Direct
    Decompression– Claudication
    5. Majority OOB > 2 cm coronal, 8 cm sagittal requiring
    Front + Back Pedicle Screws
    S.V.A.

    Less than 2 cm

    LESS ENERGY
    Interim X-Ray after LLIF
    showed only 10
    10 degrees
    degrees Lordosis
    Lordosis

    SVA 6 cm
    Kyphosis
    24 Degrees
    Lordosis
    Lateral Listhesis Correction
    Even with L3 embedded into L4 End Plate
    1
    1

    2
    2
    3
    3
    4

    5
    4
    67 Year old AODM at 2 years Post-op
    17 yr old girl
    Lenke 3C
    Double Major
    48 degrees

    52 Degrees

    In Balance
    MSL and Plumb line
    52 degree down to 20 48 degrees down to 30
    Cotrel Doubosset
    Decompensation

    OOB left 5 cm
    lumbar curve = 45 degrees
    47 degrees

    42 yr old W
    L leg pain
    21 degrees
    33 degrees
    5 degrees
    36 degrees
    17 YR OLD W F
     PROGRESSIVE 52 DEGREE L LUMBAR
    CURVE
     Lenke 3C Double Major
     from Syria, no prior treatment
    Lenke 3C
    Double Major
    35 degrees thoracic
    52 degrees Lumbar

    In Balance
    Posterior pedicle Screws
    T4 to L3????
    K.A.S.S.
    Dual Rods

    T11 to L4 Fusion
    16 yr old
    Asian Girl
    Lenke 1C
    Single Major
    T4 to L3
    56 degrees
    T9 to L3
    Single Rod Kaneda
    8 DEGREES
    14 yr old M
    Lenke 1C
    T4 to L1
    84 degrees

    L1 to L5
    52 degrees
    BSL
    Lenke 1C
    T7 to L2
    48 Degrees

    16 yr old G
    BSL
    T8 to L1
    3 Degrees
    Sara Sargent
    2011 Single Sculls National
    Champion
    12 months s/p REVERE
    Jim Williams
    9 months s/p REVERE
    Guided Summit
    EVEREST

    Incremental Improvements
    Makes Life-Changing
    Advances.

    LIFE-CHANGING
    Advances

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