Dr. Buchholz: My patient is a 71-year-old male with progressive back and leg pain. We exhausted conservative measures such as physical and pool-based therapy, injections, and medication. The pain progressed, quality of life decreased, and the patient started to have weakness in his right foot. He has a mismatch of 32 degrees, sagittal imbalance, and a coronal Cobb angle of 44 degrees. Overall, he’s balanced, and the head is above the pelvis where we like it to be.
In my hands, posterior alone, seems to be more reproducible for deformity correction. It is less morbid on these patients with less operative time and anesthesia. It’s a single stage, same day surgery. Hospital stays aren’t longer than with the minimally invasive or staged anterior posterior approach.
Dr. Laratta: I don’t know exactly what drives the patient’s length of stay. Some patients that I expected to be really quick movers end up staying for a long time and some people I expect to stay longer really surprised me and were able to mobilize quickly to get out of the hospital.
Dr. Buchholz: I agree with you. I’ve seen the same thing. Some patients have minimal work done and are in horrible pain, but some patients with open T10 to pelvis feel great and go home a few days later. It’s really hard to predict.
This patient has pinched nerves, radiculopathy, and foraminal stenosis. When I see air in the disc space, I know that it’s going to be a relatively easy correction. We do a facet release, release things posteriorly, and most of the time we’ll be able to correct them fairly easily.
Joey showed a great case of using interbodies to do this. The fusion that provides is beneficial. I’m going to rely more on posterior fusion to achieve the same thing. I am going to get this with the posterior release.
We did a T10 to pelvis corrective surgery with pedicle screws at each level, a transforaminal lumbar interbody fusion (TLIF) at L4-5 and L5-S1, primarily for fusion, and we used a third rod. When we do our TLIFs, we do a big posterior column osteotomy and take down facets bilaterally. We distract posteriorly, do our disc work, and try to put a big cage anteriorly. We’re essentially doing the same technique as Joey from behind. We get a lot of correction with that cage, but we didn’t need a ton of lordosis in this case.
We found that at 4-5 and 5-1 there is some percentage of pseudarthrosis and rod fracture, so we started using cages, something Dr. Chris Shaffrey made popular. We haven’t had a problem with pseudarthrosis or rod fracture using a third or fourth rod.
We did a polyethylene weave at T8 and T9 spinous processes and tension that into our VersaTie attached to the rods. We usually put the VersaTie one or two levels below the proximal pedicle screw.
The patient was already balanced coronally, and we got a good sagittal correction. We brought the head into a better alignment above the shoulders and pelvis. We reduced the SVA, PIL mismatch, and we’re happy with this correction.
We rely on our L4-5, L5-S1 cages for fusion. Otherwise, we’re doing a large posterior lateral fusion. Interbodies are a good option for that, but that’s an expense.
We try and be good stewards of the hospital and minimize those costs. Doing a good posterolateral fusion is important for these patients; you have to rely more on carpentry for the posterolateral arthrodesis than you would using some of the anterior techniques. Neither way is wrong, but it’s been more reproducible to do posterior alone.
