Outcome and complication following single-staged posterior minimally invasive surgery in adult spinal deformity

doi:10.21203/rs.3.rs-4901263/v1

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Outcome and complication following single-staged posterior minimally invasive surgery in adult spinal deformity

https://doi.org/10.21203/rs.3.rs-4901263/v1

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Background: The aging population is experiencing a rising incidence of musculoskeletal problems and degenerative spinal deformities. Adult spinal deformity (ASD) presents challenges, with associated risks in open surgery. Minimally invasive surgery (MIS) is becoming increasingly popular due to its positive outcomes and potential benefits. This study aimed to explore the clinical outcome and complications of posterior approach MIS in patients with ASD.

Methods: We conducted a retrospective analysis of patients with adult spinal deformity who underwent posterior minimally invasive surgery. 46 patients meeting the criteria were identified between June 2017 and September 2023. Comprehensive data, including demographic information, surgical details, full-length radiographic measurements, and visual analog pain score (VAS) were gathered both before and after the surgery, as well as at the final follow-up.

Results: Totally 46 patients were included. The mean age was 68.58 years, with a minimum follow-up period of 6 months. The mean operative time was 327 min and blood loss were 307 ml. Pre-operative radiographic outcomes were as follows: Coronal Cobb angle, 18.60±11.35°; Lumbar lordosis (LL), 22.79±21.87°; pelvic incidence (PI), 53.05±14.13°; PI-LL mismatch, 30.26±23.48°; pelvic tilt (PT), 32.53±10.38°; T1 pelvic angle (TPA), 31.91±12.39°; and sagittal vertical axis (SVA), 77.77±60.47mm. At the final follow-up, coronal Cobb angle was 10.08±6.47° (𝑃<0.0001), LL was 26.16±16.92° (𝑃 = 0.4293), PI was 54.17±12.13° (𝑃= 0.6965), PI-LL mismatch was 28.00±17.03° (𝑃 = 0.6144), PT was 27.74±10.24° (𝑃= 0.0345), TPA was 25.10±10.95 (𝑃 = 0.0090) and SVA was 47.91±46.94 mm (𝑃= 0.0129). The mean Oswestry Disability Index (ODI) and VAS scores for back pain at baseline and at last follow-up were 34.9 to 23.6 and 8.4 to 3.4, respectively. The occurrence of complications related to surgery is 39.1%, associated with 4.3% low reoperation rate.

Conclusion: Single-staged posterior MIS effectively corrects global alignment in adult spinal deformities, satisfying patient demand and yielding positive clinical outcome with low re-operation rate.

adult spinal deformity

ASD

minimal invasive spinal surgery

MISS

minimal invasive surgery

MIS

Posterior minimal invasive spinal surgery

People worldwide are living longer lives. In Taiwan, the proportion of population aged over 65 in 2023 is 18.4%, and according to projections, the proportion of the population aged 65 and older is expected to reach 34.3% by the year 2045, reflecting a trend of an aging demographic. [1] With the aging of the population, musculoskeletal diseases and degenerative spinal deformities are on the rise. [2–3] Adult spinal deformity (ASD) is a complex spinal disorder caused by various factors such as uneven degeneration of spinal components, trauma, infection, rheumatoid arthritis, and medical procedures. This can result in deformities in the coronal and/or sagittal planes, such as an elevated sagittal vertical axis, excessive pelvic tilt, or an increased coronal Cobb angle. [4–5] Adult spinal deformity (ASD) is a prevalent and disabling condition that affects many older adults. It is estimated to affect as much as 32% of the general population and can be even more prevalent, reaching up to 68%, among older individuals. [6] These conditions involve painful abnormalities in muscles, tendons, joints, and nerves, affecting the curvature of the spine. Symptoms may include tingling, stiffness, or restricted movement in the upper back and waist, higher risk of vertebral fractures and falls with back or leg pain. [7–9]

While open surgery is a successful approach to treating ASD, it frequently comes with a notable risk of medical complications and significant blood loss among older patients. [10] MIS in spinal deformity has gained widespread adoption in recent time, and numerous studies have reported positive clinical and radiological outcomes associated with its use. [11–13] It is believed to decrease damage to tissues, minimize blood loss, reduce reoperation rate, lower morbidity, decrease infections at the surgical site, expedite patient recovery, shorten hospital stays, reduce costs, and alleviate postoperative pain and complications.[14–17] Anand et al. have shared their experiences from a single center regarding the treatment of ASD using MIS over 10- year follow-up. This provides insights into the outcomes observed when patients are monitored over extended periods. [18]

Due to the growing demand for ASD surgery in older individuals, it is crucial to conduct intermediate or long-term follow-up in clinical research. It is necessary to identify effective strategies of optimal surgery for good outcome achievement and complication prevention. The study objective is to offer a thorough outcomes and complications evaluation following single stage posterior minimally invasive surgery for adult spinal deformity.

Patients

We conducted a retrospective review of patients with adult spinal deformities who underwent single stage posterior minimally invasive surgery between June 2017 and September 2023. All procedures were performed by the same surgeon. A total of 46 patients met the final criteria. Demographic data that were collected included patient age, gender, body mass index (BMI), bone mineral density (BMD), history of previous spine surgeries. Surgical characteristics such as the indication for surgery, surgical approaches, levels of spinal fusion, operative time, length of hospital stay, estimated blood loss and uses of intraoperative blood salvage were recorded.

Inclusion and exclusion criteria

The criteria for inclusion in the study are: 1. Patients over 50-year-old who clinically diagnosed with adult spinal deformity. 2. Radiographic assessment showing a Sagittal Vertical Axis (SVA) greater than 50 mm and a Pelvic Incidence-Lumbar Lordosis (PI-LL) mismatch greater than 10 degrees. [19] 3. Presence of noticeable symptoms and receipt of one stage posterior MIS. 4. Follow-up duration at least 6 months after the surgery. The exclusion criteria are: 1. Insufficient information, including demographics, surgical data, and radiographic data. 2. Patients with deformities due to neuromuscular issues, tumors, inflammation, or infections.

Surgical outcome

Full-length free-standing radiographic parameters, including lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and T1 pelvic angle (TPA) were measured preoperatively, postoperatively, and at the latest follow-up. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) score for leg and back pain.

SRS-Schwab system & Etiology classification

The most world-wild used radiography criteria for diagnosing spinal deformity in adults is the Scoliosis Research Society (SRS)-Schwab Classification.[20] SRS-Schwab system consists of a classification for coronal curve types and sagittal modifiers. The coronal curve type classification is based on the location and Cobb’s angle of the scoliotic curves, as follows: (1) curve type T: thoracic major curve of >30° at the apical level of T9 or higher; (2) curve type L: thoracolumbar or lumbar curve >30° at the apical level of T10 or lower; (3) curve type D: double major curve with both thoracic and thoracolumbar/lumbar curves of >30°; and (4) curve type N: normal, all coronal curves <30°. The sagittal modifiers involve PI–LL mismatch, SVA, and PT, described as follows: (1) PI minus LL mismatch: 0 (<10°), + (between 10°–20°), and ++ (>20°); (2) PT: 0 (<20°), + (20°–30°), and ++ (>30°); and (3) SVA: 0 (<40 mm), + (40–95 mm), and ++ (>95 mm). According to etiology, adult spinal deformities can be categorized into the following types: de-novo scoliosis, progressive adolescent idiopathic scoliosis in adulthood, hyper-kyphosis, iatrogenic sagittal deformity, focal deformity due to multiple degenerative disc disease with global deformity, and post-traumatic spinal deformity [21].

Surgical technique

After inducing general anesthesia, the patient was placed in the prone position, and posture reduction was performed to partially correct the hypo-lordosis. Patients with larger scoliosis are corrected with lateral compression pads which are mounted on the side rail, allowing a strong compression force at the apex of the scoliotic curvature with a counteraction force on the opposite cranial and/or caudal trunk to achieve partial correction of the scoliotic curve and stabilize the patient on the surgical table. (Fig. 1)

Following thorough padding and patient positioning on the surgical table, the O-arm image system is activated to assess the machine’s movement path, preventing any collisions with surgical table accessories during navigation. The surgical team drapes the surgical field in a sterile fashion and marks the spinal process to know the deformity severity. We divided the surgery methods into 4 types:

Percutaneous pedicle screw (PPS) implantation correction for patients who mainly have sagittal imbalance due to kyphotic deformity with only mild scoliosis, Schwab type N. (Fig.2)
PPS plus MIS-TLIF for patients who have nerve compression syndrome with mild lumbar scoliosis and hypolordosis or mild kyphosis, Schwab type L or N. (Fig.3)
PPS, MIS-TLIF plus mini Ponte-osteotomy for patients who have nerve compression syndrome associated larger lumbar scoliosis with hypo-lordosis or kyphosis, Schwab type L or N.(Fig.4)
PPS plus mini-pedicle subtraction osteotomy (PSO) for patient who have lumbar kyphosis and scoliosis with high PI-LL mismatch and high SVA, Schwab type L or N. (Fig.5)

After the navigation scan finished, the surgical team designed the wound incision based on the most cranial and caudal pedicle screw site. Through the Wiltse approach, the para-spinal muscle was carefully dissected, and then the drill guide was used to confirm the tract of the pedicle screw (Fig.6). In PPS correction patients, we contoured the rod in a predict harmony alignment for the deformity correction using de-rotation, in-situ bending and cantilever technique according to the bone quality and pull-out strength of pedicle screws implantation (Medtronic CD HORIZON® LONGITUDE). In PPS plus MIS-TLIF patients, the pedicle screw was inserted immediately after drilling and taper on the non-decompression side. On the decompression side, the pedicle screws will delay insertion to avoid hindering decompression and inter-body fusion procedure. The bone scalpel was used for osteotomy and nerve decompression to fasten the surgery and lessen the blood loss. Under the navigation assistance, the cage was inserted to the concave side and more anterior inter-body space in order to correct the scoliosis and hypo-lordosis. For those patients who underwent osteotomy, all pedicle screws were implanted before osteotomy to avoid inaccuracy of navigation. The angle and direction of osteotomy was performed with preservation of spinal process and intervene ligament under navigation assistance. After finished mini-Ponte or mini-PSO, a contoured rod was assembled to the pedicle screw and corrected to predicted alignment by a combination of posture reduction and spine implant correction force.

Complications

Our analysis of medical and surgical complications adhered to the criteria outlined by the Klineberg et al., ISSG-AO ASD spine complications classification system[22]. This systematic multi-domain classification system considered various medical complications (cancer, cardiopulmonary issues, central nervous system disorders, gastrointestinal problems, infectious diseases, musculoskeletal issues, and renal complications), and surgical complications (implant-related issues, radiographic complications, neurologic events, intra-operative events, and wound complications). This classification framework enhances the precision and comprehensiveness of our study in evaluating and categorizing diverse complications associated with spinal interventions for ASD.

Statistical analysis

Data for continuous variables were presented as mean and standard deviation, while data for categorical variables were presented as count numbers (n) and percentages (%). Analysis was conducted using a paired sample T-test to investigate any potential significant differences between perioperative, postoperative and last follow-up radiographic parameters and patient-reported outcome. All reported P-values were one-tailed, with a significance level set at 0.05. P < 0.05 was regarded as statistically significant.

Perioperative parameters were described in Table1. A total of 46 patients with adult spinal deformity who met the inclusion criteria were included in the study. These patients underwent posterior minimally invasive surgery from June 2017 to September 2023. The average age of all patients was 68.58 years (50-86). Among them, 15 patients were between 50 and 64.9 years old, 17 patients were between 65 and 74.9 years old, and 14 patients were 75 years old or older. There were 36 females and 10 males. The mean height was 153.82±10.77 cm with the mean weight of 59.36±12.53 kg and the mean body mass index (BMI) was 25.14±4.73 kg/m2. The mean bone mineral density (T score) was -2.13±1.34. Patients were classified using SRS-Schwab (coronal curve types and sagittal modifiers) and etiology classification, which were demonstrated in Table 2 and Table 3.

Table1. Demographic characteristics and operative data

Table 2. Patients’ grouping according to SRS-Schwab classification

Table 3. Etiology classification of patients

The mean total operative time was 326.77 minutes (99–722 minutes). The mean blood loss was 306.79±249.66cc (30-1200 cc). During the surgery, an intraoperative blood salvage system was used, 14 patients (30%) required allogeneic blood transfusion and the mean blood transfusion amount was 191.50±121.58 cc (50-530 cc). Mean number of fusion levels per patient was 8.23 ± 3.32 levels (3-13 levels).

The mean preoperative and postoperative radiographic parameters were summarized in Table 4. At pre-operation, the coronal angle was 18.60±11.35°, the LL was 22.79±21.87°, the PI was 53.05±14.13°, the PI-LL mismatch was 30.26±23.48°, the PT was 32.53±10°, the SVA was 77.77±60.47mm, and the TPA was 31.91±12.39°. At post-operation immediately, the coronal angle was 9.71±6.99° (P = < 0.0001), the LL was 28.24±17.26° (P = 0.1997), the PI was 52.03±12.75° (P = 0.7220), the PI-LL mismatch was 23.79±15.95° (P = 0.1360), the PT was 25.17±10.20° (P = 0.0012), the SVA was 33.02±34.84mm (P = < 0.0001), and the TPA was 22.11±9.88° (P = 0.0001). At the last follow up, the coronal angle was 10.08±6.47° (P = < 0.0001), the LL was 26.16±16.92° (P = 0.4293), the PI was 54.17±12.13° (P = 0.6965), the PI-LL mismatch was 28.00±17.03° (P = 0. 6144), the PT was 27.74±10.24° (P = 0.0345), the SVA was 47.91±46.94mm (P = 0. 0129), and the TPA was 25.10±10.95° (P = 0.009). Mean Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) scores for back pain at baseline and at last follow-up were 34.9 to 23.6 and 8.4 to 3.4, respectively. In comparison with preoperative ODI, VAS and radiographic change, the patients with adult spinal deformity could achieve a satisfactory activity of daily living by posterior MIS surgery.

Table 4. Comparison of radiological parameters between pre, post-op and last follow up

Complications

In this study, a total of 23 patients developed one or more complications, which were demonstrated in Table 5. According to the ISSG-AO spine complications classification system, 5 patients had medical complications, representing 10.9% of the patients, including UTI and non-surgical spine site fractures unrelated to the spine operation. Three patients developed UTIs after surgery, accounting for 6.5% of the patients. One patient suffered a sacral fracture after a motorcycle accident 2 months after surgery. Another patient experienced a lacking awareness compression fracture of L3 vertebra two years after the spine surgery. 18 patients experienced surgical complications, accounting for 39.1% of the patient population. Twelve patients exhibited halo sign of pedicle screw without prominent symptoms and no revision surgery was needed for the screw loosening. Among them, two patients showed halo sign on both cranial and caudal screws, while twelve patients showed the same halo sign on caudal screws. In one case, a 55-year-old male underwent navigation assisted MIS-TLIF at L2-3-4-5 for decompression and correction developed a right-side drop foot after surgery. Another 49-year-old female patient was bothered of subcutaneous irritation due to too-long of left cranial rod end. We shortened the cranial rod end to overcome subcutaneous irritation. Additionally, one patient presented with asymptomatic PJK at T9 after PPS revision surgery from T9 to L5 for previous morbidity of screw penetration at L1 vertebra. Another Parkinsonism patient associated kyphoscoliosis, experienced asymptomatic rod breakage and PJF at T11 after PPS correction surgery from T11 to S1. Due to only mild soreness on back, no additional surgery was needed. One patient with previous surgery by Dynesys and Coflex system on L1-5 level underwent PPS implantation correction T6-L5 due to iatrogenic kyphoscoliosis. This patient was noted with right rod broken between L2-3 level in regular follow-up exam, a distal broken rod was replaced and linked to the upper rod with a longitudinal connector.

Table 5. Postoperative complications, event intervention and resolution of complication

MIS has garnered significant attention and acceptance, particularly in recent decades, for its effectiveness in treating degenerative spinal diseases. In our study, employing posterior MIS on 46 patients have consistently shown that MIS techniques offer substantial benefits for ASD. These advantages include restoring sagittal balance and the coronal plane while simultaneously reducing major surgical complications, with notably lower reoperation rates observed in MIS patients. The positive impact on patients' quality of life is evident across various clinical settings, mirroring findings from traditional open ASD surgery and MIS procedures. [23–25] Among our patients, in addition to achieving good radiographic outcomes, most reported high satisfaction after surgery. The mean ODI and VAS scores between baseline and last follow-up for back pain decreased from 34.9 to 23.6 (resulting in a 32.3% decrease) and from 8.4 to 3.4 (resulting in a 59.5% decrease), respectively. These findings demonstrate patients with adult spinal deformity after posterior MIS surgery achieve satisfactory daily living activities in comparison with preoperative levels.

Currently, the surgical treatment for adult spinal deformities involves an anterior procedure followed by posterior instrumentation and fusion. The circumferential approach has been considered necessary to enhance deformity correction especially in kyphosis correction. [26] However, compared to circumferential MIS or the anterior approach, many articles also mention the favorable outcomes of the posterior-only MIS approach. A study illustrated that using a posterior-only approach for the treatment of degenerative lumbar scoliosis, kyphosis, or both combined with spondylolisthesis showed an improved positive correlation between the increase in JOA score and the increase in the lumbar lordosis angle.[27] Kim et al.'s published study demonstrated that posterior segmental spinal instrumentation and fusion without anterior apical release of lumbar curves resulted in superior total SRS scores, comparable complication rates, and analogous radiographic parameters. [28] Verde et al. conducted both double-route and isolated posterior-route procedures, achieving significant corrections in both approaches. [29] Good et al. proposed that single-way access is effective in correcting moderate and severe curves, potentially reducing the side effects associated with the double approach.[30]

Compared to anterior or circumferential approaches, the posterior only approach provides several advantages. Firstly, the posterior only approach offers the convenience of a single-stage procedure performed in a single position, eliminating the need to reposition the patient, which is a source of increased surgical time and potentially patient risk correlation with anesthesia. Secondly, the surgical technique outlined in this study combines posterior decompression and correction, optionally supplemented with other decompression methods such as TLIF, PONTE, and PSO, as necessary. Thirdly, unlike anterior fusion, which carries risks of injuring major vessels and abdominal organs, posterior procedure only minimizes the likelihood of damaging intra-abdominal structures.

Despite the effectiveness of MIS techniques in addressing degenerative pathologies and their evident advantages over open approaches, there are still face challenging. For patients requiring extensive fusions into the thoracic spine or those with prior instrumentation or individuals with coronal deformities exceeding 20°may not be suitable candidates for MIS techniques. [31–32] Eastlack et al. found that patients selected for MIS had smaller coronal deformity correction compared to those eventually offered open surgery. [33] However, our surgical results demonstrate that the posterior MIS procedure provides a straight forward method for correcting not only improvement of SVA but also coronal deformities. Anand et al. with similar reported significant correction of the Cobb's angle from 18.93° to 6.19° through minimally invasive multilevel percutaneous screw fixation. [34] In our study, a retrospective review of radiographs revealed a notable improvement resulting in a 45.8% decrease in the Cobb's angle (from 18.60 to 10.08). This outcome demonstrates that the posterior MIS approach only can similarly achieve the correction of coronal angle.

In our study, utilizing the posterior MIS approach, significant improvements (P-value < 0.05) were observed not only in the coronal angle but also PT, TPA, and SVA after surgery. Kumar et al. published that lateral access MIS (OLIF and PPS) for adult spinal deformity revealed preoperatively, the measurement of initial SVA was 96.5 mm and improved to 24.1 mm postoperatively. [35] Another study, Park et al. revealed the circumferential MIS approach for treating ASD, demonstrating that it led to an improvement of 3.0° in LL and an increase of 2.1 mm in the SVA, and a decrease of 2.2° in PI-LL. [36] Compared to our results from studies involving lateral access or circumferential MIS, the single-stage posterior MIS approach also achieves excellent corrective effects. Particularly noteworthy is the substantial improvement in SVA, decreasing from 78 mm preoperatively to 33 mm postoperatively (resulting in a 57.7% decrease), indicating remarkable improvement. This is further supported by our statistical analysis of surgical outcomes, providing strong confirmation.

The complication was higher in ASD surgery, especially in the cases need with aggressive deformity correction. Traditional open surgery, exemplified by osteotomy, is effective in restoring sagittal balance but is prone to various complications, including excessive blood loss, neurological deficits, and pseudoarthrosis. [37] In our surgical outcomes, 18 patients experienced surgical complications, accounting for 39.1% of the patient population. Although the complication rate appears high, most cases were only identified through radiographic findings. Specifically, the majority of cases involve asymptomatic (69.6%) or mild pain with low reoperation rate 4.3% for revision surgery. Compared to traditional open surgery, which is associated with relatively high perioperative and postoperative complication rates and medical complications following surgery range from 35–40%, and the reoperation rate varies between 10–50%. [38–40] Regarding the MIS, the diverse nature of approaches such as LLIF, TLIF, PPS, OLIF, etc., introduces considerable variation and contributes to the occurrence of different types of complications. Chan et al. reported that those undergoing cMIS had fewer overall complications compared to hybrid techniques (p = 0.006). [41] Sleiman et al. found that while both the combined approach and the posterior-only approach had similar complication rates [42]

Regarding the reoperation rate, Scheer et al. reported that data collected from a multicenter adult spinal deformity database show an overall reoperation rate of 17% among those who underwent open surgery. [43] Another study published by Hamilton et al. reported an 11% revision rate for MIS, including lumbar interbody fusion (LIF) or transforaminal lumbar interbody fusion (TLIF), and percutaneous pedicle instrumentation. [44] Compared to our statistics, only two individuals, accounting for 4.3%, required reoperation, have similar outcomes compared to other posterior-MIS surgery.

Our study affirms the effectiveness of a posterior-only approach combined minimally invasive procedure, demonstrating satisfactory clinical outcomes. Despite facing surgery-related complications, such as screws loosening, rod breakage and PJK, the technique proves advantageous in correcting overall sagittal and coronal balance. Furthermore, it boasts benefits, including minimal muscle damage, a low risk of nerve injury, minimal bleeding, prompt post-operative recovery, and high patient satisfaction. [45] Utilization of a posterior-only minimally invasive approach as a secure and effective strategy for managing ASD, and decrease revision surgery rate. With the ongoing utilization of MIS surgery for spinal deformities, the inclusion of more patients in future prospective studies will enhance the consolidation and corroboration of the results of this study.

Limitation

There are several limitations to the study. Firstly, it lacks relatively long-term follow-up results. The majority of patients were followed up for six months to five years, lacking sufficient data for a long-term analysis. Since the pattern of early functional improvement, followed by maximal benefit, and then a slight decline, is observed in many interventions for degenerative pathologies. [46] Secondly, this study represents a case series without a comparator, either a younger group of patients undergoing MIS or patients of all ages undergoing open surgery. A relatively small number of patients and common biases associated with retrospective studies, such as selection and reporting biases, were also observed. Thirdly, this study categorized complications based on the classification proposed by the Klineberg et al., ISSG-AO ASD spine complications classification system, making it comparable only with other studies using this classification. Fourthly, the majority of patients are concentrated in the N/L type of coronal curve. However, for T type patients, further data are needed to ascertain the feasibility of utilizing Ponte or performing PSO procedures.

While various surgical approaches efficiently correct ASD disease with good results, they also carry higher complication and re-operation rates compared to common degenerative disease surgery. The posterior-only MIS approach provides an alternative method for reducing re-operation rates while yielding similar outcomes. As MIS surgery for spinal deformities continues to be utilized, including more patients in future studies will strengthen and validate the results of this study. Further research, including extended follow-up and multi-center studies, is needed to confirm these findings.

Adult spinal deformity (ASD)

Minimally invasive surgery (MIS)

Visual analog pain score (VAS)

Lumbar lordosis (LL)

Pelvic incidence (PI)

Pelvic tilt (PT)

T1 pelvic angle (TPA)

Sagittal vertical axis (SVA)

Oswestry Disability Index (ODI)

Minimal invasive spinal surgery (MISS)

Body mass index (BMI)

Bone mineral density (BMD)

Patient-reported outcome measures (PROMs)

Scoliosis Research Society (SRS)

Percutaneous pedicle screw (PPS)

Transforaminal Lumbar Interbody Fusion (TLIF)

Pedicle subtraction osteotomy (PSO)

International Spine Study Group-AO (ISSG-AO)

Urinary tract infection (UTI)

Proximal junctional kyphosis (PJK)

Japanese Orthopaedic Association (JOA)

Circumferential Minimally Invasive Surgical (cMIS)

Lumbar interbody fusion (LIF)

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of China Medical University Hospital and obtained the unique identification number of research registration (approval number: CMUH109-REC1-009). Each patient signed a written informed consent form. In this study, all methods were performed in accordance with the Declaration of Helsinki relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

Data cannot be provided due to identifying information of participants but are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author contributions

CY has made substantial contributions in the acquisition, analysis and interpretation of data; and was a contributor in writing the manuscript. PHH has made conception and design of the work, and substantively written and revised the manuscript. HTC has made substantial contributions in conception and design of the work, and substantively written and revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Author details

1. Department of Education, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; [email protected]

2. Department of Orthopaedic Surgery, China Medical University Hospital, China Medical University, Taichung 404, Taiwan; [email protected] (M.J.-W.C.); [email protected] (P.-H.H.); [email protected] (C.-Y.L.); [email protected] (Y.-S.L.); [email protected] (C.T.); [email protected] (L.-Y.L.); [email protected] (C.-Y.L.)

3. Spine Center, China Medical University Hospital, China Medical University, Taichung 404, Taiwan

4. Department of Orthopedic Surgery, China Medical University Beigang Hospital, China Medical University, Yunlin County 651, Taiwan

5. Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404, Taiwan

6. Department of Sport Medicine, College of Health Care, China Medical University, Taichung 404, Taiwan

7. Minimally invasive spine and joint center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; [email protected]

8. Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan

9. Department of Orthopaedic, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan

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Tables 1 to 5 are available in the Supplementary Files section.

No competing interests reported.

Table1.png
Table1. Demographic characteristics and operative data
Table2.png
Table 2. Patients’ grouping according to SRS-Schwab classification
Table3.png
Table 3. Etiology classification of patients
Table4.png
Table 4. Comparison of radiological parameters between pre, post-op and last follow up
Table5.png
Table 5. Postoperative complications, event intervention and resolution of complication

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Outcome and complication following single-staged posterior minimally invasive surgery in adult spinal deformity

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