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Revision Surgery After 3-Column Osteotomy in 335 Patients With Adult Spinal Deformity: Intercenter Variability and Risk Factors

Maier, Stephen P., BA*; Smith, Justin S., MD, PhD; Schwab, Frank J., MD*; Obeid, Ibrahim, MD; Mundis, Gregory M., MD§; Klineberg, Eric, MD; Hostin, Richard, MD; Hart, Robert A., MD**; Burton, Douglas, MD††; Boachie-Adjei, Oheneba, MD‡‡; Gupta, Munish, MD; Ames, Christopher, MD§§; Protopsaltis, Themistocles S., MD*; Lafage, Virginie, PhD* International Spine Study Group

doi: 10.1097/BRS.0000000000000304

Study Design. Multicenter, retrospective review.

Objective. To assess rates, site variability, and risk factors for revision surgery (RS) after 3-column osteotomy (3CO).

Summary of Background Data. Complex spinal osteotomies, including 3CO, are being increasingly performed in the setting of patients with adult spinal deformity with sagittal plane deformity. Three-column osteotomy procedures are associated with high complication and RS rates, but risk factors for complications and variability across centers for revision have not been well defined.

Methods. The incidence and indications for RS in 335 patients with adult spinal deformity were analyzed. RS indications were classified as “mechanical” (MR: implant failure, pseudarthrosis, junctional failure, and loss/lack of correction) or “nonmechanical” (NMR: neurological deficit, infection, wound dehiscence, and stenosis). Risks factors for RS were analyzed using generalized linear models.

Results. Three-month and 1-year RS incidences were 12.3% and 17.6%, respectively. Single-level 3CO (n = 311) had lower RS rates than multilevel 3CO (n = 24, 15.8% vs. 41.7%, P = 0.001). The 16.7% rate for single-level lumbar 3CO included 11.4% for MR and 5.7% for NMR. For all RS, 50% of MR and 78.6% of NMR occurred within 3 months of the index surgery. There was significant variation in rates across sites (range = 6.3%–31.9%, P = 0.001), however low- and high-volume sites had similar rates (18.2% vs. 16.2%, P = 0.503). Patients with MR were more likely to be sagittally undercorrected at 3 months (sagittal vertical axis = 7 cm vs. 3.2 cm, P = 0.003). Patients with NMR had more caudal 3CO levels (L4 vs. L3, P = 0.014) and larger 3CO bone resections than patients who did not (34°vs. 24.5°, P = 0.003).

Conclusion. Three-column osteotomy procedures for adult spinal deformity surgery can provide significant deformity correction and lead to marked improvement in function despite established complication and revision rates. This study shows that RS is associated with lower level osteotomy and higher residual sagittal vertical axis. There is significant variability in revision rates across sites independent of site volume, suggesting potential systems and practice variations that warrant further study.

Level of Evidence: 4

This multicenter, retrospective review of patients with adult spinal deformity who underwent 3-column osteotomies demonstrated an average 1-year revision rate of 17.6%, with significant variability in rates across sites independent of site volume. Multiple or more caudal osteotomies, as well as greater bony resection, were identified as risk factors for revision.

*Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY

Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA

Bordeaux University Hospital, Bordeaux, France

§San Diego Center for Spinal Disorders, La Jolla, CA

Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA

Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX

**Department of Orthopaedic Surgery, Oregon Health and Science University, Portland, OR

††Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS

‡‡Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY

§§Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, CA; and

¶¶ISSGF, Littleton, CO.

Address correspondence and reprint requests to Virginie Lafage, PhD, 306 E 15th Street, New York, NY 10003; E-mail:

Acknowledgment date: October 4, 2013. Revision date: January 13, 2014. Acceptance date: January 30, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

The International Study Group Foundation from Depuy Spine grant funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, employment, payment for lectures, patents, royalties, payment for development of educational presentations, stocks, travel/accommodations/meeting expenses.

© 2014 by Lippincott Williams & Wilkins