A Staged Protocol for Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity

BACKGROUND: Minimally invasive surgery (MIS) techniques used for management of adult spinal deformity (ASD) aim to decrease the physiological demand on patients and minimize postoperative complications. A circumferential MIS (cMIS) protocol offers the potential to maximize this advantage over standard open approaches, through the concurrent use of multiple MIS techniques. OBJECTIVE: To demonstrate through a case example the execution of a cMIS protocol for management of an ASD patient with severe deformity. METHODS: Thorough preoperative assessment, surgical planning, and medical optimization were completed. Deformity correction was performed over 2 stages. During the first stage, interbody fusion was performed via an oblique lateral approach at all levels of the lumbar spine intended to be included in the final construct. The patient was kept as an inpatient and mobilized postoperatively. They were then re-imaged with standing films. The second stage occurred after 3 d and involved percutaneous instrumentation of all levels. Posterior fusion of the thoracic levels was achieved through decortication of pars and facets. These areas were accessed through the intermuscular plane established by the percutaneous screws. The patient was mobilizing on their first postoperative day. RESULTS: In a 66-yr-old female with severe sagittal imbalance and debilitating back pain, effective use of this cMIS protocol allowed for correction of the Cobb angle from 52 degrees to 4 degrees correction of spinopelvic parameters and 13 cm of sagittal vertical axis improvement. No complications were identified by 2 yr postoperative. CONCLUSION: As a systematization of multiple MIS techniques combined, in a specific and staged manner, this cMIS protocol could provide a safe and effective approach to the management of ASD.