INFLUENCE OF THE MISDEF ALGORITHM ON THE THERAPEUTIC DECISION FOR VERTEBRAL DEFORMITY IN THE ADULT

RAMOS, GUILHERME ZANDAVALLI; VIALLE, EMILIANO; PINTO, RAFAEL LUIZ; MENEZES, CRISTIANO; GUSMÃO, MAURÍCIO SANTOS; MASANÉS, NICOLAS GONZÁLEZ; FALAVIGNA, ASDRUBAL; JACOB JUNIOR, CHÁRBEL; VIALLE, LUIZ ROBERTO; FERREIRA, RAMON; HOLTMAN, GUILHERMO

doi:10.1590/S1808-185120201902222428

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ORIGINAL ARTICLE • Coluna/Columna 19 (2) • Apr-Jun 2020 • https://doi.org/10.1590/S1808-185120201902222428 linkcopy

INFLUENCE OF THE MISDEF ALGORITHM ON THE THERAPEUTIC DECISION FOR VERTEBRAL DEFORMITY IN THE ADULT

INFLUÊNCIA DO ALGORITMO MISDEF NA DECISÃO TERAPÊUTICA DE DEFORMIDADE VERTEBRAL EM ADULTOS

INFLUENCIA DEL ALGORITMO MISDEF EN LA DECISIÓN TERAPÉUTICA DE DEFORMIDAD VERTEBRAL EN ADULTOS

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective The therapeutic decision in cases of adult spinal deformity takes numerous factors into account with a consequent variability in treatment options. The objective is to compare the impact of the MISDEF (minimally invasive spine deformity) algorithm on therapeutic decisions in cases of adult spinal deformity.

Methods Prospective radiographic analysis of 40 cases of adult deformity. The cases were sent, in two steps, to 20 Latin American surgeons who had to choose among six treatment options with and without the use of the MISDEF.

Results For the conducts of decompression, decompression and short fusion, decompression and fusion with interbody device, and osteotomy with extension of fusion to the thoracic spine, no significant differences were found when comparing decisions made with and without MISDEF. For osteotomy, we observed a tendency for the number of surgeons choosing this conduct to increase when the decision is made with MISDEF. We observed that the number of surgeons who decided on conservative treatment decreased with the use of MISDEF (p <0.001). In cases with sagittal vertical axis <6 cm or pelvic tilt <25 ° or PI-LL (pelvic incidence minus lumbar lordosis) <10 ° or coronal curve <20 °, there was a decrease in the conservative treatment option and an increase in osteotomy with proximal extension of the fusion with the use of MISDEF.

Conclusions There is a tendency to increase indications of osteotomy and decrease the conservative treatment option when making a decision with MISDEF. The use of the algorithm showed no significant impact on the therapeutic decision in severe cases of adult deformity. Level of Evidence II; Prospective comparative radiographic analysis.

Adult; Scoliosis; Spine; Conservative Treatment; Osteotomy

Variable	Classification	n	%
SVA	< 6	30	75
	6 – 10	7	17.5
	> 10	3	7.5
SVA (grouped)	< 6	30	75
	≥ 6	10	25
PI-LL	<10	12	30
	10 – 30	21	52.5
	> 30	7	17.5
PI-LL (grouped)	<10	12	30
	≥ 30	28	70
PT	< 25	24	60
	≥ 25	16	40
TK	< 60	37	92.5
	≥ 60	3	7.5
Latero	Yes	34	85
	No	6	15
CC	< 20	20	50
	≥ 20	20	50

Conduct option	MISDEF	Number of evaluations	Total evaluations	Percentage (%)	*p
Decompression	With MISDEF	800		19%
	Without MISDEF	800	1600	17%	0.528
Decompression + short fusion	With MISDEF	800		11%
	Without MISDEF	800	1600	15%	0.637
Decompression + interbody device	With MISDEF	800		28%
	Without MISDEF	800	1600	27%	0.748
Osteotomy	With MISDEF	800		15%
	Without MISDEF	800	1600	22%	0.073
Osteotomy with extension of the fusion to the thoracic spine	With MISDEF	800		13%
	Without MISDEF	800	1600	17%	0.264
Conservative	With MISDEF	800		14%
	Without MISDEF	800	1600	3%	<0.001

		SVA < 6			SVA ≥ 6
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	30	18%		10	3%
	Without	30	21%	0.326	10	25%	0.415
DEC + SF	With	30	16%		10	3%
	Without	30	13%	0.885	10	3%	0.11
DEC + ID	With	30	27%		10	32%
	Without	30	28%	0.517	10	15%	0.441
OST	With	30	20%		10	37%
	Without	30	10%	0.064	10	12%	0.722
OST + TSF	With	30	18%		10	25%
	Without	30	10%	0.025	10	37%	0.142
CONS	With	30	3%		10	0%
	Without	30	17%	<0.001	10	7%	0.208

		PI-LL< 10			PI-LL ≥ 10
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	12	29%		28	11%
	Without	12	25%	0.689	28	19%	0.297
DEC + SF	With	12	17%		28	14%
	Without	12	15%	0.894	28	10%	0.638
DEC + ID	With	12	23%		28	34%
	Without	12	33%	0.117	28	26%	0.581
OST	With	12	9%		28	25%
	Without	12	5%	0.314	28	15%	0.133
OST + TSF	With	12	17%		28	13%
	Without	12	2%	0.01	28	15%	0.846
CONS	With	12	3%		28	3%
	Without	12	20%	0.008	28	14%	0.002

		PT ≥ 25			PT ≥ 250
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	24	18%		16	15%
	Without	24	21%	0.532	16	16%	0.975
DEC + SF	With	24	15%		16	14%
	Without	24	12%	0.44	16	11%	0.875
DEC + ID	With	24	31%		16	21%
	Without	24	30%	0.909	16	23%	0.691
OST	With	24	16%		16	31%
	Without	24	11%	0.348	16	19%	0.132
OST + TSF	With	24	17%		16	17%
	Without	24	8%	0.036	16	23%	0.51
CONS	With	24	3%		16	2%
	Without	24	18%	<0.001	16	9%	0.05

		TK<60			TK ≥ 60
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	37	17%		3	15%
	Without	37	19%	0.62	3	17%	-
DEC + SF	With	37	16%		3	2%
	Without	37	11%	0.362	3	13%	-
DEC + ID	With	37	25%		3	47%
	Without	37	29%	0.346	3	9%	-
OST	With	37	21%		3	27%
	Without	37	15%	0.127	3	7%	-
OST + TSF	With	37	18%		3	8%
	Without	37	12%	0.165	3	30%	-
CONS	With	37	3%		3	2%
	Without	37	13%	<0.001	3	23%	-

		With latero			Without latero
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	34	17%		6	18%
	Without	34	20%	0.294	6	11%	0.294
DEC + SF	With	34	15%		6	10%
	Without	34	12%	0.722	6	8%	0.584
DEC + ID	With	34	25%		6	38%
	Without	34	28%	0.284	6	22%	0.142
OST	With	34	21%		6	28%
	Without	34	13%	0.102	6	25%	0.753
OST + TSF	With	34	19%		6	5%
	Without	34	12%	0.114	6	26%	0.465
CONS	With	34	3%		6	2%
	Without	34	15%	<0.001	6	9%	0.109

		CC<20			CC ≥ 20
Conduct	MISDEF	N	(%)	*p	N	(%)	*p
DEC	With	20	22%		20	12%
	Without	20	22%	0.979	20	16%	0.365
DEC + SF	With	20	13%		20	16%
	Without	20	11%	0.868	20	11%	0.629
DEC + ID	With	20	22%		20	32%
	Without	20	29%	0.211	20	25%	0.243
OST	With	20	20%		20	24%
	Without	20	16%	0.5	20	13%	0.053
OST + TSF	With	20	21%		20	13%
	Without	20	9%	0.028	20	19%	0.492
CONS	With	20	3%		20	3%
	Without	20	14%	0.008	20	15%	0.002

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[TFN1] SVA (sagittal vertical axis), PI-LL (pelvic incidence-lumbar lordosis), PT (pelvic tilt), TK (thoracic kyphosis), latero (laterolisthesis) and CC (lumbar coronal curve).