Current MIS Techniques Fail to Optimize Spinopelvic Parameters in Patients with High Pelvic Incidence

Presented at SMISS Annual Forum 2016
By Gregory Mundis Jr. MD
With Robert K. Eastlack MD, Praveen Mummaneni MD, David Okonkwo MD, PhD, Stacie Nguyen MPH, Adam Kanter MD, Neel Anand MD, Paul Park MD, Pierce Nunley MD, Juan S. Uribe MD, FACS, Joseph M. Zavatsky MD, Dean Chou MD, Vedat Deviren MD, International Spine Study Group

Disclosures: Gregory Mundis Jr. MD A; ISSGF, Nuvasive. B; K2M, Medicrea, Misonix, Nuvasive. C; K2M, Nuvasive. F; Nuvasive., Robert K. Eastlack MD A; Nuvasive, Research Support in Unrestricted Grant from Trinity Orthopedics. B; Aesculap, Alphatec Spine, Depuy, DiFusion, DJ Orthopaedics, Invuity, K2M, Nuvasive, Seaspine, Stryker, Titan. C; Eli Lilly. D; Alphatec Spine, Carevature, DiFusion, Invuity, Nuvasive, Spine Innovations., Praveen Mummaneni MD C; Depuy, Globus Medical. D; Spinicity. F; Depuy., David Okonkwo MD, PhD F; Biomet., Stacie Nguyen MPH None, Adam Kanter MD A; Nuvasive. F; Nuvasive, Zimmer., Neel Anand MD A; Globus Medical. B; Globus Medical, Medtronic, Theracell, GYS Tech. C; DePuy Synthes, Stryker Spine. D; Atlas Spine, Medtronic, Globus Medical, Atlas Spine, Paradigm Spine, Theracell, AF cell, Bonovo, GYS Tech. F; Elsevier, Globus Medical, Medtronic, Nuvasive., Paul Park MD B; Biomet, Globus, Medtronic. F; Globus., Pierce Nunley MD A; AxioMed, K2M, LDR Spine, Medtronic, Orthofix, Spinal Motion, Vertiflex. B; LDR Spine, Vertiflex. C; Biomet, K2M. D; Amedica, OKO, Osprey, Spineology. F; Biomet, K2M, LDR Spine., Juan S. Uribe MD, FACS A; Nuvasive. B; Nuvasive. C; Nuvasive. D; Nuvasive. F; Nuvasive, Wolters Kluwer Health., Joseph M. Zavatsky MD B; Amendia, Biomet, Depuy, Stryker. D; Innovative Surgical Solutions, Safe Wire, Vivex. F; Biomet., Dean Chou MD F; Medtronic, Globus, Orthofix., Vedat Deviren MD A; AOSpine, Globus, Nuvasive. B; Nuvasive. F; Nuvasive., International Spine Study Group A; Biomet, Depuy, Innovasis, K2M, Medtronic, Nuvasive, Stryker.


High pelvic incidence (HPI) demands a larger lumbar lordosis (LL) to achieve ideal spinopelvic harmony. Criticisms of MIS spine surgery (cMIS: MIS ant/lateral with MIS screws) include challenges in adequately matching LL to PI. This study analyzes the radiographic and clinical outcomes of patients treated with MIS with varying PIs. 


To determine if patients with a high pelvic incidence have significantly worse radiographic and clinical outcomes with MIS surgery for adult spinal deformity. 


Retrospective review of multicenter MIS database was queried for cMIS patients. Patients were grouped as low (LPI≤43; n=14), mid (41<MPI<66; n= 46), and high (HPI≥67; n=17)) pelvic incidence, by using 1 standard deviation from the mean. Theoretical LL (tLL) was calculated based on Schwab PI-LL formula with respect to PI outliers: tLL=LPI+10, =MPI, =HPI-10. The offset was calculated as the difference between tLL and pre- or post-LL. Well aligned (WA) patients were classified to Vialle et al. Nonparametric Kruskal-Wallis test was used to assess significant differences between groups. 


420 patients were available for review, 165 patients identified in the database and 77 met inclusion. There were no differences for demographics, levels treated, iliac fixation or use of lateral interbody. At baseline LPI and MPI had lower PT than HPI (15.7 v 23.5 v 33.6; p<0.05) and preop PI-LL lower for LPI than HPI (9 v 21.9;p<0.05) with no difference in SVA or max Cobb. Post op both LPI and MPI had improved LL, but HPI did not. The tLL, and offset however, was not different between groups at pre or postop (p>0.05). All groups saw improvement in ODI, VAS back and leg, with no difference in reaching MCID. Complication occurrence was similar between groups. 


Patients with HPI remain some of the most difficult spinal deformities to treat. Current MIS techniques for treating this patient population reveal the inability to correct the PI-LL mismatch, likely due to the need for more lordosis. Consideration should be given when employing MIS techniques in patients with a high PI.