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Yahanda AT, Wegner AM, Klineberg EO, Gupta MC. Assessing Alignment Using GAP Score and Complications for Pedicle Subtraction Osteotomy Revision Surgeries for Sagittal Deformity in Previously Fused Spines Using a Satellite Rod Technique. World Neurosurg 2023; 179:e262-e268. [PMID: 37625635 DOI: 10.1016/j.wneu.2023.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Pedicle subtraction osteotomy (PSO) is a surgical technique to restore lumbar lordosis in patients with rigid sagittal deformity. Herein, we report on outcomes of a surgical technique utilizing a 4-rod PSO with satellite rods. METHODS A retrospective study was performed for a cohort of patients who underwent 4-rod PSO revision surgery for sagittal deformity. Procedures were performed by one surgeon at 2 different academic centers between 2004-2018. Alignment outcomes and complications specifically for revision surgeries in previously fused spines were assessed. RESULTS 40 patients underwent PSO with the satellite rod technique (n = 29 at L3, 72.5%; n = 7 at L4, 17.5%). Mean PSO angle was 28.7 ± 7.6°. Two patients (5%) had rod fracture necessitating revision surgery at 32 and 34 months. Three patients (7.5%) developed proximal junctional kyphosis (PJK), but none required revision. No patients developed pseudoarthrosis. Mean preoperative sagittal vertical axis (SVA) was 13.5 ± 7.3 cm, which decreased to 4.8 ± 7.3 cm (P = 0.002) postoperatively. Mean preoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch improved from 35.9 ± 16.6° preoperatively to 11.8 ± 14.6° postoperatively (P < 0.001). Mean preoperative pelvic tilt (PT) improved from 34.7 ± 9.8° preoperatively to 30.1 ± 9.0° (P = 0.026) postoperatively. Mean global alignment and proportion (GAP) score improved from 10 ± 2 preoperatively to 8 ± 2 postoperatively (P < 0.001), which was still considered severely disproportioned. CONCLUSIONS Rod failure rate after PSO with the 4-rod satellite configuration was low. SVA, PI-LL mismatch, and PT significantly improved for these previously-fused patients. Mean GAP score also improved, but was still considered severely disproportioned, likely due to the inability of PSO to correct low LL or PT in previously-fused spines.
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Affiliation(s)
- Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Adam M Wegner
- Spine Division, OrthoCarolina, Winston-Salem, North Carolina, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, UC Davis School of Medicine, Sacramento, California, USA
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Zheng GB, Hong Z, Wang Z, Zheng B. A novel technique of transpedicular opening-wedge osteotomy for treatment of rigid kyphosis in patients with ankylosing spondylitis. BMC Surg 2022; 22:155. [PMID: 35501784 PMCID: PMC9063357 DOI: 10.1186/s12893-022-01610-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 04/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the effectiveness and feasibility of a novel vertebral osteotomy technique, transpedicular opening-wedge osteotomy (TOWO) was used to correct rigid thoracolumbar kyphotic deformities in patients with ankylosing spondylitis (AS). METHODS Eighteen AS patients underwent TOWO to correct rigid thoracolumbar kyphosis. Radiographic parameters were compared before surgery, 1 week after surgery and at the last follow-up. The SRS-22 questionnaire was given before surgery and at the last follow-up to evaluate clinical improvement. The operating time, estimated blood loss and complications were analyzed. RESULTS The mean operating time and estimated blood loss were 236 min and 595 ml, respectively. The mean preoperative sagittal vertical axis (SVA), thoracic kyphosis (TK), pelvic tilt (PT) and thoracolumbar kyphosis (TLK) were 158.97 mm, 51.24 mm, 43.63 mm and 41.74 mm, respectively, and decreased to 66.72 mm, 35.96 mm, 27.21 mm and 8.67 mm at the last follow-up. The mean preoperative lumbar lordosis (LL) and sacral slope (SS) were 8.30 ± 24.43 mm and 19.67 ± 9.40 mm, respectively, which increased to 38.23 mm and 28.13 mm at the last follow-up. The mean height of the anterior column of osteotomized vertebrae increased significantly from 25.17 mm preoperatively to 37.59 mm at the last follow, but the height of the middle column did not change significantly. SRS-22 scores were improved significantly at the last follow-up compared with preoperatively. Solid bone union was achieved in all patients after 12 months of follow-up, and no screw loosening, screw removal or rod breakage was noticed at the last follow-up. CONCLUSIONS TOWO could achieve satisfactory kyphosis correction by opening the anterior column instead of vertebral body decancellation and posterior column closing, thus simplifying the osteotomy procedure and improving surgical efficacy.
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Affiliation(s)
- Guang Bin Zheng
- Department of Spine Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Ximen Road 150, Linhai, 317000, Zhejiang, China
| | - Zhenghua Hong
- Department of Spine Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Ximen Road 150, Linhai, 317000, Zhejiang, China.
| | - Zhangfu Wang
- Department of Spine Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Ximen Road 150, Linhai, 317000, Zhejiang, China
| | - Binbin Zheng
- Department of Spine Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Ximen Road 150, Linhai, 317000, Zhejiang, China
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Asaid M, Cox A, Breslin M, Siedler D, Sutterlin C, Dubey A. Restoring spinopelvic harmony with lateral lumbar interbody fusion: is it a realistic goal? JOURNAL OF SPINE SURGERY 2020; 6:639-649. [PMID: 33447666 DOI: 10.21037/jss-20-605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The importance of spinopelvic harmony [pelvic incidence (PI) = lumbar lordosis (LL) ±10 degrees] is well established in the literature. We aimed to determine whether lateral lumbar interbody fusion (LLIF) surgery in isolation is successful in restoring spinopelvic harmony, and whether the surgery maintained the relationship in those who present in a balanced state. Methods A retrospective radiographic analysis was performed on patients who underwent LLIF surgery, followed by posterior instrumented fusion, between January 2012 to August 2019 by a single surgeon (AD). Pre- and post-operative X-rays were reviewed by two authors using Surgimap spinal imaging 2.2.15.5. The LL, PI, and PI-LL mismatch, as well as a range of coronal and segmental sagittal radiographic parameters, were recorded. Results A total of 71 patients with 170 levels treated via LLIF were analysed. A mean pre-operative PI-LL of 14.3 degrees and post-operative value of 13.4 degrees was recorded (P=0.43). Of the 41 patients who were imbalanced pre-operatively, 13 (31.7%) were restored to a LL within 10 degrees of PI post-LLIF procedure. 30 patients presented in spinopelvic harmony, and 25 (83.3%) of those maintained that relationship following LLIF. Mean coronal global Cobb angles (13.7 degrees pre-operatively to 7.7 degrees post-operatively), segmental coronal Cobb angles (3.8 to 0.9 degrees), and anterior (5.2 to 9.8 mm) and posterior (3.2 to 6.7 mm) disc heights all improved significantly post-LLIF surgery (P<0.0001). Conclusions Although an effective treatment for coronal deformities and providing indirect decompression for degenerative lumbar disc disease, LLIF surgery alone is unlikely to result in correction of sagittal deformity and in particular spinopelvic harmony.
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Affiliation(s)
- Mina Asaid
- Department of Neurosurgery, Royal Hobart Hospital, TAS, Australia
| | - Aram Cox
- Department of Neurosurgery, Royal Hobart Hospital, TAS, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Declan Siedler
- Department of Neurosurgery, Royal Hobart Hospital, TAS, Australia
| | - Chester Sutterlin
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Arvind Dubey
- Department of Neurosurgery, Royal Hobart Hospital, TAS, Australia
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Shao J, Lee MY, Louis S, Knusel K, Lee BS, Pelle DW, Savage J, Tanenbaum JE, Mroz TE, Steinmetz MP. The efficacy of intraoperative multimodal monitoring in pedicle subtraction osteotomies of the lumbar spine. J Neurosurg Spine 2019; 31:683-690. [PMID: 31349220 DOI: 10.3171/2019.5.spine19125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Iatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors' aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine. METHODS All patients older than 18 years who underwent lumbar PSOs at the authors' institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson's Disease Questionnaire-39 (PDQ-39) and Patient Health Questionnaire-9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined. RESULTS A total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively). CONCLUSIONS In this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.
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Affiliation(s)
- Jianning Shao
- 1Cleveland Clinic Lerner College of Medicine and
- 4Case Western School of Medicine, Case Western Reserve University; and
| | - Maxwell Y Lee
- 1Cleveland Clinic Lerner College of Medicine and
- 4Case Western School of Medicine, Case Western Reserve University; and
| | - Shreya Louis
- 1Cleveland Clinic Lerner College of Medicine and
- 4Case Western School of Medicine, Case Western Reserve University; and
| | - Konrad Knusel
- 4Case Western School of Medicine, Case Western Reserve University; and
| | | | - Dominic W Pelle
- 3Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jason Savage
- 3Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Thomas E Mroz
- 3Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael P Steinmetz
- 2Department of Neurosurgery and
- 3Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Choi HY, Hyun SJ, Kim KJ, Jahng TA, Kim HJ. Radiographic and Clinical Outcomes Following Pedicle Subtraction Osteotomy : Minimum 2-Year Follow-Up Data. J Korean Neurosurg Soc 2019; 63:99-107. [PMID: 31658806 PMCID: PMC6952730 DOI: 10.3340/jkns.2018.0170] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/26/2019] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study was to report the results of pedicle subtraction osteotomy (PSO) for fixed sagittal imbalance with a minimum 2-year follow-up. Besides, authors evaluated the effect of adjunctive multi-level posterior column osteotomy (PCO) on achievement of additional lumbar lordosis (LL) during PSO.
Methods A total of 31 consecutive patients undergoing PSO for fixed sagittal imbalance were enrolled and analyzed. Correction angle of osteotomized vertebra (PSO angle) and other radiographic parameters including pelvic incidence (PI), thoracic kyphosis, LL, and sagittal vertical axis (SVA) were evaluated. Clinical outcomes and surgical complications were also assessed.
Results The mean age was 66.0±9.3 years with a mean follow-up period of 33.2±10.5 months. The mean number of fused segments was 9.6±3.5. The mean operative time and surgical bleeding were 475.9±160.5 minutes and 1406.1±932.1 mL, respectively. The preoperative SRS-22 score was 2.3±0.7 and improved to 3.2±0.8 at the final follow-up. The mean PI was 54.5±9.5°. LL was changed from 7.0±28.9° to -50.2±13.2°. The PSO angle was 33.7±13.5° (15.6±20.1° preoperatively, -16.1±19.4° postoperatively). The difference of correction angle of LL (57.3°) was greater about 23.6° than which of PSO angle (33.7°). SVA was improved from 189.5±93.0 mm, preoperatively to 12.4±40.8 mm, postoperatively. There occurred six, eight, and 14 cases of complications at intraoperative, early (<2 weeks) postoperative, and late (≥2 weeks) postoperative period, respectively. Additional operations were needed in nine patients due to the complications.
Conclusion PSO could provide satisfactory results for patients with fixed sagittal imbalance regarding clinical and radiographic outcomes. Additional correction of LL could be achieved with conduction of adjunctive multi-level PCOs during PSO.
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Affiliation(s)
- Ho Yong Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Feng C, Tao H, Yang K, Xu J, Duan C, Yang W, Li H, Li H. Modified Closing-Opening Wedge Osteotomy to Correct Kyphosis in Ankylosing Spondylitis. Med Sci Monit 2019; 25:6532-6538. [PMID: 31471964 PMCID: PMC6738018 DOI: 10.12659/msm.915836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The aim of this study was to analyze the clinical and radiological outcomes of modified closing-opening wedge osteotomy (mCOWO) for correcting kyphosis in ankylosing spondylitis (AS) patients. Material/Methods From April 2012 to April 2017, records of consecutive patients who underwent mCOWO were reviewed. The clinical and radiological outcomes were analyzed preoperatively, postoperatively, and at the most recent follow-up. Results Eleven AS patients underwent mCOWO, with a mean follow-up of 19.4 months (range, 12–45 months). The average sagittal vertical axis (SVA) was corrected from 191.9 mm preoperatively to 75.9 mm postoperatively (P<0.05) and 78.9 mm at the most recent follow-up (P<0.05). The average correction angles at the osteotomy site were 44.5° postoperatively and 45.0° at the most recent follow-up (P>0.05). Sagittal translation (ST) occurred in 2 patients, and 5 mm was the maximum. There was no neurologic damage. Solid fusion was observed at the most recent follow-up in all patients. Conclusions Modified closing-opening wedge osteotomy (mCOWO) is an effective technique for correcting kyphosis in patients with AS.
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Affiliation(s)
- Chaoshuai Feng
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Huiren Tao
- Department of Orthopaedics, Shenzhen University General Hospital, Shenzhen, Guangdong, China (mainland)
| | - Kai Yang
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Jiawei Xu
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Chunguang Duan
- Department of Orthopaedics, Shenzhen University General Hospital, Shenzhen, Guangdong, China (mainland)
| | - Weizhou Yang
- Department of Orthopaedics, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
| | - Huan Li
- Department of Cardiology, Xijing Hospital, Xi'an, Shaanxi, China (mainland)
| | - Haopeng Li
- Department of Orthopaedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland)
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Buell TJ, Nguyen JH, Mazur MD, Mullin JP, Garces J, Taylor DG, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Radiographic outcome and complications after single-level lumbar extended pedicle subtraction osteotomy for fixed sagittal malalignment: a retrospective analysis of 55 adult spinal deformity patients with a minimum 2-year follow-up. J Neurosurg Spine 2019; 30:242-252. [PMID: 30497176 DOI: 10.3171/2018.7.spine171367] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEFixed sagittal spinal malalignment is a common problem in adult spinal deformity (ASD). Various three-column osteotomy techniques, including the extended pedicle subtraction osteotomy (ePSO), may correct global and regional malalignment in this patient population. In contrast to the number of reports on traditional PSO (Schwab grade 3 osteotomy), there is limited literature on the outcomes of ePSO (Schwab grade 4 osteotomy) in ASD surgery. The objective of this retrospective study was to provide focused investigation of radiographic outcomes and complications of single-level lumbar ePSO for ASD patients with fixed sagittal malalignment.METHODSConsecutive ASD patients in whom sagittal malalignment had been treated with single-level lumbar ePSO at the authors' institution between 2010 and 2015 were analyzed, and those with a minimum 2-year follow-up were included in the study. Radiographic analyses included assessments of segmental lordosis through the ePSO site (sagittal Cobb angle measured from the superior endplate of the vertebra above and inferior endplate of the vertebra below the ePSO), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence and LL mismatch, thoracic kyphosis (TK), and sagittal vertical axis (SVA) on standing long-cassette radiographs. Complications were analyzed for the entire group.RESULTSAmong 71 potentially eligible patients, 55 (77%) had a minimum 2-year follow-up and were included in the study. Overall, the average postoperative increases in ePSO segmental lordosis and overall LL were 41° ± 14° (range 7°-69°, p < 0.001) and 38° ± 11° (range 9°-58°, p < 0.001), respectively. The average SVA improvement was 13 ± 7 cm (range of correction: -33.6 to 3.4 cm, p < 0.001). These measurements were maintained when comparing early postoperative to last follow-up values, respectively (mean follow-up 52 months, range 26-97 months): ePSO segmental lordosis, 34° vs 33°, p = 0.270; LL, 47.3° vs 46.7°, p = 0.339; and SVA, 4 vs 5 cm, p = 0.330. Rod fracture (RF) at the ePSO site occurred in 18.2% (10/55) of patients, and pseudarthrosis (PA) at the ePSO site was confirmed by CT imaging or during rod revision surgery in 14.5% (8/55) of patients. Accessory supplemental rods across the ePSO site, a more recently employed technique, significantly reduced the occurrence of RF or PA on univariate (p = 0.004) and multivariable (OR 0.062, 95% CI 0.007-0.553, p = 0.013) analyses; this effect approached statistical significance on Kaplan-Meier analysis (p = 0.053, log-rank test). Interbody cage placement at the ePSO site resulted in greater ePSO segmental lordosis correction (45° vs 35°, p = 0.007) without significant change in RF or PA (p = 0.304). Transient and persistent motor deficits occurred in 14.5% (8/55) and 1.8% (1/55) of patients, respectively.CONCLUSIONSExtended PSO is an effective technique to correct fixed sagittal malalignment for ASD. In comparison to traditional PSO techniques, ePSO may allow greater focal correction with comparable complication rates, especially with interbody cage placement at the ePSO site and the use of accessory supplemental rods.
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Vanaclocha V, Vanaclocha-Saiz A, Rivera-Paz M, Atienza-Vicente C, Ortiz-Criado JM, Belloch V, Santabárbara-Gómez JM, Gómez A, Vanaclocha L. S 1 Pedicle Subtraction Osteotomy in Sagittal Balance Correction. A Feasibility Study on Human Cadaveric Specimens. World Neurosurg 2018; 123:e85-e102. [PMID: 30465963 DOI: 10.1016/j.wneu.2018.11.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND A cadaveric feasibility study was carried out. Osteotomies to correct fixed sagittal imbalance are usually performed at L3/ L4. OBJECTIVE To investigate the feasibility of S1 pedicle subtraction osteotomy to correct spinal deformity and spinopelvic parameters, achieving better results with more limited exposure. The data obtained will allow a fixation construct specific for this osteotomy to be designed. METHODS S1 pedicle subtraction osteotomy was performed on 12 cadaveric specimens. Baseline and postprocedural computed tomography and biomechanical studies were performed. Data were analyzed with a fixation system SolidWorks model, and the redesigned fixation construct was described and analyzed with an ANSYS model. RESULTS S1 pedicle subtraction osteotomy is technically feasible. The fixation can be achieved with L4, L5, and iliac screws connected with bars. The system can be reinforced with a polyetheretherketone cage placed anteriorly in the S1 body osteotomy site, a cross-connecting bar, a double iliac screw, or an anterior interbody cage placed at the L5-S1 disc. The fixation strength is improved by angulating the iliac rod channel 10°, adding a semi-sphere to the locking screw contact surface and 2 fins to its saddle. The redesigned construct showed suitable stress and deformation levels, achieving the expected biomechanical requirements. DISCUSSION Compared with surgery on higher levels, S1 pedicle subtraction osteotomy allows greater correction with shorter fixation, because the osteotomy is performed at a more caudal level, modifying the spinopelvic parameters. CONCLUSIONS S1 pedicle subtraction osteotomy is technically feasible. Finite element analysis results indicate that it has appropriate biomechanical properties.
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Affiliation(s)
| | | | | | | | | | | | | | - Amelia Gómez
- Instituto de Medicina Legal de Valencia, Valencia, Spain
| | - Leyre Vanaclocha
- Medical School, University College London, London, United Kingdom
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Mao SH, Feng ZX, Qian BP, Qiu Y. The clinical relevance of the presence of bridging syndesmophytes on kyphosis correction and maintenance following pedicle subtraction osteotomy for thoracolumbar kyphotic deformity in ankylosing spondylitis: a comparative cohort study. BMC Musculoskelet Disord 2018; 19:97. [PMID: 29609565 PMCID: PMC5879751 DOI: 10.1186/s12891-018-2013-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/20/2018] [Indexed: 02/08/2023] Open
Abstract
Background The presence of bridging syndesmophytes (BS) in spinal osteotomy region serves traditionally as one critical determinant for selection of osteotomy techniques. While nowadays the proportion of kyphotic ankylosing spondylitis (AS) patients receiving pedicle subtraction osteotomy (PSO) with yet mobile neighboring disc has seen a substantial increase. Literatures investigating the clinical relevance of the presence of BS on kyphosis correction and maintenance following PSO are scarce. Methods A total of 71 thoracolumbar kyphotic AS patients treated with single-level PSO at our hospital between September 2010 and August 2014 were retrospectively reviewed, 32 of whom were stratified into the BS group (BG). The operative corrections of multiple spino-pelvic sagittal parameters were assessed. Comparison of the contribution of adjacent disc wedging to total correction per PSO segment was made between the BS and non-BS groups (NBG). The correction loss were also evaluated and compared with a minimum 2-year follow-up. Results A significantly younger age (30.97 ± 8.28 vs. 40.31 ± 8.44 yrs., p < 0.001), smaller pelvic incidence (PI) (43.03 ± 10.60 vs. 49.36 ± 9.75°, p = 0.011), greater wedging index of osteotomized vertebra (1.17 ± 0.16 vs. 1.09 ± 0.08, p = 0.011) and larger local kyphosis (19.59 ± 10.84 vs. 13.56 ± 8.50°, p = 0.013) was observed in NBG preoperatively. Patients in BG and NBG accomplished comparable amount of kyphosis correction per PSO segment (40.22 ± 7.09 vs. 43.85 ± 8.71°, p = 0.062). However, the contribution of adjacent disc wedging to total correction per PSO was significantly larger in NBG [8.10 ± 6.19 (18.5%) vs. 1.09 ± 2.88° (2.7%), p < 0.001]. By ultimate follow-up, the global kyphosis (18.26 ± 10.97 vs. 21.51 ± 10.89°, p < 0.05) and thoracic kyphosis (37.95 ± 11.87 vs. 42.87 ± 11.56°, p < 0.05) deteriorated significantly in the NBG but not BG, so was further pelvic retroversion as represented by increased pelvic tilt (19.46 ± 8.13 vs. 23.44 ± 8.19°, p < 0.05) and decreased sacral slope (23.02 ± 9.12 vs. 18.62 ± 10.10°, p < 0.05). Loss of corrections concerning contribution of adjacent disc wedging was also larger in NBG (1.41 ± 3.27 vs. 0.22 ± 1.49°, p < 0.05). Conclusions Our study might suggest that the evaluation and treatment methods of kyphotic AS patients needed to be fine-tuned with appropriate subgrouping by the presence of syndesmophytes with bamboo sign as they were potentially distinct groups with different PI, contributor of lordosing capability and prognosis that might require separate analysis.
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Affiliation(s)
- Sai-Hu Mao
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Zong-Xian Feng
- Spine Surgery, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China.,Spine Surgery, Ningbo Medical Center Lihuili Eastern Hospital, Ningbo, China
| | - Bang-Ping Qian
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China. .,Spine Surgery, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China.
| | - Yong Qiu
- Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.,Spine Surgery, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
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[Correction of kyphotic fixed lumbar segments and hypolordosis with the transforaminal lumbar interbody fusion technique]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:210-222. [PMID: 29396690 DOI: 10.1007/s00064-018-0532-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Correction of a segmental or global lumbar hypolordosis to improve a sagittal imbalance. INDICATIONS Lumbar segments fixed in kyphosis; degenerative or posttraumatic hypolordotic deformity of the lumbar spine with sagittal imbalance. CONTRAINDICATIONS Bechterew disease; extended adhesions in the retroperitoneum. SURGICAL TECHNIQUE Segmental correction of a kyphotic fixed segment using a unilateral transforaminal approach to release the annulus and anterior longitudinal ligament. With an additional posterior V‑shaped osteotomy, a segmental correction of more than 20° could be achieved to improve a global sagittal imbalance. POSTOPERATIVE MANAGEMENT Back-friendly mobilisation starting the first day after surgery with support of a physiotherapist. No sports for 3-4 months. RESULTS In all, 25 patients with 33 kyphotic fixed lumbar segments were treated using a complete anterior release of the annulus and anterior longitudinal ligament via a unilateral transforaminal approach. This enabled a lordosizing correction of the segment between 5° and 29° (mean 11.4°) without any neurological or vascular complications. A total of 10 patients treated with an additional posterior osteotomy were corrected 14-29° (mean 19°). There was a loss of reduction of the lordotic correction (mean 1°; range 0-3°) in the X‑ray control at a minimum follow-up of 6 months (range 6-33 months).
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