Modified pedicle subtraction osteotomies (mPSO) for thoracolumbar post-tubercular kyphosis in pediatric patients: retrospective clinical cases and review of the literature

Two-stage treatment for severe spinal kyphotic deformity secondary to tuberculosis: halo-pelvic traction followed by a posterior-only approach correction

Background and purpose

Several surgical procedures are used to treat tuberculous kyphosis. However, the treatment of extreme spinal kyphosis is challenging, and associated with various complications. Halo traction has been used as an adjunctive method in the treatment of severe spinal deformities. However, there are few reports about the effectiveness of halo-pelvic traction (HPT) for the treatment of extreme spinal kyphosis secondary to tuberculosis. This study evaluated the effectiveness of halo-pelvic traction followed by a posterior-only approach correction in the treatment of severe spinal kyphosis secondary to tuberculosis.

Methods

The records of 19 patients with severe spinal kyphosis secondary to tuberculosis were retrospectively reviewed. All 19 patients were treated with a two-stage approach: HPT combined with posterior fusion surgery by a posterior-only approach. Radiographic parameters were measured and evaluated. America Spinal Injury Association grade (ASIA), Scoliosis Research Society outcome (SRS-22) score, and complications were also evaluated.

Results

There were 9 males and 10 females, with an average age of 29.7 years at the time of surgery. The average HPT duration was 10.4 weeks. The mean kyphosis angle decreased from 131.40 ± 10.7° pre-traction to 77.1 ± 7.4° post-traction (P < 0.01). The traction correction rate was 41.3%. The mean postoperative kyphosis angle was 65.7 ± 8.5°, and the surgical correction rate was 8.7%. Of the total correction, 82.6% was the result of HPT. At a mean follow-up of 26.5 months, the average kyphosis correction loss was 2.9°. The mean sagittal balance was 11.1 ± 45.2 mm before traction, − 25.0 ± 37.4 mm after traction, 7.0 ± 13 mm after surgery, and 2.8 ± 9.6 mm at the final follow-up. The mean preoperative SRS-22 score was 3.0 and postoperative was 4.2 (P < 0.01). The neurological status of most patients was improved. The total complication rate was 15.7%, including 1 neurological and 2 non-neurological complications.

Conclusions

HPT is effective in the management of severe spinal kyphotic deformity secondary to tuberculosis. Preoperative HPT can greatly reduce global kyphosis, and the need for corpectomy.

Retrospective analysis of deformed complex vertebral osteotomy in children with severe thoracic post-tubercular angular kyphosis

Background

Many surgical options have been described to manage post-tubercular kyphosis, but the standard approach for treating severe post-tubercular angular kyphosis in children has not been established yet. The present study was performed to evaluate the safety and efficacy of deformed complex vertebral osteotomy (DCVO) for the treatment of severe thoracic post-tubercular angular kyphosis (> 70°) in children.

Methods

Deformed complex vertebrae indicated that multiple deformed and fused vertebrae were usually involved with two or more vertebral bodies and the partial or total fusion of many segments' facet joints and intervertebral discs. Thus, DCVO indicated that a wider posterior wedge-shaped and three-column osteotomy was performed within deformed complex vertebrae to correct a more extensive range of angles. From 2010 to 2017, 15 children who suffered from severe thoracic post-tubercular angular kyphosis underwent DCVO. Deformed complex vertebrae involved two vertebral bodies in 9 patients and three vertebral bodies in 6 patients. The Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were assessed preoperatively and at the final follow up. This was a retrospective study analysing the outcome after grade 4/5 spinal osteotomies in deformed complex vertebrae.

Results

The mean duration of surgery was 239 ± 37.81 min. The average period of follow-up was 31.6 ± 6.98 months. The preoperative mean kyphosis of deformed complex vertebrae was 83.39° ± 9.04°; the mean thoracic kyphosis (TK) and lumbar lordosis (LL) were 81.09° ± 8.51° and 80.51° ± 7.64°, respectively; the mean sagittal vertical axis (SVA) was 3.83 cm ± 1.43 cm. The postoperative mean kyphosis of deformed complex vertebrae was reduced to 19.98° ± 2.47° (P < 0.001) with a mean kyphosis correction of 63.41°; at the final follow up, it was 18.4° ± 2.29° (P < 0.001) without obvious loss of correction. The postoperative mean TK, LL, and SVA were reduced to 24.05° ± 3.84°, 46.9° ± 3.53°, and 0.6 cm ± 0.34 cm, respectively (P < 0.001 for all); and there was no obvious loss of sagittal alignment and balance at the final follow up (p = 0.982, p = 0.604, p = 0.754). Complicated with neural dysfunction preoperatively, 5 Frankel's grade D cases showed complete neurological recovery at final follow up. VAS score reduced from 3.6 ± 1.18 to 0.87 ± 0.64 (P < 0.001); and ODI score reduced from 22.21 ± 6.93 to 5.02 ± 2.6 (P < 0.001) at the final follow up.

Conclusions

DCVO was an individualized osteotomy for treating severe thoracic post-tubercular angular kyphosis in children and could be safe and effective in reducing the incidence of complications and significantly improving kyphosis correction.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up

PURPOSE

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy.

METHODS

The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded.

RESULTS

The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient.

CONCLUSION

Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Transpedicular bi-vertebrae wedge osteotomy in treatment of post-tubercular spinal deformity: a retrospective study

Background

In the late stage of spinal tuberculosis, the bony destruction and vertebral collapse often leads to significant kyphosis, presenting clinically as a painful gibbus deformity, with increased instability, vertebral body translations and increased risk of neurologic involvement. Spinal osteotomy is thought to be suitable for most patients with severe rigid kyphosis. The aim of this study was to evaluate the efficacy of transpedicular bi-vertebrae osteotomy technique in the patients with Pott’s kyphosis and other post-tubercular spinal deformity.

Methods

Between January 2012 and December 2015, 18 patients with post-tubercular spinal deformity underwent the transpedicular bi-vertebrae wedge osteotomy, with a minimum follow up of 27.0 months. Preoperative and postoperative kyphotic angle, sagittal plane parameters (TK for thoracic deformity, TLK for thoracolumbar and LL for lumbar deformity) and sagittal vertical axis (SVA) were measured. Oswestry Disability Index (ODI), Visual analog scale (VAS) and modified American Spinal Injury Association grading (ASIA) of preoperative and final follow-up were documented and compared.

Results

The average operation time was 305 minutes (range, 200–430 minutes) with a mean intraoperative blood loss of 425 mL (range, 200-700 mL). The kyphotic angles decreased from 80.3° (range, 28.5°-130.8°) preoperatively to 26.1° (range, 7.0°-63.3°) at the final follow-up (P<0.01). The mean VAS score was reduced from preoperative 5.2(range, 2-9) to 0.9(range, 0-2, P<0.01) and the ODI improved from 55.3% (range, 46%-76%) to 6.3% (range, 2%-18%, P<0.01). At final follow-up, there was radiographic evidence of solid fusion at the osteotomy site and fixed segments in all patients. Neurological function improved from ASIA scale D to E in 7 patients, C to D in 3 patients.

Conclusions

Our results suggest that transpedicular bi-vertebrae wedge osteotomy is a safe and effective treatment option for post-tubercular spinal deformity. This technique achieves satisfying correction and fusion rates with adequate decompression of neurological elements.

T12 pedicle subtraction osteotomy for post-laminectomy kyphoscoliotic deformity following resection of a thoracolumbar astrocytoma in an adolescent with a previous paraplegic context

STUDY DESIGN

Case report.

PURPOSE

To describe a rare case of iatrogenic post-laminectomy thoracolumbar kyphoscoliosis in an adolescent, and its surgical management with pedicle subtraction osteotomy (PSO).

BACKGROUND

Kyphoscoliosis secondary to multilevel laminectomies for intradural astrocytoma resection is rare and its management can be very challenging.

METHODS

We report the case of 15-year-old boy who has been complaining of a progressively increasing hump in his back during the past 6 months. Two years prior to presentation, he underwent multilevel thoracolumbar laminectomies from T10 to L2 for resection of an intradural astrocytoma that was causing progressive paraplegia predominant on the right side. Full spine anteroposterior and lateral X-rays revealed a thoracolumbar kyphosis with an angulation of 73° between T10 and L1, with a long left thoracolumbar scoliosis of 24 degrees. CT scan confirmed the multilevel laminectomies and showed T12 anterior wedging. MRI did not show any tumor recurrence.

RESULTS

The patient underwent T12 PSO with instrumentation from T4 to L3 with the use of a one-sided domino on the convex side. Thoracolumbar kyphosis was corrected to 9°, and scoliosis was corrected to 7°, with a maintained correction at 7 years of follow-up.

CONCLUSION

Literature is sparse on the management of post-laminectomy kyphoscoliotic deformity after intradural astrocytoma resection. Despite previous paraplegia context, aggressive correction technique such as PSO can be a safe option if proper management of the scar tissues and adhesions is performed, with satisfactory clinical and radiological long-term results.

Apical Vertebral Column Resection with Sagittal Rotation and Controlled Anterior Opening and Posterior Closing Maneuver for the Treatment of Severe Post-Tubercular Kyphosis: Case Series and Literature Review

Study Design

Retrospective case series.

Purpose

Describe the technique and evaluate the outcome of apical vertebral column resection (VCR) with sagittal rotation and anterior opening and posterior closing (AOPC) maneuver for correction of severe post-tubercular kyphosis (PTK).

Overview of Literature

The surgical procedures described for the correction of PTK are VCR, pedicle subtraction osteotomy, transpedicular decancellation osteotomy, and closing-opening osteotomy.

Methods

We retrospectively evaluated 21 patients who had been operated on with single stage apical VCR with AOPC maneuver. Radiographs were obtained before surgery and at regular follow-up intervals. These were used to calculate the angle of kyphosis. Back pain was rated using the Visual Analog Scale (VAS) and neurological status was graded using Frankel grading. Radiological outcome was assessed by the improvement in the angle of kyphosis and fusion following surgery. Neurological status was assessed using Frankel grading.

Results

The study included eight males and 13 females with a mean age of 21.9 and average follow-up time of 30.4 months. The average number of vertebral bodies destroyed was 2.57. Kyphosis was improved from a mean of 68.42°±13.23° preoperative to 8.71°±4.58° postoperative. The average correction achieved was 87.10%. Preoperative VAS score improved from a mean of 6.38±0.92 preoperative to 1.38±0.49 postoperative. No patients had any sign of neurological deterioration. Seven out of eight patients with a preoperative neurological deficit improved following surgery. Two patients developed superficial wound maceration, one had persistent postoperative hypotension, and the other developed hemothorax. All patients recovered fully without a need for additional surgery.

Conclusions

Single stage simultaneous anterior column lengthening and posterior column shortening is an effective method for surgical correction of severe PTK.

Surgical approaches to upper thoracic Pott's disease with spinal instability during childhood: two cases

PURPOSE

Tuberculosis is a common disease worldwide that is caused by Mycobacterium tuberculosis. Tuberculosis is primarily a pulmonary disease, but extrapulmonary manifestations are not uncommon, especially in children and adolescents.

METHODS

We present two pediatric patients who underwent surgery in our clinic for Pott's disease in the upper thoracic region. The patients were investigated to describe their age, complaints, neurological examination results, disease location, surgical procedure, and complications.

RESULTS

The patients were 2 and 14 years old and exhibited disease located in the upper thoracic region (T2-T3 and T1-T2). Both patients displayed severe neurological deficits (Frankel B and C). The kyphotic angles were 82.2° and 43.2°. The patients were stabilized by applying fusion using transpedicular screws via a posterior approach. They also underwent anti-tuberculosis treatment for approximately 1 year. One year later, neither patient exhibited any neurological deficit, and their kyphotic angles were measured as 11° and 1°, respectively.

CONCLUSIONS

The recommended treatment approach for unstable cases of Pott's disease located in the upper thoracic region who exhibit neurological deficit and severe kyphotic angling or the development of kyphosis on the thoracic vertebrae is surgical. Decompression, stabilization, and fusion and kyphotic correction can be safely performed via a posterior approach. One of the present cases is the youngest patient described in the literature to undergo transpedicular surgery as a result of Pott's disease. Our other case is the first described in the literature who developed ptosis as a result of tuberculosis and underwent a procedure via posterior transpedicular screw.

Posterior Vertebral Column Resection With Intraoperative Manual Retraction for the Treatment of Posttubercular Kyphosis in Upper Thoracic Spine or Cervicothoracic Junction

STUDY DESIGN

This is a case-series.

OBJECTIVE

To evaluate the clinical and radiologic outcomes of posterior vertebral column resection (PVCR) for treatment of posttubercular kyphosis in upper thoracic spine and cervicothoracic junction (CTJ).

SUMMARY OF BACKGROUND DATA

Surgical management of severe posttubercular kyphosis in upper thoracic spine or CTJ is challenging. A new technique that combines PVCR and intraoperative manual traction in a single procedure, was developed to maximize the correction rate and minimize the risk of dural buckling and spinal cord injury. However, the safety and effectiveness of the procedure is yet to be established.

MATERIALS AND METHODS

Ten patients with upper thoracic or CTJ posttubercular kyphosis, who underwent PVCR with intraoperative manual traction between December 2008 and 2013, were studied retrospectively. Data pertaining to operation time, blood loss, and perioperative complications were collected. Outcomes were evaluated using the visual analog scale; the 12-Item Short Form Health Survey (SF-12), Mental Component Summary, and SF-12 Physical Component Summary. Neurological status was assessed using American Spinal Injury Association (ASIA) impairment scale. Radiologic outcomes including fusion and deformity correction were assessed using plain radiography and computed tomography.

RESULTS

The average duration of follow-up was 53.6±7.2 months. Average operating time and blood loss were 263±35.3 minutes and 2490±569 mL, respectively. Visual analog scale score for back pain, SF-12 Mental Component Summary, and Physical Component Summary showed significant improvement postoperatively. Kyphosis improved from a preoperative average of 73.6±13.1 degrees to an average of 37.9±8.7 degrees at final follow-up (correction rate: 48.5%). No postoperative neurological deterioration was observed based on the ASIA score. As of the last follow-up, solid fusion was not achieved only in 1 patient.

CONCLUSIONS

PVCR with intraoperative manual traction is a safe and effective procedure for treatment of upper thoracic or CTJ posttubercular kyphosis.

LEVEL OF EVIDENCE

Level 4.

Comparison of Clinical and Radiological Improvement Between the Modified Trephine and High-speed Drill as Main Osteotomy Instrument in Pedicle Subtraction Osteotomy

High-speed drill is the main osteotomy instrument in pedicle subtraction osteotomy (PSO) currently. Considering the long duration of surgery, the large amount of blood loss, and the high incidence of neurovascular injury, the osteotomy procedure is challenging. Use of trephine for the osteotomy displays high efficiency by shortening surgery time and reducing blood loss in anterior cervical corpectomy and fusion. However, the potential risk of neurological injury is high. We modified the trephine by adding locking instrument, when the serrated top of the trephine reaches the tip of the probe; the locking instrument on the probe restricts the trephine and improves security during the osteotomy procedure.The aim of this study was to compare the clinical and radiological improvement between the modified trephine and high-speed drill as main osteotomy instrument in PSO.From February 2009 to 2013, 50 patients with severe thoracolumbar kyphotic deformity caused by old compressive vertebrae were prospectively reviewed. All patients were randomly assigned to the experimental group (27 patients received PSO with modified trephine) and the control group (23 patients received PSO with high-speed drill). The clinical records were reviewed and compared for surgical time, operative blood loss, functional improvement (Oswestry Disability Index), and pain relief (visual analog scale). The radiological records were reviewed and compared for correction of kyphotic deformity postoperatively and correction loss at 2-year follow-up.All patients successfully finished the PSO procedure, and got satisfactory kyphotic deformity correction and overall function improvement. The surgery time was shorter in the experimental group than that in the control group (132.7 ± 12.6 vs 141.7 ± 16.7 min; P = 0.03). No significant difference was found in blood loss (882.9 ± 98.9 mL vs 902.2 ± 84.9 mL; P = 0.47) or correction of the kyphotic angle (33.4 ± 3.4° vs 32.1 ± 2.5°, P = 0.13) postoperatively between the 2 groups. At 24-month follow-up, no difference was discovered in loss of the correction (4.9 ± 1.6° vs 4.5 ± 1.6°; P = 0.42), change of Oswestry Disability Index (49.4 ± 6.2% vs 48.2 ± 4.2%; P = 0.44), or in back pain relief (6.2 ± 1.4 vs 6.4 ± 1.2 min; P = 0.51) between the 2 groups. No internal fixation related complication occurred and bony fusion was detected in lateral X-ray in all patients. In the control group, 2 patients had transient nerve root deficit, 14 patients at 3-month follow-up and 3 patients at 2-year follow-up experienced graft donor site morbidity, and pain killer medicine was always required.In conclusion, the modified trephine obviously shortens surgery time, and prevents graft donor site morbidity when compared to a high-speed drill. The learning curve for using the modified trephine in PSO procedure is short.