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Hariharan AR, Nugraha HK, Huser AJ, Feldman DS. Surgery for Spinal Stenosis in Achondroplasia: Causes of Reoperation and Reduction of Risks. J Pediatr Orthop 2024; 44:448-455. [PMID: 38595075 DOI: 10.1097/bpo.0000000000002687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Individuals with achondroplasia are prone to symptomatic spinal stenosis requiring surgery. Revision rates are thought to be high; however, the precise causes and rates of reoperation are unknown. The primary aim of this study is to investigate the causes of reoperation after initial surgical intervention in individuals with achondroplasia and spinal stenosis. In addition, we report on surgical techniques aimed at reducing the risks of these reoperations. METHODS A retrospective review was conducted over an 8-year period of all patients with achondroplasia at a single institution that serves as a large referral center for patients with skeletal dysplasias. Patients with achondroplasia who underwent spinal surgery for stenosis were identified and the need for revision surgery was studied. Data collected included demographic, surgical, and revision details. Fisher exact test was used to determine if an association existed between construct type and the need for revisions. RESULTS Thirty-three of the 130 (22%) patients with achondroplasia required spinal stenosis surgery. Twenty-four individuals who met the criteria were selected for analysis. The initial spine surgery was at an average age of 18.7 years (SD: 10.1 y). Nine patients (38%) required revision surgeries, and 3 required multiple revisions. Five of 9 (56%) of the revisions had primary surgery at an outside institution. Revision surgeries were due to caudal pseudarthrosis (the distal instrumented segment) (8), proximal junctional kyphosis (PJK) (7), and new neurological symptoms (7). There was a significant association found between construct type and the need for revision ( P =0.0111). The pairwise comparison found that short fusions were significantly associated with the need for revision compared with the interbody group ( P =0.0180). PJK was associated with short fusions when compared with the long fusion group ( P =0.0294) and the interbody group ( P =0.0300). Caudal pseudarthrosis was associated with short fusions when compared with the interbody group ( P =0.0015). Multivariate logistic regression found long fusion with an interbody was predictive of and protective against the need for revision surgery ( P =0.0246). To date, none of the initial cases that had long fusions with caudal interbody required a revision for distal pseudarthrosis. CONCLUSIONS In patients with achondroplasia, the rate of surgery for spinal stenosis is 22% and the risk of revision is 38% and is primarily due to pseudarthrosis, PJK, and recurrent neurological symptoms. Surgeons should consider discussing spinal surgery as part of the patient's life plan and should consider wide decompression of the stenotic levels and long fusion with the use of an interbody cage at the caudal level in all patients to reduce risks of revision. LEVEL OF EVIDENCE Level IV-Retrospective case series.
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Affiliation(s)
- Arun R Hariharan
- Paley Orthopedic & Spine Institute, 901 45th Street,West Palm Beach, FL
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Tani Y, Naka N, Ono N, Kawashima K, Paku M, Ishihara M, Adachi T, Ando M, Taniguchi S, Saito T. Can We Rely on Prophylactic Two-Level Vertebral Cement Augmentation in Long-Segment Adult Spinal Deformity Surgery to Reduce the Incidence of Proximal Junctional Complications? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:860. [PMID: 38929477 PMCID: PMC11205771 DOI: 10.3390/medicina60060860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods: The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results: With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions: Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata-City 573-1010, Japan; (Y.T.); (N.N.); (N.O.); (K.K.); (M.P.); (M.I.); (T.A.); (M.A.); (S.T.)
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Kanbara S, Katayama Y, Matsumoto T, Matsumoto T, Ogura K, Ito Y, Tachi H, Ito K. Posterior spinal cord injury due to dorsal migrated disc herniation caused by thoracolumbar fusion surgery: A case report. J Orthop Sci 2024; 29:445-448. [PMID: 36241559 DOI: 10.1016/j.jos.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/05/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Shunsuke Kanbara
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan.
| | - Yoshito Katayama
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Tomohiro Matsumoto
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Taro Matsumoto
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Keisuke Ogura
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Yuya Ito
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Hiroaki Tachi
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Keigo Ito
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, 455-8530, Japan
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Kim YH, Ha KY, Park HY, Ko MS, Ko YI, Sin KJ, Kim SI. Junctional Failures at Both Ends After Long Fusion Arthrodesis Stopping at L5: Incidences and Risk Factors. World Neurosurg 2023; 180:e288-e295. [PMID: 37748733 DOI: 10.1016/j.wneu.2023.09.063] [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: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Junctional failures after long fusion stopping at L5 can present at both proximal and distal ends. The purpose of this study was to investigate incidences and risk factors of proximal junctional failure (PJF) and distal junctional failure (DJF) after long lumbar instrumented fusion stopping at L5 for adult spinal deformity. METHODS Sixty-three patients who underwent long fusion surgery stopping at L5 with a minimum follow-up of 3 years were reviewed retrospectively. PJF and DJF were defined as newly developed back pain and/or radiculopathy with corresponding radiographic failures. The incidence and risk factors of each junctional failure were analyzed using a log-rank test and Cox proportional hazards model. RESULTS Twelve men and 51 women were included in our study. Their mean age was 68.5 ± 7.0 years and the mean follow-up period was 84.5 ± 45.3 months. PJF and DJF occurred in 17 (27%) and 16 patients (25.4%), respectively. PJF and DJF developed at median durations of 32.1 months and 13.3 months, respectively, showing no significant difference between the two. Three patients presented with both PJF and DJF. Risk factors for PJF included lower body mass index, higher preoperative lumbar lordosis, and higher postoperative sagittal vertical axis (SVA) (hazard ratio, 0.570, 1.055, and 1.040, respectively). For DJF, higher preoperative SVA was an independent risk factor (hazard ratio, 1.010). CONCLUSIONS After long fusion surgery stopping at L5, PJF and DJF occurred at similar rates. Lower body mass index, higher preoperative lumbar lordosis, and higher postoperative SVA were risk factors for PJF. Higher preoperative SVA was an independent risk factor for DJF.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung-Hee University Hospital at Gangdong, Seoul, South Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Myung-Sup Ko
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Young-Il Ko
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyung-Jun Sin
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Lee JJ, Park JH, Oh YG, Shin HK, Jung SK. Should cervicothoracic junctions be avoided in long cervical posterior fusion surgery? Analysis of clinical and radiologic outcomes over two years. J Orthop Surg (Hong Kong) 2022; 30:10225536221137751. [PMID: 36315967 DOI: 10.1177/10225536221137751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE This study aimed to confirm the usefulness of surgery that avoids the cervicothoracic junction (CTJ) by comparing the clinical and radiographic outcomes after posterior cervical fusion at C5/6 with those at C7/T1. METHODS Patients who underwent laminectomy and posterior cervical instrument fusion for cervical spondylotic myelopathy (CSM) from 2012 to 2019 were retrospectively reviewed and divided according to whether the end level was at C5/6 (group 1) or C7/T1 (group 2). Demographic variables and incidence of distal junctional kyphosis (DJK) were compared between the groups. Clinical outcomes (visual analog scale [VAS] score for arm and neck pain and the Neck Disability Index value) and radiologic outcomes (T1 slope, cervical lordosis, segmental lordosis, C2-7 sagittal vertical axis, T1 slope-cervical lordosis mismatch) were compared over time. RESULTS Sixty-seven patients were included. There were 32 patients in group 1 and 35 in group 2. The VAS score for neck pain was significantly lower in group 1 than in group 2 at 2 years after surgery (p = 0.03). The C2-7 sagittal vertical axis was significantly larger in group 2 than in group 1 at 1 year and 2 years postoperatively (p = 0.04). The incidence of DJK was higher in group 2 than in group 1 (28.57% vs 9.37%, p = 0.04). CONCLUSION This study found that when CTJs are included in the posterior cervical long fusion surgery, although it would be better than preoperation, postoperative kyphosis and consequent neck pain may progress. The results of this study advocate the concept of avoiding CTJ fusion if possible.
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Affiliation(s)
- Jung Jae Lee
- Department of Neurosurgery, 65443Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Gyu Oh
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hong Kyung Shin
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, 65443Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Cho W, Auerbach JD, Riew KD. Crossing the Cervico-Thoracic Junction in Long Posterior Cervical Fusions Reduces Caudal Adjacent Segment Pathology. Global Spine J 2022; 12:1636-1639. [PMID: 33504198 PMCID: PMC9609522 DOI: 10.1177/2192568220984470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
STUDY DESIGN Retrospective case control. OBJECTIVES The purpose of this study is to compare clinical outcomes and rates of symptomatic caudal adjacent segment pathology (ASP) in posterior cervical fusions (PCF) constructs with end-instrumented vertebrae in the cervical spine (EIV-C) to PCF constructs that end in the proximal thoracic spine (EIV-T). METHODS Retrospective review of 1714 consecutive cervical spinal fusion cases was done. Two groups were identified: 36 cervical end-instrumented vertebra patients (age56 ± 10 yrs) and 53 thoracic EIV patients (age 57 ± 9 yrs). Symptomatic ASP was defined as revision surgery or nerve root injection (or recommended surgery or injection) at the adjacent levels. RESULTS EIV-C patients had a significantly higher rate of caudal-level symptomatic ASP requiring intervention compared with EIV-T patients (39% vs 15%, p = 0.01). The development of caudal-level ASP was highest at C7 (41%), followed by C6 (40%). The overall complication rate and surgical revision rates, however, were similar between the groups. Neck Disability Index outcomes at 2 years postop were significantly better in the EIV-T group (24.5 vs. 34.0, p = 0.05). CONCLUSIONS Long PCF that cross the C-T junction have superior clinical outcomes and reduced rates of caudal breakdown, at the expense of longer fusions and higher EBL, with no increase in the rate of complications. Crossing the C-T junction affords protection of the caudal adjacent levels without adding significant operative time or morbidity.
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Affiliation(s)
- Woojin Cho
- Albert Einstein College of Medicine,
Bronx, NY, USA,Montefiore Medical Center, Bronx, NY,
USA,Woojin Cho, 3400 Bainbridge Ave, 6th Fl.,
Bronx, NY 10461, USA.
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Kurra S, Farhadi HF, Metkar U, Viswanathan VK, Minnema AJ, Tallarico RA, Lavelle WF. CT based bone mineral density as a predictor of proximal junctional fractures. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 11:100130. [PMID: 35783005 PMCID: PMC9240645 DOI: 10.1016/j.xnsj.2022.100130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/07/2022]
Abstract
Background Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk. Methods Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups. Results N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr. Conclusions Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size. Level of Evidence: 3
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Postoperative Evolution of Sagittal Parameters Over Time Does Not Differ by Upper Instrumented Vertebra. Spine (Phila Pa 1976) 2022; 47:800-807. [PMID: 34669675 DOI: 10.1097/brs.0000000000004251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The aim of this study was to examine sagittal alignment over time in adult spinal deformity (ASD) and to understand whether these changes vary by choice of upper instrumented vertebra (UIV). SUMMARY OF BACKGROUND DATA Recent ASD literature has focused on specific alignment goals. Less is known about how sagittal parameters evolve over time after surgical correction and whether these changes differ by choice of UIV. METHODS This was a retrospective review of ASD patients from a single institution. Routine 36″ sagittal x-rays were obtained preoperatively, before hospital discharge, and at 6 months, 1 year, and 2 years and sagittal parameters were measured. Patients with UIV T6 and above were classified as upper thoracic (UT) and T7 and below as lower thoracic (LT). RESULTS A total of 102 patients with mean age 66.0 years (±7.7) were included in the analysis (49 UT, 53 LT). All sagittal and coronal alignment parameters demonstrated significant improvement from preoperatively to any postoperative time point. Although multiple parameters maintained correction over time, others (TK, TPA, and PT) demonstrated significant increase from discharge to 2 years postoperatively, with changes occurring relatively early after surgery, whereas overall global alignment was maintained. Both UT/LT groups demonstrated significantly greater TK from preoperatively to discharge to 6 months (P < 0.05), stabilizing at that time point out to 2 years, whereas TLK preferentially increased in the LT group. There was significant improvement in sagittal vertical axis after surgery, which was maintained out to 2years of follow-up (P > 0.05). CONCLUSIONS Our data suggest that although several key parameters are maintained over time out to 2years postopera- tively, TK tends to worsen over time for all patients, whereas TLK preferentially increases in the LT group. Nevertheless, despite these trends, compensatory changes are seen in PT such that global alignment is relatively maintained.Level of Evidence: 3.
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Park SJ, Park JS, Nam YJ, Choi YT, Lee CS. The Long-term Fate of Asymptomatic Proximal Junctional Kyphosis Following Long Instrumented Fusion in Elderly Patients with Sagittal Imbalance. Spine (Phila Pa 1976) 2021; 46:E1097-E1104. [PMID: 33710109 DOI: 10.1097/brs.0000000000004027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to investigate the long-term fate of asymptomatic PJK focusing on the elderly patients with sagittal imbalance by comparing the patients with and without PJK. SUMMARY OF BACKGROUND DATA Most of previous studies demonstrated that PJK does not negatively affect the clinical outcome compared to that of the patients without PJK. The question "will the asymptomatic PJK remain asymptomatic even in long-term follow-up?" has not been answered yet because the previous results were based on the short follow-up duration. METHODS Patients >60 years who underwent four or more level fusions to the sacrum for sagittal imbalance were followed up for >5 years. The radiographic and clinical outcomes were compared between PJK (n = 30) and non-PJK groups (n = 43). PJK was defined by proximal junctional angle (PJA) >10°. Only patients with >3 years of follow-up duration after PJK development were included in PJK group. The clinical outcome measures included visual analog scale (VAS) for the back and leg, Oswestry disability index (ODI), and Scoliosis Research Society (SRS)-22 scores. RESULTS The mean age was 69.2 years. Total follow-up duration was 92.4 months. Time between PJK development and the last follow-up was 67.4 months in PJK group. Although there were no differences between the two groups in terms of pelvic incidence-lumbar lordosis mismatch, pelvic tilt, or sacral vertical axis, PJA significantly increased from 6.5° postoperatively to 21.2° at the final follow-up in the PJK group. The clinical outcomes were worse (such as VAS for the back, ODI, and SRS-22 scores) in the PJK group than in non-PJK group, except for the satisfaction domain. Three (10%) of 30 patients underwent a revision surgery for PJK progression. CONCLUSION Even if PJK was asymptomatic at initial development, it progressed radiographically with time and eventually gave a negative impact on the clinical outcomes in long-term follow-up.Level of Evidence: 3.
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Affiliation(s)
- Se-Jun Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Liao JC, Chen WJ. The Influences of Spinopelvic Parameters and Associated Factors on Development of Proximal Instrumented Fracture After Posterior Instrumentation. World Neurosurg 2021; 157:e308-e315. [PMID: 34648985 DOI: 10.1016/j.wneu.2021.10.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate influences of spinopelvic parameters, such as lumbar lordosis (LL) angles, pelvic incidence, sacral slope, pelvic tilt, and sagittal vertical axis, on development of the proximal junctional failure fracture type after posterior instrumentation. METHODS This retrospective 1:3 matched case-control cohort study included 24 patients who developed proximal instrumented fracture in the study group and 72 patients without proximal junctional failure in the control group. Weighted Charlson Comorbidity Index and bone mineral density with T-score were recorded. In addition to spinopelvic parameters, proximal local kyphosis (PLK), which refers to a kyphosis angle between the upper end plate of upper instrumented vertebra plus 1 level and the lower end plate of upper instrumented vertebra; pelvic incidence-LL mismatch; and spinopelvic realignment score were calculated. RESULTS More comorbidities (Charlson Comorbidity Index, P = 0.002) and poorer bone density (T-score, P = 0.001) were noted in the study group. Before surgery, the study group had significantly lower LL (P = 0.046) and sacral slope (P = 0.043) and significantly higher PLK (P < 0.001) and pelvic tilt (P = 0.044) than the control group. Postoperatively, the study group had significantly higher PLK (P < 0.001) and lower LL (P = 0.031) than the control group; the degree of pelvic incidence-LL mismatch (P = 0.007) remained significantly higher in the study group. Preoperative (P = 0.026) and postoperative (P = 0.045) spinopelvic realignment scores was worse in the study group. Multivariate analysis revealed that postoperative PLK was the most significant radiographic factor to predict proximal instrumented fracture (P = 0.002, odds ratio 1.140, 95% confidence interval). CONCLUSIONS In our experience, appropriate LL and lower PLK should be obtained at surgery to prevent development of instrumented fracture.
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Affiliation(s)
- Jen-Chung Liao
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Wen-Jer Chen
- Department of Orthopedics Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Tohmeh AG, Jabbouri SS, Vesselle A, Howell KM. Short-segment minimally disruptive anterior column release for focal sagittal deformity correction of the thoracolumbar spine. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 6:100068. [PMID: 35141633 PMCID: PMC8820079 DOI: 10.1016/j.xnsj.2021.100068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 10/26/2022]
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Virk S, Platz U, Bess S, Burton D, Passias P, Gupta M, Protopsaltis T, Kim HJ, Smith JS, Eastlack R, Kebaish K, Mundis GM, Nunley P, Shaffrey C, Gum J, Lafage V, Schwab F. Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons. JOURNAL OF SPINE SURGERY 2021; 7:37-47. [PMID: 33834126 DOI: 10.21037/jss-20-598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background The decision upper-most instrumented vertebrae (UIV) in a multi-level fusion procedure can dramatically influence outcomes of corrective spine surgery. We aimed to create an algorithm for selection of UIV based on surgeon selection/reasoning of sample cases. Methods The clinical/imaging data for 11 adult spinal deformity (ASD) patients were presented to 14 spine deformity surgeons who selected the UIV and provided reasons for avoidance of adjacent levels. The UIV chosen was grouped into either upper thoracic (UT, T1-T6), lower thoracic (LT, T7-T12), lumbar or cervical. Disagreement between surgeons was defined as ≥3 not agreeing. We performed a descriptive analysis of responses and created an algorithm for choosing UIV then applied this to a large database of ASD patients. Results Surgeons agreed in 8/11 cases on regional choice of UIV. T10 was the most common UIV in the LT region (58%) and T3 was the most common UIV in the UT region (44%). The most common determinant of UIV in the UT region was proximal thoracic kyphosis and presence of coronal deformity. The most common determinant of UIV in the LT region was small proximal thoracic kyphosis. Within the ASD database (236 patients), when the algorithm called for UT fusion, patients fused to TL region were more likely to develop proximal junctional kyphosis (PJK) at 1 year post-operatively (76.9% vs. 38.9%, P=0.025). Conclusions Our algorithm for selection of UIV emphasizes the role of proximal and regional thoracic kyphosis. Failure to follow this consensus for UT fusion was associated with twice the rate of PJK.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Uwe Platz
- Department of spine surgery, Schön Kllink Neustadt, Neustadt, Germany
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | | | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Robert Eastlack
- Scripps Clinic Medical Group Division of Orthopaedic Surgery, La Jolla, CA, USA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gregory M Mundis
- Scripps Clinic Medical Group Division of Orthopaedic Surgery, La Jolla, CA, USA
| | | | | | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
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Hounsfield Unit for Assessing Vertebral Bone Quality and Asymmetrical Vertebral Degeneration in Degenerative Lumbar Scoliosis. Spine (Phila Pa 1976) 2020; 45:1559-1566. [PMID: 32756284 DOI: 10.1097/brs.0000000000003639] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVES The aim of this study was to demonstrate the correlation between degenerative lumbar scoliosis (DLS) and osteoporosis based on Hounsfield unit (HU) measurement from computed tomography (CT) scans, and to investigate the asymmetrical vertebral degeneration in DLS. SUMMARY OF BACKGROUND DATA The correlation between DLS and osteoporosis measured by dual-energy x-ray absorptiometry (DEXA) is debated, since T-scores measured by DEXA scan can be overestimated due to abdominal vessel wall calcification, degenerative bony spurs, and facet hypertrophy. The reliability and accuracy of HU to determine osteoporosis are shown in many reports, but it has never been used to assess the vertebral bone quality for DLS patients. METHODS Nighty-five DLS patients were retrospectively reviewed. Regions of interest for HU were measured on three coronal images of the lumbar vertebrae. HU measurement of the whole vertebrae from L1 to L5 was obtained, then HU measurement within concave and convex sides were obtained separately in L5, upper and lower end vertebrae, apex vertebrae, neutral vertebrae, stable vertebrae. RESULTS HU value presented a gradually increasing trend from L1 to L5. No correlation was detected between Cobb angle and mean HU value of the 5 lumbar vertebrae, or between Cobb angle and HU value of every lumbar vertebrae separately. HU value was higher within concavity than that within convexity of the same vertebrae both in major and compensatory curve. Asymmetric HU ratio in apex vertebrae positively correlated with Cobb angle. Stable vertebrae were the first proximal vertebrae that present opposite orientation of asymmetric HU ratio from the other lumbar vertebrae. CONCLUSION Progression of degenerative scoliosis presents no correlation with osteoporosis based on HU measurement but could increase the asymmetrical vertebral degeneration, especially in apex vertebrae. Distraction of the pedicle screws at concave side, instead of compression of pedicle screws at convex side, should be a priority to correct lumbosacral curve. LEVEL OF EVIDENCE 3.
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Lafage R, Ang B, Alshabab BS, Elysee J, Lovecchio F, Weissman K, Kim HJ, Schwab F, Lafage V. Predictive Model for Selection of Upper Treated Vertebra Using a Machine Learning Approach. World Neurosurg 2020; 146:e225-e232. [PMID: 33091645 DOI: 10.1016/j.wneu.2020.10.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To train and validate an algorithm mimicking decision making of experienced surgeons regarding upper instrumented vertebra (UIV) selection in surgical correction of thoracolumbar adult spinal deformity. METHODS A retrospective review was conducted of patients with adult spinal deformity who underwent fusion of at least the lumbar spine (UIV > L1 to pelvis) during 2013-2018. Demographic and radiographic data were collected. The sample was stratified into 3 groups: training (70%), validation (15%) and performance testing (15%). Using a deep learning algorithm, a neural network model was trained to select between upper thoracic (T1-T6) and lower thoracic (T7-T12) UIV. Parameters used in the deep learning algorithm included demographics, coronal and sagittal preoperative alignment, and postoperative pelvic incidence-lumbar lordosis mismatch. RESULTS The study included 143 patients (mean age 63.3 ± 10.6 years, 81.8% women) with moderate to severe deformity (maximum Cobb angle: 43° ± 22°; T1 pelvic angle: 27° ± 14°; pelvic incidence-lumbar lordosis mismatch: 22° ± 21°). Patients underwent a significant change in lumbar alignment (Δpelvic incidence-lumbar lordosis mismatch: 21° ± 16°, P < 0.001); 35.0% had UIV in the upper thoracic region, and 65.0% had UIV in the lower thoracic region. At 1 year, revision rate was 11.9%, and rate of radiographic proximal junctional kyphosis was 29.4%. Neural network comprised 8 inputs, 10 hidden neurons, and 1 output (upper thoracic or lower thoracic). After training, results demonstrated an accuracy of 81.0%, precision of 87.5%, and recall of 87.5% on testing. CONCLUSIONS An artificial neural network successfully mimicked 2 lead surgeons' decision making in the selection of UIV for adult spinal deformity correction. Future models integrating surgical outcomes should be developed.
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Affiliation(s)
- Renaud Lafage
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Bryan Ang
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA.
| | - Basel Sheikh Alshabab
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Jonathan Elysee
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Karen Weissman
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Frank Schwab
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
| | - Virginie Lafage
- Department of Spine Surgery, Hospital for Special Surgery, Department of Spine Surgery, New York, New York, USA
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Li Y, Ou Y, Zhu Y, He B, Xu S, Yu H. Effectiveness of Short-Segment Fixation versus Long-Segment Fixation for Degenerative Scoliosis with Cobb Angle 20°~40°: A Retrospective Observational Study. Med Sci Monit 2020; 26:e923656. [PMID: 32694499 PMCID: PMC7392055 DOI: 10.12659/msm.923656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There remains a great deal of controversy regarding the selection of long-segment fixation and short-segment fixation, especially for degenerative scoliosis (DS) patients with Cobb angle 20°~40°. The purpose of this study was to investigate the effects of different fixation levels in DS patients with Cobb angle 20°~40°. MATERIAL AND METHODS We enrolled 96 DS patients, divided into a long-segment fixation group (>3 segments) and a short-segment fixation group (≤3 segments). The visual analogue scale (VAS) and Oswestry disability index (ODI) were used to evaluate the clinical outcomes. The spinal-pelvic parameters and complications were also collected and analyzed. RESULTS The short-segment fixation group had the advantages of less blood loss, shorter operation time and shorter fluoroscopy time (P<0.05). The 2 groups achieved similar effects in leg pain (VAS) and ODI after operation (P>0.05); however, there was a better relief of low back pain in the long-segment fixation group (P<0.05). The changes of Cobb angle, sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS) in the long-segment fixation group were more obvious than that in the short-segment fixation group at the final follow-up (P<0.05). The prevalence of complications in the long-segment fixation group was significantly higher than in the short-segment fixation group (P<0.01). CONCLUSIONS Short-segment fixation has less surgical trauma and fewer complications, whereas long-segment fixation has more advantages in improving spine-pelvis parameters and relieving low back pain.
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Affiliation(s)
- Yuanqiang Li
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Yunsheng Ou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Yong Zhu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Bin He
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Shuai Xu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
| | - Haoyang Yu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (mainland)
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Should Thoracolumbar Junction Be Always Avoided as Upper Instrumented Vertebra in Long Instrumented Fusion for Adult Spinal Deformity?: Risk Factor Analysis for Proximal Junctional Failure. Spine (Phila Pa 1976) 2020; 45:686-693. [PMID: 31842105 DOI: 10.1097/brs.0000000000003364] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The aim of this study was to investigate the risk factors for proximal junctional failure (PJF) following long instrumented fusion stopping at thoracolumbar junction (TLJ) in adult spinal deformity (ASD) and to determine which cases are suitable for TLJ stop without increasing the risk for PJF. SUMMARY OF BACKGROUND DATA PJF following long fusion for ASD is a well-recognized complication that negatively affects clinical outcomes. Generally, the uppermost instrumented vertebra (UIV) at the TLJ is associated with the risk of PJF. Little is known about the risk factors for PJF in case with the UIV at TLJ. METHODS Radiographic and clinical data of 63 consecutive patients who underwent instrumented fusion from sacrum to TLJ (T11, T12, and L1) for the treatment of ASD with a minimum 2-year follow-up were analyzed to identify the risk factors for PJF, which was defined as proximal junctional angle (PJA) ≥20°, fracture at UIV or UIV+1, failure of UIV fixation, myelopathy, or 'need for proximal extension of fusion. RESULTS During the average follow-up duration of 51.7 months, PJF developed in 23 patients (36.5%) at a mean of 9.3 months after surgery. Multivariate analysis revealed that age >70 years (odds ratio [OR]: 1.119), osteoporosis (OR: 4.459), and preoperative kyphotic PJA (OR: 1.138) were significant risk factors for the development of PJF. No PJF occurred in 14 patients lacking any risk factors. The last follow-up clinical results were significantly inferior in the PJF group than in the non-PJF group in terms of Oswestry Disability Index and Scoliosis Research Society-22 score. CONCLUSION Age >70 years, osteoporosis, and PJA greater 0° were identified as significant risk factors for PJF. Therefore, the TLJ level can be considered as UIV selectively for patients younger than 70 years without osteoporosis and with lordotic preoperative PJA. LEVEL OF EVIDENCE 3.
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Park JH, Kim YB, Hyun SJ, Kang KB, Park PS. Changes in Thoracic Kyphosis and Thoracolumbar Kyphosis in Asymptomatic Korean Male Subjects Aged >50 Years: Do They Progress Above T5, T10, T12, or L2? Asian Spine J 2019; 14:192-197. [PMID: 31575109 PMCID: PMC7113465 DOI: 10.31616/asj.2019.0060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 05/09/2019] [Indexed: 12/03/2022] Open
Abstract
Study Design Retrospective analysis of prospectively collected data. Purpose To evaluate the natural progression of segmental kyphosis in thoracic and thoracolumbar spine with advancing age. Overview of Literature To our knowledge, the evolution of segmental thoracic kyphosis (TK) in individuals aged >50 years has not been reported. Methods Total 179 normal, asymptomatic Korean men were divided in to three groups (6th, 7th, and 8th decade) according to their age. Standard sagittal spinopelvic parameters, including TK and thoracolumbar kyphosis, were measured and subdivided into the following four segments: A (C7 upper end plate [UEP]–T5 UEP), B (T5 UEP–T10 UEP), C (T10 UEP–T12 lower end plate [LEP]), and D (T12 LEP–L2 LEP). These segments of the three study groups were analyzed. Results In segment B, the segmental kyphosis of group 3 (20.2°±8.0°) showed a statistically larger value than that of group 1 (15.6°±6.8°) and group 2 (16.7°±8.8°) (p=0.017). In segment C, the segmental kyphosis of group 2 (12.9°±6.5°) and group 3 (12.2°±7.1°) showed statistically larger values than that of group 1 (9.5°±6.2°) (p=0.016). The A and D segments of the three groups were not significantly different. Conclusions Increased TK was observed in the middle (segment B) and lower (segment C) thoracic segments in normal asymptomatic male subjects with age. The results from the natural progression of segmental kyphosis with age would provide baseline reference data to help surgeons choose the optimal point of the upper instrumented vertebra level for preventing proximal junctional kyphosis.
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Affiliation(s)
- Jae-Hong Park
- Department of Orthopedics, Asan Medical Center, Seoul, Korea
| | - Youngbae B Kim
- Department of Orthopedics, Seoul Veterans Hospital, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosugery, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Kyu-Bok Kang
- Department of Orthopedics, Seoul Veterans Hospital, Seoul, Korea
| | - Pil-Sun Park
- Department of Orthopedics, Seoul Veterans Hospital, Seoul, Korea
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Paholpak P, Shah I, Acevedo-Moreno LA, Tamai K, Buser Z, Wang JC. Thoracic spine disc degeneration, translation, and angular motion: An analysis using thoracic spine kinematic MRI (kMRI). J Clin Neurosci 2019; 66:113-120. [PMID: 31130352 DOI: 10.1016/j.jocn.2019.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/29/2019] [Accepted: 05/08/2019] [Indexed: 12/18/2022]
Abstract
The aim of this study was to evaluate disc degeneration and kinematic changes in translation and angular motion of the thoracic spine using kinematic MRI (kMRI). 105 thoracic spine kMRI were analyzed from T4-5 to T11-12 using MRAnalyzer3. Translational and angular motion were evaluated in neutral, flexion, and extension positions. Thoracic disc height and disc degeneration grading were measured in the neutral position. Intraclass Correlation Coefficients were used to analyze agreement among three observers. The Friedman's test was used to analyze the difference in disc height, disc degeneration, translational motion, and angular motion. The Wilcoxon-signed rank test was used for post-hoc analysis with a Bonferroni correction. A p-value of 0.00625 was used to establish a statistically significant difference. Analysis using the Friedman's test revealed that translational motion, disc height, and disc degeneration were significantly different from T4-5 to T11-12 (p < 0.001). The T4-5 level showed the least translational motion, while the T10-11 showed the most translational motion. The lower thoracic level (T8-12) showed significantly more translational motion, more advanced disc degeneration, and greater disc height than the upper thoracic level (T4-8, p < 0.001). T11-12 showed the most advanced disc degeneration. There was a significant negative correlation between disc degeneration and translational motion at the upper thoracic level (p = 0.013). The lower thoracic region (below T8) had significantly more translational motion, more advanced disc degeneration, and greater disc height. This information is crucial in further understanding thoracic spinal kinematics and may contribute to determining the stopping level in fusion surgeries involving the thoracic spine.
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Affiliation(s)
- Permsak Paholpak
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States; Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ishan Shah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Lou-Anne Acevedo-Moreno
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Koji Tamai
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States.
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, United States
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Zhu WY, Zang L, Li J, Guan L, Hai Y. A biomechanical study on proximal junctional kyphosis following long-segment posterior spinal fusion. Braz J Med Biol Res 2019; 52:e7748. [PMID: 31038576 PMCID: PMC6487758 DOI: 10.1590/1414-431x20197748] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 02/11/2019] [Indexed: 11/29/2022] Open
Abstract
Posterior long-segment spinal fusion may lead to proximal junctional kyphosis (PJK). The present study sought to identify the appropriate fusion levels required in order to prevent PJK using finite element analysis. A finite element model was constructed based on the whole-spine computed tomography findings of a healthy adult. Nine commonly used posterior spinal fusion methods were selected. Stress on the annulus fibrosis fibers, the posterior ligamentous complex, and the vertebrae after various spinal fusions in the upright position were compared. This study was divided into two groups: non-fusion and fusion. In the former, the stress between the T10 and the upper thoracic vertebrae was higher. Comparing thoracic and lumbar segments in the fusion group, the peak stress values of the upper instrumented vertebrae (UIV) were mainly observed in T2 and L2 whilst those of the UIV+1 were observed in T10 and L2. After normalization, the peak stress values of the UIV and UIV+1 were located in T2 and L2. Similarly, the peak stress values of the annulus fibrosus at the upper adjacent level were on T10 and L2 after normalization. However, the peak stress values of the interspinal/supraspinal complex forces were concentrated on T11, T12, and L1 after normalization whilst the peak stress value of the pedicle screw was on T2. Controversy remains over the fusion of T10, and this study simulated testing conditions with gravitational loading only. However, further assessment is needed prior to reaching definitive conclusions.
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Affiliation(s)
- Wen-Yi Zhu
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lei Zang
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jian Li
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li Guan
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Liang Y, Zhao Y, Wang T, Zhu Z, Liu H, Mao K. Precision Treatment of Adult Lumbar Degenerative Scoliosis Complicated by Lumbar Stenosis with the Use of Selective Nerve Root Block. World Neurosurg 2018; 120:e970-e975. [PMID: 30196177 DOI: 10.1016/j.wneu.2018.08.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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The influence of spinal fusion length on proximal junction biomechanics: a parametric computational study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2262-2271. [PMID: 30039253 DOI: 10.1007/s00586-018-5700-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE Proximal junctional kyphosis and failure are frequent complications in adult spinal deformity surgery with long fusion constructs. The aim of this study was to assess the biomechanics of the proximal segment for fusions of various lengths. METHODS A previously established musculoskeletal model of thoracolumbar spine was used to simulate full-range flexion task for fusions (modeled by introduction of rigid constraints) with lower instrumented vertebrae at L5 or S1 and upper instrumented vertebrae (UIV) at any level above, up to T2. Inverse dynamics simulations with force-dependent kinematics were performed for gradually increasing spinal flexion in order to predict global and segmental range of flexion, maximum passive moment, segmental compression and shear forces, which were compared to the uninstrumented case. RESULTS For long fusions, with the UIV at T11 or higher, the model predicted an increase in segmental flexion (by 33-860%, or 1.6°-4.7°) and passive moment (by 39-1370%, or 13-31 Nm) at the proximal junction-generally increasing with fusion length. While the maximum shear force was 57-239% (135-283 N) higher for the proximal junction at the upper thorax (UIV at T6 or above), the compression forces were reduced by up to 44% (375 N). CONCLUSIONS The length of the instrumentation has an important effect on the proximal segment biomechanics. Despite the limitations of the current model, musculoskeletal modeling appears to be a promising and versatile method to support planning of spinal instrumentation surgeries in the future. These slides can be retrieved under Electronic Supplementary Material.
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Kang X, Dong L, Yang T, Wang Z, Huang G, Chen X. Clinical and radiographic outcomes of upper thoracic versus lower thoracic upper instrumented vertebrae for adult scoliosis: a meta-analysis. ACTA ACUST UNITED AC 2018; 51:e6651. [PMID: 29490003 PMCID: PMC5856438 DOI: 10.1590/1414-431x20176651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 11/20/2017] [Indexed: 12/02/2022]
Abstract
The aim of this study was to evaluate the clinical and radiographic outcomes of upper thoracic (UT) versus lower thoracic (LT) upper instrumented vertebrae (UIV) for adult scoliosis by meta-analysis. We conducted a literature search in three databases to retrieve related studies up to March 15, 2017. The preliminary screened studies were assessed by two reviewers according to the selection criteria. All analyses were carried out using the statistical software package R version 2.31. Odds ratios (OR) with 95% confidence intervals (CI) were used to describe the results. The I2 statistic and Q statistic test were used for heterogeneity assessment. Egger's test was performed to detect publication bias. To assess the effect of each study on the overall pooled OR or standardized mean difference (SMD), sensitive analysis was conducted. Ten trials published between 2007 and 2015 were eligible and included in our study. Meta-analysis revealed that the UT group was associated with more blood loss (SMD=0.4779, 95%CI=0.3349-0.6209, Z=6.55, P<0.0001) and longer operating time (SMD=0.5780, 95%CI=0.1971-0.958, Z=2.97, P=0.0029) than the LT group. However, there was no significant difference in Oswestry Disability Index, Scoliosis Research Society (SRS) function subscores, radiographic outcomes including sagittal vertical axis, lumbar lordosis, and thoracic kyphosis, length of hospital stay, and revision rates between the two groups. No evidence of publication bias was found between the two groups. Fusion from the lower thoracic spine (below T10) has as advantages a shorter operation time and less blood loss than upper thoracic spine (above T10) in posterior long-segment fixation for degenerative lumbar scoliosis.
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Affiliation(s)
- X Kang
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
| | - L Dong
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
| | - T Yang
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
| | - Z Wang
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
| | - G Huang
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
| | - X Chen
- Hong-Hui Hospital, Department of Bone Diseases, Xi'an Jiaotong University, Xi'an, China
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Prophylactic vertebral cement augmentation at the uppermost instrumented vertebra and rostral adjacent vertebra for the prevention of proximal junctional kyphosis and failure following long-segment fusion for adult spinal deformity. Spine J 2017; 17:1499-1505. [PMID: 28522402 DOI: 10.1016/j.spinee.2017.05.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/22/2017] [Accepted: 05/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common problems after long-segment (>5 levels) thoracolumbar instrumented fusions in the treatment of adult spinal deformity (ASD). No specific surgical strategy has definitively been shown to lower the risk of PJK as the result of a multifactorial etiology. PURPOSE The study aimed to assess the incidence of PJK and PJF in patients treated with prophylactic polymethylmethacrylate (PMMA) cement augmentation at the uppermost instrumented vertebrae (UIV) and rostral adjacent vertebrae (UIV+1). STUDY DESIGN/SETTING This is a retrospective cohort-matched surgical case series at an academic institutional setting. PATIENT SAMPLE Eighty-five adult patients over a 16-year enrollment period were identified with long-segment (>5 levels) posterior thoracolumbar instrumented fusions for ASD. OUTCOME MEASURES Primary outcomes measures were PJK magnitude and PJF formation. Secondary outcomes measures were spinopelvic parameters, as well as global and regional sagittal alignment. METHODS The impact of adjunctive PMMA use in long-segment (≥5 levels) fusion for ASD was assessed in adult patients aged 18 and older. Patients were included with at least one of the following: lumbar scoliosis >20°, pelvic tilt >25°, sagittal vertical axis >5 cm, central sacral vertical line >2 cm, and thoracic kyphosis >60°. The frequency of PJF and the magnitude of PJK were measured radiographically preoperatively, postoperatively, and at maximum follow-up in controls (Group A) and PMMA at the UIV and UIV+1 (Group B). RESULTS Eighty-five patients (64±11.1 years) with ASD were identified: 47 control patients (58±10.6) and 38 patients (71±6.8) treated with PMMA at the UIV and UIV+1. The mean follow-up was 27.9 and 24.2 months in Groups A and B, respectively (p=.10). Preoperative radiographic parameters were not significantly different, except the pelvic tilt which was greater in Group A (26.6° vs. 31.4°, p=.03). Postoperatively, the lumbopelvic mismatch was greater in Group B (14.6° vs. 7.9°, p=.037), whereas the magnitude of PJK was greater in controls (9.36° vs. 5.65°, p=.023). The incidence of PJK was 36% (n=17) and 23.7% (n=9) in Groups A and B, respectively (p=.020). The odds ratio of PJK with vertebroplasty was 0.548 (95% confidence interval=0.211 to 1.424). Proximal junctional kyphosis was observed in 6 (12.8%) controls only (p=.031). The UIV+1 angle, a measure of PJK, was significantly greater in controls (10.0° vs. 6.8°, p=.02). No difference in blood loss was observed. No complications were attributed to PMMA use. CONCLUSIONS The use of prophylactic vertebral cement augmentation at the UIV and rostral adjacent vertebral segment at the time of deformity correction appears to be preventative in the development of proximal junctional kyphosis and failure.
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Raman T, Miller E, Martin CT, Kebaish KM. The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study. Spine J 2017; 17:1489-1498. [PMID: 28506822 DOI: 10.1016/j.spinee.2017.05.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/27/2017] [Accepted: 05/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The incidence of proximal junctional kyphosis (PJK) ranges from 5% to 46% following adult spinal deformity surgery. Approximately 66% to 76% of PJK occurs within 3 months of surgery. A subset of these patients, reportedly 26% to 47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK and PJF incidence at long-term follow-up. PURPOSE The purpose of this study is to evaluate the long-term radiographic and clinical outcomes, and incidence of PJK and PJF, after prophylactic vertebroplasty for long-segment thoracolumbar posterior spinal fusion (PSF). STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE Thirty-nine patients, of whom 87% were female, who underwent two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF were included in this study. OUTCOME MEASURES Clinical outcomes were assessed using the Scoliosis Research Society-22 (SRS-22), and Short-Form (SF) 36 questionnaires, and the Oswestry Disability Index (ODI). Radiographic parameters including PJK angle, and coronal and sagittal alignment, were calculated, along with relevant perioperative complications and revision rates. METHODS Of the 41 patients who received two-level prophylactic vertebroplasty at the upper instrumented and supra-adjacent vertebrae at the time of index PSF, and comprised a cohort with previously published 2-year follow-up data, 39 (95%) completed 5-year follow-up (average: 67.6 months). Proximal junctional kyphosis was defined as a change in the PJK angle ≥10° between the immediate postoperative and final follow-up radiograph. Proximal junctional failure was defined as acute proximal junctional fracture, fixation failure, or kyphosis requiring extension of fusion within the first 6 months postoperatively. RESULTS Thirty-nine patients with a mean age of 65.6 (41-87) years were included in this study. Of the 39 patients, 28.2% developed PJK (11: 7.7% at 2 years, 20.5% between 2 and 5 years), and 5.1% developed acute PJF. Two of the 11 PJK patients required revision for progressive worsening of the PJK. There were no proximal junctional fractures. There was no significant difference in preoperative, immediate postoperative, and final follow-up measurements of thoracic kyphosis, lumbar lordosis, and coronal or sagittal alignment between patients who developed PJK, PJF, or neither (p>.05). There was no significant difference in ODI, SRS-22, or SF-36 scores between those with and without PJK or PJF (p>.05). CONCLUSIONS This long-term follow-up demonstrates that prophylactic vertebroplasty may minimize the risk for junctional failure in the early postoperative period. However, it does not appear to decrease the incidence of PJK at 5 years.
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Affiliation(s)
- Tina Raman
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21287, USA.
| | - Emily Miller
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Christopher T Martin
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21287, USA
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Hey HWD, Tan KA, Neo CSE, Lau ETC, Choong DAW, Lau LL, Liu GKP, Wong HK. T9 versus T10 as the upper instrumented vertebra for correction of adult deformity-rationale and recommendations. Spine J 2017; 17:615-621. [PMID: 27856380 DOI: 10.1016/j.spinee.2016.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/18/2016] [Accepted: 11/09/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity correction sometimes involves long posterior pedicle screw constructs extending from the lumbosacral spine to the thoracic vertebra. As fusion obliterates motion and places supraphysiological stress on adjacent spinal segments, it is crucial to ascertain the ideal upper instrumented vertebra (UIV) to minimize risk of proximal junctional failure (PJF). The T10 vertebra is often chosen to allow bridging of the thoracolumbar junction into the immobile thoracic vertebrae on the basis that it is the lowest immobile thoracic vertebra strut by the rib cage. PURPOSE This study aimed to characterize the range of motion (ROM) of each vertebral segment from T7 to S1 to determine if T10 is truly the lowest immobile thoracic vertebra. STUDY DESIGN/SETTING This is a prospective, comparative study. PATIENT SAMPLE Seventy-nine adults (mean age of 45.4 years) presenting with low back pain or lower limb radiculopathy or both, without previous spinal intervention, metastases, fractures, infection, or congenital deformities of the spine, were included in the study. OUTCOME MEASURES A ROM >5° across two vertebral segments as determined by the Cobb method from radiographs. METHODS Lumbar flexion-extension and neutral erect radiographs were obtained in randomized order using a slot scanner. Segmental ROM was measured from T7-T8 to L5-S1 and analyzed for significant differences using t tests. Age, gender, radiographical indices such as standard spinopelvic parameters, sagittal vertical axis (SVA), C7-T12 SVA, T1 slope, thoracic kyphosis (TK), and lumbar lordosis (LL) were studied via multivariate analysis to identify predictive factors for >5° change in ROM at the various segmental levels. There were no sources of funding and no conflicts of interest associated with this study. RESULTS In the thoracolumbar spine, significant decreases in ROM when compared with the adjacent caudad segment occurs up to T9-T10, with mean total ROM of 1.98±1.47° (p<.001) seen in T9-T10, 2.19±1.67° (p<.001) in T10-T11, and 3.92±3.21°(p<.001) in T11-T12. The total ROM of T8-T9 (2.53±1.79°) was not significantly different from that of T9-T10 (p=.261). At the thoracolumbar junction, absence of scoliosis (OR 11.37, p=.020), high pelvic incidence (OR 1.14, p=.046), and low T1 slope (OR 1.45, p=.030) were predictive of ROM >5°. CONCLUSIONS Lumbar spine flexion-extension ROM decreases as it approaches the thoracolumbar junction. T10 is indeed the lowest immobile thoracic vertebra strut by the rib cage, and the last significant decrease in ROM is observed at T9-T10, in relation to T10-T11. However, because this also implies that a UIV of T10 would mean there is only one level of fixation above the relatively mobile segment, while respecting other factors that influence UIV selection, we propose the T9 vertebra as a more ideal UIV to fulfill the biomechanical concept of bridge fixation. However, this decision should still be taken on a case-by-case basis.
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Affiliation(s)
| | - Kimberly-Anne Tan
- Department of Orthopedic Surgery, National University Health System, Singapore
| | | | - Eugene Tze-Chun Lau
- Department of Orthopedic Surgery, National University Health System, Singapore
| | | | - Leok-Lim Lau
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Gabriel Ka-Po Liu
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Hee-Kit Wong
- Department of Orthopedic Surgery, National University Health System, Singapore
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Choi JH, Jang JS, Kim HS, Jang IT. What Is the More Appropriate Proximal Fusion Level for Adult Lumbar Degenerative Flat Back? World Neurosurg 2017; 106:827-835. [PMID: 28342920 DOI: 10.1016/j.wneu.2017.03.051] [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: 11/14/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the optimal proximal fusion level after long instrumented fusion to the sacrum for lumbar degenerative flat back. METHODS Data from 70 patients with lumbar degenerative flat back were reviewed retrospectively. Three groups were designated according to the upper instrumented vertebrae (UIV): group 1 (UIV = T10 or above), group 2 (UIV = T11-12), and group 3 (UIV = L1 or below). Pre- and postoperative pelvic parameters, degree of correction, and prevalence of proximal junctional kyphosis (PJK) and its risk factors were evaluated. RESULTS The prevalence of PJK was 27.1% (average 35.5 months of follow-up). Preoperative pelvic incidence (PI) and sacral slope (SS) in group 1 were higher in the PJK group than in the non-PJK group (P = 0.03 and P = 0.001, respectively). Preoperative thoracolumbar (TL) in group 3 was higher in the PJK group than in the non-PJK group (P = 0.01). Postoperative pelvic tilt (PT) was lower (<20°) in the non-PJK group than in the PJK group (P = 0.025 in group 3). Postoperative TL in group 3 was lower than in the non-PJK group (P = 0.024). CONCLUSIONS If the PI is ≥50°, TL kyphosis is ≥5°, and SS is ≥20°, the UIV should be raised above T10 up to the midthoracic level. If the PI is ≥50°, SS is ≤20°, and thoracic kyphosis (TK) is normal despite TL kyphosis, the UIV should be at T10. Even if the PI is ≥50°, TK is normal, and there is no TL kyphosis, the UIV should be set at L1 or below. Regardless of the UIV, the postoperative PT should be ≤20°.
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Affiliation(s)
- Jeong-Hoon Choi
- Department of Neurosurgery, Nanoori Suwon Hospital, Gyeonggi-do, Korea
| | - Jee-Soo Jang
- Department of Neurosurgery, Nanoori Suwon Hospital, Gyeonggi-do, Korea.
| | - Hyeun-Sung Kim
- Department of Neurosurgery, Nanoori Suwon Hospital, Gyeonggi-do, Korea
| | - Il-Tae Jang
- Department of Neurosurgery, Nanoori Hospital, Seoul, Korea
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Fu X, Sun XL, Harris JA, Sheng SR, Xu HZ, Chi YL, Wu AM. Long fusion correction of degenerative adult spinal deformity and the selection of the upper or lower thoracic region as the site of proximal instrumentation: a systematic review and meta-analysis. BMJ Open 2016; 6:e012103. [PMID: 27852709 PMCID: PMC5128941 DOI: 10.1136/bmjopen-2016-012103] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare outcomes when the upper and lower thoracic regions were used as the site of proximal instrumentation to treat adult spinal deformity. METHODS MEDLINE, Embase and Cochrane library searches were performed to identify studies that compared outcome measures when the upper and lower thoracic vertebrae (UTV and LTV, respectively) were used as the site of proximal instrumentation. The weighted mean difference (WMD) was calculated for continuous outcomes, and the relative risk (RR) was calculated for dichotomous outcomes. RESULTS Seven articles (n=554 patients) met the final inclusion criteria, and we compared the outcome measures of a long fusion extending to the upper and lower thoracic regions. The pooled analysis revealed that extending fixation into the upper thoracic region decreased the risk of proximal junctional kyphosis (PJK) revision surgery (RR: 0.36, 95% CI 0.14 to 0.90, p<0.05). The operation time (WMD: 0.93, 95% CI 0.48 to 1.39, p<0.05) and estimated blood loss (WMD: 0.59, 95% CI 0.33 to 0.85, p<0.05) were significantly greater in the UTV group than in the LTV group. No significant differences were found in the Scoliosis Research Society pain, self-image, function, mental health, subtotal, satisfaction or total scores; the total number of complications or the total number of revision surgeries. CONCLUSIONS Long posterior fixation extending into the upper thoracic region reduces the incidence of revision surgery related to PJK; however, it increased the operative level resulting in a longer operative time and greater estimated blood loss. This initial analysis indicates that extending fixation to the upper thoracic region is appropriate for patients who are likely to develop PJK following initial scoliosis correction.
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Affiliation(s)
- Xin Fu
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Xiao-Lei Sun
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Jonathan A Harris
- Division of Globus Medical, Musculoskeletal Education and Research Centre (MERC), Audubon, Pennsylvania, USA
| | - Sun-Ren Sheng
- Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Zhejiang Spinal Research Centre, Wenzhou, Zhejiang, China
| | - Hua-Zi Xu
- Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Zhejiang Spinal Research Centre, Wenzhou, Zhejiang, China
| | - Yong-Long Chi
- Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Zhejiang Spinal Research Centre, Wenzhou, Zhejiang, China
| | - Ai-Min Wu
- Department of Orthopaedics, Second Affiliated Hospital of Wenzhou Medical University, Zhejiang Spinal Research Centre, Wenzhou, Zhejiang, China
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Clinical Incidence of PJK/ASD in Adult Deformity Surgery: A Comparison of Rigid Fixation and Semirigid Fixation-Rigid. Spine (Phila Pa 1976) 2016; 41 Suppl 7:S35-6. [PMID: 27015073 DOI: 10.1097/brs.0000000000001439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Proximal junctional kyphosis (PJK) and adjacent segment degeneration (ASD) are important causes of reoperation for adult spinal deformity (). Reducing junctional complications can improve outcomes and cost-effectiveness of treatment. Rigid fixation is associated with significant proximal junctional pathology, but no clinical evidence indicates that less rigid fixation may reduce PJK. In lumbar degeneration, semirigid fixation has been associated with implant loosening, nonunion, and revision surgery. Rigid fixation is more reliable than semirigid fixation for management of spinal deformity.
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Wang N, Wang D, Wang F, Tan B, Yuan Z. Evaluation of Degenerative Lumbar Scoliosis After Short Segment Decompression and Fusion. Medicine (Baltimore) 2015; 94:e1824. [PMID: 26632679 PMCID: PMC5058948 DOI: 10.1097/md.0000000000001824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to investigate short segment decompression of degenerative lumbar scoliosis (DLS) and the efficiency of fusion treatment.After DLS surgery, the patients were retrospectively reviewed using the VAS (visual analog scale) and ODI (Oswestry Disability Index) to assess clinical outcomes. All patients underwent posterior lumbar decompressive laminectomy, pedicle screw internal fixation, and posterolateral bone graft fusion surgery. Radiographic measurements included the scoliotic Cobb angle, the fused Cobb angle, the anterior intervertebral angle (AIA), the sagittal intervertebral angle (SIA), and lumbar lordosis angle. The relationships between these parameters were examined by bivariate Pearson analysis and linear regression analysis.Preoperatively, the Cobb angle at the scoliotic segment was 15.4°, which decreased to 10.2° immediately following surgery (P < 0.05). The AIA significantly increased by the last follow-up (4.4 ± 3.4) compared with pre- and postoperative values (2.5 ± 2.8 and 2.2 ± 2.4, respectively; P < 0.05). However, the scoliotic Cobb angle and the AIA did not correlate with the VAS or ODI scores. At the final follow-up, no patients had pseudoarthrosis or internal instrumentation-related complications.Short fusion surgical treatment results in limited DLS correction, with correction loss over time. The AIA between the upper adjacent segment and proximal fused vertebra continues to increase postoperatively, which does not exacerbate clinical symptoms, as reflected by the low reoperation rates for repairing degeneration at adjacent levels.
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Affiliation(s)
- Naiguo Wang
- From the Department of Spinal Surgery, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
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Kim HJ, Kang KT, Son J, Lee CK, Chang BS, Yeom JS. The influence of facet joint orientation and tropism on the stress at the adjacent segment after lumbar fusion surgery: a biomechanical analysis. Spine J 2015; 15:1841-7. [PMID: 25817739 DOI: 10.1016/j.spinee.2015.03.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 03/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Facet joint orientation and tropism influence the biomechanics of the corresponding segment. Therefore, the sagittal orientation or tropism of the facet joint adjacent to the fusion segment seems a potential risk factor for adjacent segment degeneration. However, there have been no biomechanical studies regarding this issue. PURPOSE To investigate the association between adjacent facet orientation and facet tropism and stress in adjacent disc/facet joints using finite element (FE) analysis. STUDY DESIGN An FE analysis. METHODS Four intact (F50, F55, F60, and FT [facet tropism]) and matched L3-L4 fusion (F50, F55, F60, and FT fusion) models with different facet joint orientation (50°, 55°, 60° relative to the coronal plane, and facet tropism, respectively) at both L2-L3 facet joints were simulated. In each model, intradiscal pressures and facet contact force at the L2-L3 segment were investigated under pure moments and anterior shear force. RESULTS Compared with the matched-intact model, the F60 fusion model yielded the highest and largest percentage increase of intradiscal pressure at the L2-L3 segment under flexion, torsion moment, and anterior shear force among the F50, F55, and F60 fusion models. F60 fusion model also demonstrated the largest facet contact force under torsion moment among the F50, F55, and F60 fusion models. In all conditions tested, the FT fusion model demonstrated the highest intradiscal pressure and facet contact force of all the models. CONCLUSIONS Facet joint orientation and tropism at the adjacent segment influences the overstress of the adjacent segment, especially under the clinical circumstance of increased anterior shear force.
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Affiliation(s)
- Ho-Joong Kim
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam, 463-707, Republic of Korea
| | - Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, 134 Shinchon-dong, Seodaemun-gu, Seoul, Republic of Korea
| | - Juhyun Son
- Department of Mechanical Engineering, Yonsei University, 134 Shinchon-dong, Seodaemun-gu, Seoul, Republic of Korea
| | - Choon-Ki Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Bong-Soon Chang
- Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jin S Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam, 463-707, Republic of Korea.
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Results of the 2014 SRS Survey on PJK/PJF: A Report on Variation of Select SRS Member Practice Patterns, Treatment Indications, and Opinions on Classification Development. Spine (Phila Pa 1976) 2015; 40:829-40. [PMID: 25811261 DOI: 10.1097/brs.0000000000000897] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An electronic survey administered to Scoliosis Research Society membership. OBJECTIVE To characterize surgeon views regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) management providing the framework in which a PJK/PJF classification system and treatment guidelines could be established. SUMMARY OF BACKGROUND DATA PJK/PJF are common complications of adult spinal deformity surgery. To date, there is no consensus on PJK/PJF definitions, classification, and indications for revision surgery. There is a paucity of data on deformity surgeon practice pattern variations and consensus opinion on treatment and prevention. METHODS An electronic 19-question survey regarding PJK/PJF was administered to members of the Scoliosis Research Society who treat adult spinal deformity. Determinants included the surgeons' type of practice, number of years in practice, agreement with given PJK/PJF definitions, importance of key factors influencing prevention and revision, prevention methods currently used, and the importance of developing a classification system. RESULTS A total of 226 surgeons responded (38.8% response rate). Both 44.4% of surgeons selected "extremely important" and 40.8% selected "very important" that PJK in adult spinal deformity surgery is a very important issue and that a Scoliosis Research Society PJK/PJF classification system and guidelines for detection and prevention of PJK/PJF is a "must have" (18.1%) and "very likely helpful" (31.9%). Both 86.2% and 90.7% of surgeons agreed with the provided definitions of PJK and PJF, respectively. Top 5 revision indications included neurological deficit, severe focal pain, translation or subluxation fracture, a change in kyphosis angle of greater than 30°, chance fracture, spondylolisthesis greater than 6 mm, and instrumentation prominence. The majority of respondents use a PJK/PJF prevention strategy 60% of the time or more, the most common were terminal rod contour, preoperative bone mineral density testing, and frequent radiographical studies during first 3 months postoperative, preoperative bone mineral density medication for low bone mineral density. CONCLUSION The results of this study provide insight from the practicing surgeons' perspective of the management of PJK and PJF that may aid in the validation of current definitions and consensus-based treatment decisions and prevention guidelines. LEVEL OF EVIDENCE 5.
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Koerner JD, Reitman CA, Arnold PM, Rihn J. Degenerative Lumbar Scoliosis. JBJS Rev 2015; 3:01874474-201504000-00001. [DOI: 10.2106/jbjs.rvw.n.00061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976) 2014; 39:2093-102. [PMID: 25271516 DOI: 10.1097/brs.0000000000000627] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review of literature. OBJECTIVE To perform a comprehensive English language systematic literature review of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), concentrating on incidence, risk factors, health related quality of life impact, prevention strategy, and classification systems. SUMMARY OF BACKGROUND DATA PJK and PJF are well described clinical pathologies and are a frequent cause of revision surgery. The development of a PJK classification that correlates with clinical outcomes and guides treatment decisions and possible prevention strategies would be of significant benefit to patients and surgeons. METHODS The phrases "proximal junctional," "proximal junctional kyphosis," and "proximal junctional failure" were used as search terms in PubMed for all years up to 2014 to identify all articles that included at least one of these terms. RESULTS Fifty-three articles were identified overall. Eighteen articles assessed for risk factors. Eight studies specifically reviewed prevention strategies. There were no randomized prospective studies. There were 3 published studies that have attempted to classify PJK. The reported incidence of PJK ranged widely, from 5% to 46% in patients undergoing spinal instrumentation and fusion for adult spinal deformity. It is reported that 66% of PJK occurs within 3 months and 80% within 18 months after surgery. The reported revision rates due to PJK range from 13% to 55%. Modifiable and nonmodifiable risk factors for PJK have been characterized. CONCLUSION PJK and PJF affect many patients after long segment instrumentation after the correction of adult spinal deformity. The epidemiology and risk factors for the disease are well defined. A PJK and PJF scoring system may help describe the severity of disease and guide the need for revision surgery. The development and prospective validation of a PJK classification system is important considering the prevalence of the problem and its clinical and economic impact. LEVEL OF EVIDENCE N/A.
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Nishimura Y, Hara M, Nakajima Y, Haimoto S, Yamamoto Y, Wakabayashi T. Outcomes and complications following posterior long lumbar fusions exceeding three levels. Neurol Med Chir (Tokyo) 2014; 54:707-15. [PMID: 25169031 PMCID: PMC4533373 DOI: 10.2176/nmc.oa.2014-0026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The outcomes and complications of posterior-only lumbar instrumented long fusions exceeding three segments with selective segmental transforaminal lumbar interbody fusion for the treatment of degenerative lumbar scoliosis, kyphosis, or both combined with spondylolisthesis were analyzed to investigate risk factors associated with surgical instrumentation failure. Fifteen consecutive patients with degenerative lumbar scoliosis, kyphosis, or both combined with spondylolisthesis were studied retrospectively. There were 5 male and 10 female patients, with a mean age of 71.8 years. All the patients were followed for a mean duration of 19.4 months postoperatively. Radiographic evaluation included coronal Cobb angle, lumbar lordosis (LL) angle, pelvic incidence (PI), and pelvic tilt (PT). The clinical outcomes were assessed by means of Japanese Orthopedic Association (JOA) score. Patients were divided into two groups: group 1—7 patients with surgical complications; group 2—8 patients without complications. The preoperative and postoperative coronal Cobb's angle were not significantly different between groups 1 and 2. The LL highly correlated with developing surgical complications. There were statistically significant differences in preoperative and postoperative LL and the mean difference between PI and the LL (PI–LL) between groups 1 and 2. Linear correlation and regression analysis showed that there was no correlation between JOA score and the coronal Cobb angle in degenerative scoliosis patients. However, we found a positive correlation between JOA and LL. Our series of long lumbar fusions had a high complication and instrumentation failure. Creating adequate LL angle in harmony with PI was a key to prevent surgical complications and attain neurological improvement.
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Affiliation(s)
- Yusuke Nishimura
- Department of Neurosurgery, Nagoya University School of Medicine
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Blair-Pattison A, Hu RW, Swamy G, Anglin C. Forces in spinal cannulation and breaches ex vivo. Proc Inst Mech Eng H 2014; 228:693-702. [PMID: 25081905 DOI: 10.1177/0954411914540632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pedicle screw insertion, to stabilize or correct the spine, relies on creating a probe path with the correct trajectory to prevent unsafe breaching of the cortical wall. Safe pedicle cannulation is aided when the surgeon can feel the difference between a safe and unsafe path. Pedicle probe forces and torques are currently unknown. The purpose of this study was to investigate the forces and torques encountered while cannulating the pedicle tract in both correct and incorrect cannulations. METHODS Two experienced surgeons used a standard lumbar probe modified to incorporate a 6 degree-of-freedom load cell to cannulate and breach the T12 to S1 vertebrae of six fresh frozen cadavers (3 males, 3 females, ages 65 to 92). A total of 76 pedicles were tested. FINDINGS Cannulation axial forces averaged 48 N (standard deviation = 13 N), medial breach 129 N (standard deviation = 25 N), and lateral breach 86 N (standard deviation = 27 N). Cannulation values were significantly lower than the breach values in all 6 degrees of freedom (p < 0.001). There were significant differences between specimens, including males and females, and between degrees of freedom, but no significant right and left differences or by vertebral level. CONCLUSION A large range of cannulation and breach forces and torques were measured due to variations in bone quality and geometry, as experienced clinically. This is the first time that the absolute and relative force and torque levels have been reported, to our knowledge.
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Affiliation(s)
- Aubrey Blair-Pattison
- Biomedical Engineering, University of Calgary, Calgary, AB, Canada McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Richard W Hu
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ganesh Swamy
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Carolyn Anglin
- Biomedical Engineering, University of Calgary, Calgary, AB, Canada McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada Department of Civil Engineering, University of Calgary, Calgary, AB, Canada
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Surgical treatment of adult degenerative scoliosis. Asian Spine J 2014; 8:371-81. [PMID: 24967054 PMCID: PMC4068860 DOI: 10.4184/asj.2014.8.3.371] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 12/20/2013] [Accepted: 12/20/2013] [Indexed: 11/08/2022] Open
Abstract
The rapid increase of elderly population has resulted in increased prevalence of adult scoliosis. Adult scoliosis is divided into adult idiopathic scoliosis and adult degenerative scoliosis. These two types of scoliosis vary in patient age, curve pattern and clinical symptoms, which necessitate different surgical indications and options. Back pain and deformity are major indications for surgery in adult idiopathic scoliosis, whereas radiating pain to the legs due to foraminal stenosis is what often requires surgery in adult degenerative scoliosis. When selecting a surgical method, major symptoms and underlying medical diseases should be carefully evaluated, not only to relieve symptoms but also to minimize postoperative complications. Surgical options for adult degenerative scoliosis include: decompression alone; decompression and limited short fusion; and decompression coupled with long fusion and correction of deformity. Decompression and limited short fusion can be applied to patients with a small Cobb's angle and normal sagittal imbalance. For those with a large Cobb's angle and positive sagittal imbalance, long fusion with correction of deformity is required. When long fusion is applied, a careful decision regarding the extent of fusion level should be made when selecting L5 or S1 as the distal fusion level and T10 or the thoracolumbar junction as the proximal fusion level. For the fusion extending to the sacrum, restoration of sagittal balance and rigid fixation with additional iliac screws should be considered. Any surgical procedures for adult degenerative scoliosis are known to have relatively high occurrences of complications; therefore, risks and benefits should be meticulously considered before selecting a surgical procedure.
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Anand N, Baron EM, Kahwaty S. Evidence Basis/Outcomes in Minimally Invasive Spinal Scoliosis Surgery. Neurosurg Clin N Am 2014; 25:361-75. [DOI: 10.1016/j.nec.2013.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Di Silvestre M, Lolli F, Bakaloudis G. Degenerative lumbar scoliosis in elderly patients: dynamic stabilization without fusion versus posterior instrumented fusion. Spine J 2014; 14:1-10. [PMID: 23257571 DOI: 10.1016/j.spinee.2012.10.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 03/20/2012] [Accepted: 10/13/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterolateral fusion with pedicle screw instrumentation is currently the most widely accepted technique for degenerative lumbar scoliosis in elderly patients. However, a high incidence of complications has been reported in most series. Dynamic stabilization without fusion in patients older than 60 years has not previously been compared with the use of posterior fusion in degenerative lumbar scoliosis. PURPOSE To compare dynamic stabilization without fusion and posterior instrumented fusion in the treatment of degenerative lumbar scoliosis in elderly patients, in terms of perioperative findings, clinical outcomes, and adverse events. STUDY DESIGN A retrospective study. PATIENT SAMPLE Fifty-seven elderly patients were included. There were 45 women (78%) and 12 men (22%) with a mean age of 68.1 years (range, 61-78 years). All patients had degenerative de novo lumbar scoliosis, associated with vertebral canal stenosis in 51 cases (89.4%) and degenerative spondylolisthesis in 24 patients (42.1%). OUTCOME MEASURES Clinical (Oswestry Disability Index, visual analog scale, Roland-Morris Disability Questionnaire) and radiological (scoliosis and lordosis corrections) outcomes as well as incidence of complications. METHODS Patients were divided into two groups: 32 patients (dynamic group) had dynamic stabilization without fusion and 25 patients (fusion group) underwent posterior instrumented fusion. All the patients' medical records and X-rays were reviewed. Preoperative, postoperative, and follow-up questionnaires were obtained to evaluate clinical outcomes. RESULTS At an average follow-up of 64 months (range, 42-90 months), clinical results improved similarly in both groups of patients. Statistically superior scoliosis and final lordosis corrections were achieved with posterior fusion (56.9% vs. 37.3% and -46.8° vs. -35.8°, respectively). However, in the dynamic group, incidence of overall complications was lower (25% vs. 44%), and fewer patients required revision surgery (6.2% vs. 16%). Furthermore, lower average values of operative duration (190 vs. 240 minutes) and blood loss (950 vs. 1,400 cc) were observed in the dynamic group than in the fusion group. CONCLUSIONS In elderly patients with degenerative lumbar scoliosis, pedicle screw-based dynamic stabilization was less invasive with shorter operative duration, less blood loss, and lower adverse event rates than instrumented posterior fusion. Scoliosis curve reduction and lumbar lordosis were superior after fusion; however, dynamic stabilization achieved satisfying values of both these parameters, and these results were stable after an average follow-up of more than 5 years. Furthermore, there was no difference between the two techniques in terms of functional clinical outcomes at the last follow-up.
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Affiliation(s)
- Mario Di Silvestre
- Spine Surgery Department, Istituti Ortopedici Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Francesco Lolli
- Spine Surgery Department, Istituti Ortopedici Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Georgios Bakaloudis
- Spine Surgery Department, Istituti Ortopedici Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
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Kebaish KM, Martin CT, O'Brien JR, LaMotta IE, Voros GD, Belkoff SM. Use of vertebroplasty to prevent proximal junctional fractures in adult deformity surgery: a biomechanical cadaveric study. Spine J 2013; 13:1897-903. [PMID: 24094714 DOI: 10.1016/j.spinee.2013.06.039] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 04/03/2013] [Accepted: 06/14/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Vertebral compression fractures at the proximal junction are common complications of long spinal fusion surgeries that can contribute to the development of proximal junctional kyphosis or proximal junctional failure. To our knowledge, no biomechanical studies have addressed the effect of vertebral augmentation at the proximal junction. PURPOSE To evaluate the effectiveness of prophylactic vertebroplasty in reducing the incidence of vertebral compression fractures at the proximal junction after a long spinal fusion in a cadaveric spine model. STUDY DESIGN Biomechanical cadaveric study. METHODS We divided 18 cadaveric spine specimens into three groups of six spines each: a control group, a group treated with one-level prophylactic vertebroplasty at the upper instrumented vertebra, and a group treated with two-level prophylactic vertebroplasty at the upper instrumented vertebra and the supra-adjacent vertebra. In all spines, the pedicles were instrumented from L5 to T10. Using eccentric axial loading, the specimens were then compressed until failure. Failure was defined as a precipitous decrease in load with increasing compression. The effect of augmentation on load-to-failure was checked using linear regression. The effect of augmentation on incidence of adjacent fractures was checked using logistic regression. Differences at the level of p<.05 were considered significant. KyphX cement introducer was donated by Kyphon, and the pedicle screws were donated by DePuy. RESULTS Fractures occurred in 12 of 18 specimens: five in the control group, six in the one-level group, and only one in the two-level group; these differences were statistically significant. CONCLUSIONS Prophylactic vertebroplasty at the upper instrumented level and its supra-adjacent vertebra reduced the incidence of junctional fractures after long posterior spinal instrumentation in this axially loaded cadaveric model. Additional studies are necessary to determine if these results are translatable to clinical practice.
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Affiliation(s)
- Khaled M Kebaish
- Division of Spine Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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Adult's Degenerative Scoliosis: Midterm Results of Dynamic Stabilization without Fusion in Elderly Patients-Is It Effective? Adv Orthop 2013; 2013:365059. [PMID: 23781342 PMCID: PMC3677667 DOI: 10.1155/2013/365059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 12/18/2022] Open
Abstract
Study Design. A retrospective study. Purpose. Posterolateral fusion with pedicle screw instrumentation used for degenerative lumbar scoliosis can lead to several complications. In elderly patients without sagittal imbalance, dynamic stabilization could represent an option to avoid these adverse events. Methods. 57 patients treated by dynamic stabilization without fusion were included. All patients had degenerative lumbar de novo scoliosis (average Cobb angle 17.2°), without sagittal imbalance, associated in 52 cases (91%) with vertebral canal stenosis and in 24 (42%) with degenerative spondylolisthesis. Nineteen patients (33%) had previously undergone lumbar spinal surgery. Results. At an average followup of 77 months, clinical results improved with statistical significance. Scoliosis Cobb angle was 17.2° (range, 12° to 38°) before surgery and 11.3° (range, 4° to 26°) at last follow-up. In the patients with associated spondylolisthesis, anterior vertebral translation was 19.5% (range, 12% to 27%) before surgery, 16.7% (range, 0% to 25%) after surgery, and 17.5% (range, 0% to 27%) at followup. Complications incidence was low (14%), and few patients required revision surgery (4%). Conclusions. In elderly patients with mild degenerative lumbar scoliosis without sagittal imbalance, pedicle screw-based dynamic stabilization is an effective option, with low complications incidence, granting curve stabilization during time and satisfying clinical results.
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Martin CT, Skolasky RL, Mohamed AS, Kebaish KM. Preliminary Results of the Effect of Prophylactic Vertebroplasty on the Incidence of Proximal Junctional Complications After Posterior Spinal Fusion to the Low Thoracic Spine. Spine Deform 2013; 1:132-138. [PMID: 27927429 DOI: 10.1016/j.jspd.2013.01.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 01/07/2013] [Accepted: 01/09/2013] [Indexed: 01/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To evaluate, in adults undergoing posterior spinal fusions, 1) the effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), and 2) the difference in outcomes between those who did and did not develop PJK or PJF. SUMMARY OF BACKGROUND DATA Proximal junctional kyphosis occurs in 20% to 39% of adults after posterior spinal fusions; a subset develops PJF. METHODS From 2005 through 2008, we treated 41 consecutive patients (40 years old or more) with spinal deformity with 2-level prophylactic vertebroplasty (at the upper instrumented vertebrae and the supra-adjacent vertebrae) during posterior spinal fusion. The 38 patients with 24 months' follow-up formed our study group. We measured patient outcomes with the Scoliosis Research Society-24 questionnaire, the Oswestry Disability Index, and the 12-item Short Form Survey. All patients completed each assessment preoperatively, and 89% or more did so postoperatively. We compared postoperative and final follow-up radiographs to identify the PJK incidence (ie, a PJK angle change of 10° or more), and analyzed the PJK, PJF, and non-PJK/PJF groups for outcome scores with Student t test and chi-square test (significance, p < .05). RESULTS Three patients (8%) developed PJK and 2 (5%) developed PJF, markedly lower incidences than those previously reported. At final follow-up, patients with PJK or PJF reported statistically significant lower pain and satisfaction Scoliosis Research Society-24 scores than did patients in the non-PJK/PJF group, but there were no significant differences in Scoliosis Research Society-24 mental health or function scores between groups. All patients had significant improved Oswestry Disability Index and 12-item Short Form Survey scores. CONCLUSIONS Prophylactic vertebroplasty in long posterior spinal fusions for adult spinal deformity resulted in a low incidence of PJF and PJK, with only small differences in outcome scores between those who did and did not develop PJK and PJF.
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Affiliation(s)
- Christopher T Martin
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Ahmed S Mohamed
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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Selection of proximal fusion level for adult degenerative lumbar scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:394-401. [PMID: 23064878 DOI: 10.1007/s00586-012-2527-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 09/10/2012] [Accepted: 09/23/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION There is controversy regarding the appropriate proximal fusion level for adult degenerative scoliosis. Ideally, the horizontal vertebra is chosen for the upper instrumented vertebra to create a balanced spine. Fusion to T10 is recommended to prevent junctional problems at the proximal adjacent segment. The purpose of this retrospective study was to determine the optimal proximal fusion level for adult degenerative lumbar scoliosis. MATERIALS AND METHODS Fifty-one patients with adult degenerative lumbar scoliosis (mean age 64.6 years) who underwent posterior instrumentation were analyzed after a minimum 2-year follow-up. The average number of levels fused was 5.9 segments (range 3-9) with distal fusion at L5 in 30 patients and S1 in 21 patients. The upper instrumented vertebra (UIV) ranged from T9 to L2. According to the relationship between UIV, horizontal vertebra (HV) and upper end vertebra (UEV), the patients were divided into three groups in the coronal plane: Group HV (UIV = HV or above); Group HV-UEV (UIV = between HV and UEV); and Group UEV (UIV = UEV or below). In the sagittal plane; the patients were divided into Group T9-10 (UIV = T9-10), Group T11-12 and Group L1-2. RESULTS Proximal adjacent segment disease (ASD) was identified in 13 (25 %) out of 51 patients, including junctional kyphosis (n = 5), compression fractures (n = 4), progression of disc wedging (n = 2) and spinal stenosis (n = 2). Group UEV had more ASD (9 of 16 patients) compared to Group HV (2 of 21 patients) and Group HV-UEV (2 of 14 patients). It appeared that neutral vertebra could be a criterion for the selection of UIV in the coronal plane. Among the groups divided in the sagittal plane, proximal ASD was found in 47 % of 19 patients in Group L1-2, which was notably higher than 9 % in Group T9-10 and 20 % in Group T11-12. CONCLUSIONS Proximal adjacent segment disease developed more commonly when the proximal fusion stopped at the UEV or below in adult degenerative lumbar scoliosis. UIV must be above UEV in the coronal plane. Fusion to T11 or T12 was acceptable when UIV was above UEV, since there was no significant difference in the rate of proximal adjacent segment between fusion to T10 and fusion to T11 or T12.
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Upper instrumented vertebral fractures in long lumbar fusions: what are the associated risk factors? Spine (Phila Pa 1976) 2012; 37:1407-14. [PMID: 22366970 DOI: 10.1097/brs.0b013e31824fffb9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective comparative study. OBJECTIVE To investigate the risk factors associated with upper instrumented vertebral (UIV) fractures in adult lumbar deformity. SUMMARY OF BACKGROUND DATA Long segment lumbar fusions may lead to junctional failures. The purpose of this study was to determine factors associated with junctional failures. METHODS Twenty-seven consecutive patients from 2001 to 2008 with minimum 4 levels fused, lower instrumented vertebra (LIV) of L5 or S1, upper instrumented vertebra of T10 or distal, and no previous surgery proximal to the instrumentation were retrospectively reviewed. We describe the UIV angle, the sagittal angle of the upper instrumented vertebra with the horizontal. Patients were divided into 3 groups: group 1, 7 patients with UIV fractures; group 2, 6 patients with other proximal failures; and group 3, 14 patients with no proximal complications. RESULTS The mean number of levels fused was 5.7 (4-7), 5.2 (4-8), and 6.2 (4-8); mean age was 64.1, 61.8, and 64.1, and mean body mass index was 33.5, 30.0, and 31.6 for groups 1, 2, and 3, respectively (P > 0.05). Osteotomies were performed in 5 of 7 in group 1, 1 of 6 in group 2, and 5 of 14 in group 3. Mean follow-up was 26.3 months. The average intraoperative UIV angle (UIV0) and immediate postoperative UIV angle (UIV1) were 18.6°/15.4° for group 1, 5.7°/5.3° for group 2, and 10.3°/7.1° for group 3 (P < 0.05). Surgical revision rates were higher in group 1 (71%) compared with groups 2 (50%) and 3 (43%). Eight of 11 (73%) patients with upper instrumented vertebra of L1 or L2 had either UIV fracture or other proximal failure compared with 5 of 16 (31%) in patients with upper instrumented vertebra of T10, T11, or T12. CONCLUSION Our series of long lumbar fusions had a high long-term complication and revision rate. A high UIV angle on intraoperative lateral radiograph was strongly associated with UIV fractures. UIVs of L1 or L2 had a higher rate of adjacent segment or UIV failure.
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Adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia: a retrospective study of correction and fusion strategies. Arch Orthop Trauma Surg 2011; 131:475-80. [PMID: 20632021 DOI: 10.1007/s00402-010-1151-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To study the correction and fusion strategies for adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia by using posterior pedicle screw instrumentation (PPSI). Surgical intervention for Chiari malformation and syringomyelia before surgical correction of scoliosis has been reported; however, there are no clinical trials for the PPSI-based correction and fusion procedures used in these patients. METHODS From 2002 to 2009, 13 adult patients (mean age, 34.9 years) suffering from thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia underwent correction and fusion by using PPSI. Preoperative, postoperative, and final follow-up coronary Cobb angle, correction rate, pelvic obliquity (PO), apical vertebral rotation (AVR), apical vertebral translation (AVT), trunk shift (TS), sagittal thoracic kyphosis angle, and lumbar lordosis angle were analyzed on radiographs. RESULTS The preoperative and postoperative mean coronary Cobb angle was from 46.8° to 9.2°, correction rate was 80.7%, PO from 9.9° to 3.2°, AVR from 1.9° to 0.3°, AVT from 3.6 to 0.8 cm, TS from 16.8 to 1.6 cm, sagittal thoracic kyphosis angle from 18.2° to 23.5°, and lumbar lordosis angle was from 37.4° to 41.8°. The mean follow-up period was 35.2 months (range, 24-50 months). There were no obvious pseudoarticulations or loss of correction and trunk equilibrium at the final follow-up; no aggravation of the original neural symptoms or new irreversible neural injury was observed. CONCLUSIONS In patients with mild or moderate adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia, the correction and fusion by using PPSI can yield a satisfactory clinical effect.
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Wiedenhöfer B, Akbar M, Fürstenberg CH, Carstens C, Hemmer S, Schilling C. [Effect of lumbar hybrid instrumentation and rigid fusion on the treated and the adjacent segments. A biomechanical study]. DER ORTHOPADE 2011; 40:169-77. [PMID: 21279503 DOI: 10.1007/s00132-010-1717-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Degeneration of the upper adjacent segment after operative treatment of degenerative spinal diseases of the lumbar spine (degenerative disc disease DDD) is an unsolved problem. There is also no consensus on whether a rigid or dynamic treatment of DDD should be carried out to protect the segments. This study was carried out to evaluate the effect of bisegmental rigid 360° fusion and bisegmental hybrid fusion on the treated segment as well as on the upper adjacent segment under the aspect of segment protection. MATERIAL AND METHODS A total of six human spinal column preparations (L2-5) were tested under native conditions (NAT), with bisegmental rigid fusion (RIG 360°) and with hybrid fusion (Hybrid) in all three movement directions under physical load and with an preload. The range of motion (ROM) and neutral zone (NZ) were evaluated. The intradiscal pressure (IDP) was measured in the upper adjacent segment (OAS). RESULTS The RIG 360° led to a significant reduction in movement in all directions compared to NAT but Hybrid only in lateral bending (LB). In the OAS the NZ was showed a much greater increase than the ROM. The RIG 360° showed an increase of the NZ in flexion-extension of 86.8% and in LB of 49.6% as well as a significant increase in axial rotation of 52.5%. The increase in the Hybrid was not significant compared to NAT in all directions. Pressure measurements in OAS showed no significant differences for RIG 360° and for Hybrid compared to NAT for both load scenarios. DISCUSSION The range of motion of the treated segments for Hybrid were close to NAT in comparison to RIG 360° indicating a segment-protective effect. The hypothesis that rigid fusion has a significant effect on intersegmental mobility and the increase in intradiscal pressure in the upper adjacent segment could not be confirmed. The data indicate that the primary effect of fusion on the adjacent segment is very low but the fusion-linked increased frequency of extreme loads of the OAS falling within the significance level leads to degeneration. Even if the NZ values for Hybrid and RIG 360° do not significantly differ from NAT, the NZ alterations between the instrumentations tend to be strongly shifted in favor of Hybrid. CONCLUSIONS The data confirm that the clear and sometimes significant alterations of the NZ can be an essential factor for development of adjacent segment degeneration. A dynamic conclusion of instrumentation in the sense of a topping-off would appear to be useful if pathoanatomical indications for an intervertebral disc prosthesis are present.
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Affiliation(s)
- B Wiedenhöfer
- Department für Orthopädie, Unfallchirurgie und Paraplegiologie, Stiftung Orthopädische Universitätsklinik Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland.
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Risk factors of sagittal decompensation after long posterior instrumentation and fusion for degenerative lumbar scoliosis. Spine (Phila Pa 1976) 2010; 35:1595-601. [PMID: 20386505 DOI: 10.1097/brs.0b013e3181bdad89] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of clinical results of operative treatment for degenerative lumbar scoliosis. OBJECTIVE To determine the risk factors of sagittal decompensation after long instrumentation and fusion to L5 or S1. SUMMARY OF BACKGROUND DATA Little is known about the risk factors for sagittal decompensation, which was defined in this study as sagittal C7 plumb falling anterior >8 cm from the posterosuperior corner of the sacrum. METHODS Forty-five patients (mean age: 64.4 year) with adult degenerative lumbar scoliosis were reviewed retrospectively with a minimum 2 years. The mean number of levels fused was 6.1 +/- 1.6 segments. The upper instrumented vertebra ranged from T9 to L2. The lower instrumented vertebra was L5 and S1 in 24 and 21 patients, respectively. RESULTS Sagittal decompensation (SD) developed in 19 patients. The most significant risk factors of SD were preoperative sagittal imbalance and high pelvic incidence. The preoperative sagittal C7 plumb was more positive (67.9 mm) in the decompensation group than in the balance group (37.0 mm) (P = 0.002). There was a significant difference in pelvic incidence between 61.7 degrees in the decompensation and 54.9 degrees in the balance group (P = 0.01). The preoperative lumbar lordosis was hypolordotic in the decompensation group, however, it was not found to be a risk factor. Pseudarthrosis was identified at the lumbosacral junction in 5 patients, and 4 of them (80%) had SD. SD developed in 55% of patients who had loosening of the distal screws and 50% of patients with hypolordotic lumbar fusion. Distal adjacent segment disease was more likely to cause SD than proximal adjacent segment disease. CONCLUSION Sagittal decompensation is common after long posterior instrumentation and fusion for degenerative lumbar scoliosis. It is mostly associated with complications at the distal segments, including pseudarthrosis and implant failure at the lumbosacral junction. Restoration of optimal lumbar lordosis and secure lumbosacral fixation is necessary especially in patients with preoperative sagittal imbalance and high pelvic incidence in order to prevent sagittal decompensation after surgery.
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Thoracic disc herniation of the adjacent segment with acutely progressing myelopathy. Asian Spine J 2010; 4:52-6. [PMID: 20622956 PMCID: PMC2900170 DOI: 10.4184/asj.2010.4.1.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 09/21/2009] [Accepted: 09/24/2009] [Indexed: 11/08/2022] Open
Abstract
We report a case of a 66-year-old woman with progressing myelopathy. Her history revealed instrumented fusion from T10 to S1 for degenerative lumbar kyphosis and spinal stenosis. The plain radiographs showed narrowing of the intervertebral disc space with a gas shadow and sclerotic end-plate changes at T9-T10. Magnetic resonance imaging revealed a posterolateral mass compressing the spinal cord at the T9-T10 level. The patient was treated with a discectomy through the posterior approach combined with posterior instrumentation. The patient's symptoms and myelopathy resolved completely after the discectomy and instrumented fusion. The thoracic disc herniation might have been caused by the increased motion and stress concentration at the adjacent segment.
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Vertebral compression fracture in the middle of fused segments without a history of injury: a case report. Spine (Phila Pa 1976) 2010; 35:E137-9. [PMID: 20081563 DOI: 10.1097/brs.0b013e3181b7ac6a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report and review of the literature. OBJECTIVES To report a rare case of a vertebral compression fracture in the middle of fused segments in the absence of a history of trauma, and to investigate the contributory factors. SUMMARY OF BACKGROUND DATA Few articles have been published on vertebral fractures among fused segments. However, several articles have addressed fractures at juxtafused segments after implant removal. To the best of the authors' knowledge, only one case of compression fracture within fused segments has been previously reported. METHODS This study involved the case of a 62-year-old woman with vertebral compression fracture of L4 within a solid fused segment region after implant removal. An investigation was conducted to identify the factors that contributed to this compression fracture. RESULTS Plain radiographs and bone scanning showed a compression fracture of L4 within a region of fused segments (L3-S1) after implant removal without the history of injury. BMD revealed osteopenia of -2.3 SD on the neck of the femur. The patient's symptoms were relieved by conservative treatment. The contributory factors may have been persistent anterior motion, osteopenia and/or osteoporosis, and a subcortical substance defect associated with screw tracks after implant removal. CONCLUSION Vertebral compression fractures in solid fused segments may occur as a complication of implant removal. Accordingly, if spinal implant removal is needed for revision surgery, surgeons should be aware of this significant complication.
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Lam FC, Kanter AS, Okonkwo DO, Ogilvie JW, Mummaneni PV. Thoracolumbar spinal deformity: Part II. Developments from 1990 to today: historical vignette. J Neurosurg Spine 2009; 11:640-50. [PMID: 19951015 DOI: 10.3171/2009.3.spine08337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the first part of this 2-part historical review, the authors outlined the early diagnostic and therapeutic strategies used in the management of spinal deformity. In this second part, they expand upon those early innovations and further detail the advances from 1990 to the modern era.
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Affiliation(s)
- Fred C Lam
- Division of Neurosurgery, University of Alberta, Alberta, Canada
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