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Li Y, Qian BP, Qiu Y, Yu Y, Wang B. Orientation of Osteotomized Vertebrae in 2-Level Pedicle Subtraction Osteotomy Plays a Crucial Role in the Remodeling of Harmonious Sagittal Curve for Severe Thoracolumbar Kyphotic Deformity Caused by Ankylosing Spondylitis. Neurosurgery 2023; 93:128-136. [PMID: 36757186 DOI: 10.1227/neu.0000000000002390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/06/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Few studies reported the remodeling of harmonious sagittal curve after 2-level pedicle subtraction osteotomy (PSO) for severe thoracolumbar kyphosis in ankylosing spondylitis (AS). OBJECTIVE To investigate how the orientation of osteotomized vertebrae (OV) affects the remodeling of harmonious sagittal curve in patients with AS undergoing 2-level PSO. METHODS Twenty-six patients treated with 2-level PSO were reviewed. Plumb lines of thoracic apex and lumbar apex, the superior/inferior endplate angle of OV, and OV tilt were measured. Patients with AS were grouped based on the postoperative lumbar lordotic apex (LLA, L3 or L4 vs L5 or others). RESULTS The level of thoracic kyphotic apex was positively correlated with that of superior OV postoperatively. Larger sacral slope, L1-L3 lordotic angle, and plumb lines of lumbar apex could be obtained in patients with LLA at L3 or L4, accompanied with larger superior endplate angle of OV and OV tilt of inferior OV ( P < .05). Besides, larger lumbar lordotic angle (LL) was observed in these patients (marginally significant, P = .057). For patients with relocated LLA at L5 or others, lower pelvic incidence was observed, accompanied with significant loss of correction ( P < .05) and worse Visual Analog Scale scores (marginally significant, P = .054) during follow-up. CONCLUSION Ventrally leaning inferior OV combined with dorsally leaning superior OV contributed to the most harmonious sagittal curve defined as thoracic kyphotic apex at T8 or above and LLA at L3 or L4. Sagittal curve with LLA at L5 could be acceptable in patients with more severe kyphosis, especially those with low pelvic incidence.
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Affiliation(s)
- Yao Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Bang-Ping Qian
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yang Yu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Luo J, Yang Z, Duan C, Feng X, Tan L, Wei Y, Jiang L, Wu T. Prediction formulae of sagittal alignment in thoracolumbar kyphosis secondary to ankylosing spondylitis after osteotomy. Sci Rep 2023; 13:7747. [PMID: 37173425 PMCID: PMC10181984 DOI: 10.1038/s41598-023-34475-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
To construct and validate prediction formulae of sagittal alignment in thoracolumbar kyphosis secondary to ankylosing spondylitis (AS) after osteotomy. A total of 115 AS patients who suffered from thoracolumbar kyphosis and underwent osteotomy were enrolled, with 85 patients in derivation group and 30 patients in validation group. Radiographic parameters were measured on lateral radiographs, including thoracic kyphosis, lumbar lordosis (LL), T1 pelvic angel (TPA), sagittal vertical axis (SVA), osteotomized vertebral angle, pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI and LL mismatch (PI-LL). Prediction formulae of SS, PT, TPA and SVA were established; and their effectiveness was evaluated. There was no significant difference in baseline characteristics between the two groups (p > 0.05). In derivation group, LL and PI-LL were correlated with SS, and were then used to establish the prediction formula of SS[SS = - 12.791-0.765 × (LL) + 0.357 × (PI-LL), R2 = 68.3%]; PI and PI-LL were correlated with PT, and the prediction formula of PT were thus established[PT = 12.108 + 0.402 × (PI-LL) + 0.252 × (PI), R2 = 56.8%]; PT, PI-LL and LL were correlated with TPA, and were used to establish the prediction formula of TPA[TPA = 0.225 + 0.597 × (PT) + 0.464 × (PI-LL)-0.161 × (LL), R2 = 87.4%]; PT, PI-LL and age were correlated with SVA, and were used to establish the prediction formula of SVA[SVA = 36.157 + 2.790 × (PI-LL) + 1.657 × (Age)-1.813 × (PT), R2 = 41.5%]. In validation group, the predictive SS, PT, TPA and SVA were basically consistent with corresponding real values; and the mean error between predictive values and real values was of 1.3° in SS, 1.2° in PT, 1.1° in TPA and 8.6 mm in SVA. Postoperative SS, PT, TPA and SVA could be predicted with PI and the planned LL and PI-LL using prediction formulae, providing a method for AS kyphosis to plan postoperative sagittal alignment. Change of pelvic posture after osteotomy was quantitatively evaluated using the formulae.
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Affiliation(s)
- Jianzhou Luo
- Health Science Center, Shenzhen University, Shenzhen, 518000, Guangdong, People's Republic of China
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Zili Yang
- Health Science Center, Shenzhen University, Shenzhen, 518000, Guangdong, People's Republic of China
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Chunguang Duan
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Xujiao Feng
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Lei Tan
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Yanzhe Wei
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Li Jiang
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China
| | - Tailin Wu
- Department of Orthopedics, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China.
- School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, Shaanxi, People's Republic of China.
- Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, People's Republic of China.
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Wang Y, Li C, Liu L, Qi L. One-level mini-open pedicle subtraction osteotomy for treating spinal kyphosis in patients with ankylosing spondylitis. BMC Musculoskelet Disord 2021; 22:101. [PMID: 33482791 PMCID: PMC7821725 DOI: 10.1186/s12891-021-03974-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report a mini-open pedicle subtraction osteotomy (PSO) technique, to summarize the 2-year follow-up results of 25 patients, and to describe a modified operating table which allows the osteotomy to be closed in a more controllable manner. METHODS We retrospectively reviewed the records of patients with AS who received one-level mini-open PSO between July 2015 and January 2018. The 25 patients with complete medical records and 2-year radiographic follow-up were included in the analysis. Estimated blood loss, operation time, incision length, complications, bed rest period, and length of hospitalization were extracted from the medical records and recorded. RESULTS The mean age of the 25 patients (22 males and 3 females) was 39.5 years. The average global kyphosis(GK) decreased from 70.2° before surgery to 22.3° after surgery; the average C7- sagittal vertical axis (C7-SVA) decreased from 15.5 cm before surgery to 5.1 cm after surgery; the average pelvic incidence(PT) decreased from 37.8° before surgery to 22.5° after surgery. The average length of the incision was 10.2 cm. The average surgical time was 263.0 min, the average estimated blood loss was 840.0 ml, and the average time to mobilization was 4.1 days. CONCLUSIONS The current report shows that one-level PSO can be performed through an incision of about 10 cm. The one-level mini-open PSO could be superior to traditional PSO surgery with respect to cosmetic outcomes. Further comparative studies are necessary to evaluate the current and conventional techniques.
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Affiliation(s)
- Yu Wang
- Department of Orthopaedics, Peking University First Hospital, 100034, Beijing, China
| | - Chunde Li
- Department of Orthopaedics, Peking University First Hospital, 100034, Beijing, China
| | - Long Liu
- Department of Orthopaedics, Peking University First Hospital, 100034, Beijing, China
| | - Longtao Qi
- Department of Orthopaedics, Peking University First Hospital, 100034, Beijing, China.
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Combined percutaneous and open instrumentation for thoracolumbar kyphosis correction by two-level pedicle subtraction osteotomy in ankylosing spondylitis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:939-947. [PMID: 31980911 DOI: 10.1007/s00590-020-02631-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND A long global thoracolumbar kyphosis is common in ankylosing spondylitis. Surgical correction of fixed sagittal malalignment by pedicle subtraction osteotomy (PSO) might improve disability and quality of life (QoL). Two-level osteotomies represent major procedures with a risk of hemorrhage. Combined open and minimal invasive surgery has not been described and might be considered. CASE PRESENTATION A 30-year-old female with ankylosing spondylitis was treated by golimumab and teriparatide. The treatment was stopped during pregnancy which led to vertebral compression fractures and kyphosis of 50° between T11 and L3. A PSO was planned at the kyphotic apex L2. The second PSO was planned at L4 according to the pelvic incidence of 56°, matching with a spinopelvic alignment Roussouly type 3. A derived full balance integrated method was used to calculate the amount of correction. During the first stage surgery, an open approach was performed from L1 to pelvis and combined with percutaneous cement-augmented instrumentation in already fused segments T5-T12, thus reducing perioperative morbidity. A stepwise approach including L2 PSO closure with temporary rods and L4 PSO with final instrumentation was used. Blood loss was estimated around 1100 ml. The patient was able to walk on the second day after surgery. A secondary anterior fusion with LLI cages from L2 to L5 and an ALIF at L5-S1 were performed because of high non-ossified intervertebral disks to reduce the risk for nonunion and rod fractures. At 2-year follow-up, the patient's QoL had significantly improved and full spine radiographs showed stable normalized sagittal parameters. CONCLUSION The combined open and percutaneous approach was feasible and might be considered as an alternative option to conventional open surgery when planning major deformity correction in ankylosing spondylitis.
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Two-Level Osteotomy for the Corrective Surgery of Severe Kyphosis From Ankylosing Spondylitis: A Retrospective Series. Spine (Phila Pa 1976) 2019; 44:1638-1646. [PMID: 31725686 DOI: 10.1097/brs.0000000000003095] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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 To describe the treatment results of patients with severe ankylosing spondylitis (AS) kyphosis who underwent two-level osteotomy and correction surgery. SUMMARY OF BACKGROUND DATA The best solution for the fixed kyphotic deformity of AS is corrective osteotomy. Many osteotomy options are available: pedicle subtraction osteotomy (PSO), Smith-Peterson osteotomy (SPO), and vertical column resection (VCR). These procedures all provide multiplanar deformity correction. Nevertheless, when the AS deformity is severe, an additional osteotomy site to get more correction, achieve more ideal, and smooth curvature of the spine than single osteotomy. METHODS From May, 2008 to August, 2016, 19 patients of severe AS kyphosis underwent two-level spinal osteotomy and correction surgery. The patients had an average kyphosis angle greater than 90°. The radiological features and clinical evaluation, including Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 components were assessed before surgery and at follow-up. The patients underwent either one-level PSO combined with one-level SPO (n = 9) or two-level PSO (n = 10). RESULTS The height was increased after surgery in all patients (P < 0.05). The median follow-up was 24 months. The kyphosis angle improved from 92.0 ± 16.6° to 30.0 ± 17.2°. The chin-brow vertical angle improved from 37.6 ± 19.2° to -0.6 ± 2.5°. The sacral slope improved from 3.9 ± 11.8° to 21.7 ± 7.4°. Sagittal imbalance improved from 241.4 ± 115.3 mm to 74.6 ± 48.5 mm (P < 0.05). Lumbar lordosis improved from -3.9 ± 20.8° to 29.4 ± 14.1° (all P < 0.05). There were significant improvements in the ODI, VAS, and all components of SRS-22 (all P < 0.05). All patients with pseudarthrosis (n = 5) underwent PSO + SPO and achieved satisfactory results. Six complications were observed perioperatively, but without permanent sequelae. CONCLUSION Two-level osteotomy and correction procedure can achieve satisfactory results in severe AS kyphosis. PSO + SPO could be a good option for patients with pseudarthrosis because of relatively easier and faster operation. LEVEL OF EVIDENCE 4.
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Xin Z, Zheng G, Huang P, Zhang X, Wang Y. Clinical results and surgery tactics of spinal osteotomy for ankylosing spondylitis kyphosis: experience of 428 patients. J Orthop Surg Res 2019; 14:330. [PMID: 31640803 PMCID: PMC6805318 DOI: 10.1186/s13018-019-1371-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/11/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To report the clinical results and surgical tactics of spinal osteotomy for ankylosing spondylitis (AS) kyphosis based on the experiences of 428 patients. METHODS From January 2003 to January 2015, a total of 428 patients suffering from AS kyphosis who underwent a one- or two-level pedicle subtraction osteotomy (PSO) or vertebral column decancellation (VCD) osteotomy in our hospital were reviewed. Pre- and postoperative radiological parameters and the chin-brow vertical angle (CBVA) were measured. Intraoperative, postoperative, and general complications were recorded. RESULTS All patients could walk with horizontal vision and lie on their backs postoperatively. The pre- and postoperative average global kyphosis (GK) angles were corrected from 82.6 to 12.7° (p = 0.000) in the two-level group and from 55.8 to 9.6° (p = 0.000) in the one-level group, respectively. The mean sagittal vertical axis (SVA) improved from 29.4 to 8 cm (p = 0.000) in the two-level group and from 18.0 to 4.3 cm (p = 0.000) in the one-level group. The CBVA improved from 68.3 to 8.2° (p = 0.000) in the two-level group and from 46.2 to 4.2° (p = 0.000) in the one-level group. Although no major acute complications such as death or complete paralysis occurred, the complication rate was 6.5% in the one-level group and 23.6% in the two-level group. CONCLUSION Spinal osteotomy, such as PSO and VCD, can improve the quality of life of AS patients as well as correct kyphotic deformities. The one-level spinal osteotomy showed a lower complication rate, while two-level spinal osteotomy was a relatively aggressive procedure that was more suitable in correcting severe AS kyphotic deformities.
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Affiliation(s)
- Zhijun Xin
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army (301 Hospital), 28 Fuxing Rd, Beijing, 100853, China
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, China
| | - Guoquan Zheng
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army (301 Hospital), 28 Fuxing Rd, Beijing, 100853, China
| | - Peng Huang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army (301 Hospital), 28 Fuxing Rd, Beijing, 100853, China
| | - Xuesong Zhang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army (301 Hospital), 28 Fuxing Rd, Beijing, 100853, China
| | - Yan Wang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army (301 Hospital), 28 Fuxing Rd, Beijing, 100853, China.
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Wang T, Song D, Zheng G, Wang Y. Staged cervical osteotomy:a new strategy for correcting ankylosing spondylitis thoracolumbar kyphotic deformity with fused cervical spine. J Orthop Surg Res 2019; 14:108. [PMID: 31014379 PMCID: PMC6480419 DOI: 10.1186/s13018-019-1146-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background In patients with cervical ankylosis, the chin-brow vertical angle (CBVA) should be taken into consideration. Usually, the correction of sagittal balance is sacrificed to ensure the patient has a horizontal visual field. To our knowledge, a staged osteotomy strategy for ankylosing spondylitis kyphotic deformity with an ankylosed cervical spine has not been reported before. The aim of this study was to describe a new surgical strategy with emphasis on sagittal balance and gaze angle in correction of kyphotic deformity with a rigid cervical spine in ankylosing spondylitis thoracolumbar kyphotic deformity. Methods A 36-year-old man has severe thoracolumbar kyphosis accompanied with cervical hyperlordosis caused by ankylosing spondylitis. A two-stage surgery planning was managed. For the first stage, an interrupted two-level osteotomy was performed at the thoracolumbar area. After surgery, sagittal imbalance was corrected but the CBVA was − 21.7°. Cervical osteotomy was performed for the second stage. A flexion osteotomy was performed at C7, using anterior-posterior-anterior approaches. Results Both sagittal imbalance and gaze angle of the patient were improved markedly. The osteotomy sites were documented fused. Complications were not observed during and after operation. Conclusions The aim of osteotomy for ankylosing spondylitis is to reestablish sagittal balance and improve forward gaze and the visual field. A staged cervical osteotomy is an alternative to reduce cervical lordosis to obtain a normal gaze angle. An anterior-posterior-anterior approach is recommended.
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Affiliation(s)
- Tianhao Wang
- Southwest Hospital, Third Military Medical University, Chongqing, 400038, China.,Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Fuxing Road, Beijing, 100853, China
| | - Diyu Song
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Fuxing Road, Beijing, 100853, China.,Department of Orthopaedics, The General Hospital of PLA Rocket Force, Beijing, 100088, China
| | - Guoquan Zheng
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Fuxing Road, Beijing, 100853, China.
| | - Yan Wang
- Department of Orthopaedics, General Hospital of Chinese People's Liberation Army, Fuxing Road, Beijing, 100853, China.
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Koller H, Koller J, Mayer M, Hempfing A, Hitzl W. Osteotomies in ankylosing spondylitis: where, how many, and how much? 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 2017; 27:70-100. [PMID: 29290050 DOI: 10.1007/s00586-017-5421-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This article presents the current concepts of correction of spinal deformity in ankylosing spondylitis (AS) patients. Untreated AS can be a debilitating disease. In a few patients, disease progression results in severe spinal deformity affecting not only the thoracolumbar, but also the cervical spine. Surgery for correction in AS patients has a long history. With the advent of modern instrumentation, standardization of surgical and anesthesiologic techniques, surgical safety and corrective results could be improved and experiences from lumbar osteotomies could be transferred to the cervical spine. METHODS This article presents the current concepts of correction of spinal deformity in AS patients. In particular, questions regarding the localization and number of osteotomies, the optimal surgical target angle as well as planning and prediction of postoperative alignment are discussed. RESULTS Insight into recent technical developments, current challenges with correction and geometric analysis of center of rotation (COR) in cervical 3-column osteotomies (3CO) will be presented. CONCLUSION The article should encourage readers to improve surgical correction efficacy and provide a better understanding of correction geometry in 3CO for thoracolumbar and cervical spinal deformities.
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Affiliation(s)
- Heiko Koller
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany.
- Department for Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Juliane Koller
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany
| | - Michael Mayer
- Schön Klinik Nürnberg Fürth, Center for Spinal and Scoliosis Therapies, Europa-Allee 1, 90763, Fürth, Germany
- Department for Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Axel Hempfing
- Center for Spinal Surgery, Werner-Wicker-Clinic, Bad Wildungen, Germany
| | - Wolfgang Hitzl
- Research Office, Paracelsus Medical University Salzburg, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria
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