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Coskun E, Wellington IJ, Chaudhary C, Crea K, Cote MP, Rhee JM, Mallozzi S, Moss IL, Singh H. Clinical and radiologic outcomes of posterior column extension, pedicle subtraction, and vertebral column resection osteotomies in adult chin on chest deformity: A systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100324. [PMID: 38765779 PMCID: PMC11101968 DOI: 10.1016/j.xnsj.2024.100324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/22/2024]
Abstract
Background Chin-on-chest deformity is a rare and severely disabling condition characterized by kyphotic deformity in the cervicothoracic spine. To treat this deformity, various osteotomy techniques were described. Methods A comprehensive literature search of biomedical databases including MEDLINE (via PubMed), Scopus (via Elsevier), Embase (via Elsevier), and Cochrane Library in English from 1/1/1990 to 3/31/2022 was conducted using a combination of text and Medical Subject Headings (MeSH). Results The final analysis included 16 studies. All the studies were assigned a level of evidence of four. Except for two articles, all of the articles were non-comparative studies. A total of 288 patients were included in this review. Of the 288 patients, 107 underwent posterior column extension osteotomy (PCEO), 108 underwent pedicle subtraction osteotomy (PSO), and 33 underwent vertebral column resection osteotomy (VCRO). The most common osteotomy level in fifteen of the studies was C7/T1. The studies included in this review described several techniques for cervical sagittal balance correction. The range of preoperative and postoperative visual analogue scale (VAS) scores was 5.5-8.6 to 1.7-4.91, respectively. The range of preoperative and postoperative neck disability index (NDI) was 34.2-65.4 to 22.1-51.3, respectively. The most common complications were upper extremity paresthesia and hand numbness through the C8 dermatome distribution. Conclusions Corrective osteotomies provide satisfactory results in patients with chin-on-chest deformity; however, the quality of the included studies limits the evidence.
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Affiliation(s)
- Ergin Coskun
- Riley Hospital for Children, Indiana University Health, 705 Riley Hospital Dr, Indianapolis, IN 46202, United States
| | - Ian J. Wellington
- Department of Orthopedics, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
| | - Chirag Chaudhary
- Insight Surgical Hospital, 21230 Dequindre Rd Warren, MI 4809, United States
| | - Kathleen Crea
- Lyman Maynard Stowe Library, UConn Health, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
| | - Mark P. Cote
- Massachusetts General Brigham Sports Medicine, Harvard Medical School, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
| | - John M. Rhee
- Department of Orthopedic Surgery, Emory Spine Center, Emory University, 59 Executive Park South, Atlanta, GA 30327, United States
| | - Scott Mallozzi
- Department of Orthopedics, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
| | - Isaac L. Moss
- Department of Orthopedics, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
| | - Hardeep Singh
- Department of Orthopedics, The University of Connecticut, 120 Dowling Way, Farmington, CT 06032, United States
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Li W, Tong G, Cai B, Quan R. Analysis of the outcome of bi-vertebral transpedicular wedge osteotomy for correcting severe kyphotic deformity in ankylosing spondylitis. Medicine (Baltimore) 2023; 102:e34155. [PMID: 37390269 PMCID: PMC10313282 DOI: 10.1097/md.0000000000034155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/09/2023] [Indexed: 07/02/2023] Open
Abstract
To study the outcomes of bi-vertebral transpedicular wedge osteotomy in correcting severe kyphotic deformity in ankylosing spondylitis (AS). This retrospective study focused on all the patients who underwent thoracic and lumbar bi-vertebra transpedicular wedge osteotomy with pedicle screw internal fixation to treat their severe thoracolumbar kyphotic deformity of AS in our hospital from January 2014 to January 2020. The perioperative and operative data of each patient were collected and analyzed. A total of 21 male AS patients with severe kyphotic deformity were studied with a mean age of 42.2 ± 9.2 years. Intraoperatively, the mean operating time is 5.8 ± 1.6 hour with a mean blood loss of 725.5 ± 140.6 mL. The average postoperative correction of kyphosis reached 60.8o at 1 week after the surgery, which is significantly improved from preoperative presentation (P < .05), and stayed no significant change over the time during longer period of follow-ups (12-24 months) with the overall correction rate of 72.2%. Moreover, the postoperative changes in thoracic kyphosis (TK) angle, thoracolumbar kyphosis (TLK) angle, lumbar lordosis (LL) angle, maxilla-brow angle, as well as C2SVA and C7SVA sagittal balance were also significant, all of which enabled the patients to walk in upright position and sleep in the supine position with the improvements in other clinical symptoms. Bi-vertebral transpedicular wedge osteotomy of thoracic and lumbar vertebrae is a safe and effective method to restore the physiological curvature of the sagittal position of the spine and correct severe ankylosing deformity.
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Affiliation(s)
- Wei Li
- Department of Orthopedics, Jiangnan Hospital, Hangzhou, China
| | - Guojun Tong
- Department of Orthopedics, Jiangnan Hospital, Hangzhou, China
| | - Binbin Cai
- Department of Orthopedics, Jiangnan Hospital, Hangzhou, China
| | - Renfu Quan
- Department of Orthopedics, Jiangnan Hospital, Hangzhou, China
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Trends in Outcomes of a Prospective Consecutively Enrolled Single-Center Adult Cervical Deformity Series. Spine (Phila Pa 1976) 2022; 47:1694-1700. [PMID: 36007013 DOI: 10.1097/brs.0000000000004457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The aim was to describe the two-year outcomes for patients undergoing surgical correction of cervical deformity (CD). BACKGROUND Adult CD has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear. MATERIALS AND METHODS Operative CD patients >18 years with two-year (2Y) health-related quality of life/radiographic data were included. Improvement in radiographic, neurologic, and health-related quality of life outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on Neck Disability Index (NDI), numeric rating scale (NRS) neck, modified Japanese Orthopaedic Association (mJOA) were compared using multivariable analysis controlling for age, and frailty, and invasiveness. RESULTS One hundred and fifty-eight patients were included in this study. By 2Y, 96.3% of patients improved in Ames cervical sagittal vertical axis modifier, 34.2% in T1 slope minus cervical lordosis (TS-CL), 42.0% in horizontal gaze modifier, and 40.9% in SVA modifier. In addition, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from baseline to 2Y in NDI, NRS Neck, and mJOA, all P <0.05. 59.3% of patients met minimal clinically important difference for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. Ninety-seven patients presented with at least one neurologic deficit at baseline and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of distal junctional kyphosis (DJK) (∆DJKA>10° between lower instrumented vertebra and lower instrumented vertebra-2), of which 17 were distal junctional failure (distal junctional failure-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the two-year follow-up period. CONCLUSION Correction of CD results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including DJK or failure remain prevalent.
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Passias PG, Ahmad W, Oh C, Imbo B, Naessig S, Pierce K, Lafage V, Lafage R, Hamilton DK, Protopsaltis TS, Klineberg EO, Gum J, Schoenfeld AJ, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Smith JS, Shaffrey CI, Ames CP. Development of Risk Stratification Predictive Models for Cervical Deformity Surgery. Neurosurgery 2022; 91:928-935. [PMID: 36250700 DOI: 10.1227/neu.0000000000002136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/29/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification. OBJECTIVE To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations. METHODS CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics. RESULTS A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81). CONCLUSION Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Cheongeun Oh
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Sara Naessig
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Katherine Pierce
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, New York, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA
| | - Jeffrey Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Breton Line
- Denver International Spine Center, Denver, Colorado, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shay Bess
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Elias E, Bess S, Line BG, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Gupta M, Hart R, Schwab FJ, Burton D, Ames CP, Shaffrey CI, Smith JS. Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up. J Neurosurg Spine 2022; 37:855-864. [PMID: 35901674 DOI: 10.3171/2022.6.spine22422] [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: 04/17/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery. METHODS A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up. RESULTS Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2-8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up. CONCLUSIONS This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors' knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.
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Affiliation(s)
- Elias Elias
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Shay Bess
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Breton G Line
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Zeina Nasser
- 7Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | | | - Khaled Kebaish
- 9Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Alan H Daniels
- 11Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | | | - Richard Hostin
- 12Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - Alex Soroceanu
- 13Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 14Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Michael P Kelly
- 15Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Munish Gupta
- 16Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 19Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 20Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Passias PG, Krol O, Moattari K, Williamson TK, Lafage V, Lafage R, Kim HJ, Daniels A, Diebo B, Protopsaltis T, Mundis G, Kebaish K, Soroceanu A, Scheer J, Hamilton DK, Klineberg E, Schoenfeld AJ, Vira S, Line B, Hart R, Burton DC, Schwab FA, Shaffrey C, Bess S, Smith JS, Ames CP. Evolution of Adult Cervical Deformity Surgery Clinical and Radiographic Outcomes Based on a Multicenter Prospective Study: Are Behaviors and Outcomes Changing With Experience? Spine (Phila Pa 1976) 2022; 47:1574-1582. [PMID: 35797645 DOI: 10.1097/brs.0000000000004419] [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] [Received: 02/10/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time. SUMMARY OF BACKGROUND DATA As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown. MATERIALS AND METHODS Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time. RESULTS A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03). CONCLUSION Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Kevin Moattari
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Bassel Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Themistocles Protopsaltis
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank A Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | | | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Lau D, Joshi RS, Haddad AF, Deviren V, Ames CP. Incidence and Risk Factors of Mechanical Complications After Posterior-Based Osteotomies for Correction of Moderate to Severe Adult Cervical Deformity: 1-Year and 2-Year Follow-up. Neurosurgery 2022; 90:207-214. [PMID: 34995272 DOI: 10.1227/neu.0000000000001781] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rigid cervical deformity (CD) requires multilevel and/or high-grade osteotomies and long-construct fusions to achieve adequate correction. The incidence of mechanical complications (MCs) remains incompletely studied. OBJECTIVE To define the incidence and risk factors for MC. METHODS A retrospective review of consecutive patients with CD who underwent correction from 2010 to 2018 was performed. Inclusion criteria were cervical kyphosis >20° and/or cervical sagittal vertical axis (cSVA) >4 cm. MCs (junctional kyphosis/failure, pseudarthrosis, and implant failure) and reoperation at 1 and 2 yr were examined. RESULTS Eighty-three patients were included. The mean age was 63.4 yr, and 61.0% were female. Fifty-three percent underwent 3-column osteotomies. After surgery, cervical parameters were significantly improved: cSVA (6.2 vs 3.8 cm, P < .001), cervical lordosis (6.3 vs -8.3°, P < .001), cervical scoliosis (CS) (6.5 vs 2.2°, P < .001), and T1 slope (41.7 vs 36.3°, P = .007). The MC rate was 28.9%: junctional (18.1%), implant (16.9%), and pseudarthrosis (10.8%). MC rates at 1 and 2 yr were 14.5% and 25.5%, respectively: junctional (9.6% and 17.6%), implant (9.6% and 17.6%), and pseudarthrosis (2.4% and 7.8%). The overall reoperation rate was 24.1%: 14.5% at 1 yr and 19.6% at 2 yr. Body mass index (BMI) (P = .015) and preoperative CS (P = .040) were independently associated with higher odds of MC. Receiver operating characteristic curves defined CS >5° to be the threshold of risk for MCs and reoperation. CONCLUSION Correction of CD is effective by posterior-based osteotomes, but MCs are relatively high at 1 and 2 yr. BMI >30 and preoperative CS >5° predispose patients for MC and reoperation.
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Affiliation(s)
- Darryl Lau
- Department of Neurological Surgery, New York University, New York, New York, USA
| | - Rushikesh S Joshi
- Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Ghaith AK, Onyedimma C, Jarrah R, Bhandarkar AR, Graepel SP, Yolcu YU, El-Sammak S, Michalopoulos GD, Elder BD, Bydon M. Rate of C8 Radiculopathy in Patients Undergoing Cervicothoracic Osteotomy: A Systematic Appraisal of the Literature. World Neurosurg 2022; 161:e553-e563. [DOI: 10.1016/j.wneu.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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9
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A Review of Indications, Surgical Technique, and Outcomes for the Cervical Pedicle Subtraction Osteotomy. J Am Acad Orthop Surg 2022; 30:e295-e300. [PMID: 35772089 DOI: 10.5435/jaaos-d-21-00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/31/2021] [Indexed: 02/01/2023] Open
Abstract
Cervical spine deformity is a debilitating condition that can be challenging to treat. For patients with fixed, focal, kyphotic deformities near the cervicothoracic junction, a pedicle subtraction osteotomy (PSO) can be considered. Classifying a given cervical spine deformity and quantifying the mismatch between current and desired alignment are critical steps in determining whether a PSO should be done. It is also important to understand the relative contraindications for a cervical PSO and the radiographic and patient-reported outcomes associated with the procedure. Here, we review these topics and the details of our surgical technique and postoperative considerations. Specific nuances of the setup, exposure/approach, osteotomy, closure, and postoperative protocol are highlighted. A surgical video is also included (Video 1). Our aim is to provide a conceptual framework for understanding when a cervical PSO should be considered, how it can be performed effectively, and the outcomes that can be expected.
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10
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Ma S, Yu H, Zhou Z, Wu C, Liu Z, Deng W, Cao K. Case Report of Angular Post-Tuberculotic Kyphosis Corrected Through Pedicle Subtraction Osteotomy Above C7. Oper Neurosurg (Hagerstown) 2022; 22:e53-e57. [PMID: 34982923 DOI: 10.1227/ons.0000000000000026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Angular cervical kyphosis and its association with syringomyelia were rarely described. Correcting this kind of deformity from the front is extremely difficult or even impossible. Meanwhile, no study has made a report about correcting angular cervical kyphosis through pedicle subtraction osteotomy (PSO) above C7 because of the special anatomy of the vertebral artery. This is the first case of cervical deformity correction through PSO above C7. CLINICAL PRESENTATION We present the case of a 52-yr-old man who previously underwent debridement, decompression, and skull traction for cervical tuberculosis at age 6 yr. The sequelae of right-hand weakness occurred after surgery, and cervical kyphosis formed gradually. The patient recently started to complain of a severe neck pain. X-rays showed a cervical sagittal malalignment due to the angular kyphosis. Computed tomography scans revealed a fused angular kyphosis at C6-7, and MRI showed a long syringomyelia distal to the kyphosis. The definite diagnosis of the patient was post-tuberculotic cervical angular kyphosis, and because of the extremely narrow surgery corridor from the front, we decided to perform the surgery in a posterior approach. Hence, the patient was treated with the PSO with a long-segment pedicle screw fixation from C3 to T5 and received satisfactory angular kyphosis correction. CONCLUSION PSO above C7 to correct angular cervical kyphosis is feasible and reasonable when there is no other better solution, and it can achieve a satisfactory kyphotic deformity correction.
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Affiliation(s)
- Shengbiao Ma
- Orthopaedics Hospital, The First Affiliated Hospital of Nanchang University, Nanchang, China
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11
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Kim HJ, Virk S, Elysee J, Ames C, Passias P, Shaffrey C, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Hart R, Smith JS, Bess S, Schwab F, Lafage R, Lafage V. Surgical Strategy for the Management of Cervical Deformity Is Based on Type of Cervical Deformity. J Clin Med 2021; 10:jcm10214826. [PMID: 34768346 PMCID: PMC8584313 DOI: 10.3390/jcm10214826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: Cervical deformity morphotypes based on type and location of deformity have previously been described. This study aimed to examine the surgical strategies implemented to treat these deformity types and identify if differences in treatment strategies impact surgical outcomes. Our hypothesis was that surgical strategies will differ based on different morphologies of cervical deformity. Methods: Adult patients enrolled in a prospective cervical deformity database were classified into four deformity types (Flatneck (FN), Focal kyphosis (FK), Cervicothoracic kyphosis (CTK) and Coronal (C)), as previously described. We analyzed group differences in demographics, preoperative symptoms, health-related quality of life scores (HRQOLs), and surgical strategies were evaluated, and postop radiographic and HROQLs at 1+ year follow up were compared. Results: 90/109 eligible patients (mean age 63.3 ± 9.2, 64% female, CCI 1.01 ± 1.36) were evaluated. Group distributions included FN = 33%, FK = 29%, CTK = 29%, and C = 9%. Significant differences were noted in the surgical approaches for the four types of deformities, with FN and FK having a high number of anterior/posterior (APSF) approaches, while CTK and C had more posterior only (PSF) approaches. For FN and FK, PSF was utilized more in cases with prior anterior surgery (70% vs. 25%). For FN group, PSF resulted in inferior neck disability index compared to those receiving APSF suggesting APSF is superior for FN types. CTK types had more three-column osteotomies (3CO) (p < 0.01) and longer fusions with the LIV below T7 (p < 0.01). There were no differences in the UIV between all deformity types (p = 0.19). All four types of deformities had significant improvement in NRS neck pain post-op (p < 0.05) with their respective surgical strategies. Conclusions: The four types of cervical deformities had different surgical strategies to achieve improvements in HRQOLs. FN and FK types were more often treated with APSF surgery, while types CTK and C were more likely to undergo PSF. CTK deformities had the highest number of 3COs. This information may provide guidelines for the successful management of cervical deformities.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
- Correspondence:
| | - Sohrab Virk
- Department of Orthopedics, Northwell Health, Great Neck, New York, NY 11021, USA;
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Christopher Ames
- Department of Neurosurgery, University of San Francisco School of Medicine, San Francisco, CA 94143, USA;
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY 10016, USA; (P.P.); (T.P.)
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27708, USA;
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, CA 92037, USA;
| | | | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63010, USA;
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis, Davis, CA 95616, USA;
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA 22904, USA;
| | - Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children at Presbyterian St. Luke’s, Denver, CO 80218, USA;
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
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12
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Lau D, Guo L, Deviren V, Ames CP. Utility of intraoperative neuromonitoring and outcomes of neurological complication in lower cervical and upper thoracic posterior-based three-column osteotomies for cervical deformity. J Neurosurg Spine 2021:1-9. [PMID: 34624840 DOI: 10.3171/2021.5.spine202057] [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: 11/23/2020] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For severe and rigid adult cervical deformity, posterior-based three-column osteotomies (3COs) are warranted, but neurological complications are relatively high with such procedures. The performance measures of intraoperative neuromonitoring (IONM) during cervicothoracic 3CO have yet to be studied, and there remains a paucity of literature regarding the topic. Therefore, the authors of this study examined the performance of IONM in predicting new neurological weakness following lower cervical and upper thoracic 3CO. In addition, they report the 6-month, 1-year, and 2-year outcomes of patients who experienced new postoperative weakness. METHODS The authors performed a retrospective review of a single surgeon's experience from 2011 to 2018 with all patients who had undergone posterior-based 3CO in the lower cervical (C7) or upper thoracic (T1-4) spine. Medical and neuromonitoring records were independently reviewed. RESULTS A total of 56 patients were included in the analysis, 38 of whom had undergone pedicle subtraction osteotomy and 18 of whom had undergone vertebral column resection. The mean age was 61.6 years, and 41.1% of the patients were male. Among the study cohort, 66.1% were myelopathic and 33.9% had preoperative weakness. Mean blood loss was 1565.0 ml, and length of surgery was 315.9 minutes. Preoperative and postoperative measures assessed were cervical sagittal vertical axis (6.5 and 3.8 cm, respectively; p < 0.001), cervical lordosis (2.3° and -6.7°, p = 0.042), and T1 slope (48.6° and 35.8°, p < 0.001). The complication rate was 49.0%, and the new neurological deficit rate was 17.9%. When stratifying by osteotomy level, there were significantly higher rates of neurological deficits at C7 and T1: C7 (37.5%), T1 (44.4%), T2 (16.7%), T3 (14.3%), and T4 (0.0%; p = 0.042). Most new neurological weakness was the nerve root pattern rather than the spinal cord pattern. Overall, there were 16 IONM changes at any threshold: 14 at 50%, 8 at 75%, and 13 if only counting patients who did not return to baseline (RTB). Performance measures for the various thresholds were accuracy (73.2% to 77.8%), positive predictive value (25.0% to 46.2%), negative predictive value (81.3% to 88.1%), sensitivity (18.2% to 54.5%), and specificity (77.8% to 86.7%). Sensitivity to detect a spinal cord pattern of weakness was 100% and 28.6% for a nerve root pattern of weakness. In patients with a new postoperative deficit, 22.2% were unchanged, 44.4% improved, and 33.3% had a RTB at the 2-year follow-up. CONCLUSIONS Complication rates are high following posterior 3CO for cervical deformity. 3CO at C7 and T1 has the highest rates of neurological deficit. Current IONM modalities have modest performance in predicting postoperative deficits, especially for nerve root neuropraxia. A large prospective multicenter study is warranted.
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Affiliation(s)
- Darryl Lau
- 1Department of Neurosurgery, New York University, New York, New York
| | - Lanjun Guo
- 2Department of Neurophysiology, University of California, San Francisco
| | - Vedat Deviren
- 3Department of Orthopaedic Surgery, University of California, San Francisco; and
| | - Christopher P Ames
- 4Department of Neurological Surgery, University of California, San Francisco, California
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13
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Martini ML, Neifert SN, Chapman EK, Mroz TE, Rasouli JJ. Cervical Spine Alignment in the Sagittal Axis: A Review of the Best Validated Measures in Clinical Practice. Global Spine J 2021; 11:1307-1312. [PMID: 33203239 PMCID: PMC8453677 DOI: 10.1177/2192568220972076] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
STUDY DESIGN Review of the best-validated measures of cervical spine alignment in the sagittal axis. OBJECTIVE Describe the C2-C7 Cobb Angle, C2-C7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus C2-C7 lordosis, C2 slope, and different types of cervical kyphosis. METHODS Search PubMed for recent technical literature on radiograph-based measurements of the cervical spine. RESULTS Despite the continuing use of measures developed many years ago such as the C2-C7 Cobb angle, there are new radiographic parameters being published and utilized in recent years, including the C2 slope. Further research is needed to compare older and newer measures for cross-validation. Utilizing these measures to determine the degree of correction intraoperatively and postoperatively will enable surgeons to optimize patient-level outcomes. CONCLUSION Cervical spinal deformity can be a debilitating condition characterized by cervical spinal misalignment that affects the elderly more commonly than young populations. Many of these validated measures of cervical spinal alignment are useful in clinical settings due to their ease of implementation and correlations with various postoperative and health-related quality of life outcomes.
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Affiliation(s)
- Michael L. Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Michael L. Martini, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K. Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA
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14
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Abstract
The treatment of adult cervical deformity continues to be complex with high complication rates. However there are many new advancements and overall patients do well following surgical correction. To date there are now many types of cervical deformity that have been classified and there exists a variety of surgical options. These recent advances have been developed in the last few years and the field continues to grow at a rapid rate. Thus, the goal of this article is to provide an updated review of cervical sagittal balance including; cervical alignment parameters, deformity classification, clinical evaluation, with both conservative and surgical treatment options.
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Affiliation(s)
- Justin K Scheer
- Department of Neurological Surgery, 8785University of California, San Francisco, San Francisco, CA, USA
| | - Darryl Lau
- Department of Neurosurgery, 12296School of Medicine, New York University, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, 8785University of California, San Francisco, San Francisco, CA, USA
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15
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Massaad E, Shankar GM, Shin JH. Novel Applications of Spinal Navigation in Deformity and Oncology Surgery-Beyond Screw Placement. Oper Neurosurg (Hagerstown) 2021; 21:S23-S38. [PMID: 34128068 DOI: 10.1093/ons/opaa322] [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: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 12/30/2022] Open
Abstract
Computer-assisted navigation has made a major impact on spine surgery, providing surgeons with technological tools to safely place instrumentation anywhere in the spinal column. With advances in intraoperative image acquisition, registration, and processing, many surgeons are now using navigation in their practices. The incorporation of navigation into the workflow of surgeons continues to expand with the evolution of minimally invasive techniques and robotic surgery. While numerous investigators have demonstrated the benefit of navigation for improving the accuracy of instrumentation, few have reported applying this technology to other aspects of spine surgery. Surgeries to correct spinal deformities and resect spinal tumors are technically demanding, incorporating a wide range of techniques not only for instrumentation placement but also for osteotomy planning and executing the goals of surgery. Although these subspecialties vary in their objectives, they share similar challenges with potentially high complications, invasiveness, and consequences of failed execution. Herein, we highlight the utility of using spinal navigation for applications beyond screw placement: specifically, for planning and executing osteotomies and guiding the extent of tumor resection. A narrative review of the work that has been done is supplemented with illustrative cases demonstrating these applications.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Gerilmez A, Naderi S. A Novel Perspective for Analyzing Craniocervical Sagittal Balance and Horizontal Gaze. World Neurosurg 2021; 149:e924-e930. [PMID: 33516863 DOI: 10.1016/j.wneu.2021.01.077] [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: 08/17/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aimed to analyze craniocervical sagittal balance parameters in an asymptomatic population revealing the interaction of craniocervical compensation with the horizontal gaze and to identify a new parameter that can be evaluated more easily with the horizontal gaze. METHODS Lateral radiographs were taken of the 75 asymptomatic volunteers. Two independent observers measured the pelvic, spinal, and cranial parameters, spinocranial angle, and C2-7 sagittal vertical axis (C2-7SVA) distances. The correlations between these parameters and the differences in the created subgroups were analyzed. RESULTS Correlations were found between the sacral slope and L1-L5 lordosis (r = 0.700), between L1-L5 lordosis and thoracic kyphosis (r = 0.363), between thoracic kyphosis and C2-7 lordosis (r = 0.425), and between C2-7 lordosis and C2 slope (C2S) (r = -0.735). In addition, this chain was extended to include the cranium, showing a strong correlation between the C2S and the cranial slope (CS) (r = -0.827). Strong correlations were observed between the CS and C2S (r = -0.827), C2-C7 lordosis (r = 0.583), C2-7 SVA (r = -0.437). The importance of O-C2 lordosis was significantly increased in the patient cohort with a prominent C2S (≥13) and became the main determinant of the CS (r = 0.667) together with the C2S (r = -0.800). CONCLUSIONS The factors affecting horizontal gaze are C2S, C2-7 lordosis, O-C2 lordosis, and C2-7 SVA. C2S can be used as an indicator of the horizontal gaze in preoperative surgical planning and postoperative evaluation.
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Affiliation(s)
- Aydin Gerilmez
- University of Health Sciences, Umraniye Training and Research Hospital, Department of Neurosurgery, Istanbul, Turkey.
| | - Sait Naderi
- University of Health Sciences, Umraniye Training and Research Hospital, Department of Neurosurgery, Istanbul, Turkey
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17
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Maciejczak A, Wolan-Nieroda A, Guzik A. C7 extension crosswise osteotomy: a novel osteotomy for correction of chin-on-chest deformity in a patient with ankylosing spondylitis. J Neurosurg Spine 2020:1-6. [PMID: 33254144 DOI: 10.3171/2020.7.spine20258] [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: 02/22/2020] [Accepted: 07/01/2020] [Indexed: 11/06/2022]
Abstract
Extension crosswise osteotomy at C7 (C7 ECO) was developed for the correction of forward gaze in patients with chin-on-chest deformity due to ankylosing spondylitis. A modification of cervicothoracic extension osteoclasis (C/T EO), C7 ECO replaces osteoclasis of the anterior column with a crosswise cut of the C7 vertebral body to eliminate the risks of unintended dislocation of the cervical spine. C7 ECO also eliminates the risks of C7 and T1 pedicle subtraction osteotomies (C/T PSOs), in which a posteriorly based wedge excision may lead to stretching injuries of the lower cervical roots and/or failure to achieve the exact angle of excision required for an optimal correction. Furthermore, opening the osteotomy anteriorly, as in the authors' method, instead of closing it posteriorly, as in PSO, eliminates the risks related to shortening of the posterior column, such as buckling of the dura, kinking of the spinal cord, and stretching of the lower cervical nerve roots. Here, the authors report the use of C7 ECO for the surgical treatment of a 69-year-old man with severe compromise of his forward gaze due to chin-on-chest deformity in the course of ankylosing spondylitis. After uneventful correction surgery, the patient regained the ability to see objects, namely faces of people, at the level of his head while standing and to perform work tasks at a desk.
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Affiliation(s)
- Andrzej Maciejczak
- 1Department of Neurosurgery, St. Lukas Hospital, Tarnów; and.,2Medical Faculty, University of Rzeszów, Poland
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18
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Joshi RS, Lau D, Haddad AF, Deviren V, Ames CP. Risk factors for determining length of intensive care unit and hospital stays following correction of cervical deformity: evaluation of early severe adverse events. J Neurosurg Spine 2020; 34:178-189. [PMID: 33096532 DOI: 10.3171/2020.6.spine20826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Correction of rigid cervical deformities can be associated with high complication rates and result in prolonged intensive care unit (ICU) and hospital stays. In this study, the authors aimed to examine the risk factors contributing to length of stay (LOS) in both the hospital and ICU following adult cervical deformity (ACD) surgery and to identify severe adverse events that occurred in this setting. METHODS A retrospective review of ACD patients who underwent posterior-based osteotomies for deformity correction from 2010 to 2019 was performed. Inclusion criteria were cervical kyphosis > 20° and/or cervical sagittal vertical axis (cSVA) > 4 cm. Multivariate analysis was used to identify risk factors independently associated with ICU and hospital LOS. RESULTS A total of 107 patients were included. The mean age was 63.5 years, and 61.7% were female. Over half (52.3%) underwent 3-column osteotomies, while 47.7% underwent posterior column osteotomies. There was significant correction of all cervical parameters: cSVA (6.0 vs 3.6 cm, p < 0.001), cervical lordosis (8.2° vs -5.3°, p < 0.001), cervical scoliosis (6.5° vs 2.2°, p < 0.001), and T1-slope (40.2° vs 34.5°, p < 0.001). There were also reciprocal changes to the distal spine: thoracic kyphosis (54.4° vs 46.4°, p < 0.001), lumbar lordosis (49.9° vs 45.8°, p = 0.003), and thoracolumbar scoliosis (13.9° vs 11.1°, p = 0.009). Overall, 4 patients (3.7%) suffered aspiration-related complications, 3 patients (2.8%) experienced dysphagia requiring a feeding tube, and 4 patients (3.7%) had compromised airways, with 1 resulting in death. The mean ICU and hospital LOS were 2.8 days and 7.9 days, respectively. Multivariate analysis identified three factors independently associated with longer ICU LOS: female sex (3.0 vs 2.4 days, p = 0.004), ≥ 12 segments fused (3.5 vs 1.9 days, p = 0.002), and postoperative complication (4.0 vs 1.9 days, p = 0.017). These same factors were independently associated with longer hospital LOS as well: female sex (8.3 vs 7.3 days, p = 0.013), ≥ 12 segments fused (9.4 vs 6.2 days, p = 0.001), and complication (9.7 vs 6.7 days, p = 0.026). CONCLUSIONS Posterior-based osteotomies are very effective for the correction of ACD, but postoperative hospital stays are relatively longer than those following surgery for degenerative disease. Risk factors for prolonged ICU and hospital LOS consist of both nonmodifiable (female sex) and modifiable (≥ 12 segments fused and presence of complication) risk factors. Additional multicenter prospective studies will be needed to validate these findings.
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Affiliation(s)
| | | | | | - Vedat Deviren
- 2Orthopedic Surgery, University of California, San Francisco, California
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19
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Lau D, Ames CP. Three-Column Osteotomy for the Treatment of Rigid Cervical Deformity. Neurospine 2020; 17:525-533. [PMID: 33022157 PMCID: PMC7538345 DOI: 10.14245/ns.2040466.233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/02/2020] [Indexed: 11/19/2022] Open
Abstract
Adult cervical deformity (ACD) has been shown to have a substantial impact on quality of life and overall health, with moderate to severe deformities resulting in significant disability and dysfunction. Fortunately, surgical management and correction of cervical sagittal imbalance can offer significant benefits and improvement in pain and disability. ACD is a heterogenous disease and specific surgical correction strategies should reflect deformity type (driver of deformity) and patient-related factors. Spinal rigidity is one of the most important considerations as soft tissue releases and osteotomies play a crucial role in cervical deformity correction. For ankylosed, fixed, and severe deformity, 3-column osteotomy (3CO) is often warranted. A 3CO can be done through combined anteriorposterior (vertebral body resection) and posterior-only approaches (open or closed wedge pedicle subtraction osteotomies [PSOs]). This article reviews the literature for currently published studies that report results on the use of 3CO for ACD, with a special concentration on posterior based 3CO (open and closed wedge PSO). More specifically, this review discusses the indications, radiographic corrective ability, and associated complications.
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Affiliation(s)
- Darryl Lau
- Department of Orthopedic Surgery, Shriners Hospital for Children Philadelphia, Philadelphia, PA, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
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20
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Obeid I, Boissiere L, Bourghli A. Cervical Deformity Arising From Upper Thoracic Malalignment. Neurospine 2020; 17:568-573. [PMID: 33022161 PMCID: PMC7538347 DOI: 10.14245/ns.2040412.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/22/2020] [Indexed: 11/22/2022] Open
Abstract
This study aims to describe the surgical management of cervical deformity arising from outside the cervical spine because of upper thoracic malalignment, using pedicle subtraction osteotomy (PSO). Cervical spine deformity is a complex topic and it can be generally divided into 2 categories, the first category is when the primary deformity is inside the cervical spine and the treatment will focus on the cervical spine itself, whereas the second category is when the primary deformity is outside the cervical spine usually in the adjacent upper thoracic area, the cervical deformity is a compensation for the adjacent malalignment, and thus in this situation, the management will occur in the upper thoracic area. Description of a single surgeon’s technique for performing PSO to treat rigid upper thoracic deformity. PSO in the upper thoracic spine is a safe and effective procedure and can result in satisfying clinical and radiological outcome with indirect correction of the compensatory cervical deformity. Cervical deformity arising from upper thoracic malalignment should be dealt with by treating the problem at its origin outside the cervical spine by performing a PSO in the upper thoracic spine.
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Affiliation(s)
- Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Louis Boissiere
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Anouar Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, Riyadh, Saudi Arabia
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21
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Kim CW, Hyun SJ, Kim KJ. Surgical Impact on Global Sagittal Alignment and Health-Related Quality of Life Following Cervical Kyphosis Correction Surgery: Systematic Review. Neurospine 2020; 17:497-504. [PMID: 33022154 PMCID: PMC7538364 DOI: 10.14245/ns.2040476.238] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
When spinal imbalance occurs, the human body reacts through various compensatory mechanisms to maintain the head over the pelvis and to retain a horizontal gaze. These compensations occur through mobile spine segments as well as pelvic tilt and lower extremities. The purpose of this review was to understand the surgical impact on global sagittal alignment and health-related quality of life (HRQoL) following cervical kyphosis correction surgery. The cervical kyphosis correction surgery induces reciprocal changes in craniocervical and thoracolumbar alignment. Successful cervical deformity correction needs to focus not only on restoring proper cervical lordosis, but also on achieving global balance of the cervical spine with other parts of the spine. The goal of the surgery is to achieve occiputtrunk (OT) concordance (the center of gravity-C7 sagittal vertical axis < 30 mm) and cervical sagittal balance. Once OT-concordance is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize global spinal alignment. Reciprocal changes after surgery exhibit different patterns depending on whether patients have compensation ability in their thoracolumbar spine or not. C2–7 sagittal vertical axis and sagittal morphotype of the cervical kyphosis are correlated with HRQoL. Changes in cervical lordosis minus T1 slope correlate to HRQoL improvements.
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Affiliation(s)
- Chang-Wook Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Cho JY, Park W, Kim DS, Son SM, Lee JS. Radiographic predictive findings of neck pain in patients with ankylosing spondylitis. Br J Neurosurg 2020; 35:725-729. [PMID: 32940069 DOI: 10.1080/02688697.2020.1820947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between neck pain and radiological findings in ankylosing spondylitis (AS) patients. METHODS The study groups comprised 257 AS and 50 normal patients. Of the AS patients, 91 had axial neck pain (group 1) and 166 did not (group 2). Full-length radiographs of the spine in the anteroposterior and lateral planes were taken. Radiographic parameters such as the chin brow vertical angle (CBVA), McGregor slope (McGS), slope of the Line of Sight (SLS), C2 slope, C2-C7 lordosis (CL), C2-C7 sagittal vertical axis (C2-C7 SVA), and T1 slope were measured. Statistical analysis was performed. RESULTS The AS and normal patients were found to have significantly different CBVA, McGS, C2 slope, C2-C7 SVA, and T1 slope. However, no significant difference was observed for SLS and CL. Between groups 1 and 2, there were significant differences in the McGS, CL, and T1 slope. However, no significant difference between these two groups was observed for CBVA, SLS, C2 slope, and C2-C7 SVA. Logistic regression analysis was performed to identify statistically significant predictors of neck pain in AS patients and it revealed that the T1 slope and McGS were two such predictors. The T1 slope showed superior discriminatory power to McGS and CL in the receiver operating characteristic curve analysis. CONCLUSIONS This study shows that a high T1 slope and McGS are independent radiological predictors of neck pain in AS. Further well-designed studies would be necessary to substantiate our results.
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Affiliation(s)
- Jae Young Cho
- Department of Orthopaedic Surgery, Bumin Hospital Haeundae, Busan, Republic of Korea
| | - Wonseok Park
- Department of Orthopaedic Surgery, Seheung Hospital, Busan, Republic of Korea
| | - Dong Suk Kim
- Department of Orthopaedic Surgery, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seung Min Son
- Department of Orthopaedic Surgery, BioMedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jung Sub Lee
- Department of Orthopaedic Surgery, BioMedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Lau D, Deviren V, Joshi RS, Ames CP. Comparison of perioperative complications following posterior column osteotomy versus posterior-based 3-column osteotomy for correction of rigid cervicothoracic deformity: a single-surgeon series of 95 consecutive cases. J Neurosurg Spine 2020; 33:297-306. [PMID: 32384278 DOI: 10.3171/2020.3.spine191330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The correction of severe cervicothoracic sagittal deformities can be very challenging and can be associated with significant morbidity. Often, soft-tissue releases and osteotomies are warranted to achieve the desired correction. There is a paucity of studies that examine the difference in morbidity and complication profiles for Smith-Petersen osteotomy (SPO) versus 3-column osteotomy (3CO) for cervical deformity correction. METHODS A retrospective comparison of complication profiles between posterior-based SPO (Ames grade 2 SPO) and 3CO (Ames grade 5 opening wedge osteotomy and Ames grade 6 closing wedge osteotomy) was performed by examining a single-surgeon experience from 2011 to 2018. Patients of interest were individuals who had a cervical sagittal vertical axis (cSVA) > 4 cm and/or cervical kyphosis > 20° and who underwent corrective surgery for cervical deformity. Multivariate analysis was utilized. RESULTS A total of 95 patients were included: 49 who underwent 3CO and 46 who underwent SPO. Twelve of the SPO patients underwent an anterior release procedure. The patients' mean age was 63.2 years, and 60.0% of the patients were female. All preoperative radiographic parameters showed significant correction postoperatively: cSVA (6.2 cm vs 4.5 cm [preoperative vs postoperative values], p < 0.001), cervical lordosis (6.8° [kyphosis] vs -7.5°, p < 0.001), and T1 slope (40.9° and 35.2°, p = 0.026). The overall complication rate was 37.9%, and postoperative neurological deficits were seen in 16.8% of patients. The surgical and medical complication rates were 17.9% and 23.2%, respectively. Overall, complication rates were higher in patients who underwent 3CO compared to those who underwent SPO, but this was not statistically significant (total complication rate 42.9% vs 32.6%, p = 0.304; surgical complication rate 18.4% vs 10.9%, p = 0.303; and new neurological deficit rate 20.4% vs 13.0%, p = 0.338). Medical complication rates were similar between the two groups (22.4% [3CO] vs 23.9% [SPO], p = 0.866). Independent risk factors for surgical complications included male sex (OR 10.88, p = 0.014), cSVA > 8 cm (OR 10.36, p = 0.037), and kyphosis > 20° (OR 9.48, p = 0.005). Combined anterior-posterior surgery was independently associated with higher odds of medical complications (OR 10.30, p = 0.011), and preoperative kyphosis > 20° was an independent risk factor for neurological deficits (OR 2.08, p = 0.011). CONCLUSIONS There was no significant difference in complication rates between 3CO and SPO for cervicothoracic deformity correction, but absolute surgical and neurological complication rates for 3CO were higher. A preoperative cSVA > 8 cm was a risk factor for surgical complications, and kyphosis > 20° was a risk factor for both surgical and neurological complications. Additional studies are warranted on this topic.
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Affiliation(s)
| | - Vedat Deviren
- 2Orthopedic Surgery, University of California, San Francisco, California
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Safaee MM, Tan LA, Riew KD. Anterior osteotomy for rigid cervical deformity correction. JOURNAL OF SPINE SURGERY 2020; 6:210-216. [PMID: 32309659 DOI: 10.21037/jss.2019.12.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Rigid deformities of the cervical spine can be associated with significant pain, disability, and impaired quality of life. Historical treatments generally utilized posterior approaches including the opening wedge osteotomy and pedicle subtraction osteotomy (PSO). Translation can occur during osteoclasis of the opening wedge osteotomy, making it inherently less stable than a PSO. The PSO is limited to lower cervical or upper thoracic levels due to the vertebral artery and sensitivity of cervical nerve roots to compression during osteotomy closure. The anterior osteotomy, defined as an osteotomy through the cervical disc space and uncovertebral joints back to the level of the transverse foramen bilaterally, is a powerful correction technique that can be applied throughout the cervical spine. It can also be used to correct deformities in the coronal plane. This review will summarize the technical nuances of the anterior osteotomy including patient selection, preoperative planning, and surgical technique.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lee A Tan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - K Daniel Riew
- Department of Orthopedic Surgery, New York-Presbyterian Och Spine Hospital, Columbia University, New York, NY, USA
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Safaee MM, Tan LA, Ames CP. Posterior osteotomy techniques for rigid cervical deformity correction. JOURNAL OF SPINE SURGERY 2020; 6:274-279. [PMID: 32309665 DOI: 10.21037/jss.2020.01.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior cervical osteotomies are powerful techniques for the correction of rigid cervical deformity. These include a variety of subtypes including partial facet joint resection, complete facet joint resection, opening wedge osteotomy (OWO), and closing wedge osteotomy (CWO). The partial facet joint resection provides limited lordosis but can be applied across multiple levels and provides bony surface for fusion. Complete facet joint resection can also be performed across multiple segments for a cumulative effect and like the partial facet joint resection requires mobility of the anterior column. The OWO is traditionally performed at C7 and involves complete a complete laminectomy, facetectomy, and pediculectomy with special care to fully decompress the C8 nerve roots prior to osteotomy closure. The osteotomy utilizes a fulcrum of rotation in the middle column with shortening of the posterior column and lengthening of the anterior column with an osteoclastic fracture that must be performed with significant care. The CWO is similar to an OWO with the addition of an osteotomy into the vertebral body that is closed like a pedicle subtraction osteotomy (PSO). The goal of this review article is to summarize posterior osteotomy techniques for cervical deformity correction.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Lee A Tan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Meng Y, Ma J, Shu L, Yin J, Gao R, Wang C, Zhou X. Modified C7 pedicle subtraction osteotomy for the correction of cervicothoracic kyphosis. BMC Musculoskelet Disord 2020; 21:28. [PMID: 31937290 PMCID: PMC6961231 DOI: 10.1186/s12891-020-3053-7] [Citation(s) in RCA: 2] [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] [Received: 04/05/2019] [Accepted: 01/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteotomies in the cervical spine are technically challenging. The purpose of this study was to evaluate the feasibility of the modified pedicle subtraction osteotomy (PSO) technique at C7 to be used for the treatment of cervicothoracic kyphosis secondary to ankylosing spondylitis. METHODS A total of 120 cervical spine computed tomography (CT) scans (of 82 male and 38 female patients) were evaluated. The scans were taken parallel to the middle sagittal plane and the sagittal plane intersecting the pedicles. Simulated osteotomy was performed by setting the apex of the wedge osteotomy at different points, and morphologic measurements were obtained. Seven patients with cervicothoracic kyphosis who underwent a modified PSO at C7 between May 2009 and June 2015 were retrospectively evaluated. The mean follow up was 32.9 months (range 21-54 months). Preoperative and postoperative chin-brow vertical angle (CBVA), sagittal vertical axis (SVA) and sagittal Cobb angle of the cervical region were reviewed. The outcomes were analyzed through various measures, which included the 36-Item Short Form Health Survey (SF-36) and a visual analog scale for neck pain. RESULTS In this morphometric study, a modified PSO was performed on 87 patients (59 male and 28 female) with a reasonable ratio of 72.5%. In the case series, radiographic parameters and health-related quality-of-life measures were found to show significant postoperative improvement in all patients. No major complications occurred, and no implant failures were noted until the latest follow up. CONCLUSIONS The modified PSO is a safe and valid alternative to the classic PSO, allowing for excellent correction of cervical kyphosis and improvement in health-related quality-of-life measures.
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Affiliation(s)
- Yichen Meng
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jun Ma
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Lun Shu
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jia Yin
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Rui Gao
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Ce Wang
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Xuhui Zhou
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
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Obeid I, Diebo BG, Boissiere L, Bourghli A, Cawley DT, Larrieu D, Pointillart V, Challier V, Vital JM, Lafage V. Single Level Proximal Thoracic Pedicle Subtraction Osteotomy for Fixed Hyperkyphotic Deformity: Surgical Technique and Patient Series. Oper Neurosurg (Hagerstown) 2019; 14:515-523. [PMID: 28973349 DOI: 10.1093/ons/opx158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 06/08/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thoracic hyperkyphosis can display pathological deterioration, resulting in either hyperlordotic cervical compensation or sagittal malalignment. Various techniques have been described to treat fixed malalignment. Pedicle subtraction osteotomy (PSO) is commonly used in the lumbar spine and frequently limited to the distal thoracic spine. This series focuses on the surgical specificities of proximal thoracic PSO, with clinical and radiological outcomes. OBJECTIVE To report the surgical specificities and assess the clinical and radiological outcomes of proximal thoracic osteotomies for correction of rigid kyphotic deformities. METHODS This is a retrospective review of 10 consecutive patients who underwent single level proximal thoracic PSO (T2-T5). Preoperative and postoperative full-body EOSTM radiographs, perioperative data, and complications were recorded. The surgical technique and its nuances were described in detail. RESULTS Patients had mean age of 41.8 yr and 50% were female. The technique provided correction of segmental and global kyphosis, 26.6° and 29.5°, respectively. Patients reported reciprocal reduction in C2-C7 cervical lordosis (37.6°-18.6°, P < .001), significantly correlating with the reduction of thoracic hyperkyphosis (R = 0.840, P = .002). Mean operative time was 291 min, blood loss 1650 mL, and mean hospital stay was 13.8 d. Three patients reported complications that were resolved, including 1 patient who was revised because of a painful cross link. There were no neurological complications, pseudarthroses, instrumentation breakage, or wound infections at a minimum of 2-yr follow-up. CONCLUSION Proximal thoracic PSO can be a safe and effective technique to treat fixed proximal thoracic hyperkyphosis leading to kyphosis reduction and craniocervical relaxation.
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Affiliation(s)
- Ibrahim Obeid
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Bassel G Diebo
- Department of Orthopaedic Sur-gery, State University of New York, Down-state Medical Center, Brooklyn, New York
| | - Louis Boissiere
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Anouar Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, Riyadh, Saudi Arabia
| | - Derek T Cawley
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Daniel Larrieu
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Vincent Pointillart
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Vincent Challier
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Jean Marc Vital
- Orthopedic Spinal Surgery Unit 1, Bor-deaux Pellegrin Hospital, Bordeaux cedex, France
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, New York
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Yuk FJ, Rasouli JJ, Arginteanu MS, Steinberger AA, Moore FM, Yao KC, Caridi JM, Gologorsky Y. The case for T2 pedicle subtraction osteotomy in the surgical treatment of rigid cervicothoracic deformity. J Neurosurg Spine 2019; 32:248-257. [PMID: 31653807 DOI: 10.3171/2019.7.spine19350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rigid cervicothoracic kyphotic deformity (CTKD) remains a difficult pathology to treat, especially in the setting of prior cervical instrumentation and fusion. CTKD may result in chronic neck pain, difficulty maintaining horizontal gaze, and myelopathy. Prior studies have advocated for the use of C7 or T1 pedicle subtraction osteotomies (PSOs). However, these surgeries are fraught with danger and, most significantly, place the C7, C8, and/or T1 nerve roots at risk. METHODS The authors retrospectively reviewed their experience with performing T2 PSO for the correction of rigid CTKD. Demographics collected included age, sex, details of prior cervical surgery, and coexisting conditions. Perioperative variables included levels decompressed, levels instrumented, estimated blood loss, length of surgery, length of stay, complications from surgery, and length of follow-up. Radiographic measurements included C2-7 sagittal vertical axis (SVA) correction, and changes in the cervicothoracic Cobb angle, lumbar lordosis, and C2-S1 SVA. RESULTS Four male patients were identified (age range 55-72 years). Three patients had undergone prior posterior cervical laminectomy and instrumented fusion and developed postsurgical kyphosis. All patients underwent T2 PSO: 2 patients received instrumentation at C2-T4, and 2 patients received instrumentation at C2-T5. The median C2-7 SVA correction was 3.85 cm (range 2.9-5.3 cm). The sagittal Cobb angle correction ranged from 27.8° to 37.6°. Notably, there were no neurological complications. CONCLUSIONS T2 PSO is a powerful correction technique for the treatment of rigid CTKD. Compared with C7 or T1 PSO, there is decreased risk of injury to intrinsic hand muscle innervators, and there is virtually no risk of vertebral artery injury. Laminectomy may also be safer, as there is less (or no) scar tissue from prior surgeries. Correction at this distal level may allow for a greater sagittal correction. The authors are optimistic that these findings will be corroborated in larger cohorts examining this challenging clinical entity.
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Wang S, Lin G, Yang Y, Cai S, Zhuang Q, Tian Y, Zhang J. Outcomes of 360° Osteotomy in the Cervicothoracic Spine (C7-T1) for Congenital Cervicothoracic Kyphoscoliosis in Children. J Bone Joint Surg Am 2019; 101:1357-1365. [PMID: 31393426 DOI: 10.2106/jbjs.18.01428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There have been many reports on the treatment of congenital kyphoscoliosis. However, congenital deformities in the cervicothoracic spine (C7-T1) have not been well described because of the rarity of these conditions. METHODS The medical records and imaging studies of 25 children who were treated with 360° osteotomy for congenital deformities in the cervicothoracic spine (C7-T1) at a mean age of 11.4 years were reviewed. RESULTS All 25 children presented with torticollis; 4 presented with neck pain; 10, with facial asymmetry; and 3, with preoperative neurological deficits. Twenty-three patients had congenital deformities in other regions of the spine. Six patients had a total of 8 intraspinal deformities. On average, the cervicothoracic curve was corrected from 53° preoperatively to 14° at the latest follow-up, the segmental kyphosis was corrected from 25° to 12°, and the head tilt improved from 25° to 5°. Nineteen patients had a total of 28 complications, including 1 transient cord injury together with a permanent C8 nerve root injury, 11 transient nerve root injuries, 1 transient Horner syndrome, 9 cases of decompensation of a compensatory curve, 2 implant failures, 2 cases of hemothorax, 1 dural tear, and 1 case of delayed wound-healing. CONCLUSIONS Most congenital cervicothoracic deformities are fixed, and early surgical intervention may be needed. A 360° osteotomy is indicated for this type of rigid deformity and may provide satisfactory correction. However, 360° osteotomy in the cervicothoracic spine (C7-T1) is technically demanding with a higher risk of nerve root injuries, although most injuries tend to be transient. If the compensatory thoracic curve is severe and rigid, 1-stage or staged surgery in this region may be required. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shengru Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Guanfeng Lin
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Yang Yang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Siyi Cai
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Qianyu Zhuang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Ye Tian
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, People's Republic of China
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Abstract
Cervical spine deformity represents a broad spectrum of pathologies that are both complex in etiology and debilitating towards quality of life for patients. Despite advances in the understanding of drivers and outcomes of cervical spine deformity, only one classification system and one system of nomenclature for osteotomy techniques currently exist. Moreover, there is a lack of standardization regarding the indications for each technique. This article reviews the adult cervical deformity (ACD) and current classification and nomenclature for osteotomy techniques, highlighting the need for further work to develop a unified approach for each case and improve communication amongst the spine community with respect to ACD.
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Shao ZX, Yan YZ, Pan XX, Chen SQ, Fang X, Chen XB, Wu AM, Wang XY. Factors Associated with Cervical Spine Alignment in an Asymptomatic Population: A Preliminary Analysis. World Neurosurg 2019; 122:e48-e58. [DOI: 10.1016/j.wneu.2018.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/03/2018] [Accepted: 09/05/2018] [Indexed: 11/26/2022]
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Koller H, Ames C, Mehdian H, Bartels R, Ferch R, Deriven V, Toyone H, Shaffrey C, Smith J, Hitzl W, Schröder J, Robinson Y. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. 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; 28:324-344. [PMID: 30483961 DOI: 10.1007/s00586-018-5835-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND PURPOSE Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.
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Affiliation(s)
- H Koller
- Spine and Scoliosis Center, Schön Klinik Vogtareuth, Krankenhausstrasse 20, 83569, Vogtareuth, Germany. .,Department for Trauma and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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Abstract
Cervical kyphosis is a rare condition that can cause significant functional disability and myelopathy. Deciding the appropriate treatment for such deformities is challenging for the surgeon. Patients often present with axial neck pain, and it is not uncommon to find coexisting radiculopathy or myelopathy. The optimal approach for addressing this complex issue remains controversial. A comprehensive surgical plan based on knowledge of the pathology and biomechanics is important for kyphosis correction. Here we reviewed diagnoses of the cervical spine along with the literature pertaining to various approaches and management of cervical spine.
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Affiliation(s)
- Akshay Gadia
- Department of Spine, Wockhardt Hospital, Mumbai, India
| | | | - Abhay Nene
- Department of Spine, Wockhardt Hospital, Mumbai, India
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Shin JH, Yanamadala V, Cha TD. Computer-Assisted Navigation for Real Time Planning of Pedicle Subtraction Osteotomy in Cervico-Thoracic Deformity Correction. Oper Neurosurg (Hagerstown) 2018; 16:445-450. [DOI: 10.1093/ons/opy162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 05/25/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Pedicle subtraction osteotomy (PSO) at the cervicothoracic junction (CTJ) is a powerful technique to correct severe kyphosis and sagittal malalignment. Reported techniques have demonstrated the safety and efficacy of the PSO, however limited visualization of surrounding tissues increases the potential for complications with this advanced technique.
OBJECTIVE
To describe the application of computed tomographic (CT)-based image guidance to the planning and execution of PSO at the CTJ.
METHODS
Intraoperative registration and verification of anatomic landmarks are performed with the intraoperative O-arm CT across the CTJ. With the navigation probe, the targeted pedicle is identified and the intended trajectories are rehearsed and saved on the navigational computer. As the PSO is performed, the navigation probe is used to check the depth, accuracy, and trajectory through each side. The extent of soft tissue dissection around the lateral aspect of the vertebral body through which the PSO is performed is also verified in real time. This technique was performed in 12 consecutive patients from 2013-2016. An IRB approved, retrospective analysis was performed from a prospective spinal deformity outcomes database. Patient consent is not required for publication as this report does not describe a specific case but rather a surgical technique used in practice.
RESULTS
There were no vascular, esophageal, or soft tissue injuries in 12 consecutive patients. There were no cases of paralysis. Two patients developed hand weakness days after surgery. Intraoperative O-arm CT performed after closure of the osteotomy confirmed the accuracy of the osteotomy planning with no breach of the anterior cortical wall of the osteotomized vertebral body.
CONCLUSION
CT-guided navigation allows for 3-dimensional visualization of the CTJ and minimizes complications associated with inadequate surgical visualization of vascular and deep organ structures.
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Affiliation(s)
- John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vijay Yanamadala
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Protopsaltis TS, Ramchandran S, Hamilton DK, Sciubba D, Passias PG, Lafage V, Lafage R, Smith JS, Hart RA, Gupta M, Burton D, Bess S, Shaffrey C, Ames CP. Analysis of Successful Versus Failed Radiographic Outcomes After Cervical Deformity Surgery. Spine (Phila Pa 1976) 2018; 43:E773-E781. [PMID: 29227365 DOI: 10.1097/brs.0000000000002524] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective multicenter cohort study with consecutive enrollment. OBJECTIVE To evaluate preoperative alignment and surgical factors associated with suboptimal early postoperative radiographic outcomes after surgery for cervical deformity. SUMMARY OF BACKGROUND DATA Recent studies have demonstrated correlation between cervical sagittal alignment and patient-reported outcomes. Few studies have explored cervical deformity correction prospectively, and the factors that result in successful versus failed cervical alignment corrections remain unclear. METHODS Patients with adult cervical deformity (ACD) included with either cervical kyphosis more than 10°, C2-C7 sagittal vertical axis (cSVA) of more than 4 cm, or chin-brow vertical angle of more than 25°. Patients were categorized into failed outcomes group if cSVA of more than 4 cm or T1 slope and cervical lordosis (TS-CL) of more than 20° at 6 months postoperatively. RESULTS A total of 71 patients with ACD (mean age 62 yr, 56% women, 41% revisions) were included. Fourty-five had primary cervical deformities and 26 at the cervico-thoracic junction. Thirty-three (46.4%) had failed radiographic outcomes by cSVA and 46 (64.7%) by TS-CL. Failure to restore cSVA was associated with worse preoperative C2 pelvic tilt angle (CPT: 64.4° vs. 47.8°, P = 0.01), worse postoperative C2 slope (35.0° vs. 23.8°, P = 0.004), TS-CL (35.2° vs. 24.9°, P = 0.01), CPT (47.9° vs. 28.2°, P < 0.001), "+" Schwab modifiers (P = 0.007), revision surgery (P = 0.05), and failure to address the secondary, thoracolumbar driver of the deformity (P = 0.02). Failure to correct TS-CL was associated with worse preoperative cervical kyphosis (10.4° vs. -2.1°, P = 0.03), CPT (52.6° vs. 39.1°, P = 0.04), worse postoperative C2 slope (30.2° vs. 13.3°, P < 0.001), cervical lordosis (-3.6° vs. -15.1°, P = 0.01), and CPT (37.7° vs. 24.0°, P < 0.001). Multivariate analysis revealed postoperative distal junctional kyphosis associated with suboptimal outcomes by cSVA (odds ratio 0.06, confidence interval 0.01-0.4, P = 0.004) and TS-CL (odds ratio 0.15, confidence interval 0.02-0.97, P = 0.05). CONCLUSION Factors associated with failure to correct the cSVA included revision surgery, worse preoperative CPT, and concurrent thoracolumbar deformity. Failure to correct the TS-CL mismatch was associated with worse preoperative cervical kyphosis and CPT. Occurrence of early postoperative distal junctional kyphosis significantly affects postoperative radiographic outcomes. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | - Subaraman Ramchandran
- Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, New York, NY
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburg Medical Center, Pittsburgh, PA
| | - Daniel Sciubba
- Department of Orthopedic Surgery, Johns Hopkins University Medical Center, Baltimore MD
| | - Peter G Passias
- Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University Medical Center, St. Louis, MO
| | - Douglas Burton
- Department of Orthopedic Surgery, Kansas University Hospital, Kansas City, KS
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Clinic, Denver, CO
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
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Tan LA, Riew KD, Traynelis VC. Cervical Spine Deformity-Part 3: Posterior Techniques, Clinical Outcome, and Complications. Neurosurgery 2018; 81:893-898. [PMID: 29096033 DOI: 10.1093/neuros/nyx477] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/26/2016] [Indexed: 11/12/2022] Open
Abstract
The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications. Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.
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Affiliation(s)
- Lee A Tan
- Department of Orthopedic Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | - K Daniel Riew
- Department of Orthopedic Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Passias PG, Horn SR, Oh C, Ramchandran S, Burton DC, Lafage V, Lafage R, Poorman GW, Steinmetz L, Segreto FA, Bortz CA, Smith JS, Ames C, Shaffrey CI, Kim HJ, Soroceanu A, Klineberg EO. Evaluating cervical deformity corrective surgery outcomes at 1-year using current patient-derived and functional measures: are they adequate? JOURNAL OF SPINE SURGERY 2018; 4:295-303. [PMID: 30069521 DOI: 10.21037/jss.2018.05.29] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Current health-related quality of life (HRQL) metrics used to assess patient outcomes following surgical correction of cervical deformity (CD) are not deformity-specific and thus cannot capture all aspects of a patient's deformity and outcomes. The purpose of this study is to evaluate the sensitivity of different HRQL outcome measures in assessing CD patients' outcomes 1-year post-operatively. Methods Retrospective review of prospective multi-center database. Inclusion criteria: CD patients ≥18 yrs with pre- and 1-year post-operative radiographs and HRQLs [modified Japanese Orthopaedic Association (mJOA), EuroQol five-dimensions (EQ-5D), neck disability index (NDI)]. Associations between changes in EQ5D and NDI with improvement at 1-year in mJOA scores were assessed by whether or not the patient met the minimum clinically important difference (MCID) as well as whether or not they improved by one or more categories (i.e., change from moderate to mild). Odds ratios reported with 95% confidence intervals. Results Sixty-three CD patients were included (mean 62 y, 55.6% F). Average baseline NDI scores were 46.75, mJOA was 13.68, and EQ-5D 0.74. Overall baseline myelopathy breakdown: none-9.5%, mild-30.2%, moderate-42.9%, high-17.5%. At 1-year, 46% of patients improved in mJOA, 71.4% NDI, and 65.1% EQ-5D. 19% of patients met mJOA MCID, 44.4% NDI MCID, 19% EQ-5D MCID. One-point improvement in NDI increased the odds of mJOA improvement and reaching mJOA MCID (improvement: OR, 1.06, CI: 1.01-1.10, P=0.01; MCID: OR, 1.06, CI: 1.02-1.11, P=0.006). Improvement in EQ-5D by 0.1 increased the odds of improving in mJOA and reaching mJOA MCID at 1-year (improvement: OR, 3.85, CI: 1.51-9.76, P=0.005; MCID: OR, 3.88, CI: 1.52-9.88, P=0.005). While correlations exist between outcome measures, when modeling these outcomes while controlling for confounders including cSVA change, surgical invasiveness, age and CCI, these HRQLs were not strongly correlated. Conclusions Improvements in functional outcomes, as defined by mJOA score, were correlated with changes in neck based disability and general health state, defined by NDI and EQ-5D respectively. In an adjusted model, however, these direct relationships were not maintained. A CD-specific HRQL might be more useful for surgeons in assessing patient outcomes using a single metric.
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Affiliation(s)
- Peter G Passias
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Samantha R Horn
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cheongeun Oh
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Douglas C Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Virginie Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Gregory W Poorman
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Leah Steinmetz
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank A Segreto
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Han Jo Kim
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
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Brasil AVB, Fruett da Costa PR, Vial ADM, Barcellos GDC, Zauk EB, Worm PV, Ferreira MP, Ferreira NP. Cervicothoracic Lordosis Can Influence Outcome After Posterior Cervical Spine Surgery. Open Orthop J 2018; 12:91-98. [PMID: 29619122 PMCID: PMC5859459 DOI: 10.2174/1874325001812010091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/02/2018] [Accepted: 02/02/2018] [Indexed: 11/24/2022] Open
Abstract
Background: Previous studies on the correlation between cervical sagittal balance with improvement in quality of life showed significant results only for parameters of the anterior translation of the cervical spine (such as C2-C7 SVA). Objective: We test whether a new parameter, cervicothoracic lordosis, can predict clinical success in this type of surgery. Methods: The focused group involved patients who underwent surgical treatment of cervical degenerative disk disease by the posterior approach, due to myelopathy, radiculopathy or a combination of both. Neurologic deficit was measured before and after surgery with the Nurick Scale, postoperative quality of life, physical and mental components of SF-36 and NDI. Cervicothoracic lordosis and various sagittal balance parameters were also measured. Cervicothoracic lordosis was defined as the angle between: a) the line between the centroid of C2 and the centroid of C7; b) the line between the centroid of C7 and the centroid of T6. Correlations between postoperative quality of life and sagittal parameters were calculated. Results: Twenty-nine patients between 27 and 78 years old were evaluated. Surgery types were simple decompression (laminectomy or laminoforaminotomy) (3 patients), laminoplasty (4 patients) and laminectomy with fusion in 22 patients. Significant correlations were found for C2-C7 SVA and cervicothoracic lordosis. C2-C7 SVA correlated negatively with MCS (r=-0.445, p=0.026) and PCS (r=-0.405, p=0.045). Cervicothoracic lordosis correlated positively with MCS (r=0.554, p= 0.004) and PCS (r=0.462, p=0.020) and negatively with NDI (r=-0.416, p=0.031). Conclusion: The parameter cervicothoracic lordosis correlates with improvement of quality life after surgery for cervical degenerative disk disease by the posterior approach.
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Affiliation(s)
- Albert Vincent Berthier Brasil
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Pablo Ramon Fruett da Costa
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Antonio Delacy Martini Vial
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Gabriel da Costa Barcellos
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Eduardo Balverdu Zauk
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Paulo Valdeci Worm
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Marcelo Paglioli Ferreira
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
| | - Nelson Pires Ferreira
- Department of Neurosurgery, Hospital São José - Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul
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Berjano P. Expert's comment concerning Grand Rounds case entitled "Correction of dropped head deformity through combined anterior and posterior osteotomies to restore horizontal gaze and improve sagittal alignment" by W.H. Bronson et al. [Eur Spine J (2017): doi:10.1007/s00586-017-5184-6]. 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. [PMID: 29516201 DOI: 10.1007/s00586-018-5525-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Pedro Berjano
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161, Milan, Italy.
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Sabou S, Mehdian H, Pasku D, Boriani L, Quraishi NA. Health-related quality of life in patients undergoing cervico-thoracic osteotomies for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis. 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; 27:1586-1592. [DOI: 10.1007/s00586-018-5530-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 02/04/2018] [Accepted: 02/17/2018] [Indexed: 10/18/2022]
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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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Traynelis VC. Editorial. Cervical kyphotic deformity. J Neurosurg Spine 2017; 27:485-486. [DOI: 10.3171/2016.11.spine161033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Principal Radiographic Characteristics for Cervical Spinal Deformity: A Health-related Quality-of-life Analysis. Spine (Phila Pa 1976) 2017; 42:1375-1382. [PMID: 28277386 DOI: 10.1097/brs.0000000000002144] [Citation(s) in RCA: 24] [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 The aim of this study was to propose radiographic characteristics of patients with cervical disability and to investigate the relevant parameters when assessing cervical alignment. SUMMARY OF BACKGROUND DATA Although cervical kyphosis is traditionally recognized as presentation of cervical deformity, an increasing number of studies demonstrated that cervical kyphosis may not equal cervical deformity. Therefore, several other differentiating criteria for cervical deformity should be investigated and supported with quality of life scores. METHODS A database of full-body radiographs was retrospectively reviewed. Patients without previous cervical surgery, with a well-aligned thoracolumbar profile (defined as T1 pelvis angle <15°), and with an available Neck Disability Index (NDI) score were reviewed in this study. Subjects were stratified into an asymptomatic (64 subjects with NDI ≤15, Visual Analogue Scale [VAS] neck ≤3, and VAS arm ≤3) and a symptomatic group (107 subjects with NDI >15, VAS neck >3, or VAS arm >3). Independent t tests were performed to investigate differences between two groups. Logistic regressions and principal component analyses were then performed. RESULTS NDI averaged 5.43 in asymptomatic group, significantly smaller than symptomatic group (5.43 vs. 41.25). t Test revealed that C2-C7 sagittal vertical axis (SVA), McGregor slope, and the slope of line of sight (SLS) were significantly different while C2-C7 angle (cervical curvature, CC) did not show statistical difference (P = 0.09). Logistic regressions were performed using the significantly different parameters as well as CC. Results identified C2-C7 SVA and SLS as independent risk factors for low health-related quality of life. The principal component analysis leads to a new factor (0.55 × C2C7SVA + 0.34 × COC2 + 0.77 × CC) with strong correlations with NDI, VAS, and EQ5D measurements. CONCLUSION The traditional concept of cervical kyphosis should not be regarded as a standalone criterion of cervical deformity. The most clinically relevant components of cervical analysis are the C2-C7 SVA, C0C2 angle, and C2C7 angle. In addition, the three components should be assessed together in harmony and not individually. LEVEL OF EVIDENCE 4.
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Tobin MK, Birk DM, Rangwala SD, Siemionow K, Schizas C, Neckrysh S. T-1 pedicle subtraction osteotomy for the treatment of rigid cervical kyphotic deformity: report of 4 cases. J Neurosurg Spine 2017; 27:487-493. [PMID: 28841105 DOI: 10.3171/2016.8.spine121065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cervical kyphotic deformity represents a difficult to treat pathology often arising from multiple factors including, but not limited to, traumatic injuries, degenerative changes, and ankylosing spondylitis. Furthermore, treatment of these deformities becomes increasingly difficult with any preexisting instrumentation. Currently, several options exist to treat these severe deformities, with the Smith-Petersen osteotomy and C-7 pedicle subtraction osteotomy being the most frequently used approaches. However, these techniques come with significant risk to the patient including nerve root injury as well as compression of the vertebral arteries. The authors here report on a series of 4 patients with rigid cervical deformity who underwent T-1 pedicle subtraction osteotomy. The authors review the relevant literature and provide a novel, less risky, and potentially more corrective approach for treating cervical deformities.
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Affiliation(s)
| | | | | | | | - Constantin Schizas
- Spine Unit, Centre Hospitalier Universitaire Vaudois and University of Lausanne; and.,Orthopedic Spine Unit, Clinique Cecil Neuro, Lausanne, Switzerland
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Smith JS, Shaffrey CI, Lafage R, Lafage V, Schwab FJ, Kim HJ, Scheer JK, Protopsaltis T, Passias P, Mundis G, Hart R, Neuman B, Klineberg E, Hostin R, Bess S, Deviren V, Ames CP. Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients. 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; 26:2128-2137. [DOI: 10.1007/s00586-017-5071-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/22/2017] [Accepted: 03/26/2017] [Indexed: 11/24/2022]
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Asymmetric C7 pedicle subtraction osteotomy for correction of rigid cervical coronal imbalance secondary to post-traumatic heterotopic ossification: a case report, description of a novel surgical technique, and literature review. 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 2016; 26:141-145. [PMID: 28032224 DOI: 10.1007/s00586-016-4931-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 12/07/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Deformities of the cervical spine are uncommon in the coronal plane. In this report, a unique case of a 31-year-old male with a fixed, 30° left coronal deformity due to heterotopic ossification 3 years status post poly-trauma was treated with an asymmetric C7 pedicle subtraction osteotomy (PSO). METHODS Case report. RESULTS Pre-operatively, the patient had a fixed 45-degree left tilt of his neck and radiographs demonstrated a rigid 30° scoliosis, 7 cm coronal imbalance, and 4 cm negative sagittal balance, diffuse bridging bone between the spinous processes and the facet joints of C5 to T1 bilaterally. An asymmetric C7 PSO with C2-T3 posterior spinal fusion was completed without complication. There was residual 9° coronal deformity, 2.9 cm left coronal imbalance, and 2.3 cm sagittal imbalance. He had a marked improvement in his function, as assessed by the SF-36 physical component score (pre-op 31.1; post-op 44.7) and mental component score (pre-op 46.0; post-op 66.8). Post-operatively, neck disability index scores also improved (pre-op 38; post-op 16). Although the patient passed away from a drug overdose 14 months post-operatively, he did not report neck pain, he had not sought evaluation from another physician for his neck, and he had not undergone a subsequent neck operation before his passing. CONCLUSION In this one patient, an asymmetric C7 PSO was performed safely. While it was effective in addressing a fixed cervical coronal imbalance, its efficacy and safety profile should be confirmed in larger cohorts.
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Smith JS, Klineberg E, Shaffrey CI, Lafage V, Schwab FJ, Protopsaltis T, Scheer JK, Ailon T, Ramachandran S, Daniels A, Mundis G, Gupta M, Hostin R, Deviren V, Eastlack R, Passias P, Hamilton DK, Hart R, Burton DC, Bess S, Ames CP. Assessment of Surgical Treatment Strategies for Moderate to Severe Cervical Spinal Deformity Reveals Marked Variation in Approaches, Osteotomies, and Fusion Levels. World Neurosurg 2016; 91:228-37. [DOI: 10.1016/j.wneu.2016.04.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 11/29/2022]
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Lafage R, Challier V, Liabaud B, Vira S, Ferrero E, Diebo BG, Liu S, Vital JM, Mazda K, Protopsaltis TS, Errico TJ, Schwab FJ, Lafage V. Natural Head Posture in the Setting of Sagittal Spinal Deformity. Neurosurgery 2016; 79:108-15. [DOI: 10.1227/neu.0000000000001193] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Rigid cervical deformities are difficult problems to treat. The goals of surgical treatment include deformity correction, achieving a rigid fusion, and performing a thorough neural decompression. In stiff and ankylosed cervical spines, osteotomies are required to restore sagittal and coronal balance. In this chapter, we describe the clinical and radiographic workup for patients with cervical deformities, and delineate the various factors that must be considered when planning surgical treatment. We also describe in detail the various types of cervical osteotomies, along with their surgical technique, advantages, and potential complications.
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Ames CP, Smith JS, Eastlack R, Blaskiewicz DJ, Shaffrey CI, Schwab F, Bess S, Kim HJ, Mundis GM, Klineberg E, Gupta M, O’Brien M, Hostin R, Scheer JK, Protopsaltis TS, Fu KMG, Hart R, Albert TJ, Riew KD, Fehlings MG, Deviren V, Lafage V, _ _. Reliability assessment of a novel cervical spine deformity classification system. J Neurosurg Spine 2015; 23:673-83. [DOI: 10.3171/2014.12.spine14780] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification.
METHODS
Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: “C,” “CT,” and “T” for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; “S” for primary coronal deformity with a coronal Cobb angle ≥ 15°; and “CVJ” for primary craniovertebral junction deformity. The modifiers included C2–7 sagittal vertical axis (SVA), horizontal gaze (chin-brow to vertical angle [CBVA]), T1 slope (TS) minus C2–7 lordosis (TS–CL), myelopathy (modified Japanese Orthopaedic Association [mJOA] scale score), and the Scoliosis Research Society (SRS)-Schwab classification for thoracolumbar deformity. Application of the classification system requires the following: 1) full-length standing posteroanterior (PA) and lateral spine radiographs that include the cervical spine and femoral heads; 2) standing PA and lateral cervical spine radiographs; 3) completed and scored mJOA questionnaire; and 4) a clinical photograph or radiograph that includes the skull for measurement of the CBVA. A series of 10 CSD cases, broadly representative of the classification system, were selected and sufficient radiographic and clinical history to enable classification were assembled. A panel of spinal deformity surgeons was queried to classify each case twice, with a minimum of 1 intervening week. Inter- and intrarater reliability measures were based on calculations of Fleiss k coefficient values.
RESULTS
Twenty spinal deformity surgeons participated in this study. Interrater reliability (Fleiss k coefficients) for the deformity descriptor rounds 1 and 2 were 0.489 and 0.280, respectively, and mean intrarater reliability was 0.584. For the modifiers, including the SRS-Schwab components, the interrater (round 1/round 2) and intrarater reliabilities (Fleiss k coefficients) were: C2–7 SVA (0.338/0.412, 0.584), horizontal gaze (0.779/0.430, 0.768), TS-CL (0.721/0.567, 0.720), myelopathy (0.602/0.477, 0.746), SRS-Schwab curve type (0.590/0.433, 0.564), pelvic incidence-lumbar lordosis (0.554/0.386, 0.826), pelvic tilt (0.714/0.627, 0.633), and C7-S1 SVA (0.071/0.064, 0.233), respectively. The parameter with the poorest reliability was the C7–S1 SVA, which may have resulted from differences in interpretation of positive and negative measurements.
CONCLUSIONS
The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.
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Affiliation(s)
- Christopher P. Ames
- 1Department of Neurosurgery, University of California, San Francisco, California
| | - Justin S. Smith
- 2Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Robert Eastlack
- 3San Diego Center for Spinal Disorders, San Diego, California
| | | | - Christopher I. Shaffrey
- 2Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Frank Schwab
- 4Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- 5Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Han Jo Kim
- 6Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Eric Klineberg
- 7Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Munish Gupta
- 7Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Michael O’Brien
- 8Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Richard Hostin
- 8Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Justin K. Scheer
- 9Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kai-Ming G. Fu
- 10Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | - Robert Hart
- 11Department of Orthopedic Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Todd J. Albert
- 12Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - K. Daniel Riew
- 13Department of Orthopedic Surgery, Washington University, St Louis, Missouri
| | | | - Vedat Deviren
- 15Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Virginie Lafage
- 4Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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