【Abstract】 Objective To evaluate the surgical management of rigid post-traumatic thoracolumbar kyphosis (RPTK) by simultaneous posterio-anterior circumferential releasing, correction and anterior corpectomy with preserved posterior vertebral wall. Methods Twenty patients with RPTK were treated between October 2004 and October 2010 by posterior releasing, anterior subtotal corpectomy with preserved posterior vertebral wall, correction, strut graft, and short segmental fixation. There were 14 males and 6 females with an average age of 43.2 years (range, 23-63 years). The time between injury and operation was 4 months to 23 years (mean, 1.4 years). The affected locations were T11 in 1 case, T12 in 8 cases, L1 in 10 cases, and L2 in 1 case. The Cobb angle and the intervertebral height of the fractured vertebra body were measured before and after operations. The degrees of low back pain were assessed by Japanese Orthopaedic Association (JOA) scores. Results No incision infection, nerve injury, or cerebral spinal fluid leakage occurred. Seventeen patients were followed up 1-5 years with an average of 2.8 years. The JOA score at last follow-up (26.2 ± 3.9) was significantly improved when compared with the pre-operative score (14.0 ± 5.7) (t=4.536, P=0.001). One patient had aggravation of kyphosis at 3 months postoperatively, who was in stabilized condition after prolonging immobilizated time. The Cobb angle was corrected from (43.2 ± 11.5)° preoperatively to (9.8 ± 5.7)° at last follow-up, showing significant difference (P lt; 0.01). There was significant difference in the intervertebral height of the fractured vertebra body between preoperation and last follow-up (P lt; 0.05). The intervertebral height of fractured vertebra was restored to 87.0% ± 11.2% of adjacent disc height. Conclusion Posterio-anterior circumferential releasing and anterior corpectomy with preserved posterior vertebral wall can achieve satifactory clinical results, not only in pain relieving, kyphosis correction, vertebral height restoration, and spinal stability restoration, but also in the risk reduce of bleeding and spinal cord disturbance.
Objective To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the influence on effectiveness. Methods The clinical data of 36 patients with single-segment CSM with cervical kyphosis who were admitted between January 2020 and December 2022 and met the selection criteria were retrospectively analyzed. The patients were divided into 3 groups according to the positional relationship between the kyphosis focal on cervical spine X-ray film and the spinal cord compression point on MRI: the same group (group A, 20 cases, both points were in the same position), the adjacent group (group B, 10 cases, both points were located adjacent to each other), and the separated group (group C, 6 cases, both points were located >1 vertebra away from each other). There was no significant difference between groups (P>0.05) in baseline data such as gender, age, body mass index, lesion segment, disease duration, and preoperative C2-7 angle, C2-7 sagittal vertical axis (C2-7 SVA), C7 slope (C7S), kyphotic Cobb angle, fusion segment height, and Japanese Orthopedic Association (JOA) score. The patients underwent single-segment anterior cervical discectomy with fusion (ACDF). The occurrence of postoperative complications was recorded; preoperatively and at last follow-up, the patients’ neurological function was evaluated using the JOA score, and the sagittal parameters (C2-7 angle, C2-7 SVA, C7S, kyphotic Cobb angle, and height of the fused segments) were measured on cervical spine X-ray films and MRI and the correction rate of the cervical kyphosis was calculated; the correlation between changes in cervical sagittal parameters before and after operation and the JOA score improvement rate was analyzed using Pearson correlation analysis. Results In 36 patients, only 1 case of dysphagia occurred in group A, and the dysphagia symptoms disappeared at 3 days after operation, and the remaining patients had no surgery-related complications during the hospitalization. All patients were followed up 12-42 months, with a mean of 20.1 months; the difference in follow-up time between the groups was not significant (P>0.05). At last follow-up, all the imaging indicators and JOA scores of patients in the 3 groups were significantly improved when compared with preoperative ones (P<0.05). The correction rate of cervical kyphosis in group A was significantly better than that in group C, and the improvement rate of JOA score was significantly better than that in groups B and C, all showing significant differences (P<0.05), and there was no significant difference between the other groups (P>0.05). The correlation analysis showed that the improvement rate of JOA score was negatively correlated with C2-7 angle and kyphotic Cobb angle at last follow-up (r=−0.424, P=0.010; r=−0.573, P<0.001), and positively correlated with the C7S and correction rate of cervical kyphosis at last follow-up (r=0.336, P=0.045; r=0.587, P<0.001), and no correlation with the remaining indicators (P>0.05). Conclusion There are three main positional relationships between the cervical kyphosis focal and the spinal cord compression point on imaging, and they have different impacts on the effectiveness and sagittal parameters after ACDF, and those with the same position cervical kyphosis focal and spinal cord compression point have the best improvement in effectiveness and sagittal parameters.
Objective To explore the safety and effectiveness of one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation in the treatment of ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. Methods A clinical data of 20 patients with ankylosing spondylitis kyphosis combined with acute thoracolumbar spine fracture, who were treated with one-stage posterior eggshell osteotomy and long-segment pedicle screw fixation between April 2016 and January 2022, was retrospectively analyzed. Among them, 16 cases were male and 4 cases were female; their ages ranged from 32 to 68 years, with an average of 45.9 years. The causes of injury included 10 cases of sprain, 8 cases of fall, and 2 cases of falling from height. The time from injury to operation ranged from 1 to 12 days, with an average of 7.1 days. The injured segment was T11 in 2 cases, T12 in 2 cases, L1 in 6 cases, and L2 in 10 cases. X-ray film and CT showed that the patients had characteristic imaging manifestations of ankylosing spondylitis, and the fracture lines were involved in the anterior, middle, and posterior columns and accompanied by different degrees of kyphosis and vertebral compression; and MRI showed that 12 patients had different degrees of nerve injuries. The operation time, intraoperative bleeding, intra- and post-operative complications were recorded. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were used to evaluate the low back pain and quality of life, and the American spinal cord injury association (ASIA) classification was used to evaluate the neurological function. X-ray films were taken, and local Cobb angle (LCA) and sagittal vertical axis (SVA) were measured to evaluate the correction of the kyphosis. Results All operations were successfully completed and the operation time ranged from 127 to 254 minutes (mean, 176.3 minutes). The amount of intraoperative bleeding ranged from 400 to 950 mL (mean, 722.5 mL). One case of dural sac tear occurred during operation, and no cerebrospinal fluid leakage occurred after repair, and the rest of the patients did not suffer from neurological and vascular injuries, cerebrospinal fluid leakage, and other related complications during operation. All incisions healed by first intention without infection or fat liquefaction. All patients were followed up 8-16 months (mean, 12.5 months). The VAS score, ODI, LCA, and SVA at 3 days after operation and last follow-up significantly improved when compared with those before operation (P<0.05), and the difference between 3 days after operation and last follow-up was not significant (P>0.05). The ASIA grading of neurological function at last follow-up also significantly improved when compared with that before operation (P<0.05), including 17 cases of grade E and 3 cases of grade D. At last follow-up, all bone grafts achieved bone fusion, and no complications such as loosening, breaking of internal fixation, and pseudoarthrosis occurred. Conclusion One-stage posterior eggshell osteotomy and long-segment pedicle screw fixation is an effective surgical procedure for ankylosing spondylitis kyphosis combined with acute thoracolumbar vertebral fracture. It can significantly relieve patients’ clinical symptoms and to some extent, alleviate the local kyphotic deformity.
ObjectiveTo explore the clinical characteristics and surgical treatment strategies of delayed spinal cord injury (SCI) caused by atypical compression of old thoracolumbar fracture.MethodsBetween January 2011 and June 2018, 32 patients with delayed SCI caused by atypical compression of old thoracolumbar fracture who met the inclusion criteria were admitted and divided into group A (20 cases, underwent anterior subtotal vertebral body resection+titanium mesh reconstruction+screw rod internal fixation) and group B (12 cases, underwent posterior 270° ring decompression of vertebral canal+titanium mesh reconstruction+screw rod internal fixation) according to the different operation approaches. There was no significant difference between the two groups in age, gender, cause of injury, fracture segment, disease duration, preoperative American Spinal Injury Association (ASIA) classification, and preoperative back pain visual analogue scale (VAS) score, lumbar Japanese Orthopaedic Association (JOA) score, kyphosis angle, and vertebral canal occupational ratio (P>0.05). The incision length, operation time, intraoperative blood loss, complications, and bone fusion time of reconstructed vertebrae were recorded and compared between the two groups; the kyphosis angle, back pain VAS score, and lumbar JOA score were used to evaluate the effectiveness.ResultsExcept that the incision length in group A was significantly shorter than that in group B (t=−4.865, P=0.000), there was no significant difference in intraoperative blood loss and operation time between the two groups (P>0.05). There was no deaths or postoperative paraplegia cases in the two groups, and no deep infection or skin infection occurred. There was 1 case of cerebrospinal fluid leakage, 1 case of inferior vena cava injury, and 1 case of chyle leakage in group A. No serious complications occurred in group B. There was no significant difference in the incidence of complications between the two groups (P=0.274). All 32 patients were followed up 12-61 months, with an average of 20.8 months. The follow-up time for groups A and B were (19.35±5.30) months and (23.25±12.20) months respectively, and the difference was not significant (t=−1.255, P=0.219). The reconstructed vertebrae in all cases obtained bony fusion postoperatively. The fusion time of groups A and B were (8.85±2.27) months and (8.50±2.50) months respectively, and the difference was not significant (t=0.406, P=0.688). The kyphosis angle, back pain VAS score, and lumbar JOA score of the two groups at each time point after operation and last follow-up were significantly improved when compared with preoperatively (P<0.05); the lumbar JOA score was further improved with time postoperatively (P<0.05), while the kyphosis angle and the VAS score of back pain remained similarly (P>0.05). Comparison of kyphosis angle, back pain VAS score, and lumbar JOA score between the two groups at various time points postoperatively showed no significant difference (P>0.05). At last follow-up, the JOA score improvement rate in groups A and B were 83.87%±0.20% and 84.50%±0.14%, respectively, and the difference was not significant (t=–0.109, P=0.914); the surgical treatment effects of the two groups were judged to be significant.ConclusionIn the later stage of treatment of old thoracolumbar fractures, even mild kyphosis and spinal canal occupying may induce delayed SCI. Surgical correction and decompression can significantly promote the recovery of damaged spinal cord function. Compared with anterior approach surgery, posterior approach surgery has the advantages of less trauma, convenient operation, and fewer complications, so it can be preferred.
Objective To evaluate the effectiveness of using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach to treat thoracolumbar kyphosis caused by old fracture. Methods Between June 2008 and June 2010, 15 cases of thoracolumbar kyphosis caused by old fracture were treated with pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach. There were 9 males and 6 females with a mean age of 54.6 years (range, 39-65 years). The disease duration was 5 months to 3 years with an average of 1.5 years. Fractured segments included T11 in 1 case, T12 in 4 cases, L1 in 5 cases, and L2 in 5 cases. Ten patients had nerve symptom, according to American Spinal Injury Association (ASIA) grading, 3 cases were classified as grade B, 4 cases as grade C, and 3 cases as grade D, of which 3 cases had sexual and sphincter dysfunction. At preoperation, the Cobb angle was (47.4 ± 10.2)°; the Oswestry disability index (ODI) score was 67.9% ± 6.9%; and the visual analogue scale (VSA) was 8.6 ± 1.4. Results The wounds obtained primary healing. The mean follow-up time was 28 months (range, 13-60 months). X-ray films showed intervertebral bone fusion was obtained within 6-11 months (mean, 10.2 months). No fixation loosening or breaking occurred during follow-up. Kyphosis was corrected, and lumbar back pain was relieved. At 1 year after operation, Cobb angle was significantly corrected to (13.3 ± 7.7)° (t=72.80, P=0.00); ODI score was significantly improved to 25.2% ± 4.6% (t=48.04, P=0.00); VAS score was significantly decreased to 2.3 ± 0.6 (t=26.52, P=0.00). According to ASIA grading in 10 patients with spinal cord injury, the spinal cord function was improved by 1 grade in 8 cases (3 cases from grade B to C, 3 cases from grade C to D, and 2 cases from grade D to E); 3 patients with sexual and sphincter dysfunction recovered in different degrees. Conclusion Using pedical screw at the fracture level, intervertebral distraction, and Cage insertion by posterior approach is an effective method to treat thoracolumbar kyphosis caused by old fracture.
Objective To review current status of surgical treatment for angular kyphosis in spinal tuberculosis and provide reference for clinical treatment. Methods The literature on the surgical treatment for angular kyphosis of spinal tuberculosis in recent years was extensively reviewed and summarized from the aspects of surgical indications, surgical contraindications, surgical approach, selection of osteotomy, and perioperative management. Results Angular kyphosis of spine is a common complication in patients with spinal tuberculosis. If kyphosis progresses gradually, it is easy to cause neurological damage, deterioration, and delayed paralysis, which requires surgical intervention. At present, surgical approaches for angular kyphosis of the spine include anterior approach, posterior approach, and combined anterior and posterior approaches. Anterior approach can be performed for patients with severe spinal cord compression and small kyphotic Cobb angle. Posterior approach can be used for patients with large kyphotic Cobb angle but not serious neurological impairment. A combined anterior and posterior approaches is an option for spinal canal decompression and orthosis. Osteotomy for kyphotic deformity include Smith-Peterson osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection(VCR), vertebral column decancellation (VCD), posterior vertebral column resection (PVCR), deformed complex vertebral osteotomy (DCVO), and Y-shaped osteotomy. SPO and PSO are osteotomy methods with relatively low surgical difficulty and low surgical risks, and can provide 15°-30° angular kyphosis correction effect. VCR or PVCR is a representative method of osteotomy and correction. The kyphosis correction can reach 50° and is suitable for patients with severe angular kyphosis. VCD, DCVO, and Y-shaped osteotomy are emerging surgical techniques in recent years. Compared with VCR, the surgical risks are lower and the treatment effects also improve to varying degrees. Postoperative recovery is also a very important part of the perioperative period and should be taken seriously. Conclusion There is no consensus on the choice of surgical treatment for angular kyphosis in spinal tuberculosis. Osteotomy surgery are invasive, which is a problem that colleagues have always been concerned about. It is best to choose a surgical method with less trauma while ensuring the effectiveness.
ObjectiveTo introduce a self-designed adjustable operation frame and explore the feasibility and safety in the treatment of severe kyphosis secondary to ankylosing spondylitis with posterior osteotomy.MethodsBetween March 2016 and May 2018, 7 cases of severe kyphosis secondary to ankylosing spondylitis were treated with posterior osteotomy using self-designed adjustable operation frame with prone position. There were 5 males and 2 females with an average age of 49.4 years (range, 40-55 years). The disease duration was 10-21 years (mean, 16.7 years). The apical vertebrae of kyphosis were located at T11 in 2 cases, T12 in 1 case, L1 in 1 case, and L2 in 3 cases. Among the 7 cases, 2 were classified as typeⅠ, 4 as type ⅡB, and 1 as type ⅢA according to 301 classification system. There was no neurological deficit of all cases; but 1 case suffered bilateral hip joints ankylosed in non-functional position. The parameters of chin-brow vertical angle (CBVA), global kyphosis (GK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sagittal vertical axis (SVA) were measured; and the operation time, the intraoperative blood loss, and the complications were also collected and analyzed.ResultsAll operations completed successfully. The operation time was 310-545 minutes (mean, 409.7 minutes) and the intraoperative blood loss was 1 500-2 500 mL (mean, 1 642.9 mL). There were 2 cases treated with one-level osteotomy of sagittal translation, 1 case of radiculopathy symptom of L3, and 3 cases of tension of abdominal skin. All patients were followed up 20-35 months (mean, 27.9 months). There were significant differences in CBVA, GK, TLK, LL, and SVA between pre- and post-operation (P<0.05); but no significant difference between 1 week after operation and last follow-up (P>0.05). All the osteotomies and bone grafts fused well and no complications of loosening and breakage of internal fixator occurred during the follow-up.ConclusionIn the posterior osteotomy for correction of severe kyphosis secondary to ankylosing spondylitis, the self-designed adjustable operation frame is convenient for the patient to be placed in prone position. It is safe, feasible, and effective to perform osteotomy correction with the aid of the self-designed adjustable operation frame.
Objective To investigate the effectiveness of transvertebral space and under the pedicle osteotomy for thoracolumbar kyphosis caused by old osteoporotic vertebral compression fracture (OVCF). Methods The clinical data of 11 patients with thoracolumbar kyphosis caused by old OVCF treated by transvertebral space and under the pedicle osteotomy between January 2016 and December 2020 were retrospectively analyzed. There were 2 males and 9 females, with an average age of 61.3 years (range, 50-77 years) and with a median disease duration of 8 years (range, 6 months to 50 years). Fracture reasons: 9 cases had a clear history of trauma, and 2 cases had no obvious incentive. A total of 11 vertebrae was involved in fracture, including T12 in 3, L1 in 7, L2 in 1. The operation time, intraoperative blood loss, postoperative drainage volume, and complications were recorded. Full-length X-ray films of spine and local X-ray films of the operation area were examined before operation, at 7 days after operation, and at last follow-up. The Cobb angle of thoracolumbar kyphosis was measured, and the correction rate was calculated. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were recorded to assess patients’ pain and functional improvement before operation, at 1 month after operation, and at last follow-up. Results All operations were successfully completed. The average operation time was 188.6 minutes (range, 140-215 minutes); the average intraoperative blood loss was 268.2 mL (range, 100-500 mL); the average postoperative drainage volume was 615.5 mL (range, 160-1 500 mL). One patient developed bilateral thigh rebound pain after operation, which relieved after symptomatic treatment of nutritional nerve and acesodyne. All patients were followed up 14.7 months on average (range, 6-56 months). At last follow-up, osseous fusion was observed in all patients, and no fracture, loose, or displacement of internal fixator was observed on imaging. At 7 days after operation and at last follow-up, the Cobb angle of thoracolumbar kyphosis significantly improved when compared with preoperative one (P<0.05), and there was no significant difference between at 7 days after operation and at last follow-up (P>0.05); the correction rates of Cobb angle at 7 days after operation and at last follow-up were 68.0%±9.8% and 60.3%±11.9%, respectively. At 1 month after operation and at last follow-up, the VAS score and ODI significantly improved when compared with preoperative ones, and further improved at last follow-up when compared with those at 1 month after operation, all showing significant differences (P<0.05). ConclusionTransvertebral space and under the pedicle osteotomy is an effective way to treat thoracolumbar kyphosis caused by old OVCF with less trauma, shorter operation time, and less intraoperative blood loss. Patients can obtain good orthopedic results and quality of life.
Objective To introduce a scout view scanning technique of back-forward bending CT (BFB-CT) in simulated surgical position for evaluating the remaining real angle and flexibility of thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture. Methods A total of 28 patients with thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture who met the selection criteria between June 2018 and December 2021 were included in the study. There were 6 males and 22 females with an average age of 69.5 years (range, 56-92 years). The injured vertebra were located at T10-L2, including 11 cases of single thoracic fracture, 11 cases of single lumbar fracture, and 6 cases of multiple thoracolumbar fractures. The disease duration ranged from 3 weeks to 36 months, with a median of 5 months. All patients received examinations of BFB-CT and standing lateral full-spine X-ray (SLFSX). The thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), local kyphosis of injured vertebra (LKIV), lumbar lordosis (LL), and the sagittal vertical axis (SVA) were measured. Referring to the calculation method of scoliosis flexibility, the kyphosis flexibility of thoracic, thoracolumbar, and injured vertebra were calculated respectively. The sagittal parameters measured by the two methods were compared, and the correlation of the parameters measured by the two methods was analyzed by Pearson correlation. Results Except LL (P>0.05), TK, TLK, LKIV, and SVA measured by BFB-CT were significantly lower than those measured by SLFSX (P<0.05). The flexibilities of thoracic, thoracolumbar, and injured vertebra were 34.1%±18.8%, 36.2%±13.8%, and 39.3%±18.6%, respectively. Correlation analysis showed that the sagittal parameters measured by the two methods were positively correlated (P<0.001), and the correlation coefficients of TK, TLK, LKIV, and SVA were 0.900, 0.730, 0.700, and 0.680, respectively. Conclusion Thoracolumbar kyphosis secondary to old osteoporotic vertebral compression fracture shows an excellent flexibility and BFB-CT in simulated surgical position can obtain the remaining real angle which need to be corrected surgically.
Objective To investigate the effect of the sequence of intermediate instrumentation with long screws and distraction-reduction on mild to moderate thoracolumbar fractures treated by posterior open and short-segmental fixation. MethodsThe clinical data of 68 patients with mild to moderate thoracolumbar burst fractures who met the selection criteria between January 2016 and June 2019 were retrospectively analyzed. The patients were divided into group ISDRF (intermediate screws then distraction-reduction fixation, 32 cases) and group DRISF (distraction-reduction then intermediate screws fixation, 36 cases) according to the different operation methods. There was no significant difference between the two groups in age, gender, body mass index, fracture segment, cause of injury, and preoperative load-sharing classification score, thoracolumbar injury classification and severity score, vertebral canal occupational rate, back pain visual analogue scale (VAS) score, anterior height of fractured vertebra, and Cobb angle (P>0.05). The operation time, intraoperative blood loss, complications, and fracture healing time were recorded and compared between the two groups. The vertebral canal occupational rate, anterior height of fractured vertebra, kyphosis Cobb angle, and back pain VAS score before and after operation were used to evaluate the effectiveness. Results There was no significant difference in intraoperative blood loss and operation time between the two groups (P>0.05). No vascular or spinal nerve injury and deep infections or skin infections occurred in both groups. At 1 week after operation, the vertebral canal occupational rate in the two groups was significantly improved when compared with that before operation (P<0.05), no significant difference was found in the difference of vertebral canal occupational rate before and after operation and improvement between the two groups (P>0.05). The patients in both groups were followed up 18-24 months, with an average of 22.3 months. All vertebral fractures reached bone union at 6 months postoperatively. At last follow-up, there was no internal fixation failures such as broken screws, broken rods or loose screws, but there were 2 cases of mild back pain in the ISDRF group. The intra-group comparison showed that the back pain VAS score, the anterior height of fractured vertebra, and the Cobb angle of the two groups were significantly improved at each time point postoperatively (P<0.05); the VAS scores at 12 months postoperatively and last follow-up were also improved when compared with that at 1 week postoperatively (P<0.05). At last follow-up, the anterior height of fractured vertebra in the ISDRF group was significantly lost when compared with that at 1 week and 12 months postoperatively (P<0.05), the Cobb angle had a significant loss when compared with that at 1 week postoperatively (P<0.05); the anterior height of fractured vertebra and Cobb angle in DRISF group were not significantly lost when compared with that at 1 week and 12 months postoperatively (P>0.05). The comparison between groups showed that there was no significant difference in the remission rate of VAS score between the two groups at 1 week postoperatively (P>0.05), the recovery value of the anterior height of fractured vertebra in ISDRF group was significantly higher than that in DRISF group (P<0.05), the loss rate at last follow-up was also significantly higher (P<0.05); the correction rate of Cobb angle in ISDRF group was significantly higher than that in DRISF group at 1 week postoperatively (P<0.05), but there was no significant difference in the loss rate of Cobb angle between the two groups at last follow-up (P>0.05). ConclusionIn the treatment of mild to moderate thoracolumbar burst fractures with posterior short-segment fixation, the instrumentation of long screws in the injured vertebrae does not affect the reduction of the fracture fragments in the spinal canal. DRISF can better maintain the restored anterior height of the fractured vertebra and reduce the loss of kyphosis Cobb angle during the follow-up, indicating a better long-term effectiveness.