Modified partial pedicle subtraction osteotomy for the correction of post-traumatic thoracolumbar kyphosis

doi:10.1016/j.spinee.2015.04.047

The Spine Journal

Volume 15, Issue 9, 1 September 2015, Pages 2009-2015

https://doi.org/10.1016/j.spinee.2015.04.047 Get rights and content

Abstract

Background context

Pedicle subtraction osteotomy (PSO) is the most commonly recommended technique for the correction of local post-traumatic thoracolumbar deformity; however, the surgical results are not always satisfactory because the possibly damaged upper disc is preserved, and all the posterior elements are resected.

Purpose

The aim was to compare the results of standard PSO and modified PSO in the treatment of post-traumatic thoracolumbar kyphosis.

Study design

This was a retrospective multicenter comparative clinical study.

Patient sample

A total of 86 patients were included in the final analysis.

Outcome measures

The outcome measures included local Cobb angle of the kyphosis, visual analog scale (VAS) score, and Oswestry disability index (ODI) score.

Methods

The upper disc was resected, and the inferior wall of the index pedicle and the lower facet joint were preserved in the modified PSO. Patients with focal kyphosis greater than 30° who were treated with one-level osteotomy, without the presence of spine neoplasm, infection, or previous surgery, were included. The measurements included the VAS score, ODI score, and preoperative and postoperative Cobb angles.

Results

Forty-two patients in the modified PSO group and 44 in the standard PSO group were included in the final analysis. The mean surgical time and blood loss were similar between the two groups. Both the VAS and ODI scores had improved significantly at the final follow-up in the two groups. The mean Cobb angle significantly improved from 39.6° to 5.6° in the modified PSO group and from 39.1° to 4.8° in the standard PSO group, with no significant difference between the two groups preoperatively or at the final follow-up.

Conclusions

The modified PSO provides an alternative method with which to correct kyphotic deformity in patients with post-traumatic thoracolumbar kyphosis.

Introduction

Evidence & Methods

The authors present a retrospective review of results of their modified pedicle subtraction osteotomy (PSO) technique as compared to conventional PSO. Their technique involves resection of the proximal endplate with preservation of the inferior wall of the pedicle and the inferior aspect of the facet joint.

The authors' review their results in 42 cases and compare short-term outcomes to 44 patients treated using conventional PSO. Comparable outcomes and perioperative measures are reported between the two groups.

The authors' results should not be surprising as their modification is unlikely to impact most perioperative metrics. As a retrospective review of a limited sample, subject to selection, indication and possibly information bias, this study should be viewed as providing Level IV evidence.

—The Editors

Late post-traumatic kyphosis is the most common sequela of spinal column fractures, developing most commonly after flexion-compression-type fractures. Late kyphotic deformity is thought to be caused by progressive wedging of the vertebral body and weakness of the posterior osseous-ligamentous complex. The thoracolumbar junction from T11 to L2 is the most commonly involved area of the spine [1]. Surgery is recommended for patients with significant pain or progressive neurologic deficits, with a sagittal index of 20° being the cutoff value for surgical intervention. The main aim of surgical treatment for kyphotic deformity is to restore the normal sagittal balance and release the neural structures to improve pain and neurologic symptoms [2].

Since 1945, many surgical procedures have been proposed for the correction of thoracolumbar kyphosis [3]. The correction angle, potential risks, and suitable indications are different for different types of osteotomies. Pedicle subtraction osteotomy (PSO) is the most commonly recommended technique to correct local post-traumatic thoracolumbar deformity because it does not lengthen the anterior column and potentially reduces the need for an anterior procedure [4]. However, the surgical results are not always satisfactory because the potentially damaged upper disc is preserved, and all the posterior elements are resected during this procedure.

Therefore, we developed a modified PSO in which the upper disc is resected, and the inferior wall of the index pedicle and the lower facet joint are preserved. The purpose of this study was to compare the radiographic and clinical results of modified PSO and standard PSO for the correction of post-traumatic thoracolumbar kyphosis. Our hypotheses were as follows: the correction of the focal kyphotic deformity would be nearly identical in the two groups; improvement in the visual analog scale (VAS) and Oswestry disability index (ODI) scores would be identical; blood loss and surgical time would be equal in both the groups; complications would be substantial in both the groups; and the need for anterior surgery would be identical in both the groups.

Section snippets

Subjects and study design

This study was a retrospective, multicenter (three centers) study. Between January 2010 and December 2011, a total of 44 patients underwent modified PSO, and 45 patients underwent standard PSO for late post-traumatic thoracolumbar kyphosis. The inclusion criterion was one-level osteotomy for the treatment of symptomatic kyphosis. Patients aged 18 to 65 years with focal thoracolumbar kyphosis greater than 30° due to a previous vertebral body fracture (time interval≥6 months) were included. The

Patient characteristics

Two patients in the modified PSO group and one in the standard PSO group were lost to follow-up postoperatively; thus, there were 86 patients included in the final analysis. Demographic data are shown in Table 1. The mean age at the time of surgery was 46.9±6.2 years (range 32–58 years), and 65.1% of the patients were males. The levels of the osteotomy were T11 (n=5), T12 (n=29), L1 (n=42), and L2 (n=10). The mean time interval between injury and surgery was 31.4±17.9 months (range 6–84

Discussion

The aim of this study was to evaluate the safety and efficacy of modified PSO in the treatment of post-traumatic thoracolumbar kyphosis by comparing it with standard PSO. We determined in this study that the modified PSO yielded similar results with respect to clinical and radiologic outcomes as the standard PSO. The improvement in the VAS, ODI, and focal Cobb angle was not significantly different between the two groups, and there were no severe complications in either group, similar surgical

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Correction of post-traumatic thoracolumbar kyphosis using pedicle subtraction osteotomy
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Cited by (24)

Distal junctional failure after corrective surgery without pelvic fixation for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture
2023, Journal of Orthopaedic Science
Thoracolumbar junctional kyphosis (TLJK) due to osteoporotic vertebral fracture (OVF) negatively impacts patients’ quality of life. The necessity of pelvic fixation in corrective surgery for TLJK due to OVF remains controversial. This study aimed to: 1) evaluate the surgical outcomes of major corrective surgery for thoracolumbar junctional kyphosis due to osteoporotic vertebral fracture, and 2) identify the risk factors for distal junctional failure to identify potential candidates for pelvic fixation.
Patients who underwent surgical correction (fixed TLJK>40°, OVF located at T11–L2, the lowermost instrumented vertebra at or above L5) were included. Sagittal vertical axis, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis (L1-S1), local kyphosis, and lower lumbar lordosis (L4-S1) were assessed. Proximal and distal junctional kyphosis (P/DJK) and failures (P/DJF) were evaluated. Pre/postoperative spinopelvic parameters were compared between DJF and non-DJF patients.
Thirty-one patients (mean age: 72.3 ± 7.9 years) were included. PJK was observed in five patients (16.1%), while DJK in 11 (35.5%). Twelve cases (38.7%) were categorized as failure. Among the patients with PJK, there was only one patient (20%) categorized as PJF and required an additional surgery. Contrary, all of eleven patients with DJK were categorized as DJF, among whom six (54.5%) required additional surgery for pelvic fixation. In comparisons between DJF and non-DJF patients, there was no significant difference in pre/postoperative LK (pre/post, p = 0.725, p = 0.950). However, statistically significant differences were observed in the following preoperative alignment parameters: SVA (p = 0.014), LL (p = 0.001), LLL (p = 0.006), PT (p = 0.003), and PI-LL (p < 0.001).
Spinopelvic parameters, which represent the compensatory function of lumbar hyperlordosis and pelvic retroversion, have notable impacts on surgical outcomes in correction surgery for TLJK due to OVF. Surgeons should consider each patient's compensatory function when choosing a surgical approach.
Partial Hemivertebra Resection (Grade 4 Osteotomy) for Congenital Scoliosis: A Comparison with Radical Hemivertebra resection
2019, World Neurosurgery
Citation Excerpt :
Therefore, less invasive surgical strategy, instead of radical HV resection, may be better indicated for patients with relatively moderate deformity. Grade 4 osteotomy, defined by Schwab et al.5 in 2014, was recently used in patients with posttraumatic thoracolumbar kyphosis with satisfactory correction.6,15 Shi et al.7 reported 38 patients with congenital kyphosis following grade 4 osteotomy, demonstrating its excellent utility in moderate kyphosis.
To compare radiological and clinical outcomes between partial and radical hemivertebra (HV) resection in congenital scoliosis (CS) patients with single nonincarcerated HV.
CS patients with single HV undergoing partial HV resection from February 2011 to May 2016 were retrospectively reviewed and included in the P group; those undergoing radical HV resection were included in the R group. Patients in R group were age-, sex-, curve magnitude-, and apex location-matched with those in P group. Comparisons were performed in terms of radiological results, clinical outcomes, and complications preoperation, postoperation, and at the last follow-up between the P and R groups.
Both P and R groups included 25 CS patients, and the mean age at surgery was 10.1 ± 5.2 years. Compared with the R group, the P group had a similar correction of the Cobb angle at postoperation (38.6 ± 6.7° vs. 35.2 ± 5.6°, P = 0.057) and at the last follow-up (38.4 ± 7.0° vs. 34.7 ± 6.7°, P = 0.062). The estimated blood loss was 690.9 ± 291.3 mL in the R group and 502.2 ± 223.8 mL in the P group (P = 0.023), and the operating time was 259.4 ± 70.2 minutes in the R group and 206.9 ± 61.2 minutes in the P group (P = 0.007). During follow-up, no significant correction loss and major complication were observed in the P group, whereas 1 patient in the R group had rod breakage with pseudarthrosis at 24-month follow-up.
Partial HV resection is a safe, effective, and less invasive procedure and achieved comparable correction with radical HV resection in the treatment of CS patients with single nonincarcerated HV.
SRS-Schwab Grade 4 osteotomy for congenital thoracolumbar kyphosis: a minimum of 2 years follow-up study
2018, Spine Journal
Citation Excerpt :
It is noteworthy that, although the Grade 4 osteotomy was literarily defined in 2014 by Schwab et al. [9], this particular surgical strategy has been earlier practically applied in our scoliosis center since 1999. Initially, the Grade 4 osteotomy was used for the treatment of late-onset kyphosis secondary to thoracolumbar burst fracture by vertebral shortening, and satisfying clinical outcomes were confirmed by previous studies [17,18]. Similarly, we believe that the SRS-Schwab Grade 4 osteotomy should also be suitable for patients with CK, particularly for those with moderate deformities.
Several osteotomy techniques including pedicle subtraction osteotomy and vertebral column resection have been employed in the correction of congenital kyphosis (CK) and satisfying outcomes have been demonstrated. However, the Scoliosis Research Society (SRS)-Schwab Grade 4 osteotomy, defined as resection of posterior elements, partial vertebral body, and superior adjacent disc, is rarely reported in the treatment of CK.
The present study aimed to evaluate the efficiency and safety of SRS-Schwab Grade 4 osteotomy in patients with CK, and to propose its optimal indication.
This is a retrospective analysis of clinical and radiographic outcomes of patients with CK undergoing SRS-Schwab Grade 4 osteotomy.
Patients with thoracolumbar CK undergoing SRS-Schwab Grade 4 osteotomy from January 2010 to May 2015 followed up for at least 2 years were retrospectively reviewed.
The thoracic kyphosis, lumbar lordosis, segmental kyphosis (SK), sagittal vertical axis (SVA), pelvic incidence, pelvic tilt, and sacral slope were measured on lateral spinal x-rays. Patients were required to fulfill the SRS-22 questionnaire at preoperation and the last follow-up.
The sagittal spinal-pelvic parameters were assessed at preoperation, postoperation, and last follow-up. The comparison between preoperation and postoperation was performed by paired samples t test.
A total of 38 patients with CK (17 male and 21 female) with an average age of 16.5±9.9 years were included. The mean operating time was 242.7±88.1 minutes and blood loss was 634.5±177.8 mL. The mean follow-up was 38.8±20.3 months. The SK was 49.5±11.7° at preoperation, 6.8±7.4° at postoperation (p<.001), and 8.0±8.1° at the last follow-up. No significant correction loss during follow-up was found in SK (p=.125). The SVA was improved from −36.0±18.3 mm at preoperation to 3.7±17.8 mm at postoperation (p<.001), and the correction was well maintained during follow-up (p=.113). Compared with preoperation, the mean postoperative scores of each domains of SRS-22 questionnaire improved at different levels. Intraoperative complications included one case with incidental dural tear and another with transient root injury. Proximal junctional kyphosis occurred in three patients at 6 months after operation and remained stable during the follow-up. At the last follow-up, all patients were identified to have achieved solid bony fusion.
The SRS-Schwab Grade 4 osteotomy, if selected appropriately, could provide satisfying correction of congenital kyphosis. The correction could be well maintained during the longitudinal follow-up.
Malunion of post-traumatic thoracolumbar fractures
2018, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Initial correction of the deformity combined with decompression will prevent the development of syringomyelia [26]. The goal of surgery is to alleviate the patients’ pain and improve their function [23,27–32] while correcting the deformity [33]. However, it is very difficult to make treatment recommendations based on the literature.
Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.
Does restoration of focal lumbar lordosis for single level degenerative spondylolisthesis result in better patient-reported clinical outcomes? A systematic literature review
2017, Journal of Clinical Neuroscience
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Further, it is critical to determine whether this will have any impact on patient-reported quality of life outcomes [5]. Surgical restoration of sagittal balance and spinopelvic angulation has been shown to improve patient-reported outcomes in spinal fusions involving multiple levels [6,7]. The optimal treatment for degenerative spondylolisthesis, however, remains controversial.
It is controversial whether the surgical restoration of sagittal balance and spinopelvic angulation in a single level lumbar degenerative spondylolisthesis results in clinical improvements. The purpose of this study to systematically review the available literature to determine whether the surgical correction of malalignment in lumbar degenerative spondylolisthesis correlates with improvements in patient-reported clinical outcomes. Literature searches were performed via Ovid Medline, Embase, CENTRAL and Web of Science using search terms “lumbar,” “degenerative/spondylolisthesis” and “surgery/surgical/surgeries/fusion”. This resulted in 844 articles and after reviewing the abstracts and full-texts, 13 articles were included for summary and final analysis. There were two Level II articles, four Level III articles and five Level IV articles. Most commonly used patient-reported outcome measures (PROMs) were Oswestery disability index (ODI) and visual analogue scale (VAS). Four articles were included for the final statistical analysis. There was no statistically significant difference between the patient groups who achieved successful surgical correction of malalignment and those who did not for either ODI (mean difference −0.94, CI −8.89–7.00) or VAS (mean difference 1.57, CI −3.16–6.30). Two studies assessed the efficacy of manual reduction of lumbar degenerative spondylolisthesis and their clinical outcomes after the operation, and there was no statistically significant improvement. Overall, the restoration of focal lumbar lordosis and restoration of sagittal balance for single-level lumbar degenerative spondylolisthesis does not seem to yield clinical improvements but well-powered studies on this specific topic is lacking in the current literature. Future well-powered studies are needed for a more definitive conclusion.
Treatment of rigid post-traumatic thoracolumbar kyphosis by a novel technique of spinal joints release
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: FDA device/drug status: Not applicable.

: Author disclosures: RG: Nothing to disclose. JW: Nothing to disclose. WY: Nothing to disclose. CY: Nothing to disclose. FP: Nothing to disclose. XZ: Nothing to disclose.

: JW and RG contributed equally to this work.

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Clinical StudyModified partial pedicle subtraction osteotomy for the correction of post-traumatic thoracolumbar kyphosis

Abstract

Background context

Purpose

Study design

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Subjects and study design

Patient characteristics

Discussion

Spine J

Post-traumatic spinal deformity

Spine

Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications and technical aspects

Eur Spine J

Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis

J Bone Joint Surg

Comparison of Smith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance

Spine

Transpedicular closing wedge osteotomy in the treatment of thoracic and lumbar kyphotic deformity with different etiologies

Eur J Orthop Surg Traumatol

Correction of post-traumatic thoracolumbar kyphosis using pedicle subtraction osteotomy

Eur J Orthop Surg Traumatol

Modified posterior closing wedge osteotomy for the treatment of posttraumatic thoracolumbar kyphosis

J Trauma

A carbon fiber implant to aid interbody lumbar fusion. Two-year clinical results in the first 26 patients

Spine

Posttraumatic kyphosis: current state of diagnosis and treatment: results of a multinational survey of spine trauma surgeons

J Spinal Disord Tech

Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis

Clin Orthop Relat Res

Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach

Spine

Clinical Study
Modified partial pedicle subtraction osteotomy for the correction of post-traumatic thoracolumbar kyphosis