The New Three-column Osteotomy For Correction Of Spinal Kyphosis And Kyphoscoliosis Deformity

Spinal deformity is a common spine disorder that affects both physical and mental development.The incidence of various types of spinal deformity in China is generally higher than in Europe and the United States,and even higher than other Asian regions.Because of the incomplete medical treatment system and the expensive cost of medical treatment for deformity correction,Many patients progressively progress and eventually develop into serious spine Kyphosis and Kyphoscoliosis.The deformity cause respiratory,digestive,circulatory,urinary and nervous system dysfunction,and expose both individuals and families to tremendous economic and mental stress.Serious spinal deformity with traditional conservative treatment is often ineffective,only by surgery.Now,Smith-Petersen osteotomy(SPO),Ponte osteotomy(PO)Pedicle subtraction osteotomy(PSO)and Vertebral column resection(VCR)are commonly used osteotomy methods.Since SPO and PO only remove the posterior column structure of the spinal column,the three-column osteotomy technique,including PSO and VCR,is widely used in severe spinal deformity.Each type of spinal deformity has its own characteristics,such as the more common clinical types of spinal deformities:post-traumatic thoracolumbar kyphosis,kyphosis secondary to Ankylosing Spondylitis,Kyphoscoliosis.Due to the cause and course of the diseases are different,the final deformity is also very different.No osteotomy is perfect for all spinal deformities.Therefore,it is necessary to adjust the three-column osteotomy technique according to different types of spinal deformity,so as to obtain satisfactory clinical results.In this study,The data information of patients with post-traumatic thoracolumbar kyphosis,kyphosis secondary to Ankylosing Spondylitis and Kyphoscoliosis who underwent three-column osteotomy were retrospectively analysis to investigate and assess the safety and effectiveness of each three-column osteotomy technique.Part 1:Modified Pedicle Subtraction Osteotomy for correction of post-traumatic thoracolumbar kyphosisObjective:To evaluate the safety,efficacy and advantage of the modified PSO technique for correction of post-traumatic thoracolumbar kyphosisMethods:According to inclusion criteria,21 patients with post-traumatic thoracolumbar kyphosis who underwent modified PSO were enrolled,including 10 males and 11 females,with an average age of 55.4 ± 8.7 years(35-67 years).According to the same inclusion and exclusion criteria,20 patients with post-traumatic thoracolumbar kyphosis who underwent PSO at the same period were also selected.Full-length spine radiographs including the whole spine and pelvis were available for all patients.Local Cobb angle,Sagittal Vertical Axis(SVA),pelvis incidence(PI),pelvis tilt(PT),and Sacral slope(SS)were documented to evaluate the global sagittal balance.Clinical outcomes were assessed by Oswestry Disability Index(ODI)and visual analogue scale(VAS).At the same time,operation time,blood loss,and general complications were recorded.Results:21 patients were treated with single segment modified PSO.The average follow-up time was 28.1 ± 2.2 months(25-36 months),operation time was 256.2 ± 30.9 minutes(200-320 minutes),blood loss was 461.9 ± 56.2ml(400-600ml).The local Cobb angle ranged from 55.3 ± 10.1°(35-67 °)preoperatively to 8.5 ± 4.3°(5-14 °)postoperatively,and the Cobb angle at the final follow-up was 9.2 ±3 °(7-16 °).Preoperative SVA + 10.1 ± 3.7 cm(+7.2-+ 14.1 cm)corrected to postoperative + 4.3 ± 2.8 cm(+3.2-+5.3 cm),the last follow-up + 4.8 ± 2.1 cm(+3.5 to +5.8 cm).The preoperative ODI score was 65.2 ± 18.3%(51.0-87.0%)and the last follow-up was 25.2 ±13.8%(14.0-32.0%)(P<0.05).The preoperative VAS score was 7.5 ± 1.7(6-9),at the last follow-up improved to 1.5± 1.3(1-3)(P<0.05).There were 8 patients ranging from preoperative ASIA grade D to the last follow-up ASIA grade E.No permanent nerve injury,vascular injury,infection,failure of internal fixation and other complications occurred.There was no significant difference between the PSO group and the new modified technique group in the general demographic data,such as gender and age.Modified PSO could achieve greater local Cobb angle correction than PSO with the similar operation time and blood loss.Conclusions:In this study,modified PSO was performed:the upper injury intervertebral disc was removed and the appropriate type of intervertebral device with autologous bone were implanted in the osteotomy plane.Compared with the traditional osteotomy,this technique could get a greater correction angle and obtain a more solid bone fusion,What’s more,avoiding the excessive shortening of the spine to ensure the stability of the osteotomy process.For post-traumatic thoracolumbar kyphosis,the surgical approach can be used as a safe and effective treatment.Part 2:Vertebral Column Decancellation(VCD)for correction of thoracolumbar kyphosis secondary to Ankylosing SpondylitisObjective:To analyze the clinical outcomes of VCD osteotomy for correction of thoracolumbar kyphosis secondary to Ankylosing Spondylitis in the orthopedic department of Chinses PLA General Hospital.Methods:According to inclusion criteria,32 patients with AS kyphosis who underwent VCD surgery were enrolled.All patients were surgically treated with Surgimap Spine for detailed surgical planning.Among them,there were 26 males and 8 females with an average age of 40.8 ± 5.8 years(30-52 years).The average follow-up time was 31.3 ±3.2 months(24-37 months).According to the same inclusion and exclusion criteria,28 patients with AS kyphosis who underwent PSO at the same period were also selected.Preoperative,postoperative and the final follow-up full-length photographs of standing spine and the appearance of photos were routinely taken.Thoracolumbar kyphosis(TLK),lumbar lordosis(LL),SVA,PI,PT,SS,and CBVA were measured.Clinical outcomes were assessed by ODI and SRS-22 score.Operation time,blood loss,osteotomy level and general complications were recorded.Results:32 cases were treated with single segment VCD.The osteotomy level was L1 in 13 cases,L2 in 14 cases and T12 in 5 cases.The average operative time was 222.8 ±24.3min(190-280min).The intraoperative blood loss was 442.8 ± 49ml(390-590ml).The Cobb angle of the thoracolumbar ranged from 56.9 ± 5.8 °(32-64°)preoperatively to 9.6± 3.4°(5.0-14.0 °)postoperatively,and the local Cobb angle at the final follow-up was 12.8 ± 4.6°(9.0-18.0 °).Preoperative SVA + 12.5± 4.4 cm(8.5-18.3 cm)improved to+4.6 ± 2.1 cm(3.6-8.4 cm)postoperatively,with a final follow-up of +5.5 ± 2.3 cm(4.6-9.4 cm).The patients’ preoperative ODI score was 67.8 ± 12.3%(57.6-86.5%),the last follow-up was 13.4 ± 5.6%(10.4-23.5%)(P<0.05).SRS-22 score after surgery were significantly improved.No permanent nerve injury,vascular injury,infection,failure of internal fixation and other complications occurred.The operation time and blood loss were similar between VCD group and PSO group,however,VCD technique could achieve greater correction than PSO.There was no significant difference in the improvement of clinical function score including ODI and SRS-22.Conclusions:VCD is a safe and effective treatment option for AS patients with kyphosis deformity,this approach achieves satisfactory kyphosis correction and improvement in neurological function.Surgimap Spine as a dedicated spine measurement and surgical planning software provides a helpful method to analyze the spino-pelvic parameters and simulate the procedure of osteotomy.Part 3:The Asymmetric Vertebral Column Decancellation(AVCD)for Correction of kyphoscoliosis.Objective:To evaluate the safety and effectiveness of asymmetrical AVCD osteotomy osteotomies in kyphoscoliosis to establish its presence as a new option to correct these severe rigid curves.Methods:According to inclusion criteria,18 patients who underwent AVCD were enrolled,including 8 males,10 females.13 patients with congenital scoliosis,5 patients with idiopathic scoliosis.The average age of 21.6 ± 13.3 years(13-57 years).According to the same inclusion and exclusion criteria,13 patients who underwent PSO and 10 patients who underwent VCR were also selected.Preoperative,postoperative and the final follow-up full-length photographs of standing spine and the appearance of photos were routinely taken.The max Cobb’s angle,the coronal plane,the Apical vertebrae translation(AVT),local kyphosis Cobb angle and SVA were measured..All patients underwent preoperative Bending images to evaluate spinal flexibility,CT plain scan and three-dimensional reconstruction were used to evaluate the presence or absence of bony mediastinal and vertebral bodies in vertebral canal,the development of pedicle;MRI was performed to evaluate the whether spinal cord or nerve injury.Clinical outcomes were assessed by ODI and SRS-22 score.Neurologic deficits were assessed by Asia Spinal Injury Association(ASIA)grading system.Operation time,osteotomy segments,fusion segments,blood loss,and complications occurred.Results:18 cases were treated with AVCD technique.The amount of bleeding was 439.4 ± 42 ml(390-530 ml)and the operation time was 225.6 ± 24.3 minutes(190-280 minutes).Fusion segments were 6.8 ± 3.3(3-10).The max coronal Cobb angle was corrected from 67.6 ± 15.8 °(49-98 °)before surgery to 21.3 ± 8.4 °(18-34 °)after surgery,with a final follow-up of 23.5 ± 7.6 °(20-39 °).Coronal balance improved from 2.7 ± 1.3 cm(1.3-5.1 cm)preoperatively to 1.1 ± 0.6 cm(0.5-1.9 cm)postoperatively,at the final follow-up of 1.3 ± 0.5 cm(0.8-2.1)cm.The maximal sagittal kyphosis Cobb angle was corrected from preoperative 58.1± 14.3 °(35-85。)to postoperative 11.5± 8.3°(9-24 °)with a final follow-up of 15.3 ± 7.7 °(11-27°).There were significant differences between the preoperative indexes and the postoperative indexes,the preoperative indexes and the last follow-up(P<0.05),but no significant difference between the last follow-up and postoperative follow-up(P>0.05).The patients’ preoperative ODI score and SRS-22 score improved significantly compared with preoperative indexes.Three patients with preoperative ASIA grade D improved to grade E at the last follow-up.No permanent nerve injury,vascular injury,infection,failure of internal fixation and other complications occurred.There was no significant difference between the AVCD group and PSO group,AVCD group and VCR group in the general demographic data,such as gender and age.AVCD could achieve greater correction in coronal and sagittal plane with the similar operation time and blood loss;VCR has the strongest correction ability,but the incidence of postoperative complications was significantly higher than the AVCD and PSO.Conclusions:AVCD presents a safe and reliable procedure towards solving the problems of kyphoscoliosis.This approach achieves satisfied realignment of the deformed spine,successful fusion,acceptable intraoperative blood loss,and favorable clinical outcomes without additional neurological complications.However,AVCD is a technically demanding procedure,which should be perfomed by the most experienced spine surgeons.