| BackgroundAnkylosing spondylitis is a common chronic inflammatory disease,affecting the sacroiliac joint,spine and pelvis.The spine will become stiff and lose the mobility.In advanced stage,some patients will present as kyphosis deformity.The thoracic hyper-kyphosis and loss of lumbar lordosis will result in sagittal imbalance.Patients may suffer from back pain,horizontal vision loss,swallowing difficulty and other dysfunctions.The spinal osteotomy is recognized as an effective treatment.Previous studies have confirmed that PSO can achieve a satisfactory result.PSO includes CWO and COWO.COWO is attracting more and more orthopedists’ attention,as it can provide a greater correction and retain more vertebral height than CWO.However,rare studies compared the correction capacity between CWO and COWO.In recent years,with the development of perioperative management and surgical technique,two-level spinal osteotomy is recommended for patients with severe kyphosis secondary to AS.Rare studies focused on the two-level spinal osteotomy for thoracic,thoracolumbar or lumbar kyphosis secondary to AS,and the indications for surgery is unclear.The correction result and complications vary a lot in different medical centers.Purpose1.Compare the correction result and complications between CWO and CO WO in patients with thoracic,thoracolumbar or lumbar kyphosis secondary to AS.2.Introduce the surgical indication,correction result,complication and key notes of two-level osteotomy in the treatment of thoracic,thoracolumbar or lumbar kyphosis secondary to AS.Part Ⅰ Comparison between CWO and COWO in patients with thoracic,thoracolumbar or lumbar kyphosis secondary to ASMethodsFrom January 2006 to December 2019,a total of 72 patients with thoracic,thoracolumbar or lumbar kyphosis secondary to AS were studied retrospectively.Of which,34 patients underwent CWO,and 38 patients underwent COWO.Standing long cassette radiographs including the whole spine and pelvis were performed before and after surgery.Radiographic parameters including sagittal plane,pelvis and coronal plane were measured.Intraoperative and post-operative complications were also recorded.ResultsThere was no significant difference in gender,age,preoperative morbidity between CWO and CO WO group(all p>0.05).The operation time was 239±70min in CWO group,and 240±50min in COWO group(p=0.563).The blood loss was 917.3±524.7mL in CWO group,and 694.7±330.0mL in COWO group(p=0.019).The osteotomy level distributed from T10 to L4 both in CWO and COWO group.The apex ranged from T10 to L3 in CWO group,and from T10 to L4 in COWO group.The fusion level number is 7.1±1.3 and 7.6±1.1,respectively(p=0.016).In CWO group,GK,SK,AFL,CL,TK,TLK,LL,T1-slope,SVA,PT,SS,T1PA,and scoliosis Cobb angle improved significantly(p<0.05).In COWO group,GK,SK,AFL,CL,TLK,LL,T1-slope,SVA,PT,SS,T1PA,and scoliosis Cobb angle got significant improvement(p<0.05).In terms of SK,CWO can achieve 32° correction,while COWO can achieve 43.8° correction(p<0.001).AFL had a correction of 30.3° in CWO group,and had 42.1° in COWO group(p=0.001).SVA corrected 67mm and 100.7mm,respectively(p=0.01).The total complication incidence was 50%in both groups.Dura tear was the most commonly happened complication.There was no significant difference in the complication incidence between the two groups.ConclusionsIn patients with thoracic,thoracolumbar or lumbar kyphosis secondary to AS,CWO and COWO can significantly improve sagittal imbalance and restore the pelvis rotation.Compared with CWO,COWO can provide greater correction result.COWO seems to be safer because of less blood loss.Part Ⅱ The outcome evaluation of two-level osteotomy in patients with severe thoracic,thoracolumbar or lumbar kyphosis secondary to ASMethodsFrom January 2014 to December 2019,a total of 14 patients with severe thoracic,thoracolumbar or lumbar kyphosis secondary to AS were studied retrospectively.All of these patients underwent two-level spinal osteotomy.Standing long cassette radiographs including the whole spine and pelvis were performed pre and postoperatively.Radiographic parameters including sagittal plane,pelvis and coronal plane were measured.Intraoperative and postoperative complications were also recorded.ResultsAmong these 14 patients,there were 11 male and 4 females.The average age was 35.2±6.5.The operation time was 400±39.4min,and the blood loss was 1235.7±759.3mL.The kyphosis apex ranged from T5 to L3.The UOV and LOV varied from T3 to L2 and T6 to L4,respectively.The fusion level number is 10.8± 1.7.GK improved from 94.4° to 46.1°.TK improved from 49.6° to 28.9°.TLK improved from 41.4° to 6.7°.LL improved from 2° to 34.2°.T1 slope improved from 58.3° to 30.8°.SVA improved from 182mm to 48.5mm.PT improved from 40.6° to 24.9°.SS improved from 9.6° to 24.6°.T1PA improved from 50.7° to 22.7°.Scoliosis Cobbs angle improved from 26.8° to 10.5°(all p<0.001).The operation time was 400±39.4min,and the blood loss was 1235.7±759.3mL.A total of 16 complications were reported among 10 patients.The total incidence is 71.4%.According to the incidence,the most common complications were dura tear,pleural tear,abdominal pain,pleural effusion,spinal cord injury,and infection.ConclusionsIn patients with severe thoracic,thoracolumbar or lumbar kyphosis secondary to AS,single level osteotomy can not achieve satisfactory correction.Two-level osteotomy at the proper vertebra can reduce thoracic hyperkyphosis,restore lumbar lordosis,so as to correct sagittal imbalance.In patients with pseudarthrosis,if single level osteotomy at the pseudarthrosis level can not restore balance,another level of osteotomy is recommended.The total complication incidence of two-level osteotomy was relatively high,while severe or acute complications were rare.Dura tear and abdominal pain were mostly common.More attention should be paid to avoid pleural tears in thoracic vertebral osteotomy. |
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