Simultaneous Anterior-Posterior Approach Through a Costotransversectomy for the Treatment of Congenital Kyphosis and Acquired Kyphoscoliotic Deformities

Background: Congenital kyphosis and acquired kyphoscoliotic deformities are uncommon but are potentially serious because of the risk of progressive deformity and possible paraplegia with growth. Our current approach for the treatment of these deformities is to use a single posterior incision and costotransversectomy to provide access for simultaneous anterior and posterior resection of a hemivertebra or spinal osteotomy, followed by anterior and/or posterior instrumentation and arthrodesis. To our knowledge, this approach has not been reported previously. Methods: The medical records and radiographs for sixteen patients who had been managed at our institution for the treatment of congenital kyphosis and acquired kyphoscoliosis between 1988 and 2002 were analyzed. The mean age at the time of surgery was twelve years. The diagnosis was congenital kyphosis for fourteen patients and acquired kyphoscoliotic deformities following failed previous surgery for two. The mean preoperative kyphotic deformity was 65° (range, 25° to 160°), and the mean scoliotic deformity was 47° (range, 7° to 160°). Fifteen patients were managed with vertebral resection or osteotomy through a single posterior approach and costotransversectomy, anterior and posterior arthrodesis, and posterior segmental spinal instrumentation. The other patient was too small for spinal instrumentation at the time of vertebral resection. A simplified outcome score was created to evaluate the results. Results: The mean duration of follow-up was 60.1 months. The mean correction of the major kyphotic deformity was 31° (range, 0° to 82°), and the mean correction of the major scoliotic deformity was 25° (range, 0° to 68°). Complications occurred in four patients; the complications included failure of posterior fixation requiring revision (one patient), lower extremity dysesthesias (one patient), and late progressive pelvic obliquity caudad to the fusion (two patients). The outcome, which was determined with use of a simplified outcomes score on the basis of patient satisfaction, was rated as satisfactory for thirteen patients, fair for two patients, and poor for one patient. Conclusions: A simultaneous anterior and posterior approach through a costotransversectomy is a challenging but safe, versatile, and effective approach for the treatment of complex kyphotic deformities of the thoracic spine, and it minimizes the risk of neurologic injury. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

To explore the clinical efficacies of skipping two-level transpedicular wedge osteotomy in the correction of severe kyphotic deformity in ankylosing spondylitis (AS). From January 2003 to December 2009, a total of 38 consecutive patients with AS and severe kyphosis (chin-brow vertical angle (CBVA) or global thoraco-lumbar kyphosis angle (TLKA) over 70°) undergoing skipping two-level transpedicular wedge osteotomy at the Department of Orthopedics of Chinese PLA General Hospital were reviewed retrospectively. There were 32 males and 6 females with an average age of 38.0 years (range: 22 - 65). The preoperative parameters of TLKA, T11-L2 kyphotic angle, L1-S1 lordosis angle, sagittal imbalance and CBVA were obtained from the total spine radiography or computed tomography and clinical lateral photograph. According to the characteristic curves and normal spinal alignment, their profiles of osteotomy location and angle were determined and confirmed by computer simulations. Improvement in postoperative parameters was observed and treatment satisfaction evaluated The average operating duration was 309 minutes and the average volume of blood loss was 2050 ml. The parameters of TLKA, T11-L2 kyphotic angle and L1-S1 lordosis angle improved from 101.0° ± 21.3°, 45.2° ± 13.6°, -28.2° ± 23.3° at preoperation to 26.0° ± 12.1°, 2.8° ± 11.6°, 28.9° ± 13.3° postoperation respectively (P < 0.01). CBVA improved from 79.4° ± 15.9° to 13.6 ° ± 10.9° (P < 0.01). The sagittal imbalance distance improved from (49 ± 13) to (15 ± 7) cm (P < 0.01). All patients could walk with orthophoria and lie horizontally postoperatively. The average follow-up was 32 months (range: 24 ∼ 78 months). Fusion of osteotomy was achieved in all patients and there was no event of loss of correction or implant failure. The SRS-22 average score improved from 1.8 to 4.2. For severe kyphosis in AS, skipping two-level transpedicular wedge osteotomy is a satisfactory and reliable approach for the correction of kyphotic deformity and it may improve appearance and function significantly.

Objective To describe a successful method by which vertebral column resection is performed through a unilateral posterior approach for old thoracolumbar compressive fracture accompanied with kyphotic deformity. Methods From February 2009 to January 2013, 49 patients with old thoracolumbar compressive fracture accompanied with kyphotic deformity were treated at our department. Twenty-three of them were treated by posterior unilateral vertebral column resection (PUVCR), and 26 by posterior vertebral column resection (PVCR). The 2 groups were compatible in general clinical data (P>0.05). Their clinical records were reviewed and compared in terms of operation time, intraoperative blood loss, postoperative drainage, correction of kyphotic deformity, neural functional improvement by Oswestry disability index (ODI), and pain by visual analogue scale (VAS). Results The operation time, intraoperative blood loss and postoperative drainage in the PUVCR group were significantly less than in the PVCR group (P 0.05). No significant differences were observed between the 2 groups either in terms of improved ODI or decreased VAS at one-year follow-up (P>0.05). Conclusions In treatment of old thoracolumbar compressive fracture accompa-nied with kyphotic deformity, PUVCR can achieve satisfactory correction of sagittal deformity, neural func-tional improvement and pain relief as well as conventional osteotomy, but it has advantages of shorter operation time, reduced blood loss and decreased incidence of nerve root impingement. Key words: Thoracic vertebrae; Lumber vertebrae; Fractures, bone; Osteotomy

Clinical Outcome and Complications of Transpedicular Closing-wedge Osteotomy for Correction of Deformity in Ankylosing Spondylitis in a Regional Hospital

Spinal osteotomy in ankylosing spondylitis: radiological, clinical, and psychological results

A nonrandomized descriptive case series. To analyze the results of spinal fusion in patients with total-body-involvement cerebral palsy to determine early and late outcomes, including caregiver satisfaction. Data from 79 to 100 patients with total-body-involvement spastic cerebral palsy who underwent posterior Luque instrumentation, or anterior spinal fusion, or both, were adequate to be included in the study. Functional status was evaluated by physical examination, and a personal interview was conducted with the patient, parents, and primary caregiver. Median follow-up was 4 years (range, 2-14 years). Late progression of scoliosis (> 10 degrees), pelvic obliquity (> 5 degrees), and decompensation (> 4cm ) were noted in more than 30% of the patients. More than 75% of patients with late progression were skeletally immature at the time of surgery and underwent a posterior procedure only. Twenty-one percent of the patients required a revision procedure because of disease progression. Progression was not noted in any patient who underwent anterior fusion (with or without anterior instrumentation) plus posterior instrumentation from the upper thoracic spine to the pelvis. Eighty-five percent of parents or caregivers were very satisfied with the results of surgery and noted a beneficial impact of the patient's sitting ability, physical appearance, ease of care, and comfort. To avoid late progression of trunk deformity in skeletally immature patients, anterior spinal release and fusion combined with posterior segmental spinal instrumentation and fusion from the upper thoracic spine to the pelvis are recommended. Skeletally mature patients with good curve flexibility can be treated with posterior instrumentation and fusion only. Skeletally mature patients with large fixed curves benefit from an anterior-posterior procedure for better correction of the scoliosis and pelvis obliquity. Despite the surgical complexity and expected complications, the overall good surgical results and high patient and caregiver satisfaction confirm that corrective spinal surgery is indicated and is beneficial for most patients with total-body-involvement cerebral palsy and scoliosis.

Treatment of congenital kyphosis in myelomeningocele is a difficult problem. Current thinking supports kyphectomy and postoperative internal fixation. Since 1989, vertebral resection with modified Luque fixation has been the procedure of choice for correction of myelomeningocele kyphotic deformity at the author's institution. The study objective was to evaluate long-term results with this technique. Most investigators agree that kyphotic deformity in myelomeningocele should be treated with vertebral resection. There is less uniform consensus about postoperative fixation. Reports in the literature support fixation with modified segmental instrumentation. Sixteen patients, observed for an average of 57.2 months (range, 36-94 months), underwent vertebral resection from the proximal aspect of the apical vertebra cephalad into the compensatory lordotic curve. Fixation was segmental instrumentation wired to the thoracic spine and anterior to the sacrum. The average blood loss was 1121 mL (range, 450-2580 mL). Kyphotic deformity averaged 111 degrees before surgery (range, 75-157 degrees), 15 degrees after surgery (range, -18-36 degrees) and 20 degrees at latest follow-up (range, -17-83 degrees). Loss of correction was 6 degrees (range, 0-27 degrees). Postoperative immobilization was with a thoracolumbosacral orthosis for 18 months. Complications occurring in 8 of the 16 patients were transient headache, superficial wound breakdown, supracondylar femur fractures, and one late infection secondary to skin breakdown that necessitated early rod removal, resulting in some loss of correction. Kyphectomy is an excellent method of correcting rigid kyphotic deformity in the patient with myelodysplasia. Segmental spinal instrumentation provided three distinct advantages: rigidity of the construct, greater correction of the deformity and low-profile instrumentation.

Retrospective study. To evaluate the outcomes of anterior decompression and fusion followed by posterior instrumented fusion using pedicle screws without intentional correction of severe angular kyphosis deformity with myelopathy. Treatment of severe angular kyphosis with myelopathy is extremely difficult and dangerous. Although surgical circumferential spinal osteotomy via a single posterior approach has been reported in several studies, serious neurologic complications are a possible outcome. Among 51 patients surgically treated for angular kyphosis from 1988 to 2004, 16 patients (follow-up period, 32-168 months; mean, 72 months) with severe (>70 degrees ) angular kyphosis with progressive myelopathic symptoms underwent anterior decompression and fusion, followed by posterior pedicle screw instrumentation and bone graft without attempted correction of the deformity. Radiologic assessment, clinical findings including pain and daily activity scores, and neurologic status using the modified Frankel grade were analyzed before surgery and at the last follow-up. Curve progression or nonunion did not occur in any of the cases. The mean pain and daily activity score were 3.1 and 2.3 before surgery and 4.7 and 4.2 after surgery, respectively. The modified Frankel grade indicated that every patient but one had improved neurologic function by one or more grades. Nine (75%) of 12 patients with ankle clonus, 10 (71%) of 14 patients with Babinski sign, and 6 (55%) of 11 patients with bowel and bladder dysfunction showed full improvement at the last follow-up. Postoperative complications included 1 screw pullout case and 2 infection cases which resolved without incidence. Anterior decompression and fusion followed by posterior pedicle screw instrumentation and fusion without correction effectively improved neurologic symptoms and halted progression of kyphotic deformity in cases of severe angular kyphosis with myelopathy.

Radiographic analysis of anterior and posterior instrumentation for adolescent idiopathic scoliosis. To compare effects of anterior versus posterior instrumentation on sagittal plane parameters. The sagittal plane is critical to the long-term success of scoliosis surgery, but few studies have compared the effect of anterior versus posterior instrumentation. Standing, full spine lateral radiographs of 110 consecutive patients (mean age 14 years) who had surgery for adolescent idiopathic scoliosis between 1996 and 1998 at one institution with a minimum 24-month (mean 32 months) follow-up were evaluated. Fifty patients were instrumented anteriorly with single screw-rod constructs. Sixty patients were instrumented posteriorly with segmental implants (5.5 mm; hooks, wires, and/or pedicle screws). At the final follow-up, the proximal junctional measurement (measured between the proximal instrumented vertebra and the segment two levels cephalad) increased most with posterior instrumentation (+7 degrees increase for posterior thoracic +1 degrees increase for anterior thoracic instrumentation, P= 0.02; +9 degrees increase for posterior thoracic and lumbar instrumentation vs. +4 degrees for anterior thoracolumbar instrumentation, P= 0.03). Thoracic kyphosis (T5-T12) increased significantly with anterior versus posterior thoracic instrumentation (+4 degrees vs. -2 degrees change, P= 0.04). Lumbar lordosis (T12-S1) was enhanced with either anterior or posterior instrumentation. No significant changes in distal junctional measurement (measured between the distal instrumented vertebra and the segment two levels caudal) were noted. The C7 sagittal plumbline remained negative in all groups at the final follow-up. Anterior and posterior instrumentation had differential effects on the sagittal plane in patients with adolescent idiopathic scoliosis. However, the overall magnitude of the differences was small. Properly performed, both approaches can result in acceptable sagittal profiles.

A retrospective study. To analyze the long-term proximal junctional change in adolescent idiopathic scoliosis (AIS) following segmental posterior spinal instrumentation and fusion 5 years or more after surgery. No study has concentrated on time-dependent long-term proximal junctional change in AIS following segmental posterior spinal instrumentation and fusion after 5 years postoperation. Risk factors for developing proximal junctional kyphosis (PJK) are unknown. A total of 193 consecutive AIS patients with a minimum 5-year follow-up (average, 7.3 years; range, 5-16.7 years) treated with segmental posterior spinal instrumentation and fusion were evaluated. Radiographic measurements analyzed included sagittal Cobb angle at the proximal junction on preoperative, early postoperation, 2-year postoperation, and final follow-up (> or = 5 years) by standing long cassette radiographs. Postoperative Scoliosis Research Society (SRS)-24 outcome scores were also evaluated. Abnormal PJK was defined as the final proximal junctional sagittal Cobb angle between the lower endplate of the uppermost instrumented vertebra and the upper endplate of two vertebrae supra-adjacent, which was > 10 degrees and at least 10 degrees greater than the preoperative measurement. The incidence of PJK at 7.3 years postoperation was 26% (50 of 193 patients). The average proximal junctional angle increased 15.2 degrees until 2 years postoperation and then increased 1.7 degrees until final follow-up in the PJK group (n = 50). Factors that were statistically significant for PJK development were as follows: a thoracoplasty procedure (P = 0.001), preoperative hyperkyphotic thoracic alignment (T5-T12 > 40 degrees) (P = 0.015), and hybrid instrumentation (proximal hooks and distal pedicle screws) compared with the hooks only group (P = 0.029). The number of fused vertebrae more than 11 was also related with PJK (P = 0.08). The level of the uppermost instrumented vertebra did not affect the PJK incidence. SRS-24 outcome scores did not demonstrate any significant differences (P = 0.54 for total score and P = 0.49 for self-image subscale) between the PJK and non-PJK groups. The incidence of proximal junctional kyphosis at 7.3 years postoperation was 26% and did not progress significantly after 2 years postoperation. Risk factors for developing PJK were an associated thoracoplasty, hybrid instrumentation (proximal hooks and distal pedicle screws), and a preoperative larger sagittal thoracic Cobb angle (T5-T12 > 40 degrees). The SRS-24 outcome instrument was not affected by PJK.

Objective. To identify risk factors for development of proximal junctional kyphosis (PJK) in patients with idiopathic scoliosis treated with segmental posterior spinal instrumentation. Material and Methods . Radiographs of 95 patients with idiopathic scoliosis operated on using segmental posterior spinal instrumentation were analyzed. Preoperative and postoperative spondylograms and images taken at the end of the second year of follow-up were evaluated. The PJK was defined as 10° or more increase in the angle of kyphosis between the caudal endplate of the upper instrumented vertebra and the cephalad endplate of two adjacent proximal vertebrae as compared with preoperative angle at the same level. Results . The prevalence of PJK at the end of the second year of follow-up was 24 %. Before surgery the average value of the proximal transition angle was 6.7° ± 5.4° in patients with PJK (Group I) and 6.1° ± 4.6° in patients who have not formed PJK (Group II). Within two weeks after surgery, the angle increased to 15.0° ± 6.7° in patients of Group I and to 6.9° ± 4.4° in patients of Group II. Two years after surgery the angle was 23.0° ± 6.0° and 8.4° ± 5.6°, respectively. Conclusion . Statistically significant risk factors were initial hyperkyphosis of the thoracic spine (>40°), significant change in thoracic kyphosis in the postoperative period, initial value of the proximal transition angle, distal location of the upper instrumented vertebra, and the use of hybrid fixation.

A prospective study. To assess the significance of chin-brow vertical angle in planning and evaluating the correction of kyphotic deformity with ankylosis of the cervical spine in ankylosing spondylitis patients. Accurate assessment and measurement of spinal kyphotic deformity is required when planning treatment and assessing its results. Thirty-four ankylosing spondylitis patients with cervical ankylosis who had undergone pedicle subtraction extension osteotomy for correction of kyphotic deformity were studied. Radiographic assessment for sagittal balance was performed by measuring thoracic kyphosis, lumbar lordosis, the distance between the vertical line on the anterosuperior point of T1 and that of S1, and sacral inclination. Chin-brow vertical angle was measured on the clinical photos of the patients. Clinical outcomes were assessed by a questionnaire. The preoperative and postoperative chin-brow vertical angles were 35.5 degrees and 1.8 degrees, respectively. Final follow-up radiographs showed an increase in lumbar lordosis from 5.5 degrees to 43.2 degrees (an increase of 37.7 degrees ), and thoracic kyphosis remained stable from 50.4 degrees to 50.2 degrees. Sagittal imbalance significantly improved from 101.5 mm to 12.7 mm. The decreased chin-brow vertical angle correlated negatively with the correction angle. The patients with a chin-brow vertical angle of less than -10 degrees had significantly low scores on horizontal gaze. Chin-brow vertical angle was an objective index for evaluating horizontal gaze. Based on the results of this study, measurement of chin-brow vertical angle is recommended for planning correction of kyphosis and accurate evaluation of treatment outcome.

A retrospective review of transpedicular instrumentation used in a series of 24 patients with myelodysplastic spinal deformities and deficient posterior elements. To describe the usefulness and efficacy of these instruments in the treatment of complicated myelodysplastic spinal deformity. The mean preoperative scoliosis was 75.7 degrees (range, 39-130 degrees) in the 22 patients with scoliotic deformities; 4 patients with thoracic hyperkyphoses averaged 70.5 degrees (range, 46-90 degrees) and 10 patients with lumbar kyphoses averaged 80.5 degrees (range, 42-120 degrees). The instrumentation extended to the sacrum in 4 patients and the pelvis in 9; 10 patients also underwent anterior release and fusion and 7 underwent concomitant spinal cord detethering. At an average follow-up of 4.0 years (2.0-7.7 years; one patient died at 8 months), all patients have fused (with the exception of two lumbosacral pseudarthroses). At last follow-up, deformity measured 32.1 degrees scoliosis (range, 6-85 degrees), 30.8 degrees thoracic kyphosis (range, 24-35 degrees), and 0.0 degree lumbar kyphosis (range, 35 degrees kyphosis to 29 degrees lordosis). Three patients lost some neurologic function after surgery; two recovered within 6 months and one has incomplete recovery. No ambulatory patient lost the ability to walk. Five patients required additional surgical procedures; in three cases, there was instrumentation breakage associated with pseudarthrosis or unfused spinal segments. Pedicle screw instrumentation is uniquely suited to the deficient myelodysplastic spine. Compared with historical control subjects, these devices have proven capable of significant correction of both scoliotic and kyphotic deformities. This instrumentation appears particularly useful in preserving lumbar lordosis in all patients and may preserve more lumbar motion in ambulatory myelodysplasia patients.

A prospective study was performed in 45 patients with ankylosing spondylitis. To assess the outcomes of decancellation pedicle subtraction extension osteotomy in ankylosing spondylitis patients with severe fixed kyphotic deformity. There have been several studies regarding correction of kyphotic deformity in ankylosing spondylitis. However, most of them concern surgical technique. There have been no reports concerning clinical results of decancellation pedicle subtraction osteotomy in ankylosing spondylitis. The kyphotic deformity was corrected by a one-stage pedicle subtraction extension osteotomy. Radiographic assessment for sagittal balance was performed by measuring thoracic kyphosis, lumbar lordosis, distance between the vertical line on anterosuperior point of T1 and that of S1, and sacral inclination. Chin brow-vertical angle was measured on the preoperative and postoperative clinical photograph of patients. Clinical outcomes were assessed by questionnaire measuring changes in physical function, indoor activity, outdoor activity, psychosocial activity, pain, and patient satisfaction with surgery. Final follow-up radiograph showed an increase in lumbar lordosis from 10 degrees to 44 degrees (an increase of 34 degrees), whereas thoracic kyphosis remained stable from 50 degrees to 54 degrees. Sagittal imbalance significantly improved from 94 to 8 mm, whereas sacral inclination increased from 8 degrees to 24 degrees. The chin brow-vertical angle was 32.0 degrees before surgery and 0.9 degrees after surgery. Satisfactory clinical outcome was achieved; however, clinical improvements did not correlate with changes in radiologic measurements. Most of the patients maintained good correction and had good clinical results. Based on the results of this study, pedicle subtraction extension osteotomy is effective for correction of kyphotic deformity in ankylosing spondylitis.