Ponte Osteotomies Research Articles

The surgical management of scheurmann’s kyphosis: Efficacy and safety of a low density posterior pedicle screw construct

Background: To see if employing a low pedicle screw density in the posterior therapy of Scheuermann kyphosis is safe, radiologically effective, and clinically effective. Methods: Patients with Scheuermann kyphosis underwent posterior surgical correction between 2016 and 2019. Low Screw Density, peri apical Ponte osteotomies and cantilever correction maneuver were our surgical technique for deformity correction. Two observers performed a radiological evaluation of the before and postoperative Spinopelvic parameters. Validated Arabic version of Scoliosis Research Society 22 questionnaire were used to assess the preoperative and postoperative clinical results. Cost saving analysis was performed. Results: This study enlisted the participation of thirty patients. The patients mean age 21.8 ±3.4 years and mean follow up 34.8±7.9 months. The mean surgical time was 165.33 ±17.9 minutes , the mean number of osteotomies was 4.2± 0.8 , and the mean blood loss was 770± 139.3cc.The mean preoperative dorsal kyphosis 87.5°±4.6 °and the mean postoperative dorsal kyphosis 43.1°± 3.7° at final follow up (P<0.001).The mean preoperative scoliosis research society 22 questionnaire 2.8±0.4 and the mean postoperative scoliosis research society 22 questionnaire 4.3±0.8 at final follow up (P<0.001). Conclusions: Posterior Surgical Intervention with low Screw Density construct and periapical Ponte osteotomies is safe , radiologically , clinically and cost effective way in surgical management of Scheuermann kyphosis. Study Design: Prospective Cohort Study. Level of Evidence: Level IV.

Postoperative complications following Schwab-grade-I versus Schwab-grade-II PCO in treating severe rigid kyphoscoliosis patients: comparative matched-group outcomes with minimum 2-year follow-up

BACKGROUND CONTEXTStandard partial facetectomies, (Smith-Petersen Osteotomy, (SPO), (Schwab-grade-I) and complete facet resection also known as Ponte osteotomy, (PO), (Schwab-grade-II) are narrowly akin and collectively appreciated as posterior column shortening osteotomies (PCOs). The former is considered a gentler osteotomy grade than the latter. The spine literature provides very little information on their comparison regarding perioperative complications and major curve correction rate outcomes. PURPOSETo determine whether Schwab-grade-I PCO (SPO) and Schwab-grade-II PCO (PO) are comparably safe in the surgical management of severe rigid scoliosis or kyphoscoliosis patients. STUDY DESIGN/SETTINGRetrospective single-center comparative clinical study. PATIENT SAMPLEA total of 38 patients with severe rigid scoliosis or kyphoscoliosis were propensity score matched in this study, (SPO-treated); n=21 (55.30%) and (PO-treated); n=17 (44.70%), who underwent primary spinal deformity corrective surgery, respectively. OUTCOME MEASURESOutcomes included demographics, baseline pulmonary functional outcomes, perioperative complications incidence, hospital costs, Oswestry disability index (ODI), and the Scoliosis Research Society-22 (SRS-22) questionnaire scores. METHODSFollowing approval by the Institutional Review Board (IRB) of Beijing Chaoyang Hospital-Affiliated Capital Medical University in Beijing, out of a total of 82 consecutive surgical patients with complete data demonstrating severe and/or rigid spinal deformity, a pool of 38 of the 82 (46.3%) propensity-matched adult (≥18 years) patients with severe rigid scoliosis or kyphoscoliosis defined with a preoperative major curve magnitude of ≥80° on anteroposterior plain radiographs, and flexibility of <25% on bending plain radiographs who underwent primary spinal deformity corrective surgery were retrospectively evaluated. The patients were dichotomized into two osteotomy groups: standard (partial) facetectomy (SPO-treated), n=21 with an average age of 24.67 years, (Schwab-grade-I PCO) and complete facet excision, (PO-treated), (ie, Schwab-grade-II PCO), n=17 with an average age of 23.12 years. The minimum follow-up period was 2 years. Primary outcomes included baseline demographics and clinical features. Secondary outcomes included perioperative [intraoperative, immediate, and 2-year postoperative] complication rates. Tertiary outcomes included perioperative ODI and SRS-22 scores. Statistical analyses were carried out by Student t-test and Pearson's Chi-square test (Fisher's Exact Test), through Python statistical software package. Statistical significance was set at (p<.05). RESULTSOf the 38 matched severe rigid scoliosis or kyphoscoliosis patients, 55.30% (n=21) were SPO-treated and 44.70% (n=17) were PO-treated patients, respectively. The overall average age of patients was 23.97 years, with a female incidence of 76.32%. Major curve correction rates were 49.19% and 57.40% in SPO-treated and PO-treated patients, respectively, (p>.05). Immediately following surgery, comparable overall complication rates of 28.57% (n=6/21) versus 29.41% (n=5/17) were observed in the SPO-treated and PO-treated patients, respectively, (p=.726). We observed incidences of 9.52%, (n=2/21) versus 5.88%, (n=1/17) for surgical intensive care unit (SICU) admission, and incidences of 4.76%, (n=1/21) versus 5.88%, (n=1/17) for cardiopulmonary events in SPO-treated versus PO-treated patients following corrective surgery, respectively, (p>.05). The incidences of neurological deficits in the SPO-treated and PO-treated patients were respectively, 14.29%, (n=3/21) versus 17.65%, (n=3/17) immediately following surgery, (p>.05), and 0.00%, (n=0/21) in SPO-treated versus 14.28%, (n=3/21) in PO-treated patients at ≥2 years postoperative, (p<.05). Among the three patients that reported neurological deficits in the PO-treated group at ≥2 years postoperative, two patients had pre-existing baseline neurological deficits. The ODI score in the PO-treated group was significantly inferior at a minimum 2-year follow-up, (p<.05). CONCLUSIONSIn the current study, both SPO-treated and PO-treated patients demonstrated statistically comparable surgical complications immediately following corrective surgery. Severe rigid kyphoscoliosis patients with preexisting baseline neurological deficits were more inclined to sustain neurological morbidity following corrective surgery. PCO corrective techniques are warranted as safe options for treating patients with severe rigid spine deformity phenotypes.

Clinical outcomes of surgical treatment for Copenhagen syndrome: a case series

BackgroundCopenhagen syndrome (CS) is a rare disorder mostly observed in adolescent. The onset of the disease, with a progressive anterior vertebral ankylosis in the thoracic and/or lumbar areas often clinically revealed by thoracolumbar kyphosis. We report a series of three patients of CS with good outcome.Case presentationThe mean age of patients were 14.0 (SD = 3.6) years at admission time. Patients underwent clinical and radiological examination (MRI, CT scan, and bone scan) before surgery and revealed Copenhagen syndrome. Case 2 received conservative treatment braces and regular follow-up. Finally, all patients were treated according to their clinical conditions through a combined surgical approach such as pedicle subtraction osteotomy (PSO), ponte osteotomy, hook, pedicular screw insertion, and fusion. In postoperative follow-up, the deformity correction was achieved with proper alignment in all the cases.ConclusionThe treatment of CS with PSO plus ponte osteotomy seems to result in an excellent surgical procedure and outcome for our patients based on deformity severity. Bone scan imaging could be considered as an aid to differential diagnosis, which is an effective method.

Аналіз результатів лікування грудного ідіопатичного сколіозу з кутом Cobb 80-100º

Anterior spinal mobilization is an effective method of staged correction of thoracic idiopathic scoliosis with a Cobb angle of 80-100º. The introduction of modern transpedicular implants and osteotomies of the posterior support complex into clinical practice has reduced the frequency of its use, but increased the number of neurological complications. Purpose - to compare the results of anterior mobilization in combination with posterior corrective fusion and posterior corrective fusion alone in patients with stiff thoracic idiopathic scoliosis. Materials and methods. A retrospective comparative analysis of the results of surgical treatment of 167 patients with thoracic idiopathic scoliosis with a Cobb angle of 80-100º was performed. Patients were divided into two groups: the Group 1 - 83 patients (mean age - 13.7 years) who underwent anterior curvature mobilization and posterior corrective fusion, the Group 2 - 84 patients (mean age - 14.7 years) who underwent posterior corrective fusion and Ponte osteotomy at 3-5 levels. Results. The average thoracic Cobb angle before surgery in the Group 1 was 87.1º (±1.96), in the Group 2 - 83.8º (±2.85); after surgery - 32.2º (±2.24), or 63% correction, and 44.2º (±3.22), or 47% correction, respectively. The total average duration of surgical interventions in the Group 1 was 410 minutes (140 minutes + 270 minutes), in the Group 2 - 320 minutes. Intraoperative blood loss was 890 ml and 900 ml, respectively. The average volume of haemotransfusion was 650 ml and 672 ml, respectively. The average hospital stay was 15.6 days and 8.6 days, respectively. Conclusions. Compared with posterior corrective fusion, the use of two-stage treatment, which includes anterior mobilization of the curvature and posterior corrective fusion for surgical correction of stiff scoliotic spinal deformities, allows to increase the intraoperative correction of the main curvature by 17%. The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the Local Ethics Committee of all the institutions mentioned in the study. Informed consent was obtained from the patients. No conflict of interests was declared by the authors.

A cost-effectiveness analysis of intraoperative autologous transfusion in adolescent idiopathic scoliosis surgery: a single-centre retrospective study

BackgroundIntraoperative autologous transfusion (IAT) has been used in scoliosis surgery for decades; however, its cost-effectiveness remains debatable. This study aimed to evaluate the cost-effectiveness of IAT in adolescent idiopathic scoliosis (AIS) surgery and identify risk factors of massive intraoperative blood during this surgery.MethodsThe medical records of 402 patients who underwent AIS surgery were reviewed. The patients were divided into different groups according to the intraoperative blood loss volume (group A: ≥500 to < 1000 mL, B: ≥1,000 to < 1,500 mL, and C: ≥1,500 mL) and whether IAT was used (i.e., IAT and no-IAT groups). The volume of blood loss, volume of transfused allogeneic red blood cells (RBC), and RBC transfusion costs were analysed. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors of massive intraoperative blood loss (≥ 1,000 mL and ≥ 1,500 mL). A receiver operating characteristic (ROC) curve was used to analyse the cut-off values of the factors contributing to massive intraoperative blood loss.ResultsIn group A, no significant difference was observed in the volume of allogeneic RBC transfused during and after procedure between the IAT and no-IAT groups; however, total RBC transfusion costs was significantly higher in the IAT group. In groups B and C, the patients in the IAT group compared with those in the no-IAT group had a lower volume of allogeneic RBC transfused during the operation and on the first day after the operation. However, in group B, the total RBC transfusion cost in the patients who used IAT was significantly higher. In group C, total RBC transfusion cost in the patients who used IAT was significantly lower. The number of fused vertebral levels and Ponte osteotomy were found to be independent risk factors for massive intraoperative blood loss. ROC analysis showed that more than eight and 10 fused vertebral levels predicted ≥ 1,000 mL and ≥ 1,500 mL intraoperative blood loss, respectively.ConclusionThe cost-effectiveness of IAT in AIS was related to the volume of blood loss, and when the blood loss volume was ≥ 1,500 mL, IAT was cost-effective, drastically reducing the demand for allogeneic RBC and total RBC transfusion cost. The number of fused vertebral levels and Ponte osteotomy were independent risk factors for massive intraoperative blood loss.

Staged osteotomy in lateral position for the treatment of severe kyphotic deformity secondary to ankylosing spondylitis: a retrospective study

BackgroundPatients with severe kyphotic deformity (Cobb > 100°) secondary to ankylosing spondylitis (AS) occasionally cannot undergo corrective surgery in the prone position. Osteotomy in the lateral position might provide a possible solution. In this study, we aim to evaluate the clinical efficacy and safety of staged osteotomy in the lateral position for the treatment of AS-related severe kyphosis with a minimum of 2-year follow-up.MethodsIn total, 23 patients who underwent staged osteotomy in the lateral position from October 2015 to June 2017 were analyzed. In the first stage of surgery, all but one patient underwent a single-level Ponte osteotomy, which was followed by a pedicle subtraction osteotomy in the second stage. Mean follow-up was 30.8 ± 4.6 months. Global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), osteotomized vertebra intervertebral angle (OVI), chin-brow vertical angle (CBVA), Oswestry Disability Index (ODI) score and Scoliosis Research Society-22 Patient Questionnaire (SRS-22) were all compared pre- and postoperation.ResultsAll kyphosis parameters were significantly improved (all P < 0.05). GK was corrected from 115.0 ± 13.4° to 46.5 ± 9.0° postoperatively, with a mean correction of 68.5°. SVA was improved from 21.2 ± 5.1 cm to 5.1 ± 1.8 cm postoperatively. After surgery, CBVA was adjusted from 64.1 ± 23.2° to 5.7 ± 10.6° and OVI was changed from 9.0 ± 2.7° to − 20.1 ± 5.6°. Both the ODI and SRS-22 showed substantial improvements (all P < 0.05). Four patients with mild complications were observed perioperatively.ConclusionIn AS patients with severe kyphosis, satisfactory correction can be safely achieved with staged osteotomy in the lateral position, which can not only correct the sagittal imbalance of the spine with acceptable complications but also facilitate the placement of the intraoperative position.

Preoperative standing to prone spinal-pelvic sagittal parameter changes in old traumatic spinal fractures with kyphosis

To investigate the changes in spinal-pelvic sagittal parameters from preoperative standing to prone position in old traumatic spinal fractures with kyphosis. The clinical data of 36 patients admitted between December 2016 and June 2021 for surgical treatment of old traumatic spinal fractures with kyphosis, including 7 males and 29 females, aged from 50 to 79 years (mean, 63.9 years), were retrospectively analyzed. Lesion segments included 2 cases of T 11, 12 cases of T 12, 2 cases of T 11, 12, 4 cases of T 12 and L 1, 12 cases of L 1, 2 cases of L 2, 1 case of L 2, 3, and 1 case of L 3. The disease duration ranged from 4 to 120 months, with an average of 19.6 months. Surgical procedures included Smith-Petersen osteotomy in 4 cases, Ponte osteotomy in 6 cases, pedicle subtraction osteotomy in 2 cases, and improved fourth level osteotomy in 18 cases; the remaining 6 cases were not osteotomized. The bone mineral density ranged from -3.0 to 0.5 T, with a mean of -1.62 T. The spinal-pelvic sagittal parameters from preoperative standing to prone positions were measured, including local kyphosis Cobb angle (LKCA), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and PI and LL mismatch (PI-LL). The kyphotic flexibility=(preoperative standing LKCA-preoperative prone LKCA)/preoperative standing LKCA×100%. Spinal-pelvic sagittal parameters were compared between standing position and prone position before operation, and Pearson correlation was used to judge the correlation between the parameters of standing position and prone position before operation. When the position changed from standing to prone, LKCA and TK decreased significantly ( P<0.05), while SS, LL, PT, and PI-LL had no significant difference ( P>0.05). Pearson correlation analysis showed that LL was significantly correlated with SS and PI-LL in both standing and prone positions ( P<0.05), and the correlation strength between LL and SS in prone position was higher than that in standing position. In the standing position, LKCA was significantly correlated with SS and PT ( P<0.05). However, when the position changed from standing to prone, the correlation between LKCA and SS and PT disappeared, while PT and PI-LL was positive correlation ( P<0.05). The kyphotic flexibility was 25.13%-78.79%, with an average of 33.85%. For the patients of old traumatic spinal fractures with kyphosis, the preoperative LKCA and TK decrease significantly from standing position to prone position, and the correlation between spinal and pelvic parameters also changed, which should be taken into account in the formulation of preoperative surgical plan.

The effectiveness of pre-contoured titanium alloy rods in inducing thoracic kyphosis after sequential spinal releases in an in vitro biomechanical model.

Evaluate the ability of pre-contoured rods to induce thoracic kyphosis (TK) in human cadaveric spines and determine the effectiveness of sequential surgical adolescent idiopathic scoliosis (AIS) release procedures. Six thoracolumbar (T3-L2) spine specimens were instrumented with pedicle screws bilaterally (T4-T12). Over correction using pre-contoured rods was performed for intact condition and Cobb angle was measured. Rod radius of curvature (RoC) was measured pre- and post-reduction. The process was repeated following sequential release procedures of (1) interspinous and supraspinous ligaments (ISL); (2) ligamentum flavum; (3) Ponte osteotomy; (4) posterior longitudinal ligament (PLL); and (5) transforaminal discectomy. Cobb measurements determined the effective contribution of release on TK and RoC data displayed effects of reduction to the rods. The intact TK (T4-12) was 38.0° and increased to 51.7° with rod reduction and over correction. Each release resulted in 5°-7°of additional kyphosis; the largest releases were ISL and PLL. All releases resulted in significant increases in kyphosis compared to intact with rod reduction and over correction. Regionally, kyphosis increased ∼2° for each region following successive releases. Comparing RoC before and after reduction showed significant 6° loss in rod curvature independent of release type. Kyphosis increased in the thoracic spine using pre-contoured and over corrected rods. Subsequent posterior releases provided a substantial, meaningful clinical change in the ability to induce additional kyphosis. Regardless of the number of releases, the ability of the rods to induce and over correct kyphosis was reduced following reduction.

No short-term clinical improvement and mean 6° of thoracic kyphosis correction using limited-level Ponte osteotomy near T7 for Lenke type 1 and 2 adolescent idiopathic scoliosis: a preliminary study.

This study was a retrospective single surgeon case series approved by institutional review board and showed the efficacy of limited Ponte osteotomy at T6/7, 7/8 and 8/9 (limited-PO) in the sagittal plane for patients with Lenke type 1 and 2 adolescent idiopathic scoliosis (AIS). A total of 37 consecutive patients [7 males and 30 females; average age 16.0 ± 2.5 (range: 12-21)] over a 4-year period with posterior corrective fusion surgery were included. Initially, 18 patients were operated on without limited-PO [P(-)-group]. Midway in the series, the senior author switched to the limited-PO [P(+)-group]. The limited-PO has been performed to form the apex of thoracic kyphosis at the T7 level, together with the restoration of thoracic kyphosis. The mean amount of the correction angle of thoracic kyphosis was more in the P(+)-than in P(-)-group (13.8 ± 9.6° vs. 7.8 ± 8.0°, P = 0.046) at 1-year after surgery. Cervical lordosis was spontaneously corrected more in P(+)-than in P(-)-group. The apex of thoracic kyphosis was controlled around the T7 level postoperatively in most cases (18/19 cases). There was no significant difference between the two groups in terms of blood loss and operative time per level, or Scoliosis Research Society-22 domain scores. Limited-PO contributed to the restoration of the whole spinal sagittal alignment for Lenke type 1 and 2 AIS; however, in this preliminary study, the clinical improvement was unclear at least in the short term, because the kyphosis angle obtained by limited-PO was only approximately 6°.

Introduction of a Novel Sequential Approach to the Ponte Osteotomy to Minimize Spinal Canal Exposure

Ponte osteotomy is an increasingly popular technique for multiplanar correction of adolescent idiopathic scoliosis. Prior cadaveric studies have suggested that sequential posterior spinal releases increase spinal flexibility. Here we introduce a novel technique involving a sequential approach to the Ponte osteotomy that minimizes spinal canal exposure. One fresh-frozen adult human cadaveric thoracic spine specimen with 4 cm of ribs was divided into three sections (T1-T5, T6-T9, T10-L1) and mounted for biomechanical testing. Each segment was loaded with five Newton meters under four conditions: baseline inferior facetectomy with supra/interspinous ligament release, superior articular process (SAP) osteotomy in situ, spinous process (SP) osteotomy in situ, and complete posterior column osteotomy with SP/SAP excision and ligamentum flavum release (PCO). Compared to baseline, in situ SAP osteotomy alone provided 3.5%, 7.6%, and 7.2% increase in flexion/extension, lateral bending, and axial rotation, respectively. In situ SP osteotomy increased flexion/extension, lateral bending, and axial rotation by 15%, 18%, and 10.3%, respectively. PCO increased flexion/extension, lateral bending, and axial rotation by 19.6%, 28.3%, and 12.2%, respectively. Our report introduces a novel approach where incremental increases in range of motion can be achieved with minimal spinal canal exposure and demonstrates feasibility in a cadaveric model.

Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity.

Surgical correction of large, rigid scoliotic and kyphotic curves carries an increased risk of perioperative complications, such as neurological injury and excessive blood loss, compared with correction of less severe curves. Titanium temporary flexible rods (TFRs), designed for pediatric long bone fracture fixation, may be helpful as adjuncts to achieve gradual, stepwise intraoperative correction of severe pediatric spinal deformities. A retrospective review was conducted of spinal fusion cases for pediatric scoliosis or kyphosis at our institution that used TFRs as a correction technique from 2007 to 2019. Patients underwent posterior spinal fusion with predominantly pedicle screw instrumentation. Intraoperatively, a non-contoured titanium elastic nail was temporarily positioned in the screws unilaterally to achieve partial correction while the contralateral side was instrumented. Then, the TFR was removed and replaced with a permanent rod. Thirty-four patients with severe spinal deformities underwent posterior spinal fusion. Seventeen had scoliosis (mean major Cobb angle, 89.3°) and 17 had kyphosis (mean T5-T12 kyphosis, 73.8°). Idiopathic deformity was the most common etiology; neuromuscular, syndromic, and postsurgical causes contributed to the remainder of cases. All patients had Ponte osteotomies. Four patients (11.8%) had neuromonitoring alerts, 1 of which was related to insertion of the TFR; all were reversible. For patients with scoliosis, the mean postoperative Cobb angle measured 40.2° (53.6% correction). For patients with kyphosis, the mean postoperative T5-T12 angle measured 43.3° (30.4° of correction). TFRs appear to be helpful adjuncts for correction of severe pediatric spinal deformities, facilitating gradual intraoperative correction in a single-stage operation. Neuromonitoring alerts are common but reversible. [Orthopedics. 2023;46(4):234-241.].

Tips and Pearls in Spinal Osteotomy

Background and Aim: Spinal osteotomy is a general term for techniques applied to correct spinal deformity. The aims of osteotomy are to create a normal range of spine curvature, pain relief, and to improve quality of life. In the cases where spinal deformities cannot be corrected using instrumentation alone or by facet or ligament release, osteotomy is indicated. In spinal osteotomies, spinal alignment is corrected by removing part of the spinal bone. Osteotomies can be performed as anteroposterior or posterior-only procedures with a greater predilection for posterior-only procedures. Different types of osteotomy are available, including the Smith-Petersen osteotomy (SPO), Ponte osteotomy (PO), pedicle subtraction osteotomy (PSO), corner osteotomy (CO), or bone-disc-bone osteotomy (BDBO), vertebral column decancellation (VCD) and vertebral column resection (VCR). Methods and Materials/Patients: In this narrative study, to provide up-to-date information, we precisely reviewed articles in the osteotomies context. Using the keywords spinal osteotomy, spinal deformity, Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), vertebral column resection (VCR), vertebral column decancellation (VCD), Ponte osteotomy (PO), corner osteotomy (CO), all the relevant articles were retrieved from PubMed, Google Scholar, Medline, and critically reviewed and analyzed. Results: In the spine surgery, osteotomy is performed to correct the deformity in uncorrectable spinal deformity. The suitable type of osteotomy is selected based on the etiology, type, and apex of deformity, surgeon's experience, availability of blood and bleeding control agents, and availability of intensive care. A wider acceptance of posterior-only procedures exists in osteotomy. Conclusion: In spinal deformity surgery, more degrees of correction are needed for better cosmetic results, and for this purpose, spinal osteotomy has a central role. For this reason, all spine surgeons should be familiar with these osteotomy techniques.

Do hypokyphotic adolescent idiopathic scoliosis patients treated with Ponte osteotomy obtain a better clinical efficacy? A preliminary retrospective study

Study designA retrospective case–control study.ObjectiveTo evaluate whether Ponte osteotomy improves thoracic kyphosis and to determine its clinical efficacy in hypokyphotic adolescent idiopathic scoliosis (AIS).MethodsEighty consecutive Lenke type 1 AIS patients with hypokyphotic curves who underwent posterior spinal fusion by one spine surgeon at a single institution were recruited. According to whether Ponte osteotomy was performed, the patients were divided into two groups. The preoperative, immediate, one-year postoperative, and two-year postoperative radiographs were analyzed. The demographic characteristics, surgical information, radiographic parameters, Scoliosis Research Societye-22 (SRS-22) questionnaire, and complications were compared.ResultsThe sagittal alignment and coronal alignment were both improved in the Ponte group and the control group postoperatively. There was no significant difference in the preoperative parameters between the two groups, except the TL/L, CB, and LL. Significant differences were found in the MT (15.18° ± 2.84° vs. 20.33° ± 3.75°, P < 0.001) and TK (24.23° ± 2.71° vs. 19.93° ± 2.38°, P < 0.001) at the two-year follow-up. The Ponte group had a longer operation time and more intraoperative blood loss. No significant difference was observed between the groups in the SRS-22 scores at the final follow-up.ConclusionsPonte osteotomy could obtain better coronal correction and sagittal contour restoration in AIS patients with hypokyphosis. However, Ponte osteotomies might lead to more intraoperative blood loss and longer operation time. Moreover, no discrepancy was found in the postoperative health-related quality of life of the included patients. Therefore, we considered that the Ponte osteotomy may be an alternative method to restore the desired thoracic kyphosis, which needs further study.

Multisegment transforaminal lumbar interbody fusion (TLIF) combined with Ponte osteotomy in degenerative lumbar scoliosis (DLS) surgery: a minimum of five years’ follow-up

PurposeTo evaluate the long-term clinical outcomes of degenerative lumbar scoliosis (DLS) with the administration of multisegment transforaminal lumbar interbody fusion (TLIF) combined with Ponte osteotomy long-level fixation fusion, as well as to identify the factors affecting health-related quality of life (HRQOL).MethodsThis was a retrospective single-centre study involving comprehensive clinical data. The Oswestry Disability Index (ODI), visual analog scale (VAS) outcomes, and Scoliosis Research Society (SRS-22) questionnaire were recorded to assess HRQOL. A correlation analysis was performed to determine the association between HRQOL and radiographic parameters.ResultsA total of 41 consecutive patients (15 males and 26 females) met the inclusion criteria with a follow-up of 8.62 ± 1.20 years. Factors associated with HRQOL were significantly improved post-operation. Global sagittal parameters, including the sagittal vertebral axis (SVA) and T1 pelvic angle (TPA), and local parameters, including apical vertebral translation (AVT) and apical vertebral rotation (AVR), were significantly improved at the last follow-up. Significantly strong correlations between each clinical and radiographic parameter were demonstrated. Moreover, a multiple linear regression analysis demonstrated that the differences in AVT and AVR were significantly correlated with the difference in lumbar lordosis (LL), which was significantly correlated with the differences in SVA and TPA.ConclusionThe surgical treatment of DLS with multisegment TLIF accompanied by Ponte osteotomy and long-level fixations improved the quality of life of patients with a long-term effect. AVR correction is an important factor for LL restoration that significantly correlates with improvements in the sagittal balance parameters SVA and TPA, which are key factors for guaranteeing good HRQOL.

Pectus excavatum, kyphoscoliosis associated with thoracolumbar spinal stenosis: a rare case report and literature review

BackgroundPectus excavatum is the most common congenital chest wall defect. Thoracolumbar spinal stenosis and kyphoscoliosis was seen in patients with pectus excavatum. It can be caused by ossification of the ligamentum flavum, which is rare in patients with pectus excavatum.Case presentationWe reported a 26-year-old woman presented bilateral lower extremities weakness and numbness for two months, progressive worsening. She was diagnosed as thoracolumbar spinal stenosis with ossification of the ligamentum flavum, thoracolumbar kyphoscoliosis associated with pectus excavatum. The posterior instrumentation, decompression with laminectomy, and de-kyposis procedure with multilevel ponte osteotomy were performed. Her postoperative course was uneventful and followed up regularly. Good neurologic symptoms improvement and spinal alignment were achieved.ConclusionsPectus excavatum, kyphoscoliosis associated with thoracolumbar spinal stenosis is rare, and thus her treatment options are very challengeable. Extensive laminectomy decompression and de-kyphosis procedures can achieve good improvement of neurologic impingement and spinal alignment.

Complication risks and costs associated with Ponte osteotomies in surgical treatment of adolescent idiopathic scoliosis: insights from a national database.

Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients. Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (± PO) between 2007 and 2015 in the IBM® MarketScan® Commercial Databases. Costs and trends of POs were evaluated. Odds of neurological complications and readmissions within 90days and reoperations within 90days and 2years were assessed. We identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p < 0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p = 0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p < 0.001) and reoperation (2.03 [1.13-3.59]; p = 0.015) within 90days, but there were no differences in the odds of reoperation within 2years (p = 0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p < 0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p < 0.001). Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90days. By 2years, differences in reoperation rate were not significant. III.

The Sagittal Plane in Spinal Fusion for Adolescent Idiopathic Scoliosis.

Sagittal balance is widely recognized as the primary determinant of optimal outcomes in adult spinal deformity. In adolescent idiopathic scoliosis (AIS), coronal correction risks being obtained at the expense of sagittal malalignment after posterior spinal fusion. Apical lordosis, often underestimated on two-dimensional imaging, is the primary deforming factor in AIS. Failure to restore thoracic kyphosis and lumbar lordosis during posterior spinal fusion contributes to problematic early surgical complications, including proximal or distal junctional kyphosis and failure. Although adolescent patients often compensate for sagittal imbalance in the short-term and mid-term, late sequelae of iatrogenic sagittal imbalance include flatback syndrome, disk degeneration, cervical kyphosis, and late decompensation. Objective criteria using spinopelvic parameters and preoperative three-dimensional planning can guide sagittal plane correction during PSF for AIS. Technical caveats can help avoid sagittal plane complications, including instrumentation level selection, anchor type, and anatomic protection of adjacent levels. Other surgical techniques to optimize restoration of thoracic kyphosis include higher implant density, stiffer rod material, Ponte osteotomies, and deformity correction technique.

The Effect of Ponte Osteotomies on the Sagittal Shape of Rods and Spine Derotation in Adolescent Idiopathic Scoliosis: A Single-Center, Retrospective Cohort Study

BackgroundAdding a Ponte osteotomy (PO) to other surgical techniques for correcting adolescent idiopathic scoliosis (AIS) profoundly affects the entire sagittal shape of the rod. POs are an effective procedure for correcting thoracic hypokyphosis in patients with AIS.MethodsA retrospective review of 40 patients with AIS was conducted. The sample was divided into 2 groups: PO and non-PO. On a lateral radiograph, the rod end angle (A) was calculated using the intersections of the tangents with the rod end points. The maximal deflection (D) was obtained for each rod. In addition, the rod apex angle (B) was calculated using the intersection of the tangents at 2 points, each 1 cm to 1 side of the rod apex; the distance between the rods at the apex was then measured.ResultsConcave rods tended to be straight or even lordotic at the apex in the non-PO group (−0.9° vs. +5.9° in the PO group; P = 0.000). The rod end angle and deflection were significantly lower in the non-PO group (15.2° and 7.1 mm vs. 26.3° and 17.8 mm in the PO group; P = 0.000 and P = 0.000). The convex rods were less kyphotic in the non-PO group; for the non-PO group, the end angle and deflection were 27.6° and 16 mm versus 33.4° and 23.8 mm in the PO group (P = 0.03 and P = 0.000). No significant difference between the groups was observed for the convex rod apex angle (P = 0.8). The rod apices were more superimposed in the PO group (2.9 mm vs. 9.3 mm in the non-PO group; P = 0.000).ConclusionsPOs increase the overall sagittal kyphosis and improve the three-dimensional derotation of the apex in patients with AIS.

Ponte osteotomies increase risk of intraoperative neuromonitoring alerts in adolescent idiopathic scoliosis surgery.

Background: Ponte osteotomies (PO) are commonly used in adolescent idiopathic scoliosis (AIS) surgeries to improve the coronal and sagittal deformity correction. Here, we compared the incidence of perioperative neurologic complications for patients undergoing AIS with versus without PO.Methods: In a retrospective cohort study of 80 consecutive AIS patients undergoing scoliosis correction, 40 underwent PO, while 40 did not. All operations were performed by one surgeon at one tertiary care center. Patients’ demographics, Lenke classifications, surgical data, and deformity characteristics were comparable in both groups. Perioperative neurologic complications, defined as spinal cord or nerve root injuries identified by the surgeon, were tracked for those undergoing AIS surgery with or without PO being performed.Results: The risk of IOM alerts was significantly higher in the PO patients (12.5%: 5 patients) versus those in the No-PO group (0%, P = 0.021). Despite these changes, no patient incurred an increased postoperative deficit. Nevertheless, PO group patients demonstrated a higher coronal deformity correction rate (PO: 71% ± 10.9 vs. NoPO: 64.2% ± 11.5, P = 0.008) and a greater kyphosis Cobb angle (PO: 25.2 ± 6 vs. No-PO: 17.5 ± 9.4, P = 0.0001) on postoperative follow-up.Conclusion: While PO improved 3D correction of AIS, it increased the risk of IOM alerts in 12.5% of cases.

Outcomes of Definitive Spine Fusion Using All-pedicle-Screw Constructs in Skeletally Immature Patients Aged 8 to 10 Years With Severe Idiopathic Early-Onset Scoliosis.

The choice between growth-sparing techniques or definitive spine fusion for severe idiopathic early-onset scoliosis (IEOS) in skeletally immature patients aged 8 to 10 years represents a challenging dilemma. Although growth-sparing techniques show high complication rates in severe IEOS, the outcomes of definitive fusion in borderline skeletally immature patients with severe IEOS have not been investigated. We aimed to investigate the outcomes of early definitive fusion using all-pedicle-screw constructs in skeletally immature patients aged 8 to 10 years with severe IEOS. The inclusion criteria were as follows: IEOS, age 8 years or above, major coronal curve ≥90 degrees, thoracic height >18 cm, no history of previous spine surgery, no intraspinal anomalies and at least 3 years of postoperative follow-up. Patients underwent instrumented spinal fusion with all-pedicle-screw constructs and multiple Ponte osteotomies. All patients completed the Scoliosis Research Society 22 revision (Arabic version) questionnaire and Body Image Disturbance Questionnaire-Scoliosis version (BIDQ-S) preoperatively and at the last follow-up. Fifty-five patients (24 males, 31 females; mean age: 8.96 y; range: 8 to 10 y) with severe IEOS met the inclusion criteria (mean follow-up period: 4.1±0.6 y; range: 3 to 5 y). The mean major coronal Cobb angle improved significantly (P<0.001) from 107±12.5 degrees to 26.8±6.8 degrees. Mean thoracic kyphosis improved significantly (P<0.001) from 57.2±15.8 degrees to 31.2±4.4 degrees. The loss of correction at the latest follow-up was nonsignificant. The total Scoliosis Research Society 22 revision (SRS-22r) score improved significantly from 2.5±1 to 4.3±0.7. The mean BIDQ-S score improved significantly from 4.1±0.3 to 1.6±0.3. The immediate postoperative gains in the mean thoracic height (T1-T12) and spinal height (T1-S1) were 14.9% and 19.6%, respectively, and the overall height increase at the latest follow-up was 17.8% and 23.8%, respectively. One patient underwent revision for implant failure (rod breakage). Early definitive fusion for skeletally immature patients with severe IEOS yielded excellent correction with major improvements in patient quality of life. Severe IEOS poses a significant risk, but definitive fusion can potentially mitigate that risk in patients aged 8 to 10 years.