Ponte Osteotomies Research Articles

High Density Pedicle Screws through Posterior Only Approach for Surgical Correction of Severe Adolescent Idiopathic Scoliosis > 70o

Background Data: The classic treatment of severe rigid adolescent idiopathic scoliosis (AIS) was performed by combined anterior and posterior surgery which carries higher morbidity to the patient. Recently, posterior only surgery using allpedicle screws has been used for treatment of severe AIS with many advantages over combined approaches.Purpose: To evaluate the safety and effectiveness of high density pedicle screws through posterior only approach in correction of severe cases of adolescent idiopathic scoliosis (AIS) with curves > 70o. Study Design: Prospective cohort study. Patients and Methods: Between 2012 and 2014, fourteen patients were surgically treated for severe AIS with curves > 70o and were prospectively followed up for a minimum of 1 year (Range 1-4 years). Clinical outcomes were evaluated using SRS- 22 questionnaire. All patients were classified according to Lenke et al classification.Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. Side bending films were used to assess curve flexibility. High density pedicle screws and multiple Ponte osteotomies were used in all patients. Five patients required asymmetrical pedicle subtraction osteotomy due to very rigid curve. Results: This study included 14 patients (8 females, 6 males).The mean age at time of surgery was 17.4 years (range 14-24 years). The mean correction rate for the coronal Cobb angle of the major and minor curves was 73.7% (80.4o preoperativeand 21.7o postoperative) and 68.7% (51.5o preoperative and 19.63o postoperative) respectively. The mean thoracic kyphosis angle was 44.2o preoperatively, 28.55o postoperatively and 28.1o at latest follow up. The mean SRS-22 questionnaire scores improved significantly from 2.8 preoperatively to 3.7 at the final follow up (P>0.001). No cases of pseudarthrosis, metal failure or neurological deficits were encountered. One patient with asymmetrical PSO developed hemothorax that was managed with chest tube insertion and follow up. Conclusion: High density pedicle screws through posterior only approach is a safe and effective method in treatment of severe AIS. It can achieve coronal curve correction comparable to combined anterior and posterior approaches without the morbidity of combined approaches. It also restores the sagittal profile leading to good functional outcomes and better quality of life. (2014ESJ073)

Treatment of severe rigid scoliosis with one-stage posterior Ponte osteotomy and two-stage posterior orthopedics

Objective To discuss the efficacy and safety of one-stage posterior Ponte osteotomy and two-stage posterior orthopedics in treatment of severe rigid scoliosis. Methods Retrospective review was conducted for 24 patients with severe rigid scoliosis (Cobb angle >100°) who underwent one-stage posterior Ponte osteotomy and two-stage posterior orthopedics between June 2010 and December 2012, including 9 male patients and 15 female patients. The average age is 21.4±4.1 (ranging from 14 to 30). The major curve Cobb angle on preoperative coronal plane was 106°-156° (125.8° on the average); kyphosis angle was 59°-141° (100.1° on the average). All patients experienced one-stage posterior Ponte osteotomy, screw insertion, postoperative Haloskeletal traction through supracondyle of femur and two-stage posterior orthopedic fusion. The Cobb angles of the major curve at the standing position before surgery, at supine position after posterior release and traction and on postoperative coronal plane and on coronal plane in the last follow-up. Results The flexibility of major curve at bending position before the surgery was 14.8%±7.5%; the flexibility of major curve after posterior release and traction was 29.1%±9.9%; it improves 14.3% compared with that before the surgery. The difference has statistical significance. The Cobb angle of major curve after posterior orthopedics was 74.4°±14.5° on the average; the mean correction rate was 41.0%±8.1%. It boots 26.2% and 11.9% respectively compared with preoperative bending position and posterior release and traction. The different has statistical significance. The post-operation follow-up duration was 15-36 months (24.0±5.9 months on the average). At the last follow-up, the average loss of Cobb angle of major curve was 1.4°. The post-operative kyphosis angle was 53.0°±13.7° on the average which significantly improves compared with pre-operation (100.1°±23.7°). The mean correction rate was 46.1% ±11.9%. No correction loss was shown in the last follow-up. One patient experienced superficial pin-site infection and two patients had deep venous thrombosis of the left limb. Conclusion Posterior Ponte osteotomy combined with Halo-femoral traction could achieve satisfactory correction rate for patients with severe rigid scoliosis. However, the risk caused by thrombus of lower extremity veins should be noticed during the whole procedure. Key words: Scoliosis; Osteotomy; Traction; Orthopedic procedures

Camptocormia and Dropped Head Syndrome Induced by Chemoradiotherapy for Base Tongue Carcinoma: A Case Report and Review of Literature

Introduction Camptocormia (bent spine syndrome) is an acquired postural disease characterized by forward flexion of the thoracolumbar spine. Camptocormia leads to lumbar kyphosis and increases during walking or standing. Management of Camptocormia is still a challenge and the literature on this topic is limited. There is no specific pharmacologic treatment for primary axial myopathy. Patients and Methods Our patient is a 68-year-old man, diagnosed in 2009 with a base tongue squamous cell carcinoma, surgically removed in September 2010. By May 2011, it was diagnosed with local recurrence, submitted to radiosensitive chemotherapy, and followed by radical radiotherapy 35 fractions of 70 Gy. Results After general anesthesia, and neuromonitoring a median incision was made from C3 to the sacrum, former instrumentation C3–T3 were tested, and no loosening or breakage was detected. Pedicle screws were inserted by free hand technic except C7 and T1 because the small space for rod connectors and T6, T10, L2, and L5 were osteotomies were performed total of 28 screws until S2 with sacropelvic fixation. In T6 and T10, Ponte osteotomies were made, and closing wedge pedicle subtraction in L2 and laminectomy of L3. Patient presented good outcome, receiving discharge at 7th postoperatory day, and initiated naturotherapy, fonotherapy, and physiotherapy, and nasoenteral catheter were maintained until 3 weeks and some swallowing improvement reported by the 6th week. In the follow-up, patient maintained satisfied with procedure and returned to work by 3rd month, screening showed no recurrence of the tumor or distant metastasis. Conclusion This is the first case described where dropped head syndrome and camptocormia occurred in the same patient because of radiosensibilizing chemotherapy for a nasopharyngeal carcinoma. We only found a single case report of a patient with dropped head syndrome associated with chemoradiotherapy for a nasopharyngeal carcinoma in a 59-year-old Japanese patient, described by Hashimoto (2012), treated without surgery who developed symptoms 2 years after chemoradiotherapy.

Treatment of Pediatric Scoliosis with Daytona Instrumentation Using the Cluster Technique

Introduction The authors show their experience with the use of Daytona instrumentation in the treatment of pediatric spine deformities. In the correction maneuvers it is important to build up clusters that are groups of pedicle screws joined together for stability in the derotation and provide greater force in the correction and also to prevent the hypokyphosis effect of all screw construct in the scoliosis correction. Materials and Methods Our department used the Daytona system in 81 patients with pediatric scoliosis since March 2011. The Daytona instrumentation is a novel instrumentation that uses pedicle screws with long tulips in their basic construction. The screws are uniplanar or polyaxial and the tulips are 30 mm long, which makes it much easier to put the rod in the construction without the need of a persuader and helps in the initial correction maneuver. The caps are specially designed to embrace the rod and prevent splaying of the screw during the tightening and untightening. The scoliosis correction maneuver that we used were rod derotation, derotation of the spine with groups of screws (cluster), “in situ” bending, compression and distraction, and segmental derotation. Using the clusters, there are less chances of screw pullout and splaying. Generous Ponte osteotomies are important for spine flexibility and better correction. We use Lenke's classification for the classification of scoliosis. We analyze the follow-up time, curve angles, flexibility, and the Cincinnati index. For patients with idiopathic scoliosis, we use the SRS 22r outcomes questionnaire. Results Retrospectively, we analyze 81 patients with scoliosis, 64 female and 17 male, with a mean age of 13.96 years (10–17 years). A total of 88% of the patients had idiopathic scoliosis. Others are neuromuscular and syndromic patients. Preoperatively, the mean angle was 78.09 degrees (38–120 degrees) and the mean flexibility index was 30.7%. Postoperatively, the mean angle was 23.6 degrees (5–62 degrees). Correction percentage was 68.1% and the Cincinnati index was 3.33%. The mean follow-up time was 16.9 months, at last follow-up the mean curve angle was 24.7 degrees, representing a loss to the postoperative period of 5% of loss of correction. The most frequent complications that we encounter were temporary loss of MEP and screw breakage. Comparing with the literature, the Daytona system is as effective as other systems in the market. Conclusion The Daytona instrumentation is a very good system for the treatment of adolescent idiopathic scoliosis; it is as effective as other systems with the added advantage of being much easier to place in the patient, and with the cluster technique we can save money with fewer screws and the derotation maneuver with clusters is a powerful correction technique.

Surgical treatment of Scheuermann´s disease by the posterior approach. Case series

OBJECTIVE: To describe the results of surgical treatment of Scheuermann's disease by the posterior approach. METHOD: A descriptive, retrospective, longitudinal study in which patients with Scheuermann's disease, treated surgically by the posterior approach at the Hospital de Traumatologia y Ortopedia [Hospital for Traumatology and Orthopedics] "Lomas Verdes" IMSS. The Cobb method was used to measure the kyphosis in all the patients, of T5-T12. The surgical technique used was vertebral shortening by the Ponte osteotomy technique, at the apex of the deformity, accompanied by transpedicular instrumentation and posterior arthrodesis. RESULTS: Five patients were included; three men and two women, with an average age of 16.6 years. The initial average kyphosis was 76º, which was corrected to 42º after surgery. Blood loss was 590 ml, with a surgery time of 3 hours. Three patients were submitted to neurophysiological monitoring. No neurological lesion was found. There was no loss of correction at 6 months of evolution. CONCLUSIONS: The vertebral shortening technique with posterior instrumentation eliminates the use of the anterior approach to release the anterior longitudinal ligament. Osteotomies by the Ponte technique make the spine more flexible, and together with pedicular instrumentation, correct the deformity and preserve the correction over time.

Ponte osteotomies to treat major thoracic adolescent idiopathic scoliosis curves allow more effective corrective maneuvers

There is controversy regarding the effect of the Ponte osteotomies in the improvement of coronal correction, its maintenance during follow-up, and the restoration of thoracic kyphosis in adolescent idiopathic scoliosis (AIS). Seventy-three AIS patients with Lenke type 1-4 curves were included. A prospective description of 43 consecutive patients who underwent apical Ponte osteotomies and sublaminar wires with hybrid instrumentation was retrospectively compared to a historical cohort of 30 patients without "Ponte osteotomies". The surgical details and complications were recorded. We evaluated the radiological measurements and SRS-22 Questionnaire scores over a 2-year follow-up. The Ponte group achieved better postoperative (70 vs 57 %) and final (62 vs 50 %) main curve correction P < 0.001, with no significant loss of correction (4.2° vs 2.5°) P = 0.2 at the final follow-up (48 vs 106 months). We did not find a difference in thoracic (T5-T12) postoperative (22° vs 24°) and final (25° vs 26°) mean kyphosis angle. However, the "Ponte osteotomies" helped to achieve a normal sagittal profile, increasing preoperative hypokyphotic curves (<10°) from 6° to 17° (control: 9°-12°; P = 0.01); and preoperative hyperkyphotic curves (>40°) from 52° to 26° (control: 46°-39°; P = 0.01). The length of surgery was similar (4.3 vs 4.6 h), as were the SRS-22 scores. No major complications were found. Ponte osteotomies in major thoracic AIS curves treated by sublaminar wires allowed more effective corrective maneuvers, which improved coronal correction without a significant loss during follow-up. The sagittal profile appears to be determined by other variables; however, "Ponte osteotomies" facilitate the contouring of the desired kyphosis.

Progressive Camptocormia and Dropped Head Syndrome Induced By Chemoradiotherapy for Base of Tongue Carcinoma. Case Report

Background: Camptocormia (bent spine syndrome) is an acquired postural disease characterized by forward flexion of the thoracolumbar spine. Dropped head syndrome is characterized by severe weakness of the cervical paraspinal muscles, resulting in gradual sagging of the head and culminating in the classic chin-on-chest deformity. Objective: To report, for the first time, a case of dropped head syndrome and camptocormia in the same patient. Methods and results: A 68-years-old man was diagnosed with base tongue squamous cell carcinoma, surgically removed. He had local recurrence and underwent radiosensitive chemotherapy and radiotherapy (35 fractions of 70Gy). After 12 months, he developed progressive cervical extensor muscle weakness, and a flexible chin-on-chest deformity, treated with passive reduction and C3-T3 fixation. Three months later, camptocormia was diagnosed, and initially treated conservatively. Ten months later, the deformity became rigid, and he was operated with Ponte and pedicle subtraction osteotomies in thoracic and lumbar spine, and C3 to sacrum arthrodesis with instrumentation. The patient resumed professional activities by the third month. Oncological screening showed no tumoral recurrence or distant metastases, after one year from last surgery. Conclusion: This is the first report of dropped head syndrome and camptocormia in the same patient, due radiosensibilizing chemotherapy for a nasopharyngeal carcinoma.

Osteotomies in proximal junctional kyphosis in the cervicothoracic area.

Proximal junctional kyphosis (PJK) of the cervicothoracic spine is a deformity that can affect patients who have undergone long thoracolumbar instrumented fusion. Preoperative hyperkyphosis of the thoracic spine and changes of more than 30° in lumbar lordosis are independent risk factors for the onset of PJK. When PJK occurs in the cervicothoracic spine, extension of the fusion with eventual application of osteotomy techniques is frequently necessary to treat symptomatic patients or in case a neurological deficit occurs. Ponte osteotomy and pedicle subtraction osteotomy (PSO) are the two most used techniques to restore a good cervicothoracic alignment, although they are still demanding procedures even for expert surgeons. In junctional fractures, a vertebral column resection can be performed to support the anterior column. Ponte osteotomy ideally restores 10° at each treated level, while PSO allows a segmental correction up to 30°-35°. Adequate preoperative planning is fundamental for outlining the correct surgery and choosing the appropriate osteotomy. The aim of corrective surgery is to restore the cervicothoracic alignment, obtaining an adequate postoperative sagittal balance and decreasing the risk of further complications and new revision surgeries.

Ponte osteotomies in thoracic deformities

Thoracic hyperkyphosis is a sagittal deformity that can cause back pain and neurological impairment, leading to difficulties in maintaining a straight gaze. Sagittal thoracic malalignment has different etiologies and different corrective strategies. An adequate preoperative planning is mandatory to address correctly the surgical treatment, using an appropriate sagittal deformities classification and the rules that relate pelvic parameters to spine curvatures to determine the correction needed to restore a good sagittal alignment. Ponte osteotomies are performed in long non-angular hyperkyphotic thoracic deformities, even if idiopathic scoliosis, rigid deformities or proximal junctional kyphosis after instrumented fusions can benefit from the application of this technique that requires a mobile anterior column for the correction of the deformity. Ponte's is, together with Smith-Petersen osteotomy, a posterior column osteotomy. The magnitude of correction can reach 10° per level if intervertebral discs are still mobile.

Surgical management of cervical deformity with osteotomy

Cervical sagittal balance is as an important clinical and radiographic parameter. The normal cervical spine is lordodic, and all kyphotic deformities should be explored. In patients with suspected cervical pathology, a thorough history and physical exam is mandatory. While axial neck pain commonly exists with kyphotic deformity, radiculopathy or myelopathy often exists as well. AP and lateral radiographs detect bony abnormalities and disc space collapse. A C2–7 plumb line may be drawn to measure angulation of the cervical spine. Adjuvant CT scan, to further delineate the bony architecture, and MRI scan, to assess for neural compression, are often useful in the management of a kyphotic spine. Nonoperative management is the usual initial mode of treatment. Physical therapy, aimed at posterior cervical paraspinal muscle strengthening, may improve lordosis in patients with flexible kyphosis. Anti-inflammatory medications and injections may cause symptomatic improvement but they do not address anatomic problems. Close follow-up is needed with these patients to monitor for neurologic deterioration. Operative treatment is indicated when nonoperative management has failed or in the setting of severe or rapidly progressive neurologic symptoms. Techniques for sagittal correction exist on a spectrum. Partial facet resections or Ponte osteotomies cause relatively small segmental lordosis but result in large sagittal improvement when used in long constructs. Anterior corpectomy with adjuvant posterior soft tissue release results in more focal lordosis. Three-column osteotomies are performed at either C7 or T1 to avoid the vertebral artery. Anterior column lengthening is relatively more powerful than a pedicle subtraction osteotomy. However, anterior lengthening is associated with a higher risk of damage to the surrounding neurovascular structures and soft tissue due to traction. Lastly, a vertebral column resection results in the greatest angular correction but is rarely performed due to its high potential for complication.

Skip pedicle screw fixation combined with Ponte osteotomy for adolescent idiopathic scoliosis.

This study aimed to determine whether Ponte osteotomy combined with skip pedicle screw fixation (SPSF) can improve the correction rate and restore thoracic kyphosis for patients with adolescent idiopathic scoliosis. Surgical time, blood loss, preoperative Cobb angle of the main thoracic curve, flexibility, Cobb angle at 1 year after surgery, thoracic curve correction rate, and Cincinnati correction index (CCI) were determined for both the Ponte (n = 17) and non-Ponte (control; n = 21) groups. Furthermore, kyphotic angles at T5-T12 before and 1 year after the surgery were measured. The following measurements were obtained for the Ponte and control groups, respectively: surgical time, 236 ± 13 and 187 ± 9 min; blood loss, 1,141 ± 150 and 745 ± 120 g; preoperative Cobb angle of the main thoracic curve, 52.5° ± 10.4° and 51.5° ± 9.2°; flexibility, 31.7 ± 13.2 and 45.1 ± 12.3% (p = 0.003); thoracic curve correction rate, 62.0 ± 2.5 and 63.6 ± 2.5%; CCI, 2.2 ± 0.2 and 1.5 ± 0.1 (p = 0.003); preoperative kyphotic angle at T5-T12, 11.3° ± 11.2° and 13.0° ± 9.0°; and kyphotic angle at T5-T12 at 1 year after the surgery, 21.8° ± 1.7° and 24.2° ± 1.9°. Ponte osteotomy was combined with SPSF in case of rigid curve. CCI was significantly greater in the Ponte group. Postoperative thoracic kyphotic angles were identical in both groups.

Flexibility of thoracic spines under simultaneous multi-planar loading.

The corrective potential of two posterior-only destabilization procedures for scoliosis deformity was quantified under single and multi-planar loading using cadaveric spines. Ten full-length human cadaveric thoracic spines were mounted in an 8-df servohydraulic load frame. Cyclic, pure moments were applied in: (1) flexion-extension, (2) lateral bending, (3) axial rotation, (4) flexion-extension with axial rotation, and (5) lateral bending with axial rotation at 0.5°/s, to ±4 Nm. Each specimen was tested intact, and again after nine en bloc bilateral total facetectomies, and one, two, three, and four levels of Ponte osteotomies. Motion was measured throughout loading using optical motion tracking. Under single-plane loading, facetectomies and Ponte osteotomies increased thoracic spine flexibility in all three planes. Compared to total facetectomies, higher per-level increases were seen following Ponte osteotomies, with increases in total range of motion (total ROM) of up to 2.7° in flexion-extension, 1.4° in lateral bending, and 3.1° in axial rotation following each osteotomy. Compared to the facetectomies, four supplemental osteotomies increased total ROM by 23% in flexion (p<0.01) and 8% in axial rotation (p<0.01). Increases in lateral bending were smaller. Under multi-planar loading, each Ponte osteotomy provided simultaneous increases of up to 1.4°, 1.6°, and 2.2° in flexion-extension, lateral bending, and axial rotation. Ponte osteotomies provided higher per-level increases in ROM under single-plane loading than total facetectomies alone. Further, Ponte osteotomies provided simultaneous increase in all three planes under multi-planar loading. These results indicated that, to predict the correction potential of a surgical release, multi-planar testing may be necessary.

Effects of rod reduction on pedicle screw fixation strength in the setting of Ponte osteotomies

Background contextThe use of a rod reduction device can have deleterious consequences on pedicle screw pullout strength (POS) in the thoracic spine. However, posterior-only osteotomies in the thoracic spine are often performed to improve flexibility of the spine and offset forces of deformity correction maneuvers. PurposeTo investigate the effect on pedicle screw POS caused by the rod reduction technique in the presence of facet osteotomies in the thoracic spine. Study design/settingThe study is a biomechanical study using human cadaveric spine specimens. MethodsThoracic Ponte osteotomies were performed on 3 thoracic levels in 15 cadaveric specimens. The right rod was contoured with a 5-mm residual gap at the middle level and was reduced using a rod reduction device. On the left side (paired control), a rod with no mismatch was placed. Biomechanical testing was performed with tensile load to failure “in line” with the screw axis and POS measured in Newtons (N). ResultsAfter rod reduction, thoracic pedicle screw POS was significantly decreased (40%) compared with the control (419±426 N vs. 708±462 N, p=.002) and remained statistically significant after adjusting for bone mineral density (BMD) (p=.05). Eleven (73%) of the pedicle screws had visible pullout/failure during the reduction attempt and occurred irrespective of BMD. ConclusionsDespite thoracic Ponte osteotomies and increased flexibility of the spinal segments, the rod reduction device still significantly decreased pedicle screw POS, typically resulting in outright failure of the screw-bone interface. Therefore, rod reduction technique of any kind should be performed with caution as it frequently results in suboptimal pedicle screw fixation.

Blood loss during posterior spinal fusion for adolescent idiopathic scoliosis.

Retrospective uncontrolled case series. The purpose of this study was to determine the association, if any, between intraoperative blood loss and need for transfusion with the use of periapical (Ponte) osteotomies, as well as other patient and surgical variables among patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion. Blood loss during posterior spinal fusion for AIS can be substantial. Numerous techniques are used to minimize intraoperative blood loss and the need for allogeneic transfusion. However, it is unclear which patient and surgeon variables affect blood loss most significantly. A review was conducted on consecutive patients with AIS who had undergone posterior spinal fusion from July 1997 to February 2013 by a single primary surgeon at 1 institution. The relationship of estimated blood loss, normalized blood loss (normalized blood loss = estimated blood loss/number of levels fused/patient's weight in kilograms), autologous blood retrieved, and allogeneic transfusion received with various patient- and procedure-related variables were analyzed. Estimated blood loss, normalized blood loss, and autologous blood retrieved were higher in patients who underwent periapical Ponte osteotomies (n = 38) (P < 0.0001, P < 0.001, P < 0.01, respectively). The mean major curve correction was 64% in patients without osteotomies, and 65% in patients with osteotomies (P = 0.81). All patients who underwent osteotomies (38/38) received allogeneic transfusion versus 26% (19/73) of those without osteotomies (P < 0.001). The likelihood of transfusion correlated with increasing number of osteotomies and a lower preoperative hemoglobin level (odds ratio, 3.34; P = 0.003; and odds ratio, 0.51; P = 0.02, respectively). In patients with AIS undergoing posterior spinal fusion with instrumentation, performing periapical osteotomies increased all measures of intraoperative blood loss and need for transfusion without substantially improving major curve correction. As expected, a lower preoperative hemoglobin level was observed in patients who received a blood transfusion after posterior instrumentation and fusion. 4.

Osteotomies/spinal column resection in paediatric deformity.

The spinal deformities in paediatric population differ from those in the adult population. Vertebral osteotomies are indicated when the deformity is too rigid to be corrected either with instrumentation alone or with the addition of soft tissue releases. When surgical intervention is to be carried out, correcting the deformity and ceasing progression should be aimed at as well as allowing further growth and improving pulmonary function. Osteotomies in the spine surgery should aim to achieve an appropriate balance in both sagittal and coronal planes. Varied clinical and radiological scenarios necessitate different osteotomy types. The purpose of this article is to introduce each osteotomy type and discuss their indications, prerequisites and complications. Osteotomy options for correcting spinal deformities are Ponte osteotomy, Smith-Petersen osteotomy, pedicle subtraction osteotomy, bone-disc-bone osteotomy and vertebral column resection. All the osteotomy types are technically demanding. Appropriate selection of the type of the osteotomy depends on the surgeons' experience, type of the deformity, magnitude of the curve, remaining growth potential and operative goals. Neuromonitoring should be an indispensible part of the procedure. Spine osteotomies are effective procedures for the treatment of paediatric spine deformities if experienced surgical team performs them.

Correction of post-traumatic kyphosis in the thoracolumbar spine through Ponté osteotomy and interbody fusion with impacted morsellized bone graft

Objective To describe Ponte osteotomy and interbody fusion with impacted morsellized bone graft and to investigate the safety and efficacy for the correction of post-traumatic kyphosis (PTK) in the thoracolumbar spine.Methods From June 2010 to March 2013,13 patients with PTK in the thoracolumbar spine were treated through Ponte osteotomy and interbody fusion with impacted morsellized bone graft.There were 7 males and 6 females,aged from 32 to 78 years,average 54.5 years.The apex level of kyphosis was T11 in 1,T12 in 4,L1 in 5 and L2 in 3.There was failure of first surgery in seven patients,and inappropriate conservative treatment in six,that all suffered from pain,progressive deformity,and deteriorating neurologic status.During the operation,the intervertebral space was loosened radically through Ponte osteotomy and discectomy,and the kyphosis was firstly corrected using the morcellized impacted graft technique.Then the kyphosis was corrected using the correction rod technique with the hinge of the morcellized impacted graft.Radiographical assessments included localized kyphosis,thoracic kyphosis,lumbar lordosis,sacral tilt angle,sagittal vertical axis,bony fusion and the relative height of the interbody fusion vertebra.Visual analogue scale (VAS),Oswestry disability index (ODI) and ASIA were evaluated before and after surgery,and the operative duration,blood loss were recorded.Results All patients were successfully followed up for an average time of (20.0±9.1) months.Bony fusion was achieved in all patients at 12 months follow-up.Localized kyphosis was reduced from an average of 42.2° (26° to 54°) to 7.1° (-7° to 13°) with an correction rate of 83.2％ on average.Sagittal alignment from T1 to the sacrum became more physiologic from 2.91cm (-3.0 to 7.8 cm) to 1.35cm (-0.5 to 3.8 cm).Thoracic kyphosis,lumbar lordosis and sacral tilt angle all improved at followup.The average VAS score was 6.38±0.87 (range,5 to 8) before operation and 2.23±0.83 (range,1 to 4) at final follow-up.The average ODI score was 55.0± 12.1 (range,39 to 72) before operation and 20.6±7.3 (range,11 to 34) at final follow-up.Neurological function improved from C to D in two patients,from C to E in four patients,and from D to E in seven patients.Conclusion Application of Ponte osteotomy and interbody fusion with impacted morsellized bone graft for the correction of PTK in the thoracolumbar spine has several advantages:large angle correction,high fusion rate,mini-invasion,and little nerve complications. Key words: Thoracic vertebrae; Lumbar vertebrae; Spinal fractures; Kyphosis; Spinal fusion; Bone transplantation

Pediatric iatrogenic thoracic kyphosis and tension myelopathy treated with a thoracic pedicle subtraction osteotomy: a case report and review of the literature

Pediatric kyphotic deformity is an uncommon clinical entity that can occur following posterior spinal operations and has significant complexity in its treatment. Tension myelopathy in a pediatric patient with a thoracic kyphotic deformity has not been reported in the literature. We present a 17-year-old boy with a progressive thoracic kyphosis and tension myelopathy 4years after he underwent a thoracic laminoplasty at an outside institution for the treatment of a dorsal spinal arachnoid cyst. At our institution, he was treated with a pedicle subtraction osteotomy as well as thoracic Ponte osteotomies for sagittal plane correction to relieve the tension myelopathy. Both clinical and radiographic improvements were observed after surgery. We review the literature on pediatric thoracic kyphosis and tension myelopathy and the treatment of these pathologies.

Multicenter Comparison of the Factors Important in Restoring Thoracic Kyphosis During Posterior Instrumentation for Adolescent Idiopathic Scoliosis

Study DesignMulticenter review, prospectively collected data. ObjectivesTo determine factors predictive of postoperative correction of hypokyphosis when segmental posterior pedicle screw implants were used in treating thoracic adolescent idiopathic scoliosis (AIS). Summary of Background DataCorrecting hypokyphosis, which is common in patients with thoracic AIS, may be important in preventing junctional kyphosis, maintaining lumbar lordosis, and improving pulmonary function. MethodsA multicenter, prospective database was reviewed for Lenke type 1–4 AIS patients with preoperative kyphosis of 5° to 20°, treated with posterior pedicle screws and 5.5-mm rods. Surgeons with a minimum of 20 patients identified were included. Patients were divided into 2 groups postoperatively based on first erect X-rays: those remaining hypokyphotic (HK) (T5–T12 less than 20° or an increase less than 5° in T5–T12 kyphosis) and those restored to normal kyphosis (NK) (T5–T12 greater than 20° with 5° or more increase). Regression analysis was done on 5 preoperative factors thought to influence the postoperative kyphosis: preoperative kyphosis, surgeon, rod material (standard, high-strength, and ultra–high-strength steel; titanium; and cobalt chromium), implant density, and use or no use of a posterior release (Ponte osteotomies). ResultsOf 280 patients included, 222 remained hypokyphotic and 53 achieved normal kyphosis. There were no differences in preoperative kyphosis (13.4° ± 5°, HK group vs. 14.5° ± 4°, NK group) and age (14.7, HK group vs. 14.6, NK group) between patients brought to greater than 20° (NK) and those who remained less than 20° (HK). Of the factors evaluated, the surgeon who performed the operation was the only significant predictor of restoration of normal kyphosis. Comparison of surgeons showed that the rate of normalizing kyphosis ranged from 6% to 42% (p = .001). There was no difference in the degree of preoperative kyphosis among surgeons. ConclusionsRestoration of thoracic kyphosis remains a challenge in posteriorly treated thoracic AIS patients. The surgeon was the only significant predictor of restoring normal kyphosis, which emphasizes the importance of intraoperative techniques.

Factors influencing the residual rib hump after posterior spinal fusion for adolescent idiopathic scoliosis with Lenke 1 and 2 curves

BackgroundDespite remarkable improvement in Cobb angle after surgery for scoliosis, many patients have a residual rib hump. We studied the factors responsible for this hump and their influence on patient satisfaction. MethodsWe recruited 2 men and 38 women (mean age 14.9years) who underwent skip pedicle screw fixation combined with direct vertebral body derotation for adolescent idiopathic scoliosis with Lenke type 1 and 2 curves. Hump size was evaluated by measuring apical trunk rotation (ATR). Patients with postoperative ATR ≤10° were categorized as group A and those with postoperative ATR >10° as group B. We analyzed postoperative self-image and satisfaction subscores of the SRS-22 questionnaire. We also compared the rate of postoperative improvement in ATR between patients who underwent additional Ponte osteotomy and those who did not. ResultsPreoperative ATR, preoperative apical translation, and preoperative and postoperative apical rotation significantly differed between groups A and B. In contrast, Cobb angles before and after surgery, Cobb angle correction rates, apical translation after correction, and postoperative self-image and satisfaction scores did not differ significantly between the groups. However, the rate of improvement in ATR showed a strong correlation with self-image (correlation coefficient 0.64) and satisfaction (correlation coefficient 0.52). This improvement rate did not differ significantly between subjects who underwent additional Ponte osteotomy and those who did not. ConclusionsPreoperative apical rotation and ATR were clearly related to postoperative residual hump. For decreasing the postoperative rib hump, removal of the deformation by apical rotation was considered more important than correction of Cobb angle. Patient satisfaction and self-image scores were not significantly related to postoperative residual hump size, but they were influenced by improvement in ATR.

The Biomechanical Consequences of Rod Reduction Following Thoracic Ponte Osteotomy and Lumbar Facetectomy

The Biomechanical Consequences of Rod Reduction Following Thoracic Ponte Osteotomy and Lumbar Facetectomy