Progressive Thoracic Kyphosis Research Articles

Osteoporotic vertebral fractures-From diagnosis to treatment

The aim of the present work is an overview of current concepts in the treatment of osteoporotic vertebral fractures, risk factors, clinical presentation and conservative and operative management. Osteoporotic vertebral fractures are awidespread problem, affecting between 700,000 and 1.5million adults annually in the USA alone. Osteoporotic vertebral fractures can cause severe physical impairment, including back pain, dysfunction, and progressive thoracic kyphosis. Mortality after osteoporotic vertebral fractures is still increased compared to age-matched controls. In the reality of care, advocates of purely conservative therapy as well as advocates of surgical treatment can be found all over the world. In summary, understanding the risk factors, appropriate clinical evaluation and treatment strategies are crucial. When surgery is indicated, balloon kyphoplasty shows significantly better pain reduction and lower mortality compared to nonsurgical treatment.

Using the "ligamentum flavum gap" to identify originally missed type B vertebral fractures.

Background:Spine fractures may involve the ligamentum flavum (LF). Here, we utilized the “ligamentum flavum gap,” defined by the discontinuity of the LF at the level of a vertebral fracture, to document a vertebral fracture.Methods:Utilizing X-rays, computed tomography (CT), and magnetic resonance (MR) studies, 10 patients with type B vertebral fractures were diagnosed with the ligamentum flavum gap (LFG: discontinuity of the LF) at the fracture levels. The fractures were located in 2 patients in the cervical and 8 in the thoracolumbar spine.Results:All 10 patients with vertebral fractures had complained of axial pain. Four also showed progressive thoracic kyphosis. Notably, all demonstrated a loss of continuity in the LF at the level of fracture “ligamentum flavum gap.” T2-weighted and short tau inversion recovery (STIR) MR sagittal studies were best at locating LFG at the level of a fracture.Conclusion:Here, we identified best on sagittal T2 and STIR-weighted MR studies 10 patients for whom discontinuity of the ligamentum flavum (LFG) correlated with the location of type B vertebral fractures.

Norrbottnian clinical variant of Gaucher disease in Southern Italy

The Norrbottnian type of Gaucher disease (GD), as described many years ago, is due to a unique neuronopathic variant (c.1448T>G; L444P) that may have appeared during or before the sixteenth century in northern Sweden. It is a well-defined nosological entity with a characteristic course of clinical manifestations. In particular, Norrbottnian patients described in Sweden and Poland seem to share identical clinical histories characterized by the early onset of significant hepatosplenomegaly, often requiring splenectomy at an early age. Neurological involvement generally appears during the first or second decade of life, and includes horizontal gaze palsy, epilepsy, myoclonic movements, ataxia, dementia and cognitive impairment. Osteopenia occurs primarily in the spine, causing a severe and progressive thoracic kyphosis, although the involvement of other skeletal sites cannot be excluded. Here, we report on four Gaucher type 3 patients with Southern Italian ancestry presenting with clinical features and disease progression comparable to those of the 'Norrbottnian' Swedish phenotype, particularly regarding skeletal involvement with poor responsiveness to any therapeutical approach. Although a common ancestry among Southern Italian and Swedish Norrbottnian GD patients could not be investigated, the genotype [L444P]+[L444P] is the most frequently encountered in Southern Italy.

Proximal Instrumented Vertebral Body Chance Fracture After Pedicle Screw Instrumentation in a Thoracic Kyphosis Patient With Osteoporosis

We present a case of proximal vertebral body chance fracture after pedicle screw instrumentation and fusion in a 67-year-old woman with osteoporosis and thoracic kyphosis. To report the rare and unique complication of proximal vertebral body chance fracture after pedicle screw instrumentation and fusion in a kyphosis patient. Pedicle screw instrumentation has been associated with complications not limited to neurological or vascular injury, loss of curve correction, intraoperative pedicle fracture or loosening, dural laceration, deep infection, and pseudarthrosis. To the best of our knowledge, there are no previous reports describing a chance-type fracture generated by a pedicle screw fixation at the proximal end of a construct. A 67-year-old woman suffered from progressive thoracic kyphosis and mid thoracic pain presented 2 weeks after pedicle screw instrumentation and correction. She developed a vertebral body fracture at the proximal end of the instrumentation construct. Surgical intervention, including removal of the screws in the fractured vertebrae and extension of the instrumented fusion across the cervicothoracic junction, effectively restored the physiological sagittal alignment. Postoperatively, at 12-month follow-up, the patient is doing exceptionally well with near-complete relief of back pain and an excellent maintenance of correction. Chance fracture in osteoporotic bone at the proximal end of a construct due to a pedicle screw is a rare complication but it may result in catastrophic consequences. Early recognition of this complication, reduction of the fraction-dislocation, and an extension of the instrumentation can be utilized for realignment and long-term stabilization.

Progressive Changes in Sagittal Contour After Anterior Spinal Fusion With Instrumentation of Different Sizes for Thoracic Adolescent Idiopathic Scoliosis: Is Continued Posterior Spinal Growth an Issue in Skeletally Immature Children?

Study DesignRetrospective analysis of radiographs for a prospective group of 196 adolescent patients with thoracic idiopathic scoliosis after anterior spinal fusion with instrumentation. ObjectivesTo analyze progressive changes in the sagittal profile of immature and mature patients during the first 2 postoperative years. Summary of Background DataIn a previous study of similar patients, a flexible 3.2-mm rod construct was used. An additional 15° (average) of kyphosis was seen in 60% of Risser 0 patients. The current patient group had fusion with solid rod (>4.0-mm) instrumentation. MethodsAll included patients had single anterior rod instrumentation, clinical and radiographic evidence of solid fusion, a minimum follow-up of 2 years, and a coronal progression of ≤5° including adequate biplanar standard radiographs at preoperative, immediate postoperative, and 2-year follow-up visits. Patients were stratified by skeletal maturity and preoperative thoracic kyphosis. Significant sagittal progression was defined as >10°. ResultsSignificant sagittal progression that caused the patient to be hyperkyphotic (T5–T12 > 40°) occurred in 18.37% of the 196 study patients. A total of 55 who were group I Risser 0 at the time of surgery and 141 were group II Risser 1–5. Progression occurred much more frequently in Risser 0 patients who had a preoperative T5–T12 of ≥30° (67.67%) versus Risser 1–5 patients (25.00%). ConclusionsCompared with the authors' previous work, solid rod instrumentation (>4.0 mm) for anterior spinal fusion for thoracic scoliosis is better at preventing progressive thoracic kyphosis than the flexible rod (3.2 mm). However, when performing a thoracic anterior spinal instrumented fusion in skeletally immature patients when the preoperative T5–T12 sagittal curve is >30° it is recommended to leave a low normal kyphosis (20°) in the instrumented region of T5–T12.

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.

Anesthetic management for the endoscopic sinus surgery of a patient with coexisting severe cervical spine ankylosing spondylitis and unruptured cerebral aneurysm: A case report.

A 61-year-old man was admitted to the emergency room complaining of a severe left exophthalmos caused by frontal and ethmoid sinus mucoceles that were visualized on a brain computerized tomogram. In addition, he had coexisting ankylosing spondylitis with a 20 year duration that resulted in total fixation of the cervical spine and progressive thoracic kyphosis. An unruptured anterior communicating artery aneurysm was found incidentally on the cerebral angiogram. We report that the anesthetic management for endoscopic sinus surgery of a frontal sinus mucocele in a patient with coexisting severe cervical spine ankylosing spondylitis and an unruptured cerebral aneurysm requires a detailed preoperative assessment of the airway, cardiac, pulmonary, and neurologic system. This case highlights the need for careful measures to avoid rupturing the cerebral aneurysm by the increased blood pressure induced by endotracheal intubation and the infiltration of an epinephrine-containing local anesthetic.

Friday, November 1, 2001 3:45– 4:28 pm Concurrent Session 3A: Deformity Techniques: 3:45 Selective anterior fusion and instrumentation for the treatment of neuromuscular scoliosis

Purpose of study: Neuromuscular spinal deformity has been traditionally managed using posterior fusion and instrumentation techniques extending to the sacropelvis. This study examines the use of selective anterior fusion/instrumentation in the treatment of certain neuromuscular spinal deformity.Methods used: A retrospective clinical and radiographic review of over 700 children with neuromuscular spinal deformity was completed. Inclusion of 27 patients (mean age, 10.3 years, range, 1 to 18 years) treated with selective anterior fusion/instrumentation technique. Surgical indications included a flexible primary curve, pelvic obliquity and acceptable sagittal balance. Mean follow-up was 5 years (range, 2 to 10 years), with a minimum follow-up of 2 years. The most common diagnoses were myelomeningocele (13 patients) and spinal cord injury (4 patients). Anterior spinal fusion/instrumentation was performed over an average of five levels (range, 3 to 10). Rib autograft and structural allograft were used for fusion. Moss-Miami instrumentation was used in the majority of cases.of findings: Primary curve correction of 70% was achieved (preoperative mean was 60.4 degrees; range, 30 to 108 degrees; postoperative mean was 18.3 degrees; range, 0 to 70 degrees). At final follow-up the mean primary curve was 24.1 degrees (range, 0 to 90 degrees). Pelvic obliquity (preoperative mean was 15.1 degrees; range, 0 to 50 degrees), was significantly reduced (postoperative mean was 3.7 degrees; range, 0 to 15 degrees). One patient experienced significant curve progression resulting from pseudarthrosis and loss of fixation at the proximal end of the construct. Another developed progressive thoracic kyphosis proximal to the instrumented segment requiring proximal extension of fusion 6 years after the initial procedure. A third patient required extension of the anterior fusion because of progression below the fused segment. There was no change in the coronal or sagittal alignment of the fused segments at final follow-up.Relationship between findings and existing knowledge: Neuromuscular spinal deformity has been traditionally managed using posterior fusion and instrumentation techniques extending to the sacropelvis. Little literature exists on the use of anterior spinal fusion and instrumentation alone in neuromuscular spinal deformity.Overall significance of findings: Selective anterior fusion/instrumentation is a viable treatment option in the management of certain neuromuscular deformities. It allows for greater primary curve correction with maintenance of mobile lumbar motion segments, as well as excellent correction of pelvic obliquity.Disclosures: No disclosures.Conflict of interest: No conflicts.

Polysegmental lumbar posterior wedge osteotomies for correction of kyphosis in ankylosing spondylitis.

Between 1984 and 1993 we treated 21 consecutive patients who had progressive thoracic kyphosis due to ankylosing spondylitis by polysegmental posterior lumbar wedge osteotomies. In 19 patients we used the Universal Spinal Instrumentation System and in the last 2 patients the H-frame. The average correction in 20 of 21 patients at follow-up was 25.6 degrees (range 0 degrees-52 degrees), with a mean segmental correction of 9.5 degrees and a mean loss of correction after operation of 10.7 degrees (range 0 degrees-36 degrees). There were no fatal complications, but in one patient no correction could be obtained during surgery and another patient was reoperated due to lack of correction. Breaking out of screws through the pedicle during compressive correction was seen in seven patients. Implant failure, such as breakage of the threaded rods and/or loosening of the junction between the pedicle screw and the rod, occurred in 9 out of 21 patients. Two patients required reoperation at long-term follow-up. Five out of seven deep wound infections required removal of the implant. Polysegmental lumbar wedge osteotomies for correction of progressive thoracic kyphosis in ankylosing spondylitis is only recommended in patients at a mild stage of the disease with mobile discs and in combination with strong instrumentation.

Sternal release and advancement with thoracotomy and osteotomy for idiopathic osteopenia

Transient neurologic changes developed in a rare case of progressive thoracic kyphosis secondary to idiopathic osteopenia with marked spinal and chest cage deformities. The patient underwent correction by both anterior thoracic and posterior spinal approaches, with concomitant sternal release and advancement. After 16 months he continues to have good anatomic and functional results.

Insufficiency fractures of the sternum: a consequence of thoracic kyphosis?

Osteoporosis often leads to thoracic compression fractures and progressive thoracic kyphosis. The kyphosis creates a deforming stress on the sternum that may eventuate in an insufficiency-type stress fracture. The findings in four women with osteoporosis, thoracic kyphosis, and insufficiency fractures of the sternum are reported.