Usefulness of the preoperative thoracic inlet angle in comparison to the T1 slope for predicting cervical kyphosis after laminoplasty.

PURPOSE: Thoracic inlet angle (TIA) is a sagittal radiographic parameter with a constant value regardless of posture and is significantly correlated with the sagittal balance of the cervical spine. However, the practical use of TIA has not been studied. This study aimed to investigate the usefulness of the preoperative TIA for predicting the development of kyphotic deformity after cervical laminoplasty in comparison to the preoperative T1 slope (T1S). METHODS: A total of 98 patients who underwent cervical laminoplasty without preoperative kyphotic alignment were included (mean age, 73.7 years; 41.8% female). Radiography was evaluated before surgery and at the 2-year follow-up examination. The cervical sagittal parameters were measured on standing radiographs, and the TIA was measured on T2-weighted MRI in a supine position. Cervical alignment with a C2-C7 angle of ≥ 0° was defined as lordosis, and that with an angle of < 0° was defined as kyphosis. RESULTS: Postoperative kyphosis occurred in 11 patients (11.2%). Preoperatively, the kyphosis group showed significantly lower values in the T1S (23.5° vs. 30.3°, p = 0.034) and TIA (76.1° vs. 81.8°, p = 0.042). We performed ROC curve analysis to clarify the impact of the preoperative TIA and T1S on kyphotic deformity after laminoplasty. The optimal cutoff angles for TIA and T1S were 68° and 19°, respectively, with similar diagnostic accuracy. CONCLUSION: This study demonstrated the clinical utility of the preoperative TIA for predicting the risk of postoperative kyphotic deformity after cervical laminoplasty. These findings suggest the importance of the preoperative assessment of thoracic inlet alignment in cervical spine surgery.

A new mathematical model for evaluating surface changes in the mid-abdominal sagittal plane after two-level pedicle reduction osteotomy in patients with ankylosing spondylitis.

BACKGROUND: The purpose of this study was to create a mathematical model to precalculate the acreage change in the abdominal median sagittal plane (ac-AMSP) of patients with ankylosing spondylitis (AS) for whom two-level pedicle subtraction osteotomy (PSO) was planned. METHODS: A single-centre retrospective review of prospectively collected data was conducted among 11 adults with AS. Acreage of the abdominal median sagittal plane (a-AMSP) was performed. The distances and angles between the osteotomy apexes, anterosuperior edge of T12, xiphoid process, superior edge of the pubis, and anterosuperior corner of the sacrum were measured on preoperative thoracolumbar computed tomography. A mathematical model was created using basic trigonometric functions in accordance with the abdominal parameters. Planned osteotomized vertebra angles (POVAs) were substituted into the mathematical model, and the predictive ac-AMSP (P-AC) was obtained. A paired sample t test was performed to determine the differences between the P-AC and actual ac-AMSP (A-AC) and between the predictive acreage change rate (P-CR) and actual acreage change rate (A-CR). RESULTS: The mean age and GK were 44.4 ± 8.99 years and 102.9° ± 19.17°, respectively. No significant difference exists between A-CR and P-CR via mathematical modeling (p > 0.05). No statistically significant difference existed between POVA and actual osteotomized vertebra angles (AOVA) (p > 0.05). A statistically significant difference was observed between preoperative and postoperative measurements of LL, SVA, and GK variables (p < 0.001). CONCLUSIONS: The novel mathematical model was reliable in predicting the ac-AMSP in AS patients undergoing two-level PSO.

Is restoration of vertebral body height after vertebral body fractures and minimally-invasive dorsal stabilization with polyaxial pedicle screws just an illusion?

INTRODUCTION: Thoracolumbar spine fractures often require surgical treatment as they are associated with spinal instability. Optimal operative techniques and treatment are discussed controversially. Aim of our prospective cohort study was to investigate the sagittal alignment after reduction, the secondary loss of reduction and the subjective outcome as well as the causal correlation of these parameters after minimally invasive stabilization of thoracic and lumbar fractures with polyaxial pedicle screws. MATERIALS AND METHODS: In a single-center study, a total of 78 patients with an average age of 61 ± 17 years who suffered a fracture of the thoracic or lumbar spine were included and subjected to a clinical and radiological follow-up examination after 8.5 ± 8 months. The kyphotic deformity was measured by determining the vertebral body angle, the mono- and bi-segmental wedge angle at three time points. The patients' subjective outcome was evaluated by the VAS spine score. RESULTS: After surgical therapy, a significant reduction of the traumatic kyphotic deformity was shown with an improvement of all angles (vertebral body angle: 3.2° ± 4.4°, mono- and bi-segmental wedge angle: 3.1° ± 5.6°, 2.0° ± 6.3°). After follow-up, a significant loss of sagittal alignment was observed for all measured parameters with a loss of correction. However, no correlation between the loss of reduction and the subjective outcome regarding the VAS spine scale could be detected. CONCLUSION: The minimally invasive dorsal stabilization of thoracic and lumbar spine fractures with polyaxial pedicle screws achieved a satisfactory reduction of the fracture-induced kyphotic deformity immediately postoperatively with a floss of reduction in the further course. However, maybe the main goal of this surgical procedure should be the prevention of a complete collapse of the vertebral body instead of a long-lasting restoration of anatomic sagittal alignment. LEVEL OF EVIDENCE: II.

Correction of pediatric cervical kyphosis with standalone posterior approach-a single-center experience of seven cases.

PURPOSE: To study clinical and radiological outcomes of pediatric cervical kyphosis correction with a standalone posterior cervical approach. Cervical spine kyphotic deformity in pediatric age group is a distinct entity and the management is challenging. Pediatric cervical kyphosis is less often encountered, and literature is sparse with only few case series. Management algorithms are devised keeping the flexibility of the deformity at the core of decision making. Circumferential fusion is mostly recommended for non-flexible (rigid) kyphosis. METHODS: Authors present a single center retrospective analysis of cases of pediatric cervical kyphosis managed by a standalone posterior approach. Pre- and post-operative clinical and radiological parameters were recorded and analyzed. Changes in neurological status, kyphosis correction and bony fusion were assessed. Surgical and implant related complications were noted. RESULTS: Seven cases (6 male, 1 female) were included. Mean age was 13.9±2.9 years, ranging from 8-17 years. Etiology was traumatic in 2 cases, developmental in 2, and syndromic, Hirayama disease and post-laminectomy in 1 case each. Mean kyphosis correction was 36.80±19.30 (87%±21%) with a mean pre-operative kyphosis angle of 37.80±15.30 and mean immediate post-operative kyphosis angle of 3.70±8.70. Mean hospital stay duration was 10±6 days. Median follow-up duration was 36 months. Myelopathy improved in 5 cases at last follow-up. Six cases demonstrated bony fusion at a mean follow-up of 8.4±1.5 months. CONCLUSION: Significant immediate correction in pediatric cervical kyphosis may be achieved with a standalone posterior approach with proper planning and technique in selected cases. Inserting pedicle screws at strategic locations of implant construct offer better corrections and pull-out strength and maintain long-term stability resulting in higher arthrodesis rates. Larger studies with longer follow up are needed to further ascertain the role of standalone posterior cervical approaches in pediatric cervical kyphosis.

Impact of the preoperative nutritional status on postoperative kyphosis in geriatric patients undergoing cervical laminoplasty.

PURPOSE: This study aimed to determine the association of preoperative malnutrition with an increased risk of cervical kyphosis after laminoplasty in geriatric patients with cervical spondylotic myelopathy (CSM). METHODS: Geriatric patients who underwent cervical laminoplasty were included. Malnutrition was defined as a geriatric nutritional risk index < 98 before surgery. The C2-7 angle and the global alignment parameters were analyzed on standing radiographs. The postoperative kyphosis was defined as a C2-7 angle < 0° during a 2-year follow-up. RESULTS: Ninety patients without preoperative kyphotic alignment were enrolled (mean age, 73.5 years old; 41.1% female). Twenty-one patients (23.3%) had malnutrition status (74.2 years old). Preoperatively, the global alignment parameters were comparable between the malnutrition and normal nutrition groups (SVA, 43.3 mm vs. 42.4 mm; T1S, 29.7° vs. 28.4°; TPA, 21.4° vs. 17.8°), with no significant difference in the C2-7 angle (15.1° vs. 15.2°). At 2 years postoperatively, the malnutrition group showed a significantly lower C2-7 angle than the normal nutrition group (9.3° vs. 15.8°, P = 0.03). Postoperative kyphosis was more prevalent in the malnutrition group (33.3% vs. 7.2%, P = 0.005). The preoperative nutritional status and C2-7 angle were independent predictors of postoperative kyphosis. The predictive C2-7 angles differed by preoperative nutritional status (malnutrition group, 11°; normal nutrition group, 7°). CONCLUSION: Among geriatric CSM patients, preoperative malnutrition was closely associated with the increased occurrence of cervical kyphosis after laminoplasty. Our results underscore the importance of preoperative nutritional assessment and management in geriatric populations undergoing cervical spine surgery, as malnutrition is a perioperative modifiable risk factor.

Sagittal imbalance of the spine is associated with poor sitting posture among primary and secondary school students in China: a cross-sectional study.

BACKGROUND: Long-term poor posture may affect the morphological development of the spine. However, there is no definite answer as to how writing posture affects students' spine. This study attempted to compare the sagittal curvature of the spine between sitting and standing postures in adolescents to reveal the variation rule of spinal sagittal curvature of students with learning posture, and to discover the key factors that may affect students' spinal health. METHODS: 1138 participants (male, 604; female, 534; age range, 6-18 years) from three schools in Tianjin, China, including 570 primary school students and 568 secondary school students. This study used SpineScan and PA200 Station Posture Assessment System to assess the sagittal curvature of the spine for three postures: sitting on a chair in upright position, seated at a desk while reading/writing, and standing in natural relaxed position. Analyze the difference between spine angle of the three postures and the correlation between the sagittal plane angle of the spine and body posture. RESULTS: The mean sagittal angle of the spine changed when the participants were in reading/writing position compared to standing position, with the lumbar lordosis angle significantly decreased (p < 0.05) and the thoracic kyphosis angle significantly increased (p < 0.05). The TKA and LLA angles were abnormal in 33 and 52% of students in reading/writing posture respectively. There was a significant correlation between sitting posture and standing spinal Angle and were positively correlated with the height of the teenager (p < 0.05). By contrast, a higher percentage of TKA and LLA subjects in the standard reading/writing posture reference range maintained normal spinal shape while standing. CONCLUSIONS: The angle of thoracic kyphosis significantly increased from standing posture to upright sitting, reading/writing posture, while lumbar lordosis significantly decreased or even disappeared. There was a significant correlation between sagittal angle of spine in different postures. The poor sitting posture associated with sagittal angle abnormalities impact the shape of the spine such that sagittal imbalance was also observed when students in natural standing posture. Height is an important factor affecting the sitting spine shape of students.

Vacuum phenomenon as a predictor of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture: a single-center retrospective study.

BACKGROUND: Posterior pedicle screw fixation without fusion has been commonly applied for thoracolumbar burst fracture. Implant removal is performed secondarily after bone union. However, the occurrence of secondary kyphosis has recently attracted attention. Secondary kyphosis results in poor clinical outcomes. The purpose of this was to determine predictors of kyphosis after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture. METHODS: This retrospective study reviewed 59 consecutive patients with thoracolumbar burst fracture who underwent implant removal following posterior pedicle screw fixation without fusion. Inclusion criteria were non-osteoporotic fracture and T11-L3 burst fracture. Old age, sex, initial severe wedge deformity, initial severe kyphosis, and vacuum phenomenon were examined as factors potentially associated with final kyphotic deformity (defined as kyphotic angle greater than 25°) or loss of correction. Logistic regression analysis was performed using propensity score matching. RESULTS: Among the 31 female and 28 male patients (mean age 38 years), final kyphotic deformity was found in 17 cases (29%). Multivariate analysis showed a significant association with the vacuum phenomenon. Loss of correction was found in 35 cases (59%) and showed a significant association with the vacuum phenomenon. There were no significant associations with other factors. CONCLUSIONS: The findings of this study suggest that the vacuum phenomenon before implant removal may be a predictor of secondary kyphosis of greater than 25° after implant removal following posterior pedicle screw fixation without fusion for thoracolumbar burst fracture, but that old age, sex, initial severe kyphosis, and initial severe wedge deformity may not be predictors.

Destructive Spondyloarthropathy due to Congenital Insensitivity to Pain with Anhidrosis: A Case Report of Long-Term Follow-Up.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare autosomal-recessive hereditary neuropathy causing congenital loss of pain sensation, thermoception, and perspiration. CIPA sometimes causes destructive spondyloarthropathy, the so-called Charcot spine, because of insensitivity to pain stimuli. Herein, we report a case of CIPA with severe spinal destruction treated by multiple spinal reconstructive surgeries and over 15 years of follow-up. A 15-year-old male patient who had been diagnosed with CIPA at the age of 17 months presented to his previous spine clinic with gait disturbance due to muscle weakness in his lower extremities. Imaging studies revealed that collapsed L3 and L4 vertebral bodies involved the spinal canal, and it was treated by L3-L4 instrumented posterior fusion. Fourteen years after surgery, the patient became unable to walk again due to spinal canal stenosis at the proximal fusion segment. An L2-L3 posterior interbody fusion alleviated his gait ability for 2 years; however, he became unable to stand again because of the collapsed fusion segment that caused severe lumbar kyphosis. Subsequently, a two-staged posterior and anterior fusion surgery from the lower thoracic spine to the pelvis was performed, and spinal fusion and neurological recovery were achieved 3 years after surgery. A kyphotic deformity in patients with CIPA-associated Charcot spine could be favorably treated by a long spinal fusion in combination with a reconstruction of an anterior spinal column. This case report provides a significant lesson for a treatment of CIPA-associated Charcot spine.

How does long thoracolumbar realignment surgery of adult spinal kyphotic deformity affect lower extremity compensation? Using full body radiograph.

PURPOSE: By using full body radiograph, the aim of the current study was to elucidate the expected degree of lower extremity compensatory change after long thoracolumbar realignment surgery with adult spinal deformity patient who had normal or only mild osteoarthritis on lower extremities. METHODS: Two novel parameters were used for assessment of regional compensation of the lower extremity. The Pearson correlation test was used to assess the correlation of postoperative changes of lower extremity compensation with the other spinopelvic parameters. RESULTS: Overall, 113 spinal deformity patients (mean age was 54.5 years) were recruited and the average number of fused vertebrae was 13.3 ± 3.5. Except pelvic tilt (PT), postoperative sacrum-femur angle (SF) changes showed only moderate correlation with all angular spinopelvic parameters (r = 0.323-0.374; p < .001 to p = .001). Also C7 sagittal vertical axis showed no significant correlation with SF (p = .584-.621). However, postoperative changes of sagittal femur-tibia angle (SFT) reported strong correlation with all parameters evaluated (r = 0.455-0.586; p < .001 to p = .046). CONCLUSION: For adult spinal deformity patients who had normal or only mild osteoarthritis on the lower extremities underwent long thoracolumbar realignment surgery, the surgeon could expect improvement of compensatory change of the knee with correction of spinopelvic parameters. However, the degree of hip compensation improvement was relatively difficult to predict than that of the knee, except PT.

Systemic changes associated with quality of life after surgical treatment of kyphotic deformity in patients with ankylosing spondylitis: a systematic review.

PURPOSE: In addition to changes in the skeletal system after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other systemic changes associated with the patients' quality of life were reported. The purpose of this study was to conduct a systemic review of the literature to determine systemic changes associated with patients' quality of life following correction of kyphotic deformity secondary to ankylosing spondylitis. METHODS: We searched the databases PubMed, EMBASE, Clinicalkey and Cochrane Library without time restriction. Selected papers were assessed by published guidelines. We investigated systemic changes associated with patients' quality of life after surgical treatment of advanced ankylosing spondylitis. RESULTS: The initial search yielded 888 citations. Twelve of these studies met the inclusion and exclusion criteria. Two were level II evidence study, and ten were level III evidence studies. Changes were reported including aorta length, abdominal morphology, digestive function, cardiopulmonary function, psychological status, and sexual activity. CONCLUSIONS: In addition to skeletal changes after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other changes were reported. Spine surgeons should pay more attention to these life quality-related changes and be aware of potential risks when performing surgery for advanced-stage AS patients. These slides can be retrieved under Electronic Supplementary Material.

Osteoporotic vertebral fractures: predictive factors for conservative treatment failure. A systematic review.

PURPOSE: To analyze clinical, radiographic and magnetic resonance findings that might predict risk of complications and conservative treatment failure of osteoporotic vertebral fractures. METHODS: The authors conducted a systematic review of observational studies, collecting data on osteoporotic vertebral fracture and complications like vertebral collapse, kyphosis, pseudoarthrosis, and neurologic deficit. MeSH items such as 'spinal fracture/radiology,' 'spinal fracture/complications,' 'spinal fracture/diagnosis' were used. PRISMA statement criteria were applied, and the risk of bias was classified as low, medium, high, following the Newcastle-Ottawa Quality Assessment Scale (NOS). RESULTS: Eleven cohort studies, either retrospective or prospective, met the eligibility criteria and were included in the review. Major risk factors that were statistically predictive of the following complications were as follows; (1) vertebral collapse: presence of intravertebral cleft, MR T1-WI 'total type fractures' and T2-WI 'hypointense-wide-type'. (2) Pseudoarthrosis (nonunion): middle-column damage, thoracolumbar vertebrae involvement, MR T2-WI confined high-intensity pattern and diffuse low intensity pattern. (3) Kyphotic deformity: thoracolumbar fracture and superior endplate fracture. (4) Neurologic impairment: a retropulsed bony fragment occupying more than 42% of the sagittal diameter of the spinal canal and a change of more than 15° in vertebral wedge angle on lateral dynamic radiography. CONCLUSIONS: Shape and level of the fracture were risk factors associated with the progression of collapse, pseudoarthrosis, kyphotic deformity and neurologic impairment. MRI findings were often related to the failure of conservative treatment. If prognosis can be predicted at the early fracture stage, more aggressive treatment options, rather than conservative ones, might be considered.

[The effect of spinal cord stretching on development of spondylogenic cervical myelopathy associated with kyphotic spinal deformity]. / Znachenie rastiazheniia spinnogo mozga v formirovanii spondilogennoi tservikal'noi mielopatii na fone kifoticheskoi deformatsii pozvonochnika.

OBJECTIVE: The study objective was to specify the role of spinal cord stretching in the pathogenesis of spondylogenic cervical myelopathy associated with kyphotic spinal deformity. MATERIAL AND METHODS: We analyzed long-term outcomes of surgical treatment for spondylogenic cervical myelopathy accompanied by kyphotic spinal deformity. RESULTS: The surgical treatment outcomes were significantly better (p<0.000001) in the case of simultaneous decompression/correction of kyphotic deformity and spine stabilization. CONCLUSION: Spinal cord stretching associated with kyphotic spinal deformity significantly contributes to the pathogenesis of clinical manifestations of spondylogenic cervical myelopathy.

Reducing kyphotic deformity by posterior vertebral column resection with 360° osteosynthesis in metastatic epidural spinal cord compression (MESCC).

PURPOSE: Metastatic epidural spinal cord compression (MESCC) often requires anterior-posterior decompression and stabilization. To reduce approach-related complications, single-stage posterolateral vertebrectomy and 360° fusion is often performed. However, a sufficient reduction of kyphotic deformity through this approach has not been reported. The purpose of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in MESCC. METHODS: A retrospective analysis and chart review was performed for 14 consecutive patients who underwent a vertebrectomy and decompression from a posterolateral approach. Anterior mesh stabilization of the ventral column is used as hypomochlion for the posterior compression manoeuvre, which leads to reduction of the kyphotic deformity. RESULTS: Pre-operative back pain was 7.2 on a visual analogue scale. Back pain was reduced to 4.4 at discharge and 2.0 at the latest follow-up with a mean follow-up of 12 months (p < 0.001). The Frankel score remains constant or improved from D to E. Radiological segmental kyphosis was corrected from a mean of 16° to 4° (p < 0.001) post-operatively with a loss of 3° at the final follow-up, but still with significant corrections compared with the pre-operative measurements (p < 0.003). CONCLUSION: Single-stage posterolateral vertebrectomy and reconstruction is a safe and less invasive approach that allows a sufficient reduction of hyperkyphosis and preservation of neurological function in patients with MESCC. This approach is an efficient alternative to anterior-posterior fusion with good pain reduction and improved sagittal profile.

The variability of vertebral body volume and pain associated with osteoporotic vertebral fractures: conservative treatment versus percutaneous transpedicular vertebroplasty.

INTRODUCTION: Osteoporotic vertebral fractures (OVF) can lead to late collapse which often causes kyphotic spinal deformity, persistent back pain, decreased lung capacity, increased fracture risk and increased mortality. The purpose of our study is to compare the efficacy and safety of vertebroplasty against conservative management of osteoporotic vertebral fractures without neurologic symptoms. MATERIAL AND METHODS: A total of 66 patients with recent OVF on MRI examination were included in the study. All patients were admitted from September 2009 to September 2012. The cohort was divided into two groups. The first study group consisted of 33 prospectively followed consecutive patients who suffered 40 vertebral osteoporotic fractures treated by percutaneous vertebroplasty (group 1), and the control group consisted of 33 patients who suffered 41 vertebral osteoporotic fractures treated conservatively because they refused vertebroplasty (group 2). The data collection has been conducted in a prospective registration manner. The inclusion criteria consisted of painful OVF matched with imagistic findings. We assessed the results of pain relief and minimal sagittal area of the vertebral body on the axial CT scan at presentation, after the intervention, at six and 12 months after initial presentation. RESULTS: Vertebroplasty with poly(methyl methacrylate) (PMMA) was performed in 30 patients on 39 VBs, including four thoracic vertebras, 27 vertebras of the thoracolumbar jonction and eight lumbar vertebras. Group 2 included 30 patients with 39 OVFs (four thoracic vertebras, 23 vertebras of the thoracolumbar junction and 11 lumbar vertebras). There was no significant difference in VAS scores before treatment (p = 0.229). The mean VAS was 5.90 in Group 1 and 6.28 in Group 2 before the treatment. Mean VAS after vertebroplasty was 0.85 in Group 1. The mean VAS at six months was 0.92 in Group 1 and 3.00 in Group 2 (p < 0.05). The mean VAS at 12 months was 0.92 in Group 1 and 2.36 in Group 2. The mean improvement rate in VAS scores was 84.40% and 62.42%, respectively (p < 0.05). For Group 1, mean area of the VBs measured on sagital CT images was 8.288 at the initial presentation, 8.554 postoperatively, 8.541 at five months and 8.508 at 12 months, respectively, and 8.388 at the initial presentation, 7.976 at six months and 7.585 at 12 months for Group 2 (Fig. 4). DISCUSSIONS: Although conservative treatment is fundamental and achieves good symptom control, in patients who suffer osteoporotic compression fractures (OCF), the incidence of late collapse is high and the prognosis is poor. In order to relieve the pain and avoid VB collapse, vertebroplasty is the recommended treatment in OCFs. Considering the above findings, the dilemma is whether vertebroplasty can change the natural history (pain and deformity) of OCFs. CONCLUSION: In our study on OVF, vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit. We believe that the possibility of evolution towards progressive kyphosis is sufficient to justify prophylactic and therapeutic intervention such as vertebroplasty, a minor gesture compared with extensive correction surgery and stabilization.

Comparison of Scheuermann's kyphosis correction by combined anterior-posterior fusion versus posterior-only procedure.

INTRODUCTION: Conventional treatment of rigid deformity in Scheuermann's kyphosis (SK) in young patients includes a preliminary anterior spinal release and fusion (ASF) followed by posterior spinal fusion and instrumentation (PSF). However, recently there are more trends to do posterior-only surgery for correction of this deformity. The aim of our study was to compare clinical and radiological outcomes of ASF/PSF and PSF-only procedures in treatment of SK. MATERIALS AND METHODS: In a prospective clinical and radiological review, thirty operated SK patients in two groups were evaluated. Group A: ASF/PSF technique (n: 16) and group B: PSF-only procedure (n: 14) were followed for at least 2 years (average 57.6 months). Two groups were well matched for the following four criteria: average age, flexibility status, posterior fusion levels, and preoperative Cobb's kyphosis angle. Oswestry disability index (ODI) and scoliosis research society questionnaire-30 (SRS-30) and radiological (kyphosis correction, correction loss, sagittal balance) parameters were evaluated before and after surgery and at the final follow-up. RESULTS: In group A, primary thoracic Cobb's kyphosis, immediate post-operative kyphosis, and final follow-up kyphosis angle were 83.6°, 41.4° and 43°, respectively (P < 0.05). Correction rate and correction loss were 50.5 % and 1.6° ± 2.4, respectively. In group B, the corresponding values were 81.9°, 40.1° and 43.2°, respectively (P < 0.05). Correction rate and correction loss were 51 % and 3.1° ± 2.5, respectively. SRS-30 and ODI scores in group A were averaged 68.5 and 21.3 preoperatively and 128.7 and 6.25 at the final follow-up, respectively. In group B, the corresponding values were 64 and 23.2 preoperatively and 133.5 and 5.8 at the final follow-up, respectively. CONCLUSIONS: Clinical and radiological parameters were similar in both groups after surgical correction while, complication rates, operation time and blood loss were significantly higher in ASF/PSF procedure.

Improvement of gastroesophageal reflux disease in Japanese patients with spinal kyphotic deformity who underwent surgical spinal correction.

BACKGROUND AND AIM: Spinal kyphotic deformity occasionally results in gastroesophageal reflux disease (GERD). The effects of acid reflux on the esophagus in kyphotic patients are unclear, however, and it is unknown whether acid reflux, endoscopic GERD, and reflux-related symptoms improve following surgical spinal correction in these patients. Herein, we investigated the characteristics of GERD in kyphotic patients and the improvement in GERD following surgical correction. METHODS: In 48 patients with severe kyphotic deformity scheduled for surgical spinal correction, we conducted esophagogastroduodenoscopy, 24-h pH monitoring and three questionnaire surveys, including the frequency scale for the symptoms of GERD (FSSG). We repeated these measurements after surgical correction and compared pre- and post-surgery values. RESULTS: Of 48 patients, 70.8% [95% CI: 55.9-83.0%, 34/48] had endoscopically evaluated esophageal mucosal injury. Regarding pH before surgery, 64.9% (CI: 47.5-79.8%, 24/37) had abnormal acid reflux (intraesophageal pH < 4 more than 5% of the time). FSSG score was significantly associated with the severity of GERD, and the positive rate was 52.6% (CI: 35.8-69.0%, 20/38). Following surgical correction, esophageal mucosal injury improved endoscopically in 90% of patients, and median total FSSG score significantly decreased from 8 (0-30) to 5 (0-19) (P = 0.005). Regarding pH after surgery, prevalence of abnormal acid reflux decreased from 66.7% (95% CI: 41.0-86.7%) to 33.3% (95% CI: 13.3-59.0%) (P = 0.045). CONCLUSION: Surgical spinal correction in kyphosis patients improves not only kyphotic deformity-related disorders but also esophageal mucosal injury, abnormal acid reflux, and reflux-related symptoms.

Surgical challenges in the management of cervical kyphotic deformity in patients with severe osteoporosis: an illustrative case of a patient with Hajdu-Cheney syndrome.

PURPOSE: No standard strategy exists for the management of cervical kyphotic deformity in patients with severe osteoporosis. In fact, in such subpopulation, standard algorithms commonly used in patients with normal bone mineral density may not be applicable. In this Grand Rounds, the authors present a challenging case of a patient with Hajdu-Cheney syndrome, a rare disorder of bone metabolism induced by a Notch-2 mutation, who presented with cervical kyphotic deformity and severe osteoporosis. METHODS: A 65-year-old female patient with a previous diagnosis of Hajdu-Cheney syndrome presented with cervical myelopathy and cervical kyphotic deformity. The initial MRi demonstrated multilevel cervical canal stenosis. The CT-scan also revealed marked spondylolisthesis of C6 over C7 as well as numerous laminar and pedicle fractures, resulting in a cervical kyphosis of approximately 50 degrees. RESULTS: The patient was submitted to 360-degree decompression and fusion of the cervical spine consisting of a staged C6 anterior corpectomy and multilevel microdiscectomies with wide opening of the posterior longitudinal ligament in order to provide a satisfactory release of anterior spinal structures, followed by 24 h of cervical halo-traction, a second anterior approach for bone graft implantation in the site of the corpectomy as well as insertion of allografts and completion of the ACDF C2-T1 and plating, and, finally, a posterior C2-T3 pedicle screw instrumentation using intra-operative CT-scan (O-arm) navigation guidance. CONCLUSIONS: This case illustrates some intra-operative nuances as well as specific surgical recommendations for cervical deformity surgery in patients with severe osteoporosis, such as avoidance of Caspar pins for interbody distraction, use of intra-operative fluoroscopy for achievement of bicortical purchase of anterior cervical screws and placement of pedicle screws during posterior instrumentation. Moreover, such illustrative case demonstrates that, in the subpopulation of patients with severe osteoporosis, it may be possible to successfully apply cervical distraction after an isolated anterior approach with a satisfactory improvement in the cervical alignment, possibly avoiding more laborious 540-degree approaches such as the previously described back-front-back or front-back-front surgical algorithms.

Favorable cervical extension capacity preventing loss of cervical lordosis after laminoplasty due to spontaneous restoration of initial lordosis.

BACKGROUND CONTEXT: Cervical laminoplasty is a common approach for the treatment of multilevel cervical spondylotic myelopathy (CSM). Postoperative loss of cervical lordosis (LCL) was associated with lower extension motion of the cervical spine before laminoplasty. PURPOSE: To analyze the possible causes of preoperative cervical extension capacity affecting LCL after laminoplasty by evaluating the changes in cervical lordosis (CL) at different stages. STUDY DESIGN/SETTING: Retrospective study. PATIENT SAMPLE: Seventy-two patients undergoing laminoplasty due to multilevel CSM. OUTCOME MEASURES: Radiographic parameters included CL, extension CL (eCL), flexion CL (fCL), range of motion (ROM), extension ROM (eROM), flexion ROM (fROM) and LCL. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) and neck disability index (NDI) score. METHODS: The data were recorded before surgery and at 3- and 24-month follow-up. All patients completed a cervical extension test preoperatively. A receiver operating characteristic (ROC) curve of eROM was constructed to discriminate the patients with and without postoperative kyphotic deformity. RESULTS: According to the optimal cut-off value of eROM, the patients were divided into two groups: extension group (eROM≥9.3°) and control group (eROM<9.3°). The radiographic outcomes demonstrated no significant differences in CL, eCL, fCL and ROM between the two groups. Both eROM and fROM were significantly different in the two groups. There was a significant change in CL in the extension group at 3-month follow-up and in the control group at 24-month follow-up. The extension group exhibited significantly lower LCL compared with the control group at follow-up. No significant difference between the two groups was noted in the JOA recovery rate, while the NDI score was significantly different at 24-month follow-up. The positivity ratio of the extension test was significantly greater in the extension group than that in the control group. CONCLUSIONS: eROM in patients with favorable preoperative cervical extension capacity (eROM≥9.3°) consisted of the actual extension capacity and compensatory flexion. The cervical alignment would be spontaneously restored to its initial lordosis in the short term after laminoplasty. These patients had no substantial LCL at 24-month follow-up and would be good candidates for laminoplasty.

Long-term outcome evaluation in ankylosing spondylitis with high-angle thoracolumbar kyphotic deformity corrected by one-stage single-level pedicle subtraction osteotomy augmented with Ponte osteotomy: A case series.

INTRODUCTION AND IMPORTANCE: A high-angle thoracolumbar kyphotic deformity (TLKD) may complicate surgical rectification of AS patients since one-stage two-level pedicle subtraction osteotomy (PSO), which provides high-angular correction, leads to excessive blood loss, neurological deficits and fixation failures. This case series presents the long-term results of one-stage single level PSO with Ponte osteotomy (PO) in the treatment of AS patients with high-angle TLKD. CASE PRESENTATION: This case series presents two AS patients with high kyphotic angles (KAs) of 86.1o. We collected data retrospectively from our institution's database between 2019 and 2023. A sagittal axis imbalance was the only complaint initially, no neurological deficits or other problems. A PSO augmented by PO was performed with a decompression laminectomy. Intraoperative monitoring (IOM) during reduction was used to observe neurological deficits. Blood loss at the highest rate was 1000 cc. It corrected 57.8o of KA postoperatively without neurological deficits. We found consistent results over 36 months. CLINICAL DISCUSSION: A thorough analytical approach may help diagnose AS. One-stage single-level PSO may correct high-angle TLKD in AS patients effectively. To achieve greater angular correction, PO, a less risky osteotomy, must be added. Decompression laminectomy is vital before osteotomy and IOM is crucial during reduction to prevent nerve injury. Even with two osteotomies, there was less blood loss than previously reported. These impressive long-term results call for further research. CONCLUSION: Combined PSO and PO with IOM efficiently magnifies the angular correction without postoperative neurological deficits or excessive blood loss in AS patients with high-angle TLKD.

Greater cervical kyphosis during flexion increases the risk of kyphotic deformity after laminoplasty in patients with cervical spondylotic myelopathy.

Kyphotic deformity following the loss of cervical lordosis can lead to unfavourable neurological recovery after cervical laminoplasty (CLP); therefore, it is essential to identify its risk factors. Recent studies have demonstrated that the dynamic parameters of the cervical spine, based on baseline flexion/extension radiographs, are highly useful to estimate the loss of cervical lordosis after CLP. However, it remains unclear whether such dynamic parameters can predict kyphotic deformity development after CLP. Hence, the present study aimed to investigate whether the dynamic parameters could predict kyphotic deformity in patients with cervical spondylotic myelopathy (CSM) after CLP. This retrospective study included 165 patients, consisting of 10 and 155 patients with and without cervical kyphosis of C2-C7 angle ≤ -10° at the final follow-up period, respectively. Among the static and dynamic parameters of the cervical spine, greater cervical kyphosis during flexion (fC2-C7 angle) demonstrated the best discrimination between these two cohorts, with an optimal cutoff value of -27.5°. Meanwhile, greater gap range of motion (gROM = flexion ROM - extension ROM ) had the highest ability to predict a loss of ≥ 10° in C2-C7 angle after CLP, with an optimal cutoff value of 28.5°. This study suggests that in patients with CSM, fC2-C7 angle ≤ -25° on baseline radiographs is a potential risk for kyphotic deformity after CLP. In clinical practice, the patients with this criterion (fC2-C7 angle ≤ -25°) along with gROM ≥ 30° are at high risk of developing significant kyphotic deformity after CLP.