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Objective:To investigate the value of relative lumbar lordosis (RLL) and lumbar distribution index (LDI) in predicting the occurrence of adjacent segment disease (ASDis) after lumbar fusion surgery.Methods:This study retrospectively reviewed 163 consecutive patients (58 males and 105 females) who had undergone lumbar fusion and had been followed over 2 years,with an average age of 58.7 years; among them, 74, 71, and 18 patients had undergone fusion of one-level, two-level, and three-level, respectively. They were divided into the non-ASDis group and ASDis group based on the presence of ASDis or not. Pre- and post-operative spinopelvic parameters were measured on the upright lateral radiographs. RLL was calculated as measured lumbar lordosis (LL) minus ideal LL, and LDI was calculated as the ratio of postoperative low lumbar lordosis (LLL) to LL. Each parameter was stratified into 1 "aligned" subgroup and 3 "disproportioned" subgroups in accordance with values. Cochran-Armitage test of trend andlogistic analysis were performed to investigate the association between these two parameters and the occurrence of ASDis.Results:The average follow-up duration after initial surgery was 46±14 months (range, 25 to 134 months). Twenty-four (14.7%) patients were diagnosed as ASDis. The age ( t=3.13, P=0.002) and the proportion of 2-level and 3-level fusion (χ 2=10.27, P=0.006) in the ASDis group were significantly higher than those in the non-ASDis group ( P<0.05). There were no statistically significant differences between groups with respect to other general data. The ratios of moderate and severe hypolordosis of RLL were significantly higher in the ASDis group than that in the non-ASDis group (χ 2=16.92, P<0.001). There was also a significant linear trend with higher degree of hypolordosis being associated with higher rates of ASDis. However, distribution of four statuses of LDI did not differ statistically between groups. After controlling the confounders, the logistic regression analysis revealed that age, odd ratio ( OR)=1.07, 95% CI: (1.01, 1.13), P=0.018), moderate[ OR=4.34, 95% CI: (1.03, 18.41), P=0.046] and severe hypolordosis [ OR=11.64, 95% CI: (1.30, 104.49), P=0.028] were significantly associated with the occurrence of ASDis. Conclusion:A significant association between postoperative RLL and occurrence of ASDis after lumbar fusion surgery were detected. Setting surgical goals according to RLL may help reduce the ASDis rate. However, LDI is not identified to be predictive factors of the occurrence of ASDis.
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Objective:To investigate the association of the cross-sectional area of lumbar paraspinal muscle with the spino-pelvic profile based on Roussouly classification.Methods:From January 2019 to December 2019, 102 patients with lumbar disc herniation were collected, the index level included L 2, 3 in 3 cases(2.9%), L 3, 4 in 14 cases(13.7%), L 4,5 in 58 cases (56.9%), and L 5S 1 in 27 cases (23.5%). According to Roussouly classification, there were 29 cases of type I (28.4%), aged 57.0±11.7 years old (range 43 to 72 years old), 31 of type II (30.4%), aged 56.9±10.3 years old (range 40 to 70 years old), 28 of type III (27.5%), aged 53.5±12.9 years old (range 42 to 70 years old), and 14 of type IV (13.7%), aged 59.7±9.5 years old (range 51 to 70 years old). The clinical status of the patients were evaluated with the MOS 36-item short-form health survey (SF-36), Oswestry disability index (ODI) and visual analog scale (VAS). Select all patients with L 1, 2, L 2, 3, L 3, 4, L 4, 5 and L 5S 1 disc level axial MRI images, to measure the cross-sectional area (CSA) of paraspinal muscles (back extensor muscle and psoas muscle) and the CSA of intervertebral disc at each disc level, and calculate the relative cross-sectional area (RCSA: the ratio of the CSA of muscles to that of the disc at the same level). One-way ANOVA was used to test the RCSA of the paraspinal muscles of the four groups, and then LSD- t test was used for pair wise comparisons to compare the RCSA of the paraspinal muscles in each group. Results:There was no significant difference in age ( F=1.067, P=0.367), female/male sex ratio ( χ2=2.412, P=0.491) and body mass index ( F=0.326, P=0.481). Roussouly type I group showed lower SF-36 score in both SF-36 PCS (31.5±6.5, F=3.207, P=0.047) and SF-36 MCS (33.9±5.7, F=3.409, P=0.031) compared with the other three types. In contrast, there were no significant differences in VAS Back Pain ( F=0.140, P>0.05), VAS leg pain ( F=0.622, P>0.05). and ODI scores ( F=1.075, P>0.05) among the types. At each level from L 1, 2 to L 5S 1, the RCSA of psoas muscle in Roussouly type IV (19.18±6.98, 35.36±10.37, 41.25±14.35, 61.58±12.03, 59.29±11.73) was significantly lower than that in patients with any other Roussouly type ( P<0.05), while no significant difference in the psoas RCSA among type I, type II and type III curves ( P>0.05). With regards to back extensor muscle, the RCSAs of back extensor muscle in Roussouly types I (135.32±19.86, 138.53±22.92, 125.06±21.44, 122.40±19.69, 110.87±18.08) and II (131.30±18.68, 136.39±24.87, 122.61±22.52, 121.10±20.47, 107.46±18.29) were significantly lower than those in Roussouly type III and IV at each level ( P<0.05), yet no significant difference between type I and II or between type III and IV. The ratio between the RCSA of back extensor muscle and psoas muscle in four types increased gradually from L 1, 2 to L 5S 1, with that being higher in type II (0.20±0.07, 0.33±0.09, 0.40±0.13, 0.58±0.11, 0.65±0.08) and lower in type IV (0.13±0.05, 0.24±0.07, 0.31±0.10, 0.47±0.10, 0.52±0.11). Conclusion:RCSA of paraspinal muscles varied among Roussouly types, suggesting a significant association between paraspinal muscles and the sagittal spino-pelvic alignment. Sagittal spino-pelvic alignment may be involved in the degeneration of paraspinal muscles.
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Objective:To investigate the outcome of posterior correction surgery for severe kyphoscoliosis secondary to spinal Gorham disease, further to explore the countermeasure in such complicated condition.Methods:From January 2005 to December 2019, a total of 12 consecutive patients were diagnosed with spinal Gorham disease. Four patients who had undergone correction surgery were reviewed retrospectively. There were 3 males and 1 female. The median age of surgery was 14.5 years (11.5 years, 27.5 years), with the median of Cobb angle of scoliosis and kyphosis 29° (21.5°, 78.0°) and 94° (78.0°, 103.0°), respectively. After Halo-gravity traction, one-stage posterior correction surgeryand Schwab grade I or II osteotomy, with pedicle screw fixation bridging the diseased vertebrae was performed. Drug therapy of bisphosphonate was recommended after surgery. The Cobb angle of scoliosis and kyphosis, coronal and sagittal balance were measured on the standing upright radiographs of the spine. CT and MRI were used to give precise evaluation of spinal and peripheral soft tissue involvement.Results:After Halo-gravity traction of 3 months (2.5 months, 3.5 months), the median of Cobb angle of scoliosis decreased to 23.5° (15.5°, 77.0°) and kyphosis decreased to 65° (57°, 83.5°) respectively. Two patients underwent facetectomyand 2 received Ponte osteotomy. The median operative time and blood loss were 5.5 h (5.1 h, 5.9 h) and 3 095ml (2 950 ml, 3 320 ml), with the fusion segment of 13.5 (12.5, 14.5) and the fixation density of 47.8% (40.9%, 57.3%). After surgery, the median of Cobb angle of scoliosis and kyphosis decreased to 18° (10.5°, 38.5°) and 59° (42.0°, 78.0°). Compared to the values before traction, the median of correction rates of scoliosis and kyphosis after surgery were 46.7% (33.1%, 59.5%) and 35% (12.3%, 51.1%) respectively. Moreover, the median of coronal balance decreased from 15.5 mm (9.0 mm, 21.0 mm) to 6.5 mm (4.0 mm, 9.0 mm), while the median of sagittal balance decreased from 14 mm (-18.0 mm, 27.5 mm) to 5.5 mm (-5.5 mm, 12.5 mm). During a median of follow-up of 2.8 years (2.0 years, 3.5 years), no complication was detected except one patient whounderwent revision surgery for rod broken.Conclusion:One-stage posterior correction surgery combined with preoperative halo-gravity tractionand postoperative anti-osteoporosis therapydemonstratedto be safe and effective for severe kyphoscoliosis secondary to spinal Gorham disease. More attention should be paid to the failure of internal fixation after surgery.
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Objective:To investigate the incidence and management of deep surgical site infection(SSI) after the spinal deformity surgery.Methods:This study retrospectively reviewed a consecutive cohort of 8818 patients with spinal deformity who received spinal deformity surgery between January1998 and December 2017 at our center. The diagnosis of deep SSI was based on the clinical symptoms, imaging data and laboratory findings. Early infection and late infection were defined as deep infections occurring <3 months and >3 months after the initial procedure, respectively. All deep SSIs were first treated with irrigation and debridement, closed suction irrigation system and antibiotics. If the infection cannot be eradicated, dressing change is recommended within 2 years after the initial surgery. The instrumentation can be removed 2 years after the initial surgery with careful evaluation of the fusion mass. The posterior-anterior and lateral radiographs were used to measure the coronal parameters and sagittal alignment.Results:Sixty patients were diagnosed as deep SSI after spinal deformity surgery, including 11 patients with early infection and 49 patients with late infection. No significant difference was observed in terms of age, gender ratio, surgical approach and fusion levels between the two groups. Deep SSI seemed to be more likely to occur between 2 and 5 years after surgery. Incidence of SSI was lowest in the patients with idiopathic scoliosis and ankylosing spondylitis, and highest in the patients with neuromuscular and syndromic scoliosis. There was a high rate of negative culture in the primary culture. Staphylococcus aureus and Escherichia coli were the most common organisms in the early infection, while patients with late infection had a high rate of low-virulent skin flora. In the early infection group, nine patients retained instrumentation while the implants were removed 2 years after the primary surgery in 2 patients. In patients with late infection, instrumentation was retained in 5 cases and removed in 10 cases until 2 years after the primary surgery. 34 cases were infected 2 years after the primary surgery and the implants were removed directly. One patient underwent reoperation with instrumentation 1 month after implant removal, another patient underwent reoperation 3 years after implant removal due to progression of deformity. Significant loss of coronal correction was noted at the latest follow-up.Conclusion:The rate of deep SSI after spinal deformity surgery was 0.68%, of which the incidence of early infection and delayed infection was 0.12% and 0.56%, respectively. An increased risk of SSI in patients with neuromuscular and syndromic scoliosis was noted. If the infection cannot be eradicated after repeated debridement, we recommend instrumentation removal 2 years after the initial surgery, but there is still a high risk of loss of correction in these patients.
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Objective:To evaluate long-term results of growth friendly non-fusion technique (GF) in the treatment of early-onset scoliosis (EOS).Methods:From August 2008 to October 2019, a total of 26 EOS patients (mean age 7.2±2.4 years old) who had completed surgery with GF treatment, including 12 males and 14 females, were reviewed retrospectively. Among them, 16 patients underwent growing rod treatment while 10 patients underwent vertical expandable prosthetic titanium rib (VEPTR) treatment. All patients had minimum 2 lengthening procedure during distraction period and over 2-year follow-up after graduation. Radiographic data were collected before and after index surgery as well as at graduation and the latest follow-up. Complications were also recorded during distraction period and after graduation.Results:A total of 145 lengthening procedures were performed in 26 patients, averagely 5.6 procedures per patient. The mean age at graduation was 12.6±1.6 years old. The average follow-up was 4.7±1.4 years duringdistraction period, and 2.9±0.9 years after graduation.The main Cobb angle was significantly decreased from 81.2°±17.3° to 41.1°±13.1°( t=8.124, P<0.001)after the index surgery, but slightly increased to 48.8°±15.4° at the end of distraction. After definitive spinal fusion, the main Cobb angle was notably decreased from 52.8°±16.1° to 45.4°±14.8° in 16 patients( t=2.415, P=0.035), with an average correction rate of 14.1%±9.4%. At the latest follow-up, the main Cobb angle was 45.2°±15.6° and the average correction rate was 44.3%±15.5% when comparing with the value before the index surgery. The thoracic and spinal height were significantly increased after initial surgery. During distraction period, the average gain of thoracic and spinal height was 3.3±0.9 cm and 5.6±1.9 cm, with the growth rate of 0.6±0.3 cm and 1.0±0.4 cm per distraction, respectively. A total of 36complications were recorded in 14 patients. There were 27 complications occurred during distraction period and 9 after graduation. Conclusion:Surgical management of EOS with growing rod and VEPTR could effectively correct the spinal deformity and maintain spinal growth. The complication rate after graduation was relative lower than distraction period. However, the correction of definitive spinal fusion during graduation was relative lower.