Research progress on the risk factors, prevention and long-term prognosis of intraoperative sagittaltranslation secondary to ankylosing spondylitis / 中华骨科杂志

Sagittal translation(ST) was defined as any measurable sagittal displacement more than 5 mm between the posterior inferior edge of the cranial vertebral body and the posterior superior edge of the caudal body at the osteotomized vertebrae(OV). Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by enthesitis and heterotopic ossification affecting sacroiliac joints and vertebral column. In the late stage, the poor quality of life caused by inability to lie supine or look straight ahead were the chief reasons for spinal osteotomy. Intraoperative ST secondary to AS thoracolumbar kyphosis contributed to improvement of sagittal vertical axis (SVA) partly. However, severe ST leaded to a huge bony step in front of dura, which was prone to vascular injury, neurologic deficit and cerebrospinal fluid leakage, thus affecting surgical outcomes. Prior research indicated there were significant correlations between intraoperative ST and inappropriate maneuver, the degree of ankylosis, the kyphosis curve pattern and correction, early fracture of the anterior cortex of the OV, excessive or insufficient decancellation of the OV, mismatch between the center of correcting forces and the center of rotation, incorrect application of cantilever technique. The use of anti-ST appliances, intraoperative fluoroscopy and nerve monitoring could prevent the occurrence of ST effectively. For AS patients with ST, relevant measures or decompressive laminectomies could be taken on the basis of neurological function to prevent neurologic deficit. Due to the strong osteogenic ability in AS patients, favorable bony reconstruction and fusion could be available during follow-up after adopting corresponding treatment involving ST. A thorough understanding of mechanism and risk factors of sagittal translation was essentially instructional to spinal surgeons thereby the incidence of intraoperative ST and complications could be decreased.

The outcome and countermeasure of posterior correction surgery for severe kyphoscoliosis secondary to spinal Gorham disease / 中华骨科杂志

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.

The long-term results of growth friendly non-fusion technique in the treatment of early-onset scoliosis / 中华骨科杂志

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.

Comparison of hybrid and traditional growing rod techniques in the treatment of early-onset congenital scoliosis / 中华外科杂志

Objective@#To compare the surgical outcomes between hybrid and traditional growing rod (GR) techniques in the treatment of early-onset congenital scoliosis (C-EOS).@*Methods@#A review was conducted of C-EOS patients who had undergone hybrid GR treatment at Department of Spine Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School. Another group of patients who had undergone traditional GR were well matched to the hybrid GR group at a 1∶1 ratio in terms of main Cobb angle, age at initial surgery, and lengthening numbers. There were 5 boys and 8 girls with an age of (5.6±2.8) years in the hybrid GR group, and 6 boys and 8 girls with an age of (6.1±3.0) years in the traditional GR group, respectively. All patients had minimum 2-year follow-up and over 2 lengthening procedures. Radiographic data were compared with paired t tests in either group between each visit, and with independent t tests between the two groups.@*Results@#On average, the hybrid group had a follow-up of (42.2±13.4) months (range:27-81 months), and had (4.0±1.8) lengthening procedures with a lengthening interval of (10.5±1.0) months; and the traditional GR group had a follow-up of (45.4±15.2) months (range: 24-76 months), and experienced (4.2±1.9) lengthenings with an interval of (10.8±1.1) months. After the index surgery, the major Cobb angle, C7 translation, apical vertebral translation, and thoracic kyphosis (TK) had remarkable improvement in both groups. Notably, the hybrid GR group had significantly higher correction rates of major Cobb angle (t=2.348, P=0.027) and TK (t=3.768, P<0.001) than the traditional GR group. At the latest follow-up, the hybrid GR group had remarkably smaller Cobb angle of the major curve than the traditional GR group (t=2.790, P=0.010). At the same time, the hybrid GR group had higher T1-S1 height gain than the traditional GR group (t=2.846, P=0.008) after the index surgery. Whereas, non-significant difference was noted between two groups with regards to the T1-S1 growth rate during follow-up (t=0.516, P=0.610). Ten complications occurred during the follow-up period, including 2 in the hybrid GR group and 8 in the traditional GR group. The incidence of rod breakage and PJK in the traditional group was 3 and 4 times as high as that of the hybrid GR group, respectively.@*Conclusions@#The hybrid growing rod can not only help to improve the correction of spinal deformity but also decrease postoperative complications during follow-up. Moreover, apical short fusion shows no significant influence on spinal growth.

Differential expression of lncRNA in the serum of ankylosing spondylitis patients / 中华骨科杂志

Objective@#To investigate the differential expression of lncRNA in the serum of ankylosing spondylitis (AS) patients, with the goal of findingnew potential biomarkers for the diagnosis and targeted treatment of AS.@*Methods@#A total of 19 AS patients and 19 age-matched healthy controls treated at Nanjing Drum Tower Hospitalfrom January 2017 to September 2017 were recruited. Average age were 38.74±7.42 (range, 25-51) and 37.00±6.86 (range, 26-50). High-throughput lncRNA sequencing technology was used to detect differently expressed lncRNAs in the serum of 3 AS patients and 3 healthy controls. Target lncRNAs for further validation were selected according to the P values and fold-changes. In the rest of the serum samples (16 AS patients and 16 healthy controls), Trizol-based technique was used to extract total RNA, and after reverse transcription to obtain cDNA, RT-qPCR was preformed to confirm the sequencing results.@*Results@#Using high-throughput lncRNA sequencing, a total of 41 up-regulated and 2 down-regulated lncRNAs were detected in the serum of AS patients. After sorted by the P values, 4 lncRNAswith a fold-change larger than 2 were chosen as the target genes for RT-qPCR (ENST00000365494.1, P=2.6×10-277, fold-change: 2.05; ENST00000364938.1, P=2.49×10-77, fold-change: 2.19; ENST 00000363046.1, P=2.67×10-29, fold-change: 2.51; ENST00000384756.1, P=6.17×10-21, fold-change: 2.28). RT-qPCR results showed the relative expression of lncRNA ENST00000365494.1 was 1.80±0.22 (P=0.304), lncRNA ENST00000364938.1was 0.78±0.07 (P=0.417), lncRNA ENST00000363046.1was 1.28±0.24 (P=0.793), lncRNA ENST00000384756.1 was 1.52±0.25 (P=0.611)and tendency of up-regulation was found in 3 of them, which was consistent with the sequencing results. However, the difference did not achieve statistical significance.@*Conclusion@#Sequencing result could not be confirmed by RT-qPCR with a larger sample size, which implied the differential expression of lncRNA might not exist in the peripheral blood of AS patients, and further studies regarding lncRNA in AS could focus more on its differential expression and function in the focal tissue.

Postoperative hemorrhage caused by lumbar artery injury in corrective osteotomy for degenerative lumbar scoliosis: case report / 中华骨科杂志

The present study reported the case of a patient with degenerative lumbar scoliosis who suffered from postoperative hemorrhage due to lumbar artery injury in corrective osteotomy. The patient presented with decline of blood pressure, extremely low hemoglobin, even after blood transfusion and fluid infusion. Digital subtraction angiography showed lumbar artery injury. Successful control of bleeding and gradually stable vital signs were observed after vascular embolisation. Severe and complex spinal deformity, severe osteophytes in the anterior edge of vertebral body, hypertension, and angiosclerosis were the risk factors of large vascular injuries in spinal osteotomy. Lumbar artery injury should be highly suspected when unknown and progressively aggravating abdominal or back pain, abdominal distention, neurological symptoms of lower limbs, decline of blood pressure, increase of heart rate, decrease of hemoglobin level, continuously bloody drainage or incision bleeding occurred. Vascular embolisation was effective and safe in the management of iatrogenic lumbar artery injury.

The evaluation of spinopelvic parameter and health related quality of life in degenerative patientwith kyphoscoliosis who utilized second sacral alar-iliac screw / 中华骨科杂志

Objective@#To evaluate the clinical outcome and health related quality of life in degenerative patients with kyphoscoliosis who underwent S2AI placement and identify the potential risk factors of pelvic incidence variation postoperative and at last follow-up.@*Methods@#The present study reviewed degenerative patients with kyphoscoliosis who accepted surgery utilized S2AI screw between January 2015 and January 2019. 25 patients were included in our study, 4 males and 21 females, among these patients, the mean age were 58.84±6.03 years, range from 50-68 years. All patients were conducted long fusion distal to pelvis utilizing S2AI screws. According to the variation of pelvic incidence at last follow-up, we divided patients into two subgroups: 1) Group I: Patients' pelvic incidence increased more than 5 degree compared with post-operation. 2) Group S: Patients' pelvic incidence varied less than 5 degree compared with post-operation. 13 patient (2 male, 11 female; mean age: 57.23±6.06 years) were categorized into group I, and 12 patients (2 male, 10 female; mean age: 60.58±5.73 years) were categorized into group S.Cobb′s angle, lumbar lordosis(LL), regional kyphosis(RK), sagittal vertical axis(SVA), pelvic incidence(PI), pelvic tilt(PT), sacral slop(SS) were recorded at pre-operation, post-operation and last follow up. The MOS item short from the health survey(SF-36) and Oswestry disability index (ODI) were also recorded at pre-operation and last follow up.@*Results@#There was no statistical difference in gender, age, preoperative Cobb angle, SVA between two groups. In group I, pelvic incidence were decreased postoperatively and increased at the last follow-up (56.92°±14.47° vs 42.69°±14.23° vs 51.62°±14.53°, P<0.05). In group S, pelvic incidence were decreased postoperatively (46.21°±12.26° vs 37.08°±12.99°, P<0.05) and remained stable at the last follow up (37.08°±12.99° vs 37.17°±13.34°, P>0.05). Cobb angle (46.08°±20.52° vs 19.96°±12.64° vs 20.28°±12.01°), RK (32.88°±15.28° vs-12.16°±17.75° vs-11.64°±17.29°), SVA (94.61±92.59 mm vs 25.49±23.89 mm) were improved significantly after surgery and remained stable at the last follow-up. HRQoL score was improved significantly in all patients at the last follow-up compared with preoperative (SF-36 PCS: 36.88±10.89 vs 67.91±10.46, P<0.05; SF-36 MCS: 33.48±10.96 vs 60.19±8.10, P<0.05; ODI: 46.00%±13.54% vs 23.40%±8.86%, P<0.05).@*Conclusion@#Pelvic fixation utilizing S2AI screw can provide substantial correction and patients' HRQoL can be improved significantly after surgery. Meanwhile, PI changed at the last follow-up in partial patient. The variation of PI may be associated with the preoperative sagittal malalignment.

Differential expression of lncRNA in the serum of ankylosing spondylitis patients / 中华骨科杂志

To investigate the differential expression of lncRNA in the serum of ankylosing spondylitis (AS) patients, with the goal of findingnew potential biomarkers for the diagnosis and targeted treatment of AS. Methods A total of 19 AS patients and 19 age?matched healthy controls treated at Nanjing Drum Tower Hospitalfrom January 2017 to September 2017 were recruited. Average age were 38.74±7.42 (range, 25-51) and 37.00±6.86 (range, 26-50). High?throughput lncRNA sequenc?ing technology was used to detect differently expressed lncRNAs in the serum of 3 AS patients and 3 healthy controls. Target ln?cRNAs for further validation were selected according to the P values and fold?changes. In the rest of the serum samples (16 AS pa?tients and 16 healthy controls), Trizol?based technique was used to extract total RNA, and after reverse transcription to obtain cD?NA, RT?qPCR was preformed to confirm the sequencing results. Results Using high?throughput lncRNA sequencing, a total of 41 up?regulated and 2 down?regulated lncRNAs were detected in the serum of AS patients. After sorted by the P values, 4 ln?cRNAswith a fold?change larger than 2 were chosen as the target genes for RT?qPCR (ENST00000365494.1, P=2.6×10-277, fold?change: 2.05; ENST00000364938.1, P=2.49×10-77, fold?change: 2.19; ENST 00000363046.1, P=2.67×10-29, fold?change: 2.51;ENST00000384756.1, P=6.17×10- 21, fold?change: 2.28). RT?qPCR results showed the relative expression of lncRNA ENST00000365494.1 was 1.80 ± 0.22 (P=0.304), lncRNA ENST00000364938.1was 0.78 ± 0.07 (P=0.417), lncRNA ENST00000363046.1was 1.28±0.24 (P=0.793), lncRNA ENST00000384756.1 was 1.52±0.25 (P=0.611)and tendency of up?regu?lation was found in 3 of them, which was consistent with the sequencing results. However, the difference did not achieve statistical significance. Conclusion Sequencing result could not be confirmed by RT?qPCR with a larger sample size, which implied the differential expression of lncRNA might not exist in the peripheral blood of AS patients, and further studies regarding lncRNA in AS could focus more on its differential expression and function in the focal tissue.

Postoperative hemorrhage caused by lumbar artery injury in corrective osteotomy for degenerative lumbar scoliosis:case report / 中华骨科杂志

The present study reported the case of a patient with degenerative lumbar scoliosis who suffered from post?operative hemorrhage due to lumbar artery injury in corrective osteotomy. The patient presented with decline of blood pressure, extremely low hemoglobin, even after blood transfusion and fluid infusion. Digital subtraction angiography showed lumbar ar?tery injury. Successful control of bleeding and gradually stable vital signs were observed after vascular embolisation. Severe and complex spinal deformity, severe osteophytes in the anterior edge of vertebral body, hypertension, and angiosclerosis were the risk factors of large vascular injuries in spinal osteotomy. Lumbar artery injury should be highly suspected when unknown and progressively aggravating abdominal or back pain, abdominal distention, neurological symptoms of lower limbs, decline of blood pressure, increase of heart rate, decrease of hemoglobin level, continuously bloody drainage or incision bleeding oc?curred. Vascular embolisation was effective and safe in the management of iatrogenic lumbar artery injury.

The evaluation of spinopelvic parameter and health related quality of life in degenerative patientwith kyphoscoliosis who utilized second sacral alar?iliac screw / 中华骨科杂志

Objective To evaluate the clinical outcome and health related quality of life in degenerative patients with ky?phoscoliosis who underwent S2AI placement and identify the potential risk factors of pelvic incidence variation postoperative and at last follow?up. Methods The present study reviewed degenerative patients with kyphoscoliosis who accepted surgery uti?lized S2AI screw between January 2015 and January 2019. 25 patients were included in our study, 4 males and 21 females, among these patients, the mean age were 58.84±6.03 years, range from 50-68 years. All patients were conducted long fusion distal to pelvis utilizing S2AI screws. According to the variation of pelvic incidence at last follow?up, we divided patients into two subgroups: 1) Group I: Patients' pelvic incidence increased more than 5 degree compared with post?operation. 2) Group S:Patients' pelvic incidence varied less than 5 degree compared with post?operation. 13 patient (2 male, 11 female; mean age:57.23±6.06 years) were categorized into group I, and 12 patients (2 male, 10 female; mean age: 60.58±5.73 years) were catego?rized into group S.Cobb′s angle,lumbar lordosis(LL),regional kyphosis(RK),sagittal vertical axis(SVA), pelvic incidence(PI), pelvic tilt(PT), sacral slop(SS) were recorded at pre?operation,post?operation and last follow up. The MOS item short from the health survey(SF?36) and Oswestry disability index (ODI) were also recorded at pre?operation and last follow up. Results There was no statistical difference in gender, age, preoperative Cobb angle, SVA between two groups. In group I, pelvic inci?dence were decreased postoperatively and increased at the last follow?up (56.92°±14.47° vs 42.69°±14.23° vs 51.62°±14.53°, P＜0.05). In group S, pelvic incidence were decreased postoperatively ( 46.21°± 12.26° vs 37.08°± 12.99°, P＜0.05) and re?mained stable at the last follow up ( 37.08°±12.99° vs 37.17°±13.34°, P＞0.05). Cobb angle (46.08°±20.52° vs 19.96°±12.64° vs 20.28°± 12.01°), RK (32.88°± 15.28° vs-12.16°± 17.75° vs-11.64°± 17.29°), SVA (94.61 ± 92.59 mm vs 25.49 ± 23.89 mm) were improved significantly after surgery and remained stable at the last follow?up. HRQoL score was improved significantly in all patients at the last follow?up compared with preoperative (SF?36 PCS: 36.88±10.89 vs 67.91±10.46,P＜0.05; SF?36 MCS:33.48±10.96 vs 60.19±8.10, P＜0.05; ODI: 46.00%±13.54% vs 23.40%±8.86%, P＜0.05). Conclusion Pelvic fixation utiliz?ing S2AI screw can provide substantial correction and patients'HRQoL can be improved significantly after surgery. Meanwhile, PI changed at the last follow?up in partial patient. The variation of PI may be associated with the preoperative sagittal malalignment.

Outcome of traditional growing rods for correction of apical vertebra rotation in early-onset scoliosis / 中华外科杂志

Objective@#To evaluate the correction result of traditional dual growing rods on apical vertebral rotation.@*Methods@#This study recruited 19 early-onset scoliosis patients (6 boys and 13 girls) who had received traditional dual growing rods treatment at Department of Spine Surgery, Nanjing Drum Tower Hospital from January 2009 to July 2015. The age at initial surgery was (5.7±1.7)years(range, 3 to 9 years). Measurements of primary curve magnitude, height of T1-S1, apical vertebral translation(AVR), apical vertebral body-rib ratio, apical vertebral rotation, thoracic rotation and rib hump were compared between pre-operatively, post-operatively, and at latest follow-up, through a paired-t test. Pearson correlation test was used for correlation analysis between parameters.@*Results@#All patients had a follow-up of (49.5±12.8)months(range, 24 to 71 months). A total of 111 operative procedures were performed, among which there were 92 lengthening procedures, averagely 4.8 lengthening procedures per patient. The average interval for each lengthening procedure was 10 months. The Cobb angle of primary curve was notably decreased from (66.5±13.2)° to (35.2±10.9)°(t=24.013, P<0.01), and no significant correction loss was found at the latest follow-up ((36.7±10.7)°)(t=-1.324, P=0.202). In addition, significant correction of AVR, thoracic rotation, apical vertebral translation, apical vertebra body-rib ratio, and rib hump were noted after initial surgery. Whereas, these parameters significant increased during follow-up(all P <0.05) except for thoracic rotation. Pearson correlation analysis showed that the increase of AVR during follow-up significantly correlated with change of apical vertebra translation, apical vertebral body-rib ratio, and rib hump(r=0.652, 0.814, 0.695; all P<0.05).@*Conclusions@#Significant correction of AVR can be achieved after initial surgery in early-onset scoliosis patients treated with traditional dual growing rods. However, such a technique can hardly prevent the deterioration of AVR during follow-up.

Comparison of clinical outcome between utilized second sacral alar-iliac and iliac screw on kyphoscoliosis patients / 中华外科杂志

Objective@#To compare the clinical outcome and health related quality of life(HRQoL)of patients with degenerative spinal deformity who underwent spino-pelvic fixation utilized second sacral alar-iliac(S2AI)with patient utilized traditional iliac screw(IS).@*Methods@#Patients diagnosed as degenerative spinal deformity who underwent spino-pelvic fixation utilized either S2AI screw or Iliac screw at Department of Spine Surgery of Drum Tower hospital from January 2013 to January 2016 were retrospectively analyzed. Patients were divided into two groups according to the pelvic fixation technique. Cobb′s angle, coronal balance distance(CBD), regional kyphosis(RK), sagittal vertical axis(SVA)were recorded at pre-operation, post-operation and last follow up. The MOS item short from the health survey(SF-36), visual analogue scale(VAS), Oswestry disability index(ODI) were also recorded at pre-operation and last follow up. Five physical examinations were administered to all patient at the last follow up to diagnose sacroiliac joint dysfunction, three tests resulting positive were regarded as dysfunction. Repeated measurement analysis of variance, t-test or non-parametric test was used to analyzed the data, respectively.@*Results@#A total of 22 patients who met the inclusion were recruited in this study. Fourteen patients were utilized S2AI screw and 8 patients were utilized iliac screw.There were no significant differences in age, gender, follow up time between two groups. Cobb′s angle, CBD, RK, SVA at pre- and post-operation and last follow up showed no significant difference between two groups.SF-36, ODI, VAS at pre-operation and last follow up showed no significant difference between two groups. Compared with baseline, Cobb′s angle(44.4°±14.0° vs. 20.2°±7.2° vs. 18.3°±7.1°), C7PL-CSVL((25.3±16.0)mm vs. (10.3±5.7)mm vs. (9.2±4.2)mm), RK(33.0°(-12.0°, 50.0°) vs. 20.0°(-33.0°, 8.5°) vs. -19.0°(-29.0°, 19.0°)), SVA((31.5±34.4)mm vs. (12.1±8.4)mm vs. (10.9±7.2)mm), SF36-physical function summary(PCS)(39.8±14.3 vs. 68.2±21.5), SF36-mental component summary(MCS)(44.9±14.8 vs. 73.9±19.9), ODI(37.7±16.9 vs. 19.8±15.8), VAS(4.8±2.1 vs. 1.8±0.9) were significantly improved postoperatively in S2AI group(P<0.05). In the IS group, compared with baseline, Cobb′s angle(54.3°±18.3° vs. 26.1°±13.2° vs. 25.6°±18.3°), C7PL-CSVL((31.0±16.0)mm vs. (13.9±7.0)mm vs. (12.4±6.6)mm), RK (47.0°(15.0°, 57.0°) vs. 4.0°(-10.0°, 16.0°) vs. 7.0°(-9.0°, 12.0°)), SVA((27.1±23.9)mm vs.(13.1±7.5)mm vs. (13.6±6.0)mm), SF36-PCS(29.7±7.1 vs. 61.1±11.2), SF36-MCS(35.9±7.1 vs. 64.0±11.1), ODI(48.6±13.4 vs. 19.0±10.7), VAS(4.9±1.8 vs. 2.6±1.3) were also significantly improved postoperatively(all P<0.05). There were two patients need revision surgery in the IS group due to the instrumentation-related complication. None of the patients in the S2AI group needed revision surgery. There were no instances of sacroiliac joint dysfunction in both groups at last follow up.@*Conclusion@#Spino-pelvic fixation utilizing S2AI screw could provide similar correction rate to iliac screw and the sacroiliac joint penetration due to S2AI won′t affect the HRQoL in patient with degenerative deformity who utilized S2AI.

Review in clinical evaluation of EOS imaging system on spinal deformity along sagittal plane / 中华骨科杂志

Spinal sagittal deformity could be frequently observed in adult spinal scoliosis,lumbar degeneration,ankylosing spondylitis,spinal tuberculosis and other diseases.Patients with the spinal sagittal malalignment were often accompanied with sagittal imbalance,cardiopulmonary function abnormity and low back pain.The importance of spinal sagittal morphology in healthrelated quality of life has been suggested by more and more spinal surgeons.Pelvic backward rotation and knee flexion could be found in patients with severe spinal sagittal deformity.Surgery was essential for advanced stage of spinal sagittal deformity,and the analysis of sagittal alignment based on radiologic methods would be the indispensable part in determining surgical intervention.Sagittal alignment analysis was limited at spine using the conventional radiologic techniques.However,with the progress of study in spinal sagittal alignment,the significant roles of full-body sagittal alignment composed of spine,pelvic and sub-pelvic and dynamic differences in spinal sagittal alignment between various functional positions were being recognized in the evaluation of spinal sagittal alignment.So the evaluation of sagittal alignment would be limited by the conventional imaging.Fortunately,the awkward situation has been retrieved by the innovative EOS imaging system through which both of the full-body sagittal alignment and dynamic spinal sagittal alignment differences could be analyzed.Inspired by the limitation of conventional radiological parameters,a series of new parameters have been adopted to assess the severity of spinal sagittal malalignment.EOS has also been applied to surgical decision making and clinical outcome assessment.This review was to summarize the clinical evaluation of EOS imaging system on spinal deformity along sagittal plane.We hoped to provide new information regarding the global spinal sagittal alignment in different functional posture to improve the understanding of spinal sagittal alignment thereby the optimal surgical strategy could be performed.

The effect of surgical approaches on postoperative sagittal profile reconstruction following selective thoracolumbar fusion for Lenke type 5 adolescent idiopathic scoliosis / 中华骨科杂志

Objective To compare the effects of anterior or posterior selective thoracolumbar/lumbar fusion (ASF or PSF) on the reconstruction of sagittal profile in Lenke type 5 adolescent idiopathic scoliosis (AIS).Methods A total of 102 Lenke type 5 AIS patients who underwent ASF or PSF from January 2005 to December 2010 with a minimum of 2 years follow-up were retrospectively evaluated.Fifty-six patients underwent ASF,while 46 patients underwent PSF.Pre-and postoperative radiological parameters were measured as follows:curve magnitude of thoracolumbar/lumbar (TL/L) and thoracic curve,thoracic kyphosis (TK),lumbar lordosis (LL),sacral slope (SS),sagittal vertical axis (SVA),thoracolumbar junctional kyphosis (TJK),instrumented segments angle (ISA),and proximal junctional angle (PJA).Results The mean follow-up duration was 6.1±2.1 years and 5.3±1.5 years in ASF and PSF group respectively.Preoperative radiographic parameters and demographic data showed no significant difference between two groups.The fusion levels in ASF group were shorter than that in PSF group (5.3±0.5 vs.5.9±0.8,P＜0.05),where as the distal preserved motion segments were similar between two groups (1.8±0.7 vs.1.7±0.7,P＞0.05).The correction rate of the TL/L curve was 73.2％±6.9％ in ASF group and 74.8％±10.8％ in PSF group at 3 month after surgery,with a 3.8％±8.7％ and 2.0％±0.2％ of correction loss at final follow-up.Thoracic curve was corrected spontaneously in both groups,and the correction rate of TL/L and thoracic curve was similar between two groups at final follow-up.In both groups,TK increased after surgery and increased at final follow-up compared to that after surgery (P＜0.05).LL decreased in ASF group after surgery (P＜0.05) and remained unchanged at final follow-up.In PSF group,LL remained unchanged after surgery and increased at final follow-up compared to that after surgery (P＜0.05).SS decreased after surgery in ASF group and increased at final follow-up compared to that after surgery (P＜0.05).In PSF group,SS increased after surgery and increased at final follow-up compared to that after surgery (P＜ 0.05).SVA and TJK decreased in both groups after surgery and increased at final follow up compared to that after surgery (P＜ 0.05).ISA remained unchanged after surgery and decreased at final follow-up compared to that after surgery in ASF group (P＜ 0.05).In PSF group,ISA increased after surgery (P＜0.05) and remained unchanged at final follow-up.PJA increased after surgery in both groups,and increased at final follow-up compared to that after surgery in PSF group (P＜0.05).At 3 month after surgery,LL was larger in PSF group.At final follow-up,LL,ISA and PJA was significantly larger in PSF group (P＜0.05).In ASF group,three patients had pseudarthrosis,one had rod breakage,three had adding-on phenomenon,and one had proximal junctional kyphosis (PJK).In PSF group,five patients had PJK and one had adding-on phenomenon.SRS-22 scores showed no significant difference between two groups.Conclusion When Lenke type 5 AIS patients were treated with selective TL/L fusion,coronal correction could be obtained by both ASF and PSF.In sagittal plane,PSF can offer larger restoration of LL and better maintenance of lordosis in the instrumented segment than those in ASF.Additionally,the incidence of PJK in PSF group was higher than that in ASF group.

Corrective osteotomy for cervicothoracic deformity secondary to ankylosing spondylitis / 中华骨科杂志

Objective To report the application of C7T1extensive osteotomy and C7pedicle subtraction osteotomy(PSO) in the correction of cervicothoracic deformity secondary to ankylosing spondylitis(AS)and to investigate the efficacy and safety of the techniques.Methods Between April 2006 and August 2017,eight male patients with cervicothoracic deformity undergoing C7T1extensive osteotomy(3 cases)or C7PSO(5 cases)were retrospectively reviewed.The mean age was 31.3±14.9 years(range, 14-60 years).C2-T1kyphosis,C2-T1scoliosis and C2-T1sagittal vertical axis(SVA)were measured on the lateral cervical radio-graphs and chin-brow vertical angle(CBVA)was measured on clinical photographs preoperatively and at the final follow-up.The operative time, blood loss and complications were recorded. Results The average follow-up duration was (11.3 ± 7.9) months (range,3-48 months).In C7T1extensive osteotomy group,the mean operative time was 305 min(300-310 min)and the average blood loss was 1 250 ml(1 000-1 500 ml).Preoperative and postoperative C2-T1kyphosis were 17.0°±16.3°and-13.3°±20.2°,re-spectively.The preoperative CBVA was 20.0°±4.5°,which improved to 4.7°±5.9°at the final follow-up with a mean correction rate of 76.5%.C2-T1SVA was improved from(6.9±4.0)cm preoperatively to(3.5±1.8)cm at the final follow-up with an average correc-tion rate of 49.3%.In C7PSO group,the mean operative time was 536 min(375-730 min)and the average blood loss was 2 450 ml (700-4 200 ml).There were four patients with concomitant scoliosis and kyphosis.Preoperative and postoperative C2-T1kyphosis were 22.8°±10.5°and-13.5°±10.0°,respectively.The preoperative C2-T1scoliosis was 24.8°±12.7°,which improved to 5.0°±3.5° at the final follow-up with a mean correction rate of 79.8%.CBVA was improved from 60.5°±10.2°preoperatively to 14.3°±8.6°at the final follow-up with an average correction rate of 76.4%.C2-T1SVA was corrected to(6.4±2.5)cm at the final follow-up from(10.4 ± 4.3) cm preoperatively. One patient was presented with severe cervicothoracic scoliosis and the C2-T1scoliosis was im-proved to 10°from 33°with a 69.7% correction rate.No neurological complications,infection,or implant-related complications were observed both intraoperatively and during the follow-up period.One patient who underwent C7PSO experienced intraopera-tive subluxation of the osteomized vertebra.Fortunately,there was no neurological deficit.Solid bony fusion was observed after six-month Halo-vest immobilization.Conclusion Both C7T1extensive osteotomy and C7PSO are effective in the correction of cervico-thoracic deformity secondary to AS with acceptable complication rate.C7PSO is particularly suitable for the correction of severe and complicated biplanar cervicothoracic deformity.

The comparison of clinical outcomes among neuromuscular scoliosis with pelvic obliquity who utilized iliac, second sacral alar-iliac and iliosacral screw fixation / 中华骨科杂志

Objective To compare the clinical outcomes of neuromuscular scoliosis(NMS)patients with pelvic obliquity who underwent spino-pelvic fixation utilized traditional iliac screw(IS),second sacral alar-iliac(S2AI)screw or iliac sacral screw. Methods All of 20 patients who met the inclusion were included in this study,with 14 cases of poliomyelitis,4 cases of spinal muscular atrophy, 2 cases of muscular dystrophy,with 11 patients utilizing IS, 6 patients utilizing S2AI,and 3 patients utilizing ISS.The radiographic parameters measured pre-and post-operation and at last follow up included coronal Cobb angle,pelvic obliq-uity,and regional kyphosis.The SRS-22 questionnaires and the Oswestry disability index(ODI)and complications were collected. Results There were no significant difference in age,Cobb angle,pelvic obliquity and regional kyphosis among three groups,the follow up times was significantly shorter in the ISS group(H=15.183,P<0.01).In the IS group,the Cobb angle at pre-or post-oper-ation and at last follow up measured 70°,35°and 40°,the pelvic obliquity measured 24°,11°and 12°,the regional kyphosis mea-sured 36°,12°and 14°.In S2AI group,the Cobb angle measured 70.5°,25.0°and 26.5°,the pelvic obliquity measured 20°,10° and 11.5°,the regional kyphosis measured 37°,12°and 12.5°,showing significant improvement compared to pre-operation(P<0.05).In the ISS group,the Cobb angle at pre or post operation and at last follow up measured 64°,25°and 27°,the pelvic obliqui-ty measured 24°,9°and 11°,the regional kyphosis measured 53°,8°and 8°,showing a decrease after surgery with P>0.05,which may attribute to the small sample size in ISS group.The pre-operative ODI score was 42%,45% in IS and S2AI group,improving significantly to 26%,25.5% at last follow up.The ODI score in ISS group improved from 36% to 24% after surgery(P=0.068).The SRS-22 score improved significantly in three groups,with P<0.05 in IS and S2AI group and P=0.066 in ISS group.In the IS group, one patient had rod breakage and underwent revision surgery,one patient had deep infection and recovered with conservative treat-ment.In the S2AI group,one patient had S2AI screw misplacement on the right side.Conclusion In the surgical management of neuromuscular scoliosis(NMS)patients with pelvic obliquity,the utilization of either iliac screw,S2AI screw or ISS fixation can ob-tain satisfied deformity correction and improvement in health-related quality of life,however,the utilization of S2AI and ISS could reduce the implant related complications.

Proximal junctional kyphosis after posterior hemivertebra resection and instrumented fusion in young children with congenital scoliosis / 中华外科杂志

Objective@#To investigate the risk factors of proximal junctional kyphosis(PJK) in young children who underwent posterior hemivertebra resection and instrumented fusion.@*Methods@#This study reviewed the charts and radiographs of 136 consecutive young children with congenital scoliosis who underwent posterior hemivertebra resection and instrumented fusion in Department of Orthopaedics, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from January 2009 to June 2014, including 75 males and 61 females, with an average age of (5.0±1.7)years(3-10 years). Proximal junctional angle(PJA), spino-pelvic parameters and segmental kyphosis (SK) were recorded pre- and post-operation and at last follow-up.The changes of PJA and radiographic features of proximal junction were also observed.χ2 test and t-test were used to analyzed enumeration data and measurement data, respectively.@*Results@#The average follow-up period was (32.8±10.3)months (ranging from 24 to 73 months) by June 2016. Among these patients, PJK occurred in 19 cases. Fifteen patients developed PJK during the first 3 months after surgery.The most common type of PJK was ligamentous failure.Compared with the non-PJK group (22.2%, 37.6%, 13.7%), the PJK group showed higher rate of preoperative TK>40°(9/19), fusion levels >4 (13/19) and greater SK change > 30°(9/19)(χ2=7.259, 6.375, 12.368; all P<0.05), while there were no difference between the two groups in terms of preoperative PJA, lumbar lordosis, SVA and upper instrument vertebra location(all P>0.05). The average PJA increased from 7.5°±2.9° to 21.3°±4.3° at 3 months after surgery to 20.6°±3.7° at the final follow-up visit in the PJK group.At the time of the final follow-up visit, ten patients received brace treatment, with no significant progression of PJA.@*Conclusions@#PJK might mainly occurs within 3 months postoperatively.Its prognostic factors include preoperative hyperkyphosis, over correction of kyphosis and ligamentous failure.

Transforaminal lumbar interbody fusion in treating degenerative spondylolisthesis at L 4 with kyphotic versus non-kyphotic angulation / 中华骨科杂志

Objective To compare the radiographic and clinical results of transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative spondylolisthesis (DS) with or without kyphotic angulation.Methods This study retrospectively reviewed a consecutive cohort of 137 patients with L4 DS (Meyerding grade Ⅰ or Ⅱ) who received TLIF between January 2009 and December 2012 and had a minimum follow-up of 2 years,including 24 males and 113 females,with the average age of 59.1±11.6 years(45-72 years).The enrolled patients were divided into two groups based on the angulation of intervertebral space:the kyphotic group and the non-kyphotic group.Slip angle (SA),anterior disc height (ADH),posterior disc height (PDH),slip percentage (SP) and segmental kyphosis (SK) was measured to evaluate the radiographic outcomes.Oswestry disability index (ODI) and visual analogue scale (VAS) was collected to evaluate the clinical results.The radiographic measurements and clinical indexes were recorded before and after surgery and at latest follow-up.The independent samples t test was performed to analyze the differences between the two groups in terms of radiographic and clinical outcomes.Results Kyphotic slip was observed in 21 (15.3％) patients,while non-kyphotic slip in 116 (84.7％) patients.No significant difference was observed in terms of age,gender,operation time and blood loss between the two groups.The preoperative SA in kyphotic and non-kyphotic group was 3.1°±2.3° and-8.2°±4.7°,respectively.The kyphotic group had significantly lower ADH and higher PDH than the non-kyphotic group,while there was no significant difference in SP between the two groups.After surgery,the postoperative and latest follow up radiographic results showed that patients of both groups had significant improvement,without significant differences between groups in terms of ADH,PDH,SA and SK,but the reduction of slip was significantly higher in the kyphotic group.Postoperative and follow-up ODI and VAS scores demonstrated remarkable improvement after surgery,without difference between groups,despite being higher in the kyphotic group than the non-kyphotic group preoperatively.Conclusion The kyphotic angulation of intervertebral space benefits to and facilitates slip reduction for L4 DS via TLIF procedure,and achieves improvements in life quality which is similar to the nonkyphotic group.

The impact of ossified anterior longitudinal ligaments surrounding osteotomy vertebra on the lordosing capability of pedicle subtraction osteotomy in thoracolumbar kyphotic deformity secondary to ankylosing spondylitis / 中华骨科杂志

Objective To investigate anterior longitudinal ligaments (ALL) ossified surrounding osteotomy vertebra impact the lordosing effect of pedicle subtraction osteotomy (PSO) in patients with thoracolumbar kyphosis secondary to ankylosing spondylitis (AS).Methods We retrospectively reviewed 102 AS patients with thoracolumbar kyphosis treated with single-level PSO at our institution from September 2007 to August 2015.There were 92 male and 10 female.The average age was (35.6±11.8)years old (range from 17 to 65 years old).Patients were stratified into ossified group (54 cases) and non-ossified group (48 cases)based on the presence of ALL ossification adjacent to osteotomy vertebra.Compared the contribution of adjacent disc wedging to total correction of each PSO segment between the ossified and non-ossified groups.The long-term correction loss of spine and pelvic sagittal morphology were also evaluated and compared between the 2 groups.Results Patients in the ossified group accomplished significantly lower amount of correction in single level segment of PSO (36.3°±6.9° vs.41.5°±6.9°),and there was significant difference between the two groups.The contribution of adjacent disc wedging to total correction of PSO was significantly larger in the non-ossified group (22.9％ vs.7.8％,P＜0.001).For subgroups with a minimum 2 year follow-up,loss of corrections concerned sagittal vertical axis (SVA),which was (1.7±4.5) cm vs.(-0.2±4.0) cm in ossified group and non-ossified group,and there was significant difference between the two groups.Pelvic tilt (PT) was 3.5°±8.2° vs.2.0°± 10.4°,lumbar lordosis (LL) was-7.9°±11.9° vs.-0.1°± 11.9° and sacral slope (SS) was 4.5°±9.3° vs.1.6°±7.9°,and there were all significant differences between the two groups.The change of adjacent disc wedging angle was marginally higher in the unossified group (-2.1°±6.2° vs.-0.1°±3.7°,P=0.09),but there was no significant difference between the two groups.No significant correction loss of osteotomy angle was observed in both groups.Conclusion Osteotomy vertebrae accompanied by unossified adjacent ALL in PSO of AS were prone to create more disc-originated lordosing effect immediately after surgery.However,a correction loss might occur more commonly during a long term follow-up.

Role of transvertebral transposition of the spinal cord in the treatment of neurologic deficit secondary to angular kypho-scoliosis / 中华骨科杂志

Objective To explore the role of transvertebral transposition of the spinal cord in the treatment of the pa?tients suffering from angular kyphoscoliosis with neurologic deficit. Methods Twelve patients with at least 1 year follow?up, in?cluding 5 females and 7 males, suffering from neurologic deficit secondary to angular kyphoscoliosis underwent transvertebral transposition of the spinal cord and posterior correction from January 2005 to June 2013 were retrospectively analyzed. The initial age averaged 21±14 years. The etiologies of deformity were congenital kyphoscoliosis in 9 patients, idiopathic kyphoscoliosis in 3 patients. Preoperative spinal cord function graded by Frankel criteria was 3 cases of grade C and 9 of grade D. The initial major curve was 79.4°±16.2° with a global kyphosis of 68.3°±25.0°. The change of distance between spinal cord and canal on the convex side at the apex was measured on MR images to evaluate the efficacy of transposition;in addition, Cobb angle on coronal and sagit?tal plane was evaluated before surgery, on discharge and at the last follow?up. Results All patients were followed up for 2 years on average (1-5 years). The post operation spinal function evaluated by Frankel criteria were as follow:with grade C of 1 case, grade D of 4 cases and grade E of 7 (7 cases changed one grade, 1 case changed two grades, 4 cases did not change obvious). At the last follow?up, all the cases got obvious recovery of spinal function, with 1 case of grade C and 11 of grade D (10 cases changed one grade, 2 cases changed two grades). The distance between spinal cord and canal on the convex side at the apex changed from 11.9±6.4 mm to 9.8±6.9 mm. After surgery, the major curve improved to 39.3°±15.1° with 50.3%±20.5%correction rate, and the mean loss of correction was 6.1%±7.5%. The mean kyphosis was 41.3°±16.6°, demonstrating a 39.0%±13.0%correction rate im?mediately after operation, and showing 3.1%±4.2%correction loss at the final follow?up. No neurologic complications or no death occurred intra?and post?operatively. No screw or rod fracture, instrumentation loosening and pseudarthrosis were found during fol?low?up. Conclusion Transvertebral transposition of the spinal cord and posterior correction is a useful procedure for the recovery of neurologic deficit secondary to angular kyphoscoliosis, with good results of deformity correction.