Major Surgical Treatment of Osteoporotic Vertebral Fractures in the Elderly: A Comparison of Anterior Spinal Fusion, Anterior-Posterior Combined Surgery and Posterior Closing Wedge Osteotomy

STUDY DESIGN: A retrospective study. PURPOSE: To clarify the differences among the three major surgeries for osteoporotic vertebral fractures based on the clinical and radiological results. OVERVIEW OF LITERATURE: Minimally invasive surgery like balloon kyphoplasty has been used to treat osteoporotic vertebral fractures, but major surgery is necessary for severely impaired patients. However, there are controversies on the surgical procedures. METHODS: The clinical and radiographic results of patients who underwent major surgery for osteoporotic vertebral fracture were retrospectively compared, among anterior spinal fusion (group A, 9 patients), single-stage combined anterior-posterior procedure (group AP, 8 patients) and posterior closing wedge osteotomy (group P, 9 patients). Patients who underwent revision surgery were evaluated just before the revision surgery, and the other patients were evaluated at the final follow-up examination, which was defined as the end point of the evaluations for the comparison. RESULTS: The operation time was significantly longer in group AP than in the other two groups. The postoperative correction of kyphosis was significantly greater in group P than in group A. Although the differences were not significant, better outcomes were obtained in group P in: back pain relief at the end point; ambulatory ability at the end point; and average loss of correction. CONCLUSIONS: The posterior closing wedge osteotomy demonstrated better surgical results than the anterior spinal fusion procedure and the single-stage combined anterior-posterior procedure.

Axial Plane Lumbar Responses after Anterior Selective Thoracic Fusion for Main Thoracic Adolescent Idiopathic Scoliosis

STUDY DESIGN: A retrospective radiographic study. PURPOSE: To evaluate the axial plane lumbar responses after anterior selective thoracic fusion (STF) in patients with main thoracic adolescent idiopathic scoliosis (MT-AIS). OVERVIEW OF LITERATURE: Anterior scoliosis surgery induces more MT derotation through disc preparation than posterior surgery. METHODS: Twenty-eight MT-AIS patients treated with STF were evaluated after a minimum follow-up (FU) of 2 years. The MT and lumbar coronal angles, as well as the MT and lumbar rotational angles at the most rotated vertebrae were measured. RESULTS: At the last FU, the MT coronal correction and derotation rates were 65% and 41%, respectively. The lumbar coronal correction rate was 61% but there was minimal lumbar derotation (2%). Nine cases were decompensated (coronal balance >10 mm). After surgery, the compensated and decompensated groups showed similar MT coronal and axial correction rates. During the FU, the MT and lumbar apecies rotated in the same direction (r=0.443). In addition, significant MT derotation occurred in the decompensated group with increasing lumbar rotational correction loss. At the last FU, while the MT coronal correction was similar between the two groups, there was more MT derotation in the decompensated group. Furthermore, the MT rotational change was strongly associated with the coronal C7 plumb line position (r=0.728). CONCLUSIONS: After anterior STF in patients with MT-AIS, the final MT derotation is strongly associated with the coronal C7 plumb line position. During the FU, the excessive MT derotation in the decompensated group was attributed to excessive lumbar rotational correction loss.

Sagittal Plane Lumbar Responses after Anterior Selective Thoracic Fusion for Main Thoracic Adolescent Idiopathic Scoliosis

STUDY DESIGN: A retrospective radiographic study. PURPOSE: To verify the correlation of sagittal and coronal plane changes after selective thoracic fusion in main thoracic (MT) adolescent idiopathic scoliosis (AIS). OVERVIEW OF LITERATURE: Sagittal plane deformity is known to be essential in the evolution of scoliosis. METHODS: Twenty-eight MT AIS patients treated by anterior selective thoracic fusion were evaluated after minimal follow-up of two years. The unfused lumbar area was divided into proximal and distal parts by the lumbar apex in the coronal plane, and into proximal and distal lumbar lordosis by L2 in the sagittal plane. Surgical motion (the difference between preoperative and postoperative values) and follow-up motion (the difference between postoperative and the last follow-up values) were compared. RESULTS: Immediately after surgery, as thoracic kyphosis increased, lumbar lordosis decreased (r=0.734); proximal lumbar lordosis increased, and distal lumbar lordosis decreased. The proximal lumbar area was mobilized in the sagittal plane, and was straightened in the coronal plane. However, the distal lumbar area was stabilized in the sagittal plane, and showed resistant motion against MT translation in the coronal plane. The surgical motion was correlated to the follow-up motion, i. e., was regulated during follow-up, and the regulatory motion was more precise in the distal than proximal lumbar area in both sagittal and coronal planes. CONCLUSIONS: Sagittal and coronal motions were co-related; optimal sagittal motions were necessary for optimal coronal motions after anterior selective thoracic fusion for MT AIS. Proximal and distal lumbar motions were different for different roles; the proximal lumbar area played a role as a bumper to absorb the MT translatory force, and the distal lumbar area played a role of resistance against MT translation.

Surgical strategy of lowest instrumented vertebrae selection of anterior correction for adolescent idiopathic scoliosis / 中国矫形外科杂志

[Objective]To investigate surgical strategy of lowest instrumented vertebrae(LIV)selection of anterior correction for adolescent idiopathic scoliosis,and to discuss correlation of lowest instrumented vertebrae and trunk balance.[Method]Twenty-eight patients with thoracolumbar/lumbar adolescent idiopathic scoliosis(Lenke 5 type)were treated by anterior correction and fusion with mean 1.5-year follow-up.Specific radiographic parameters such as LIV and fusion levels,disc wedging,LIV obliquity,global coronal balance were observed respectively,and correlation of disc wedging and these parameters was analyzed.[Result]The preoperative disc angle was(2.96??1.43?)and postoperative was(-3.60??1.75?).The postoperative disc wedging was most correlated with LIV obliquity.Trunk balance and LIV-CSVL distance,fusion segments,LIV obliquity were significant correlated.[Conclusion]Selection of LIV was correlated with various radiographic parameters.Short fusion was inappropriate in such conditions:big disc angle of lower end vertebrae between superior vertebrae,fewer vertebra between certain vertebrae and apex vertebrae,long distance from certain vertebrae to CSVL and lager obliquity of the vertebrae.Disc wedging distal to LIV tent to occur postoperatively if parallel disc was not involved.

Posterior Agumentation with Rectangle Luque for the Treatment of Tuberculosis of the Lumbosacral Junction in Adults / 대한정형외과학회잡지

From September 1987 to June 1994, the authors had performed posterolateral fusion in one patient, anterior spinal fusion alone in four patients, anterior spinal fusion after posterior augmentation with Rectangle Luque and posterolateral fusion in four patients of tuberculosis of the lumbosacral junction. The purpose of this study was evaluated the reliability of the posterior augmentation with Rectangle Luque and posterolateral fusion. We divided into two groups: the study group was anterior spinal fusion after posterior augmentation with Rectangle Luque in four patients, the control group was anterior spinal fusion alone in four patients. The average follow up was obtained at 16 months(12 to 20 months) in study group, at 42.7 months in control group. Results were as follows: 1. Clinical results according to Moskowitz criteria were 2 patients with grade I. 2 patients with grade II in the study group; one patient with grade I, one patient with grade II, one patient with grade III, one patient with grade IV in the control group. Hypolordosis(less than 10 degree) at the lumbosacral junction was associated with a higher incidence of back pain. 2. Radiographically well consolidated anterior fusion was noted in all patients within average 6 months (5-7 months) in the study group and 7.2 months (5-10 months) in the control group. 3. Radiologically the lumbosacral saggital angle was corrected after operation and the mean angle was 16.5 degrees(12 to 20 degrees) in the study group, 7.2 degrees(3 to 20 degrees) in the control group. The mean loss of angular correction was 5 degrees(1 to 8 degrees) in the study group, 6.2 degrees(1 to 13 degrees) in the control group at postoperative one year follow up. In conclusion, this results suggest that the anterior spinal fusion concomitant with the posterior augmentation with Rectangle Luque is the recommendable methods for tuberculosis of the lumbosacral junction in adults.

A Wide Muscle-splitting Approach to the Lumbosacral Spine / 대한정형외과학회잡지

20 patients with lumbosacral disorder underwent anterior spinal fusion using wide muscle splitting approach. The approach has considerable advantages over the usual muscle cutting approach or the transperitoneal approach commonly employed for this incision. The advantages of this approach are as follows: 1. The approach to the lesion site is safe and accurate. 2. The operation field is wide. 3. It is less destructive to the abdominal wall. 4, The defect left in iliac crest after removal of bone graft can be covered with external oblique layer. 5. The exposure given to the Ls-S1 intervertebral disc is superior to that given by the Rutherford Morrison approach.

Treatment of Non / 대한정형외과학회잡지

During the period of 25 years from Apr. 1959 to Jan. 1984, 58 patients of non-tuberculous infec-tion of the spine (53 pyogenic osteomyelitis and 5 iatrogenic and primary discitis) were admitted and treated at our department. Clinical analysis was carried out following results were obtained. 1. The incidence was higher in the 3rd and 4th decade and the sex ratio between male and female was 2.1:1 2. The relative frequency of the commonly involved sity were lumbar(60), thoracic(17.), cervical(9%), lumbosacral(7%), thoracolumbar(3.5%), cervicothoracic(1.5%), in that orders. 3. The morbidity period less than 1 month was only in 22% and that less than 1 year was only 4. The frequent clinical symptoms and signs were back pain(91), tenderness(88%), muscle spasm (76%), and fever and chillness(41%). 5. The causative microorganism was identified in 43 cases among which 77% was coagulase positive staphylococcus. 6. Expected spontaneous bony fusion was not found in any case of 9 follow-up cases of conservatively treated group, while excellent bony union was noticed in all 16 follow-up cases of anterior fusion group except one. 7. Anterior spinal fusion seems be to indicated in those cases such as with failure of conservative treatment, paraplegia, concomitant mechanical instability, long duration of sinus tract and even with dubious bacteriological diagnosis. 8. Anterior spinal fusion for pyogenic osteomyelitis and discitis has the advantages, that is eradication of diseased foci with easier bacteriological diagnosis, cord decpmpression, increase of bony stability, and promotion of bony union. 9. Laminectomy was indicated in those cases with epidural abscess. 10. Bone scan and computed tomography were useful in the early diagnosis and evaluation of treatment results.