Application of back-forward Bending CT localization image in the prediction of proximal junctional kyphosis after spinal deformity surgery in adults / 中国修复重建外科杂志

OBJECTIVE@#To investigate the feasibility of predicting proximal junctional kyphosis (PJK) in adults after spinal deformity surgery based on back-forward Bending CT localization images and related predictive indicators.@*METHODS@#A retrospective analysis was performed for 31 adult patients with spinal deformity who underwent posterior osteotomy and long-segment fusion fixation between March 2017 and March 2020. There were 5 males and 26 females with an average age of 62.5 years (range, 30-77 years). The upper instrumented vertebrae (UIV) located at T 5 in 1 case, T 6 in 1 case, T 9 in 13 cases, T 10 in 12 cases, and T 11 in 4 cases. The lowest instrumented vertebrae (LIV) located at L 1 in 3 cases, L 2 in 3 cases, L 3 in 10 cases, L 4 in 7 cases, L 5 in 5 cases, and S 1 in 3 cases. Based on the full-length lateral X-ray film of the spine in the standing position before and after operation and back-forward Bending CT localization images before operation, the sagittal sequence of the spine was obtained, and the relevant indexes were measured, including thoracic kyphosis (TK), lumbar lordosis (LL), local kyphosis Cobb angle (LKCA) [the difference between the different positions before operation (recovery value) was calculated], kyphosis flexibility, hyperextension sagittal vertical axis (hSVA), T 2-L 5 hyperextension C 7-vertebral sagittal offset (hC 7-VSO), and pre- and post-operative proximal junctional angle (PJA). At last follow-up, the patients were divided into PJK and non-PJK groups based on PJA to determine whether they had PJK. The gender, age, body mass index (BMI), number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, osteotomy grading, and related imaging indicators were compared between the two groups. The hC 7-VSO of the vertebral body with significant differences between groups was taken, and the receiver operating characteristic curve (ROC) was used to evaluate its accuracy in predicting the occurrence of PJK.@*RESULTS@#All 31 patients were followed up 13-52 months, with an average of 30.0 months. The patient's PJA was 1.4°-29.0° at last follow-up, with an average of 10.4°; PJK occurred in 8 cases (25.8%). There was no significant difference in gender, age, BMI, number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, and osteotomy grading between the two groups ( P>0.05). Imaging measurements showed that the LL recovery value and T 8-L 3 vertebral hC 7-VSO in the PJK group were significantly higher than those in the non-PJK group ( P>0.05). There was no significant difference in hyperextension TK, hyperextension LL, hyperextension LKCA, TK recovery value, LL recovery value, kyphosis flexibility, hSVA, and T 2-T 7, L 4, L 5 vertebral hC 7-VSO ( P>0.05). T 8-L 3 vertebral hC 7-VSO was analyzed for ROC curve, and combined with the area under curve and the comprehensive evaluation of sensitivity and specificity, the best predictive index was hC 7-L 2, the cut-off value was 2.54 cm, the sensitivity was 100%, and the specificity was 60.9%.@*CONCLUSION@#Preoperative back-forward Bending CT localization image can be used to predict the occurrence of PJK after posterior osteotomy and long-segment fusion fixation in adult spinal deformity. If the patient's T 8-L 2 vertebral hC 7-VSO is too large, it indicates a higher risk of postoperative PJK. The best predictive index is hC 7-L 2, and the cut-off value is 2.54 cm.

Accidental anterior longitudinal ligament rupture during lateral lumbar interbody fusion disclosed after posterior corrective fusion surgery resulting in local hyper-lordosis / Journal of Rural Medicine

Objective: To report a case of anterior longitudinal ligament (ALL) injury that was not noticeable during lateral lumbar interbody fusion and was disclosed after posterior corrective fusion surgery.Case presentation: After performing lateral lumbar interbody fusion followed by posterior corrective fusion surgery, we observed an anterior longitudinal ligament rupture that required additional surgery. Postoperative pain in the left lower limb and muscle weakness due to nerve traction appeared, but this was improved by stabilization between the vertebral bodies.Conclusion: Unidentified anterior longitudinal ligament rupture can result in unexpected local lordosis during posterior surgery, possibly related to lower extremity palsy. Therefore, checking for possible rupture during and after anterior surgery is important. If the ALL damage is disclosed before posterior surgery, the proper surgical strategy for the posterior surgery must be considered.

Factors Affecting Postoperative Sagittal Alignment after Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: Posterior Osteotomy, Anterior Longitudinal Ligament Rupture, and Endplate Injury

STUDY DESIGN: Prospective cohort study. PURPOSE: To identify factors that affect sagittal alignment correction in lateral lumbar interbody fusion (LIF) surgery for adult spinal deformity (ASD) and to investigate the degree of correction in each condition. OVERVIEW OF LITERATURE: LIF is a useful procedure for ASD, but the degree of correction can be affected by posterior osteotomy, intraoperative endplate injury, or anterior longitudinal ligament (ALL) rupture. METHODS: Radiographical data for 30 patients who underwent LIF for ASD were examined prospectively. All underwent two-stage surgery (LIF followed by posterior fixation). Radiographical parameters were measured preoperatively, after LIF, and after posterior fixation; these included the segmental lordotic angle, lumbar lordosis (LL), and other sagittal alignment factors. RESULTS: LL was corrected from 16.5°±16.7° preoperatively to 33.4°±13.8° after LIF (p<0.001) and then to 52.1°±7.9° following posterior fixation (p<0.001). At levels where Schwab grade 2 osteotomy was performed, the acquired segmental lordotic angles from the preoperative value to after posterior fixation and from after LIF to after posterior fixation were 19.5°±9.2° and 9.9°±3.9°, respectively. On average, 12.4° more was added than in cases without osteotomy. Endplate injury was identified at 21 levels (19.4%) after LIF, with a mean loss of 3.4° in the acquired segmental lordotic angle (5.3°±8.4° and 1.9°±5.9° without and with endplate injury, respectively). ALL rupture was identified at seven levels (6.5%), and on average 19.3° more was added in these cases between the preoperative and postoperative values than in cases without ALL rupture. CONCLUSIONS: LIF provides adequate sagittal alignment restoration for ASD, but the degree of correction is affected by grade 2 osteotomy, intraoperative endplate injury, and ALL rupture.

Effect of Indirect Neural Decompression with Oblique Lateral Interbody Fusion Was Influenced by Preoperative Lumbar Lordosis in Adult Spinal Deformity Surgery

STUDY DESIGN: Retrospective clinical study on the indirect decompressive effect of oblique lateral interbody fusion (OLIF) for adult spinal deformity. PURPOSE: To evaluate the effect of interbody distraction by OLIF for the treatment of adult spinal deformity. OVERVIEW OF LITERATURE: Adult spinal deformity with symptomatic stenosis has been addressed conventionally using a direct posterior decompression approach with fusion. However, stenotic symptoms can also be alleviated indirectly through restoration of intervertebral and foraminal heights and correction of spinal alignment. METHODS: Twenty-eight patients with adult spinal deformity underwent OLIF combined with modified cortical bone trajectory screws at 94 lumbar levels with neuromonitoring. The patients were divided into three groups based on their preoperative lumbar lordosis: group A, 20°. The cross-sectional area (CSA) of the thecal sac was measured preoperatively and postoperatively on axial magnetic resonance images. Differences in CSA were evaluated, and the relationship between the CSA extension ratio and preoperative CSA was assessed. Changes in disc height and segmental disc angle were measured from plain radiographs. RESULTS: OLIFs were performed successfully without neural complications. In group A, the mean CSA increased from 120.6 mm² preoperatively to 148.5 mm² postoperatively (p<0.001). The mean CSA for group B increased from 120.1 mm² preoperatively to 154.4 mm² postoperatively (p<0.001). Group C had an increase in mean CSA from 114.7 mm² preoperatively to 160.7 mm² postoperatively (p<0.001). The mean CSA enlargement ratio was 27.5%, 32.1%, and 60.4% in groups A, B, and C, respectively. The mean CSA extension ratio was inversely correlated with preoperative CSA. CONCLUSIONS: The effect of indirect neural decompression in adult spinal deformity with OLIF varies with the degree of preoperative lumbar lordosis.

Precautions for Combined Anterior and Posterior Long-Level Fusion for Adult Spinal Deformity: Perioperative Surgical Complications Related to the Anterior Procedure (Oblique Lumbar Interbody Fusion)

STUDY DESIGN: Retrospective, single-center study. PURPOSE: We aimed to determine the perioperative complications of oblique lumbar interbody fusion (OLIF) as a first-stage procedure in combined anterior and posterior operation for adult spinal deformity (ASD) along with sagittal imbalance. Specifically, we aimed to identify the radiological and clinical types of perioperative surgical complications and the factors affecting these complications. OVERVIEW OF LITERATURE: OLIF has recently gained popularity, and there are several reports of good outcomes and only a few of complications with OLIF; however, a few studies have focused on the perioperative surgical complications of ASD along with sagittal imbalance. METHODS: The perioperative period was a 1-week interval between the anterior and posterior procedures. All patients underwent simple radiography and magnetic resonance imaging preoperatively and postoperatively. Cage placement was evaluated for displacement (i.e., subsidence and migration) and vertebral body fracture. Clinical patient complaints were evaluated perioperatively. Student t-test was used for data analysis. RESULTS: A total of 46 patients were included, totaling 138 fusion segments. A week after OLIF, 14 patients/33 segments (30.4%/23.9%) demonstrated endplate injury-associated cage placement change. Subsidence was the most common cage placement-related complication. As compared with patients without endplate injury, those with endplate injuries showed significantly larger correction angles and a higher proportion of them had larger height cages than the disk height in the full-extension lateral view. Although 32.6% of the patients experienced perioperative clinical complications, they were relatively minor and transient. The most common complication was severe postoperative pain (Visual Analog Scale score of >7), and hip flexor weakness spontaneously resolved within 1 week. CONCLUSIONS: OLIF yielded more than expected endplate injuries from treatment modalities for ASD along with sagittal imbalance. Therefore, surgeons should be cautious about endplate injury during OLIF procedures. It is difficult to accomplish lordosis correction via OLIF alone; therefore, surgeons should not attempt this impractical correction goal and insert an immoderate cage.

Multi-Rod Constructs Can Increase the Incidence of Iliac Screw Loosening after Surgery for Adult Spinal Deformity

STUDY DESIGN: A retrospective study. PURPOSE: To investigate the incidence of iliac screw loosening with a two-rod vs. multi-rod construct and the effect on clinical and radiographic outcomes after surgery for adult spinal deformity (ASD). OVERVIEW OF LITERATURE: Multi-rod construct is useful for preventing rod fracture in ASD surgery. However, limited information is available regarding the incidence of iliac screw loosening after corrective fusion surgery using a multi-rod construct. METHODS: Total 106 patients with ASD (24 men and 82 women; mean age, 68 years) who underwent corrective fusion surgery using bilateral iliac screws and were followed up for at least 1 year were reviewed. The following variables were compared between patients who underwent surgery with a two-rod and multi-rod construct: age, sex, bone mineral density (BMD), fusion level, high-grade osteotomy, L5/S interbody fusion, screw loosening (upper instrumented vertebra [UIV], S1, and iliac), rod fracture, proximal junctional kyphosis, spinopelvic parameters, and Oswestry Disability Index (ODI) score. We also compared patients with and without iliac screw loosening in the multi-rod construct group. RESULTS: Of the 106 patients, 55 underwent surgery with a conventional two-rod construct and 51 with a multi-rod construct (three rods in 16, four rods in 35). Iliac and UIV screw loosening was observed in 24 patients (21%) and 35 patients (33%), respectively. The multi-rod group showed significantly higher incidence of iliac and UIV screw loosening and lower incidence of rod fracture. Patients with iliac screw loosening had a lower BMD than those without screw loosening; however, no significant differences were observed in the spinopelvic parameters or the ODI score. CONCLUSIONS: The use of multi-rod constructs led to a higher incidence of junctional screw loosening than the use of conventional two-rod constructs, especially in patients with osteoporosis. Iliac screw loosening did not affect sagittal alignment or clinical outcome in the short term.

Hypertension Is Related to Positive Global Sagittal Alignment: A Cross-Sectional Cohort Study

STUDY DESIGN: Cross-sectional cohort study.PURPOSE: This study aimed to investigate the relationship between hypertension and spino-pelvic sagittal alignment in middle-aged and elderly individuals.OVERVIEW OF LITERATURE: Positive global sagittal alignment is associated with poor health-related quality of life. Hypertension is associated with tissue microcirculation disorders of the skeletal muscle. We hypothesized that hypertension may be involved in positive global sagittal alignment.METHODS: In this institutional review board-approved study, 655 participants (262 men and 393 women; mean age, 72.9 years; range, 50–92 years) who underwent musculoskeletal screening in Toei town, Aichi, Japan were included. Whole spine and pelvic radiographs were taken, and radiographic parameters (thoracic kyphosis, lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence, and sagittal vertical axis [SVA]) were measured using an image-analysis software. Hypertension was assessed using the standard criteria. The study participants were divided into three subgroups as per age (50–64 years, 65–74 years, and ≥75 years). We examined the differences in the radiographic parameters of those with and without hypertension in each age subgroup.RESULTS: In each age subgroup, there was no significant difference in the age and sex of those with and without hypertension. SVA was significantly shifted forward in the hypertension group than in the non-hypertension group in those aged 50–64 years old (32.4 mm vs. 16.0 mm, p=0.018) and in those aged 65–74 years old (42.7 mm vs. 30.6 mm, p=0.012). There was no significant difference between the hypertension and non-hypertension groups in terms of the alignment of the lumbar and thoracic spine in all the subgroups. In multivariate analysis, hypertension was a significant independent factor of forward-shifted SVA (standardized beta 0.093, p=0.015).CONCLUSIONS: This study showed that hypertension was associated with forward-shifted global sagittal alignment.

Treatment of Adult Spinal Deformity with Sagittal Imbalance Using Oblique Lumbar Interbody Fusion: Can We Predict How Much Lordosis Correction Is Possible?

STUDY DESIGN: Prospective, single-center study.PURPOSE: The current trend of operative treatment for adult spinal deformity (ASD) is combined anterior-posterior staged surgery. When anterior surgery was first performed, oblique lumbar interbody fusion (OLIF) was employed; this method became increasing popular. This study aimed to determine the lordosis correction that can be achieved using OLIF and assess whether we can preoperatively predict the lordosis correction angle achieved using OLIF.OVERVIEW OF LITERATURE: Many previous studies on OLIF have shown improved clinical and radiologic outcomes. With the increase in the popularity of OLIF, several surgeons have started using larger cages to attain greater lordosis correction. Moreover, some studies have reported complications of OLIF because of immoderate cage insertion. To our knowledge, this is the first prospective study that attempted to determine whether it is possible to predict the lordosis correction angle achieved with OLIF preoperatively, using fullextension lateral view (FELV).METHODS: Forty-six patients with ASD were enrolled. All the operations were performed by a single surgeon in two stages (first, anterior and second, posterior) with a 1-week interval. Radiological evaluation was performed by comparing the Cobb’s angle of the segmental and regional lordosis obtained using preoperative and postoperative simple radiography (including the FELV) and magnetic resonance imaging (MRI).RESULTS: Regional lordosis (L1–S1) in the whole-spine standing lateral radiograph was −3.03°; however, in the supine lateral MRI, it was 20.92°. The regional lordosis of whole-spine standing lateral and supine lateral (MRI) was significantly different. In the FELV, regional lordosis was 25.72° and that in the postoperative supine lateral (MRI) was 25.02°; these values were not significantly different.CONCLUSIONS: Although OLIF offers many advantages, it alone plays a limited role in ASD treatment. Lordosis correction using OLIF as well as lordosis determined in the FELV was possible. Hence, our results suggest that FELV can help predict the lordosis correction angle preoperatively and thus aid the selection of the appropriate technique in the second staged operation.

A biomechanical study on proximal junctional kyphosis following long-segment posterior spinal fusion

Posterior long-segment spinal fusion may lead to proximal junctional kyphosis (PJK). The present study sought to identify the appropriate fusion levels required in order to prevent PJK using finite element analysis. A finite element model was constructed based on the whole-spine computed tomography findings of a healthy adult. Nine commonly used posterior spinal fusion methods were selected. Stress on the annulus fibrosis fibers, the posterior ligamentous complex, and the vertebrae after various spinal fusions in the upright position were compared. This study was divided into two groups: non-fusion and fusion. In the former, the stress between the T10 and the upper thoracic vertebrae was higher. Comparing thoracic and lumbar segments in the fusion group, the peak stress values of the upper instrumented vertebrae (UIV) were mainly observed in T2 and L2 whilst those of the UIV+1 were observed in T10 and L2. After normalization, the peak stress values of the UIV and UIV+1 were located in T2 and L2. Similarly, the peak stress values of the annulus fibrosus at the upper adjacent level were on T10 and L2 after normalization. However, the peak stress values of the interspinal/supraspinal complex forces were concentrated on T11, T12, and L1 after normalization whilst the peak stress value of the pedicle screw was on T2. Controversy remains over the fusion of T10, and this study simulated testing conditions with gravitational loading only. However, further assessment is needed prior to reaching definitive conclusions.

Spinal Deformity Surgery: A Critical Review of Alignment and Balance

Correction of the overall coronal and/or sagittal plane deformities is one of the main predictors of successful spinal surgery. In routine clinical practice, spinal alignment is assessed using several spinal and pelvic parameters, such as pelvic incidence and tilt, sacral slope, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. Standard values have been defined for all these parameters, and the formulas of correction have been set for determining the surgical strategy. However, several factors can potentially bias these formulas. First, all standard values are measured using conventional plain radiographs and are, therefore, prone to bias. The radiologist, measuring surgeon, and patient are possible confounding influencing factors. Second, spino-pelvic compensatory effects and biomechanically relevant structures for the patient’s posture, including ligaments, tendons, and muscles, have received minimal consideration in the literature. Therefore, even in cases of appropriately planned deformity correction surgeries, complications, revision rates, and surgical outcomes significantly vary. This study aimed to illustrate the current clinical weaknesses of the assessment of spinal alignment and the importance of holistically approaching the musculoskeletal system for any spinal deformity surgery. We believe that our detailed insights regarding spinal, sagittal, and coronal alignments as well as the considerations of an individual's spinal balance will contribute toward improvement in routine patient care.

Proximal Junctional Kyphosis and Proximal Junctional Failure Following Adult Spinal Deformity Surgery

The purpose of this review is the current understanding of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery. We carried out a systematic search of PubMed for literatures published up to September 2017 with “proximal junctional kyphosis,”“proximal junctional failure,” and “adult spinal deformity” as search terms. A total of 98 literatures were searched. The 37 articles were included in this review. PJK is multifactorial in origin and likely results from variable risk factors. PJF is a progressive form of the PJK spectrum including bony fracture, subluxation between UIV and UIV+1, failure of fixation, neurological deficit, which may require revision surgery for proximal extension of fusion. Soft tissue protections, adequate selection of the UIV, prophylactic rib fixation, hybrid instrumentation such as hooks, vertebral cement augmentation at UIV and UIV+1, adequate selection material of rods and age-appropriate spinopelvic alignment goals are strategies to minimize PJK and PJF. The ability to perform aggressive global realignment of spinal deformities has also led to the discovery of new complications such as the PJK and PJF. Continuous research on PJK and PJF should be proceeded in order to comprehend the pathophysiology of these complications.

Risk Factors of Proximal Junctional Kyphosis after Multilevel Fusion Surgery: More Than 2 Years Follow-Up Data

OBJECTIVE: Proximal junctional kyphosis (PJK) is radiologic finding, and is defined as kyphosis of >10° at the proximal end of a construct. The aim of this study is to identify factors associated with PJK after segmental spinal instrumented fusion in adults with spinal deformity with a minimum follow-up of 2 years. METHODS: A total of 49 cases of adult spinal deformity treated by segmental spinal instrumented fusion at two university hospitals from 2004 to 2011 were enrolled in this study. All enrolled cases included at least 4 or more levels from L5 or the sacral level. The patients were divided into two groups based on the presence of PJK during follow-up, and these two groups were compared to identify factors related to PJK. RESULTS: PJK was observed in 16 of the 49 cases. Age, sex and mean follow-up duration were not statistically different between two groups. However, mean bone marrow density (BMD) and mean back muscle volume at the T10 to L2 level was significantly lower in the PJK group. Preoperatively, the distance between the C7 plumb line and uppermost instrumented vertebra (UIV) were no different in the two groups, but at final follow-up a significant intergroup difference was observed. Interestingly, spinal instrumentation factors, such as, receipt of a revision operation, the use of a cross-link, and screw fracture were no different in the two groups at final follow-up. CONCLUSION: Preoperative BMD, sagittal imbalance at UIV, and thoracolumbar muscle volume were found to be strongly associated with the presence of PJK.

Novel Measurement Technique for the Sagittal Vertical Axis and Its Clinical Application in Adult Spinal Deformity

STUDY DESIGN: Prospective physical measurement of the sagittal vertical axis (SVA). PURPOSE: To evaluate a simple method for measuring SVA by analyzing its relationship with radiographic measurements and clinical appearance. OVERVIEW OF LITERATURE: No studies have examined physical measurements using the cranial center of gravity (CCG) in a relaxed standing position. METHODS: The physical measurement of the horizontal distance between CCG and spina iliaca posterior superior (CCG-SIPS) was measured using a straight ruler in 252 healthy volunteers and 56 patients with adult spinal deformity. Health-related quality of life (HRQOL) was evaluated using the Oswestry disability index (ODI), and clinical symptoms were assessed according to standing status and the presence of gastroesophageal reflux disease (GERD). RESULTS: CCG-SIPS increased with age in the volunteer group and strongly correlated with radiographic SVA in the patient group (r=0.984). Differences increased between CCG-SIPS in patients in the relaxed position and radiographic SVA with an increase in sagittal malalignment (r=0.692, p120 mm) was significantly larger in the patient group than in the group with low sagittal malalignment (59.9±18.8 vs. 45.1±17.0; p=0.004); these patients (CCG-SIPS>120 mm) needed crutches or walkers for standing. The patient group with GERD had significantly larger sagittal malalignment than the group without GERD (160.3 mm vs. 81.0 mm). CONCLUSIONS: The CCG-SIPS correlated with age and strongly reflected radiographic SVA and HRQOL in the patients. Moreover, it reflects a relaxed posture without a backward shift in the radiographic position even in patients with severe sagittal malalignment. The critical limit of CCG-SIPS can be relevant to clinical appearance, including standing assistance (>120 mm) and the existence of GERD (>150 mm). Thus, it will be a useful predictor of true SVA in clinical practice before radiographic evaluation.

Decision Making Algorithm for Adult Spinal Deformity Surgery

Adult spinal deformity (ASD) is one of the most challenging spinal disorders associated with broad range of clinical and radiological presentation. Correct selection of fusion levels in surgical planning for the management of adult spinal deformity is a complex task. Several classification systems and algorithms exist to assist surgeons in determining the appropriate levels to be instrumented. In this study, we describe our new simple decision making algorithm and selection of fusion level for ASD surgery in terms of adult idiopathic idiopathic scoliosis vs. degenerative scoliosis.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.

Spino-Pelvic Parameters in Adult Spinal Deformities / 대한정형외과학회잡지

In the recent 10 to 15 years, the most popular issue in the spine field is evaluation and treatment of the sagittal alignment and sagittal balance of the spine. Adult spine deformity (ASD) includes not only coronal deformity, such as degenerative scoliosis, but also sagittal deformity. Degenerative scoliosis is also associated with sagittal deformity of the spine. Even in degenerative scoliosis, accompanying sagittal deformity is more important to clinical symptoms than coronal deformity. Sagittal deformity of the spine is significantly correlated with health-related quality of life score, such as visual analogue scale and Oswestry disability index, short form-36 health survey. For the appropriate evaluation and treatment of ASD, understanding the normal and abnormal sagittal alignment and sagittal balance of the spine is very important. Various compensatory mechanisms should be applied in order to maintain the balanced upright posture. Assessment of the compensatory mechanism is also mandatory for proper surgical planning. Some spinopelvic parameters show particularly high correlation with clinical symptoms in case of sagittal imbalance. Therefore, assessment of these parameters is necessary for evaluation of surgical outcomes.

Surgical Correction of Adult Spinal Deformity / 대한정형외과학회잡지

Surgical correction of adult spinal deformity is a challenge, and is physically and mentally demanding for spinal surgeons. For satisfactory surgical outcomes, proper patient selection is fundamental and preoperative detailed physical examination, intra-operative neuromonitoring, and collaboration with anesthesiology or internal medicine department are critical for prevention of peri-operative complications associated with surgical treatments. A posterior-only or anterior-posterior combined approach can be used. Considering the patients' hemodynamic status or long-time anesthesia, surgeons can decide whether to operate by stage or one stage. Deformity correction can be performed using spinal osteotomy or anterior interbody fusion. Decision regarding correction method depends on the patient's condition and correction degree or level. In this review, the authors try to help in decision making with regard to deformity correction methods for ideal surgical technique, correction angle, fusion length etc. in reference to previous literature.

Escoliosis degenerativa del adulto / Degenerative adult scoliosis

La escoliosis del adulto es una deformidad rotacional compleja tridimensional de la columna, resultado de la degeneración progresiva de los elementos vertebrales en la edad madura, en una columna previamente recta; con un ángulo de Cobb mayor de 10º en el plano coronal, que además altera los planos sagital y axial. Se origina de una enfermedad degenerativa, asimétrica del disco y las facetas articulares, creando cargas asimétricas y posteriormente deformidad. El síntoma principal es dolor axial, radicular y déficit neurológico. El tratamiento conservador incluye fármacos y terapia física. Las infiltraciones epidurales y facetarias para bloqueo selectivo de raíces nerviosas mejora el dolor a corto plazo. El tratamiento quirúrgico se reserva para pacientes con dolor intratable, radiculopatía y/o déficit neurológico. No existe un consenso para las indicaciones quirúrgicas, sin embargo, se debe tener un entendimiento claro de los síntomas y signos clínicos. La meta de la cirugía es la descompresión de elementos neurales con restauración, modificación de la deformidad en forma tridimensional y estabilización del balance coronal y sagital.

Adult scoliosis is a complex three-dimensional rotational deformity of the spine, resulting from the progressive degeneration of the vertebral elements in middle age, in a previously straight spine; a Cobb angle greater than 10º in the coronal plane, which also alters the sagittal and axial planes. It originates an asymmetrical degenerative disc and facet joint, creating asymmetrical loads and subsequently deformity. The main symptom is axial, radicular pain and neurological deficit. Conservative treatment includes drugs and physical therapy. The epidural injections and facet for selectively blocking nerve roots improves short-term pain. Surgical treatment is reserved for patients with intractable pain, radiculopathy and / or neurological deficits. There is no consensus for surgical indications, however, it must have a clear understanding of the symptoms and clinical signs. The goal of surgery is to decompress neural elements with restoration, modification of the three-dimensional shape deformity and stabilize the coronal and sagittal balance.

Preoperative and Postoperative Pulmonary Function in Elderly Patients with Thoracolumbar Kyphoscoliosis

STUDY DESIGN: Case series. PURPOSE: The objective of this study was to investigate the change in pulmonary function in adult patients with a spinal deformity who underwent spinal corrective surgery. OVERVIEW OF LITERATURE: Degenerative lumbar and/or thoraco-lumbar deformities are is often prominent in adult spinal deformity cases, whereas a thoracic deformity involving the chest wall is inconspicuous. A lumbar spine deformity could affect the pulmonary function; however, few reports have investigated pulmonary function in adult patients with a spinal deformity. METHODS: This study included 14 adult patients with a spinal deformity who underwent posterior corrective fusion (3 males, 11 females; mean age, 67.4 years). We measured percent vital capacity (%VC) and percent forced expiratory volume in 1 second (%FEV1) before surgery and six months after surgery. We investigated the change in pulmonary function after corrective surgery and the correlation between radiographic parameters and pulmonary function. RESULTS: Mean preoperative %VC and %FEV1 values were 99.9% and 79.3%, respectively. Two cases were diagnosed with restrictive impairment, and two cases were diagnosed with obstructive impairment before surgery. %VC improved in the restrictive impairment cases six months after surgery. However, %FEV1 did not improve significantly after surgery in the obstructive impairment cases. CONCLUSIONS: Restrictive impairment was improved in adult patients with a spinal deformity by corrective spinal surgery. However, spinal surgery did not improve obstructive impairment.

Complications of Iliac Screw in Spinopelvic Fixation With Adult Spinal Deformity: Complications of Iliac Screw in Spinopelvic Fixation

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate clinical & radiologic significance about complications of spinopelvic fixation with iliac screw in patients with adult spinal deformity. SUMMARY OF LITERATURE REVIEW: Complications of iliac screw fixation in adult spinal deformity patients was obscure in spite of the good results of iliac screw fixation. MATERIALS AND METHODS: We analyzed 27 patients, followed over 1-year, with adult spinal deformity (lumbar degenerative kyphosis, degenerative lumbar scoliosis, flat back syndrome). The study was done for complications of iliac screw fixation by clinical and radiological evaluations. RESULTS: Post-operative iliac screw prominence were 15 cases (55.5%), iliac screw breakage was 1 case (3.7%), bursitis was 1 case (3.7%), sacroiliac joint pain were 5 cases (18.5%), halo sign around iliac screw were 23 cases (85.1%), and 3 cases (11.1%) were performed reoperation. There was no significance between halo sign and sacroiliac joint pain. CONCLUSIONS: Iliac screw fixation is a very useful operative method without severe complications on spinopelvic fixation. There are some complications of iliac screw fixation and iliac screw prominence is a most common problem, but few counterplan exits. So, further studies about reducing complication method, management protocols of iliac screw complication were needed.