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Sinian Wang, Liang Xu, Muyi Wang, Yong Qiu, Zezhang Zhu, Bin Wang, and Xu Sun

OBJECTIVE

This study aimed to investigate reversal of vertebral wedging and to evaluate the contribution of vertebral remodeling to correction maintenance in patients with adolescent Scheuermann’s kyphosis (SK) after posterior-only instrumented correction.

METHODS

A retrospective cohort study of patients with SK was performed. In total, 45 SK patients aged 10–20 years at surgery were included. All patients received at least 24 months of follow-up and had Risser sign greater than grade 4 at latest follow-up. Patients with Risser grade 3 or less at surgery were assigned to the low-Risser group, whereas those with Risser grade 4 or 5 were assigned to the high-Risser group. Radiographic data and patient-reported outcomes were collected preoperatively, immediately postoperatively, and at latest follow-up and compared between the two groups.

RESULTS

Remarkable postoperative correction of global kyphosis was observed, with similar correction rates between the two groups (p = 0.380). However, correction loss was slightly but significantly less in the low-Risser group during follow-up (p < 0.001). The ratio between anterior vertebral body height (AVBH) and posterior vertebral body height (PVBH) of deformed vertebrae notably increased in SK patients from postoperation to latest follow-up (p < 0.05). Loss of correction of global kyphosis was significantly and negatively correlated with increased AVBH/PVBH ratio. Compared with the high-Risser group, the low-Risser group had significantly greater increase in AVBH/PVBH ratio during follow-up (p < 0.05). The two groups had similar preoperative and postoperative Scoliosis Research Society–22 questionnaire scores for all domains.

CONCLUSIONS

Obvious reversal in wedge deformation of vertebrae was observed in adolescent SK patients. Patients with substantial growth potential had greater vertebral remodeling and less correction loss. Structural remodeling of vertebral bodies has a positive effect and protects against correction loss. These results could be help guide treatment decision-making.

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Shi-zhou Zhao, Bang-ping Qian, Ji-chen Huang, Mu Qiao, Bin Wang, and Yong Qiu

OBJECTIVE

Both unchanged upper cervical lordosis combined with decreased lower cervical lordosis and decreased upper cervical lordosis combined with decreased lower cervical lordosis have been reported to occur after correction surgery for adult spinal deformity. However, variations in cervical alignment after correction surgery in patients with ankylosing spondylitis (AS) have not been investigated. The current study aimed to investigate the variations in cervical alignment following the correction surgery in AS patients with thoracolumbar kyphosis.

METHODS

Patients with AS who underwent pedicle subtraction osteotomy (PSO) for thoracolumbar kyphosis from June 2016 to June 2019 with a minimum of 1-year follow-up were reviewed. Patients were grouped according to the presence (ossified group) and absence (non-ossified group) of total ossification of the anterior longitudinal ligament (ALL) in the lower cervical spine. Radiographic parameters, including thoracolumbar, craniocervical, and global radiographic parameters, were measured on lateral sitting EOS images.

RESULTS

Thirty-two patients (27 males and 5 females) with a mean follow-up of 1.5 years were identified. There were 21 patients in the non-ossified group and 11 patients in the ossified group. After PSO, both groups showed a decrease in the occiput–C7 angle (p < 0.001 for both). In the non-ossified group, the C2–7 angle decreased significantly (p < 0.001), while the occiput–C2 angle remained unchanged (p = 0.570). In the ossified group, the occiput–C2 angle decreased significantly (p < 0.001), while C2–7 angle remained unchanged (p = 0.311). In addition, the change in occiput–C2 was correlated with the osteotomy angle in the ossified group (R = 0.776, p = 0.005).

CONCLUSIONS

The variation patterns of cervical alignment following correction surgery for AS-related thoracolumbar kyphosis were different based on patients with or without total ossification of ALL in the lower cervical spine. When planning PSO for patients in the ossified group, restoration of the physiological upper cervical lordosis angle could be achieved by adjusting the osteotomy angle.

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Shi-zhou Zhao, Bang-ping Qian, Ji-chen Huang, Mu Qiao, Bin Wang, and Yong Qiu

OBJECTIVE

Both unchanged upper cervical lordosis combined with decreased lower cervical lordosis and decreased upper cervical lordosis combined with decreased lower cervical lordosis have been reported to occur after correction surgery for adult spinal deformity. However, variations in cervical alignment after correction surgery in patients with ankylosing spondylitis (AS) have not been investigated. The current study aimed to investigate the variations in cervical alignment following the correction surgery in AS patients with thoracolumbar kyphosis.

METHODS

Patients with AS who underwent pedicle subtraction osteotomy (PSO) for thoracolumbar kyphosis from June 2016 to June 2019 with a minimum of 1-year follow-up were reviewed. Patients were grouped according to the presence (ossified group) and absence (non-ossified group) of total ossification of the anterior longitudinal ligament (ALL) in the lower cervical spine. Radiographic parameters, including thoracolumbar, craniocervical, and global radiographic parameters, were measured on lateral sitting EOS images.

RESULTS

Thirty-two patients (27 males and 5 females) with a mean follow-up of 1.5 years were identified. There were 21 patients in the non-ossified group and 11 patients in the ossified group. After PSO, both groups showed a decrease in the occiput–C7 angle (p < 0.001 for both). In the non-ossified group, the C2–7 angle decreased significantly (p < 0.001), while the occiput–C2 angle remained unchanged (p = 0.570). In the ossified group, the occiput–C2 angle decreased significantly (p < 0.001), while C2–7 angle remained unchanged (p = 0.311). In addition, the change in occiput–C2 was correlated with the osteotomy angle in the ossified group (R = 0.776, p = 0.005).

CONCLUSIONS

The variation patterns of cervical alignment following correction surgery for AS-related thoracolumbar kyphosis were different based on patients with or without total ossification of ALL in the lower cervical spine. When planning PSO for patients in the ossified group, restoration of the physiological upper cervical lordosis angle could be achieved by adjusting the osteotomy angle.

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Tianyuan Zhang, Hongda Bao, Shibin Shu, Zhen Liu, Xu Sun, Bin Wang, Yong Qiu, and Zezhang Zhu

OBJECTIVE

Sacral agenesis (SA) is a rare congenital malformation of the spine. There has been a paucity of clinical research to investigate the surgical outcome of spinopelvic fixation in these patients. In this study, the authors aimed to evaluate the outcome of different distal fixation anchors in lumbosacral spinal deformities associated with SA and to determine the optimal distal fixation anchor.

METHODS

Patients with diagnoses of SA and lumbosacral scoliosis undergoing spinopelvic fixation with S1 screws, iliac screws, or S2-alar-iliac (S2AI) screws were analyzed. The main curve, coronal balance distance, and pelvic obliquity were compared at baseline, postoperatively, and during follow-up in three groups. The complications were also recorded.

RESULTS

A total of 24 patients were included: 8 patients were stratified into group 1 (S1 screws), 9 into group 2 (iliac screws), and 7 into group 3 (S2AI screws). The main curves were well corrected postoperatively (p < 0.05) in all groups. Coronal balance showed a tendency of deterioration during follow-up in patients with S1 screws (from 18.8 mm to 27.0 mm). Regarding pelvic obliquity, patients with both iliac and S2AI screws showed significant correction (from 3.7° to 2.3° and from 3.3° to 1.6°). Implant-related complications were rod breakage in 3 patients and infection in 1 patient in group 2, and no implant-related complications were observed in group 3. There were 3 cases of unilateral S1 pedicle screw misplacement in group 1.

CONCLUSIONS

Spinopelvic fixation is a safe and effective procedure that can achieve coronal correction in lumbosacral scoliosis associated with SA. Compared with S1 and iliac screws, S2AI screws as distal fixation anchors can achieve a more satisfactory correction with fewer implant-related complications.

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Qing-shuang Zhou, MM, Xu Sun, Xi Chen, Liang Xu, Bang-ping Qian, Ze-zhang Zhu, Bin Wang, and Yong Qiu

OBJECTIVE

The aim of this study was to investigate sagittal alignment and compensatory mechanisms in patients with monosegmental spondylolysis (mono_lysis) and multisegmental spondylolysis (multi_lysis).

METHODS

A total of 453 adult patients treated for symptomatic low-grade spondylolytic spondylolisthesis were retrospectively studied at a single center. Patients were divided into 2 subgroups, the mono_lysis group and the multi_lysis group, based on the number of spondylolysis segments. A total of 158 asymptomatic healthy volunteers were enrolled in this study as the control group. Radiographic parameters measured on standing sagittal radiographs and the ratios of L4–S1 segmental lordosis (SL) to lumbar lordosis (L4–S1 SL/LL) and pelvic tilt to pelvic incidence (PT/PI) were compared between all experimental groups.

RESULTS

There were 51 patients (11.3%) with a diagnosis of multi_lysis in the spondylolysis group. When compared with the control group, the spondylolysis group exhibited larger PI (p < 0.001), PT (p < 0.001), LL (p < 0.001), and L4–S1 SL (p = 0.025) and a smaller L4–S1 SL/LL ratio (p < 0.001). When analyzing the specific spondylolysis subgroups, there were no significant differences in PI, but the multi_lysis group had a higher L5 incidence (p = 0.004), PT (p = 0.018), and PT/PI ratio (p = 0.039). The multi_lysis group also had a smaller L4–S1 SL/LL ratio (p = 0.012) and greater sagittal vertical axis (p < 0.001).

CONCLUSIONS

A high-PI spinopelvic pattern was involved in the development of spondylolytic spondylolisthesis, and a larger L5 incidence might be associated with the occurrence of consecutive multi_lysis. Unlike patients with mono_lysis, individuals with multi_lysis were characterized by an anterior trunk, insufficiency of L4–S1 SL, and pelvic retroversion.

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Zhuo-jie Liu, Bang-ping Qian, Yong Qiu, Sai-hu Mao, Jun Jiang, and Bin Wang

OBJECTIVE

Relocation of the apex is often found in patients with ankylosing spondylitis (AS)–associated thoracolumbar/lumbar kyphosis after corrective surgery. This study evaluates the influence of different postoperative apex locations on surgical and clinical outcomes of osteotomy for patients with AS and thoracolumbar kyphosis.

METHODS

Sixty-two patients with a mean age of 34.6 ± 9.7 years (range 17–59 years) and a minimum of 2 years of follow-up, who underwent 1-level lumbar pedicle subtraction osteotomy for AS-related thoracolumbar kyphosis, were enrolled in the study, as well as 62 age-matched healthy individuals. Patients were divided into 2 groups according to the postoperative location of the apex (group 1, T8 or above; group 2, T9 or below). Demographic data, radiographic measurements (including 3 postoperative apex-related parameters), and clinical outcomes were compared between the 2 groups preoperatively, postoperatively, and at the last follow-up. Furthermore, a subgroup analysis was performed among patients with a postoperative apex located at T6–11 and postoperatively the entire AS cohort was compared with normal controls regarding the apex location of the thoracic spine.

RESULTS

In the majority of the enrolled patients, the apex location changed from T12–L2 preoperatively to T6–9 postoperatively. The sagittal vertical axis (SVA) differed significantly both postoperatively (25.7 vs 59.0 mm, p = 0.001) and at the last follow-up (34.6 vs 59.9 mm, p = 0.003) between the 2 groups, and the patients in group 1 had significantly smaller horizontal distance between the C7-vertical line and the apex (DCA) than the patients in group 2 (67.5 vs 103.7 mm, p = 0.001). Subgroup analysis demonstrated similar results, showing that the patients with a postoperative apex located at T8 or above had an average SVA < 47 mm. Notably, a significant correlation was found between postoperative SVA and DCA (r = 0.642, p = 0.001). Patients who underwent an osteotomy at L3 had limited apex relocation but larger SVA correction than those at L1 or L2. However, no significant difference was found in health-related quality of life between the 2 groups.

CONCLUSIONS

AS patients with an apex located at T8 or above after surgery tended to have better SVA correction (within 47 mm) than those who had a more caudally located apical vertebra. For ideal postoperative apex relocation, a higher (closer to or at the preoperative apex) level of osteotomy is more likely to obtain the surgical goal.

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Bang-ping Qian, Ji-chen Huang, Yong Qiu, Bin Wang, Yang Yu, Ze-zhang Zhu, Sai-hu Mao, and Jun Jiang

OBJECTIVE

To describe the incidence of complications in spinal osteotomy for thoracolumbar kyphosis caused by ankylosing spondylitis (AS) and to investigate the risk factors for these complications.

METHODS

From April 2000 to July 2017, 342 consecutive AS patients with a mean age (± SD) of 35.4 ± 9.8 years (range 17–71 years) undergoing spinal osteotomy were enrolled. Patients with complications within the 1st postoperative year were identified. Demographic, radiological, and surgical data were compared between patients with and without complications. The complications were classified into intraoperative and postoperative complications.

RESULTS

A total of 310 consecutive pedicle subtraction osteotomy (PSO) and 37 multiple Smith-Petersen osteotomy (SPO) procedures were performed in 342 patients. Overall, 47 complications were identified in 47 patients (13.7%), including 31 intraoperative complications and 16 postoperative complications. Patients with complications were older than those without (p = 0.006). A significant difference was observed in preoperative global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), and the correction of these radiographic parameters between patients with and without complications (p < 0.05). Two-level PSO (p = 0.022) and an increased number of instrumented vertebrae (p = 0.019) were significantly associated with an increased risk of complications.

CONCLUSIONS

The overall incidence of complications was 13.7%. Age; preoperative GK, LL, and SVA; the correction of GK, LL, and SVA; 2-level PSO; and number of instrumented vertebrae were risk factors. Therefore, the potential risk of extensive surgeries with large correction and long fusion in older AS patients with severe GK should be seriously considered in surgical decision-making.

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Yang Li, Xinxin Yuan, Shifu Sha, Zhen Liu, Weiguo Zhu, Yong Qiu, Bin Wang, Yang Yu, and Zezhang Zhu

OBJECTIVE

The aim of this study was to investigate how implant density affects radiographic results and clinical outcomes in patients with dystrophic scoliosis secondary to neurofibromatosis Type 1 (NF1).

METHODS

A total of 41 patients with dystrophic scoliosis secondary to NF1 who underwent 1-stage posterior correction between June 2011 and December 2013 were included. General information about patients was recorded, as were preoperative and postoperative scores from Scoliosis Research Society (SRS)–22 questionnaires. Pearson correlation analysis was used to analyze the associations among implant density, coronal Cobb angle correction rate and correction loss at last follow-up, change of sagittal curve, and apical vertebral translation. Patients were then divided into 2 groups: those with low-density and those with high-density implants. Independent-sample t-tests were used to compare demographic data, radiographic findings, and clinical outcomes before surgery and at last follow-up between the groups.

RESULTS

Significant correlations were found between the implant density and the coronal correction rate of the main curve (r = 0.505, p < 0.01) and the coronal correction loss at final follow-up (r = −0.379, p = 0.015). There was no significant correlation between implant density and change of sagittal profile (p = 0.662) or apical vertebral translation (p = 0.062). The SRS-22 scores improved in the appearance, activity, and mental health domains within both groups, but there was no difference between the groups in any of the SRS-22 domains at final follow-up (p > 0.05 for all).

CONCLUSIONS

Although no significant differences between the high- and low-density groups were found in any of the SRS-22 domains at final follow-up, higher implant density was correlated with superior coronal correction and less postoperative correction loss in patients with dystrophic NF1-associated scoliosis.

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Yi Ma, Yan-feng Li, Quan-cai Wang, Bin Wang, and Hai-tao Huang

OBJECT

The object of this study was to investigate the immediate and long-term follow-up results of glossopharyngeal nerve rhizotomy (GPNR) with or without partial vagus nerve rhizotomy (VNR) for treating glossopharyngeal neuralgia (GPN).

METHODS

A retrospective review of the case notes of patients who had undergone surgery for GPN in the authors’ department between 2008 and 2013 was performed to investigate baseline characteristics and immediate outcomes during the hospitalization. For the long-term results, a telephone survey was performed, and information on pain recurrence and permanent complications was collected. Pain relief meant no pain or medication, any pain persisting after surgery was considered to be treatment failure, and any pain returning during the follow-up period was considered to be pain recurrence. For comparative study, the patients were divided into 2 cohorts, that is, patients treated with GPNR alone and those treated with GPNR+VNR.

RESULTS

One hundred three procedures, consisting of GPNR alone in 38 cases and GPNR+VNR in 65 cases, were performed in 103 consecutive patients with GPN. Seventy-nine of the 103 patients could be contacted for the follow-up study, with a mean follow-up duration of 2.73 years (range 1 month–5.75 years). While there were similar results (GPNR vs GPNR+VNR) in immediate pain relief rates (94.7% vs 93.8%), immediate complication rates (7.9% vs 4.6%), and long-term pain relief rates (92.3% vs 94.3%) between the 2 cohorts, a great difference was seen in long-term complications (3.8% vs 35.8%). The long-term complication rate for the combined GPNR+VNR cohort was 9.4 times higher than that in the GPNR cohort.

There was no operative or perioperative mortality. Immediate complications occurred in 6 cases, consisting of poor wound healing in 3 cases, and CSF leakage, hoarseness, and dystaxia in 1 case each. Permanent complications occurred in 20 patients (25.3%) and included cough while drinking in 10 patients, pharyngeal discomfort in 8 patients, and hoarseness and dysphagia in 1 case each.

CONCLUSIONS

In general, this study indicates that GPNR alone or in combination with VNR is a safe, simple, and effective treatment option for GPN. It may be especially valuable for patients who are not suitable for the microvascular decompression (MVD) procedure and for surgeons who have little experience with MVD. Of note, this study renews the significance of GPNR alone, which, the authors believe, is at least valuable for a subgroup of GPN patients, with significantly fewer long-term complications than those for rhizotomy for both glossopharyngeal nerve and rootlets of the vagus nerve.