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Anterior cervical myelomeningocele: a rare malformation of the spinal cord

Case report

Jun Jiang, Zezhang Zhu, Bangping Qian, Zhen Liu, and Yong Qiu

Cervical myelomeningocele (MMC) is an uncommon congenital malformation of the spinal cord and accounts for a small proportion of neural tube defects. These lesions mostly occur in the dorsal part of the body. Only a single case of an anterior cervical MMC has been previously reported. The authors report a second case of anterior cervical MMC diagnosed when the patient began to experience symptoms of bilateral hand weakness in adulthood. In this patient, MR imaging of the cervical spine showed an anterior cervical MMC at the C6–7 level with hydrocephalus, thinning of the genu and trunk of the corpus callosum, maldevelopment of the cerebellar tonsils, and expansion of the fourth ventricle, posterior cranial fossa, and subarachnoid space. A CT scan and a 3D CT reconstruction of the cervical spine clearly demonstrated contiguous fusions of multiple lower-cervical vertebrae and neural arches, which was consistent with Type III Klippel-Feil syndrome. The patient was advised to undergo operative treatment to prevent the progression of her neurological deficit. However, after being notified of the potential neurological risks, the patient declined surgery and opted for conservative treatment with a hard neck collar. At 4 months' follow-up, the patient's neurological deficit remains stable with the MMC left untreated. The authors presume that the possible pathogenesis of anterior cervical MMC may greatly differ from that of posterior lesions. This lesion could also be associated with multiple other spinal abnormalities, which highlights the importance of comprehensive preoperative radiological examinations.

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Under-contouring of rods: a potential risk factor for proximal junctional kyphosis after posterior correction of Scheuermann kyphosis

Michael Grelat, Chang-Zhi Du, Liang Xu, Xu Sun, and Yong Qiu

OBJECTIVE

Scheuermann kyphosis (SK) could require surgical treatment in certain situations. A posterior reduction is the most widespread treatment so far, although the development of proximal junctional kyphosis (PJK) is one of the possible complications of this procedure. The contour of the proximal part of the rod could influence the occurrence of PJK in SK patients. The objective of this study was to analyze the impact of the proximal rod contour on the occurrence of a PJK complication in SK patients.

METHODS

This retrospective monocentric study was performed in the Nanjing Spine Surgery Department. All eligible patients had undergone posterior correction surgery with pedicle screws only between 2002 and 2017 and had at least 24 months of follow-up. The presence of PJK was quantified on radiographs using the proximal junctional angle (PJA > 10° at the last follow-up). The authors propose a new radiological parameter to measure the angulation of the proximal part of the instrumentation: the proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to the UIV. The patients were analyzed according to the presence or absence of PJK. A t-test, receiver operating characteristic (ROC) curve analysis, and logistic regression analysis were performed for statistical analysis.

RESULTS

Sixty-two patients treated for SK were included in this study. The mean age was 18.6 ± 8.5 years, and the mean follow-up was 42.5 ± 16.4 months. The mean correction rate of global kyphosis was 46.4% ± 13.7%. At the last follow-up, 17 patients (27.4%) presented with PJK. No significant difference was found between the PJK and non-PJK groups in terms of age and other preoperative variables. A significant difference in the postoperative PCRA was found between the PJK and non-PJK groups (8.2° ± 4.9° vs 15.7° ± 6.6°, respectively; p = 0.001). A postoperative PCRA less than 10.1° predicted a significantly higher risk for PJK (p = 0.002, OR 2.431, 95% CI 1.781–4.133).

CONCLUSIONS

Under-contouring of the proximal part of the rods (lower than 10°) is a risk factor for PJK after posterior correction of SK.

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Under-contouring of rods: a potential risk factor for proximal junctional kyphosis after posterior correction of Scheuermann kyphosis

Michael Grelat, Chang-Zhi Du, Liang Xu, Xu Sun, and Yong Qiu

OBJECTIVE

Scheuermann kyphosis (SK) could require surgical treatment in certain situations. A posterior reduction is the most widespread treatment so far, although the development of proximal junctional kyphosis (PJK) is one of the possible complications of this procedure. The contour of the proximal part of the rod could influence the occurrence of PJK in SK patients. The objective of this study was to analyze the impact of the proximal rod contour on the occurrence of a PJK complication in SK patients.

METHODS

This retrospective monocentric study was performed in the Nanjing Spine Surgery Department. All eligible patients had undergone posterior correction surgery with pedicle screws only between 2002 and 2017 and had at least 24 months of follow-up. The presence of PJK was quantified on radiographs using the proximal junctional angle (PJA > 10° at the last follow-up). The authors propose a new radiological parameter to measure the angulation of the proximal part of the instrumentation: the proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to the UIV. The patients were analyzed according to the presence or absence of PJK. A t-test, receiver operating characteristic (ROC) curve analysis, and logistic regression analysis were performed for statistical analysis.

RESULTS

Sixty-two patients treated for SK were included in this study. The mean age was 18.6 ± 8.5 years, and the mean follow-up was 42.5 ± 16.4 months. The mean correction rate of global kyphosis was 46.4% ± 13.7%. At the last follow-up, 17 patients (27.4%) presented with PJK. No significant difference was found between the PJK and non-PJK groups in terms of age and other preoperative variables. A significant difference in the postoperative PCRA was found between the PJK and non-PJK groups (8.2° ± 4.9° vs 15.7° ± 6.6°, respectively; p = 0.001). A postoperative PCRA less than 10.1° predicted a significantly higher risk for PJK (p = 0.002, OR 2.431, 95% CI 1.781–4.133).

CONCLUSIONS

Under-contouring of the proximal part of the rods (lower than 10°) is a risk factor for PJK after posterior correction of SK.

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Minimally invasive scoliosis surgery assisted by O-arm navigation for Lenke Type 5C adolescent idiopathic scoliosis: a comparison with standard open approach spinal instrumentation

Weiguo Zhu, Weixiang Sun, Leilei Xu, Xu Sun, Zhen Liu, Yong Qiu, and Zezhang Zhu

OBJECTIVE

Recently, minimally invasive scoliosis surgery (MISS) was introduced for the correction of adult scoliosis. Multiple benefits including a good deformity correction rate and fewer complications have been demonstrated. However, few studies have reported on the use of MISS for the management of adolescent idiopathic scoliosis (AIS). The purpose of this study was to investigate the outcome of posterior MISS assisted by O-arm navigation for the correction of Lenke Type 5C AIS.

METHODS

The authors searched a database for all patients with AIS who had been treated with either MISS or PSF between November 2012 and January 2014. Levels of fusion, density of implants, operation time, and estimated blood loss (EBL) were recorded. Coronal and sagittal parameters were evaluated before surgery, immediately after surgery, and at the last follow-up. The accuracy of pedicle screw placement was assessed according to postoperative axial CT images in both groups. The 22-item Scoliosis Research Society questionnaire (SRS-22) results and complications were collected during follow-up.

RESULTS

The authors retrospectively reviewed the records of 45 patients with Lenke Type 5C AIS, 15 who underwent posterior MISS under O-arm navigation and 30 who underwent posterior spinal fusion (PSF). The 2 treatment groups were matched in terms of baseline characteristics. Comparison of radiographic parameters revealed no obvious difference between the 2 groups immediately after surgery or at the final follow-up; however, the MISS patients had significantly less EBL (p < 0.001) and longer operation times (p = 0.002). The evaluation of pain and self-image using the SRS-22 showed significantly higher scores in the MISS group (p = 0.013 and 0.046, respectively) than in the PSF group. Postoperative CT showed high accuracy in pedicle placement in both groups. No deep wound infection, pseudarthrosis, additional surgery, implant failure, or neurological complications were recorded in either group.

CONCLUSIONS

Minimally invasive scoliosis surgery is an effective and safe alternative to open surgery for patients with Lenke Type 5C AIS. Compared with results of the open approach, the outcomes of MISS are promising, with reduced morbidity. Before the routine use of MISS, however, long-term data are needed.

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Effect of higher implant density on curve correction in dystrophic thoracic scoliosis secondary to neurofibromatosis Type 1

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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Influence of lumbar sagittal profile on pelvic orientation and pelvic motion during postural changes in patients with ankylosing spondylitis–related thoracolumbar kyphosis following pedicle subtraction osteotomy

Yao Li, Bang-ping Qian, Yong Qiu, Shi-zhou Zhao, Xiao-lin Zhong, and Bin Wang

OBJECTIVE

The objective of this study was to investigate the impact of the lumbar sagittal profile on pelvic orientation and pelvic motion during postural changes in patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis and to evaluate the potential risk of prosthetic dislocation after total hip arthroplasty (THA) following pedicle subtraction osteotomy (PSO).

METHODS

Seventy-two patients with AS-related thoracolumbar kyphosis following spinal osteotomy were retrospectively reviewed, and 21 healthy volunteers were recruited as a control group. Pre- and postoperative 2D full-body images in standing and sitting positions were obtained to evaluate the anterior pelvic plane angle (APPA), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), proximal femur angle (PFA), and femoroacetabular flexion during postural changes. Patients with AS were categorized in either a lordotic or kyphotic group based on the lumbar sagittal profile.

RESULTS

Significant increases in the SS and decreases in the APPA, PT, and LL were observed postoperatively in both the standing and sitting positions (p < 0.001 for all). Significantly higher APPA, PT, LL, and ΔPT, and lower SS, ΔSS, and ΔSS+ΔPFA were observed in the kyphotic group (p < 0.05). After undergoing PSO, ΔPT and ΔSS significantly decreased while femoroacetabular flexion significantly increased in both AS groups (p < 0.05), and no significant difference was present between the two groups (p > 0.05). Bath Ankylosing Spondylitis Radiology Hip Index scores in the kyphotic group were significantly worse than those in the lordotic group pre- and postoperatively (p < 0.05). No significant difference in parameters concerning pelvic motion (ΔAPPA, ΔPT, and ΔSS) was found when PSO was performed in the thoracolumbar or lumbar spine.

CONCLUSIONS

Lumbar sagittal profiles greatly affect pelvic orientation and pelvic motion in AS. When THA is performed before PSO, AS patients with lumbar kyphosis are at higher risk of anterior prosthetic dislocation, while those with lordotic lumbar sagittal profiles are at higher risk of posterior dislocation. PSO should be performed prior to THA. After PSO, further decreased pelvic motion indicated a potential risk of posterior prosthetic dislocation after sequential THA, whereas theoretically patients with preoperative lumbar kyphosis are at higher risk of THA dislocation. The site where PSO was performed (thoracolumbar or lumbar spine) does not influence the risk of THA dislocation.

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Assessing the unique characteristics associated with surgical treatment of dystrophic lumbar scoliosis secondary to neurofibromatosis type 1: a single-center experience of more than 10 years

Song Li, Saihu Mao, Changzhi Du, Zezhang Zhu, Benlong Shi, Zhen Liu, Jun Qiao, and Yong Qiu

OBJECTIVE

Dystrophic lumbar scoliosis secondary to neurofibromatosis type 1 (DLS-NF1) may present an atypical, unique curve pattern associated with a high incidence of coronal imbalance and regional kyphosis. Early surgical intervention is complicated and risky but necessary. The present study aimed to assess the unique characteristics associated with the surgical treatment of DLS-NF1.

METHODS

Thirty-nine consecutive patients with DLS-NF1 treated surgically at a mean age of 14.4 ± 3.9 years were retrospectively reviewed. Patients were stratified into three types according to the coronal balance classification: type A (C7 translation < 30 mm), 22 patients; type B (concave C7 translation ≥ 30 mm), 0 patients; and type C (convex C7 translation ≥ 30 mm), 17 patients. Types B and C were considered to be coronal imbalance. The diversity of surgical strategies, the outcomes, and the related complications were analyzed.

RESULTS

The posterior-only approach accounted for 79.5% in total; the remaining 20.5% of patients received either additional anterior supplemental bone grafting (12.8%) to strengthen the fixation or convex growth arrest (7.7%) to reduce growth asymmetry. The lower instrumented vertebra (LIV) being L5 accounted for the largest share (41%), followed by L4 and above (35.9%), the sacrum (15.4%), and the pelvis (7.7%). Type C coronal imbalance was found in 23 patients (59%) postoperatively, and the incidence was significantly higher in the preoperative type C group (14/17 type C vs 9/22 type A, p = 0.020). All the patients with postoperative coronal imbalance showed ameliorative transition to type A at the last visit. The rate of screw malposition was 30.5%, including 9.9% breached medially and 20.6% breached laterally, although no serious neurological impairment occurred. The incidence of rod breakage was 16.1% (5/31) and 0% in patients with the posterior-only and combined approaches, respectively. Four revisions with satellite rods and 1 revision with removal of iliac screw for penetration into the hip joint were performed.

CONCLUSIONS

Surgical strategies for DLS-NF1 were diverse across a range of arthrodesis and surgical approaches, being crucially determined by the location and the severity of dystrophic changes. The LIV being L5 or lower involving the lumbosacral region and pelvis was not rare. Additional posterior satellite rods or supplementary anterior fusion is necessary in cases with insufficient apical screw density. Despite a high incidence of postoperative coronal imbalance, improvement of coronal balance was frequently confirmed during follow-up. Neurological impairment was scarce despite the higher rate of screw malposition.

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Sequential correction technique in degenerative scoliosis with type C coronal imbalance: a comparison with traditional 2-rod technique

Benlong Shi, Dun Liu, Zezhang Zhu, Yu Wang, Yang Li, Zhen Liu, Xu Sun, and Yong Qiu

OBJECTIVE

The aim of this study was to compare the radiographic and clinical outcomes in patients with degenerative scoliosis (DS) with type C coronal imbalance who underwent either a sequential correction technique or a traditional 2-rod technique with a minimum of 2 years of follow-up.

METHODS

DS patients with type C coronal imbalance undergoing posterior correction surgery from February 2014 to January 2018 were divided into groups by technique: the sequential correction technique (SC group) and the traditional 2-rod technique (TT group). Radiographic parameters, including Cobb angle, coronal balance distance (CBD), global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope, were assessed pre- and postoperatively. The SF-36 questionnaire was used to assess quality of life.

RESULTS

A total of 34 patients were included. Significant postoperative improvement in the Cobb angle of the main curve, CBD, GK, TK, LL, SVA, and PT was found in both groups (p < 0.05). Postoperatively, the coronal balance was type A in 13 patients (92.9%) in the SC group and in 16 patients (80.0%) in the TT group (p = 0.298). In the TT group, 1 patient had deteriorative coronal imbalance immediately postoperatively, and coronal imbalance deteriorated from type A to type C in 2 patients during follow-up. The scores of Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health were statistically improved postoperatively (p < 0.05) in both groups. Type C coronal imbalance at the last follow-up was associated with a relatively worse quality of life. There were no implant failures during follow-up in the SC group, whereas rod fracture was observed in 3 patients in the TT group.

CONCLUSIONS

Compared with the traditional 2-rod technique, the sequential correction technique can simplify rod installation procedure, enhance internal instrumentation, and reduce risk of implant failures. The sequential correction technique could be routinely recommended for DS patients with type C coronal imbalance.

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Similar surgical outcomes of the growing rod technique for treatment of early-onset scoliosis with versus without untreated intraspinal anomalies

Hongru Ma, Benlong Shi, Yang Li, Dun Liu, Zhen Liu, Xu Sun, Yong Qiu, and Zezhang Zhu

OBJECTIVE

The aim of this study was to compare the radiological and clinical outcomes of early-onset scoliosis (EOS) patients with or without intraspinal anomalies (IAs) managed with growing rods (GRs), and to evaluate the safety of the GR technique in EOS patients with untreated IAs.

METHODS

EOS patients undergoing GR placement between August 2008 and July 2017 were retrospectively reviewed. Patients with untreated IAs were classified into the EOS+IA group, and those without IAs into the EOS−IA group. The radiographic parameters including Cobb angle of the major curve, T1–S1 height, and apical vertebral translation were measured, and a detailed assessment of the neurological status was performed at each visit.

RESULTS

Seventy-six patients with EOS (32 boys, 44 girls) with an average age of 6.5 ± 2.3 years at initial surgery satisfied the inclusion and exclusion criteria, including 28 patients in the EOS+IA group and 48 patients in the EOS−IA group. The radiographic measurements were comparable between groups preoperatively, postoperatively, and at the latest follow-up. One patient in the EOS+IA group experienced sensory deficit in a unilateral lower extremity after initial surgery, and an intraoperative neurophysiological monitoring event was observed in a patient in the EOS−IA group. No permanent neurological deficit was observed in either group.

CONCLUSIONS

EOS patients with and those without IAs had comparable clinical and radiological outcomes of the GR technique. Repeated lengthening procedures may be safe for EOS patients with untreated IAs.

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Sequential correction using satellite rod for severe thoracic idiopathic scoliosis: an effective method to optimize deformity correction

Yang Li, Benlong Shi, Dun Liu, Zhen Liu, Xu Sun, Yong Qiu, and Zezhang Zhu

OBJECTIVE

The aim of this paper was to compare the radiographic and clinical outcomes between the sequential correction (SC) technique and the traditional 2-rod correction (TC) technique in patients with severe thoracic idiopathic scoliosis (STIS) undergoing posterior-only correction surgery.

METHODS

Records of a consecutive series of STIS patients undergoing posterior-only correction surgery between October 2013 and October 2017 with more than 2 years of follow-up were reviewed. The radiographic parameters were assessed preoperatively, postoperatively, and at the last follow-up. Radiographic parameters, operative time, blood loss, and complications were compared between the two groups.

RESULTS

A total of 33 patients were included in the SC group, and 21 patients were included in the TC group. There was no significant difference in age, sex, or deformity magnitude (93.6° ± 7.8° vs 89.8° ± 6.6°, p = 0.070) preoperatively between groups. The operation time was shorter in the SC group than in the TC group (251.5 ± 42.8 minutes vs 275.4 ± 39.8 minutes, p = 0.020), while both blood loss (1284.6 ± 483.3 vs 1398.0 ± 558.4 ml, p = 0.432) and number of fused levels (13.1 ± 2.8 vs 13.6 ± 2.4, p = 0.503) were similar between the groups. Compared with the TC group, patients in the SC group had a higher correction rate (55.8% ± 9.2% vs 45.7% ± 8.8%, p < 0.001), less coronal (1.1° ± 0.81° vs 2.9° ± 0.93°, p < 0.001) and sagittal (1.5° ± 0.96° vs 2.1° ± 0.64°, p = 0.015) correction loss at the 2-year follow-up, and a lower incidence of intraoperative pedicle screw pullout (14.3% vs 23.8%, p = 0.026).

CONCLUSIONS

The SC technique could significantly and practically reduce the difficulty of rod installation with better deformity correction outcomes than the traditional TC technique. The SC technique was an effective alternative for patients with STIS.