Apical segmental resection osteotomy with dual axial rotation corrective technique for severe focal kyphosis of the thoracolumbar spine

Clinical article

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Object

In this paper, the authors' goal was to evaluate the feasibility, safety, and efficacy of apical segment resection osteotomy with dual axial rotation correction for severe focal kyphosis by examining outcomes.

Methods

Between May 2004 and December 2006, the authors treated 23 patients with severe focal kyphosis (average Cobb angle 86.9°, range 50°–130°) using apical segmental resection osteotomy with dual axial rotation correction and instrumented anterior column reconstruction and fusion. Radiographic assessment of sagittal plane balance and kyphotic Cobb angle (including a scoliosis Cobb angle in 9 cases) was performed in each patient before and immediately after surgery and at the last follow-up (minimum 2 years). The Frankel grading system for neurological function and Oswestry Disability Index for quality of life were evaluated before surgery and at the last follow-up. The patient satisfaction index was also used for clinical evaluation at the last follow-up.

Results

The mean surgical time was 6.7 hours. The average blood loss was 2960 ml. All patients underwent follow-up for 2 or more years after surgery. The fusion rate was 95.65%. The average kyphotic angle improved from 86.9° preoperatively to 25.6° immediately postoperatively, with an average correction rate of 72.17%. At the last follow-up, the average kyphotic angle was 27.4°, making the final correction rate 69.87%. The sagittal plane balance was significantly improved at the last follow-up. Preoperatively, 15 patients had neurological deficits, and the Frankel grade was E in 8 cases, D in 8 cases, C in 6 cases, and B in 1 case. At the last follow-up, 15 cases were Grade E, 5 were Grade D, and 3 were Grade C. The average improvement in the Oswestry Disability Index score was 43.30%. The patient satisfaction index result showed a total satisfaction rate of 91.30%. Complications included 1 case of late neurological deficit due to shifting of an expandable artificial vertebra, 5 cases of nerve root injury, 3 cases of dural tear, and 1 case of transient lower-extremity weakness due to insufficient blood supply to the spinal cord during surgery.

Conclusions

Apical segmental resection osteotomy with dual axial rotation correction and instrumented fusion is an effective and safe way to treat severe focal kyphosis of the thoracolumbar spine.

Abbreviations used in this paper: AP = anteroposterior; SSEP = somatosensory evoked potential.

Article Information

Address correspondence to: Zhongqiang Chen, M.D., Orthopaedic Department, Peking University 3rd Hospital, No 49, North Garden Street, HaiDian District, Beijing, China, 100191. email: chenzq5803@gmail.com.

Please include this information when citing this paper: published online December 10, 2010; DOI: 10.3171/2010.9.SPINE10257.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photographs. A: The pedicle screw has been inserted, and temporary fixation is performed. B: Resection of the apical segment is finished. C: Dual axial rotation correction is achieved.

  • View in gallery

    Illustrations. A: The resection area of the posterior osteotomy. B: The resection area after apical segment resection osteotomy. C: The distractor is used to distract the space between the osteotomies, and fixation instruments and a rod presser are used to make correction of kyphosis, that is, dual axial rotation correction. The blue dots indicate the rotating axis of the osteotomies. D: The kyphosis is corrected and the anterior space is distracted. E: Titanium mesh packed with minced autograft bone is placed in the anterior space created by the resection osteotomy and distraction. Autograft bone is also implanted around the mesh.

  • View in gallery

    Images obtained in a 17-year-old girl with tuberculous kyphosis of T10–L1. A: The kyphotic angle was 130° before surgery. B: Posterior segmental resection osteotomy with T6–L4 instrumentation and fusion. The Cobb angle improved to 37°. C: The correction was maintained 28 months after surgery. D: Complete fusion is seen on CT scanning 28 months after surgery. E: Preoperative photograph of the patient, showing severe kyphosis. F: Postoperative photograph showing cosmetic improvement.

  • View in gallery

    Images obtained in an 18-year-old girl with old tuberculous kyphosis of T11–12. A: Lateral (right) and AP (left) radiographs showing a kyphotic angle of 90°, and a lateral dislocation of the thoracolumbar segment before surgery. B: A CT scan showing the dislocation in the thoracolumbar segment. C: Lateral (right) and AP (left) radiographs obtained after posterior segmental resection osteotomy, T8–L4 instrumentation, with a kyphotic angle of 30°, and a full reduction in the coronal plane. D: Lateral (right) and AP (left) radiographs obtained 48 months after surgery. The correction is well preserved, and the coronal and sagittal plane balance is favorable. E: A CT scan obtained 48 months after surgery showing that the bone graft is well integrated. F: Preoperative photograph showing severe focal kyphosis in the thoracolumbar segment. G: Postoperative photograph showing cosmetic improvement.

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