Center of rotation analysis for thoracic and lumbar 3-column osteotomies in patients with sagittal plane spinal deformity: insights in geometrical changes can improve understanding of correction mechanics

View More View Less
  • 1 Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany;
  • | 2 Department for Spine Surgery, Schulthess Clinic Zurich, Switzerland;
  • | 3 Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland;
  • | 4 Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Germany;
  • | 5 Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
  • | 6 Research Office (biostatistics), Paracelsus Medical University Salzburg, Austria; and
  • | 7 Spine Center, Werner-Wicker Clinic, Bad Wildungen, Germany
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

Three-column osteotomy (3CO) is used for severe spinal deformities. Associated complications include sagittal translation (ST), which can lead to neurological symptoms. Mismatch between the surgical center of rotation (COR) and the concept of the ideal COR is a potential cause of ST. Matching surgical with conceptual COR is difficult with pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR). This mismatch influences correction geometry, which can prevent maximum possible correction. The authors’ objective was to examine the sagittal correction geometry and surgical COR of thoracic and lumbar 3CO.

METHODS

In a retrospective study of patients with PSO or VCR for severe sagittal plane deformity, analysis of surgical COR was performed using pre- and postoperative CT scans in the PSO group and digital radiographs in the VCR group. Radiographic analysis included standard deformity measurements and regional kyphosis angle (RKA). All patients had 2-year follow-up, including neurological outcome. Preoperative CT scans were studied for rigid osteotomy sites versus mobile osteotomy sites. Additional radiographic analysis of surgical COR was based on established techniques superimposing pre- and postoperative images. Position of the COR was defined in a rectangular net layered onto the osteotomy vertebrae (OVs).

RESULTS

The study included 34 patients undergoing PSO and 35 undergoing VCR, with mean ages of 57 and 29 years and mean RKA corrections of 31° and 49°, respectively. In the PSO group, COR was mainly in the anterior column, and surgical and conceptual COR matched in 22 patients (65%). Smaller RKA correction (27° vs 32°, p = 0.09) was seen in patients with anterior eccentric COR. Patients with rigid osteotomy sites were more likely to have an anterior eccentric COR (41% vs 11%, p = 0.05). In the VCR group, 20 patients (57%) had single-level VCR and 15 (43%) had multilevel VCR. COR was mainly located in the anterior or middle column. Mismatch between surgical and conceptual COR occurred in 24 (69%) patients. Larger RKA correction (63° vs 45°, p = 0.03) was seen in patients with anterior column COR. Patients with any posterior COR had a smaller RKA correction compared to the rest of the patients (42° vs 61°, p = 0.007).

CONCLUSIONS

Matching the surgical with the conceptual COR is difficult and in this study failed in one- to two-thirds of all patients. In order to avoid ST during correction of severe deformities, temporary rods, tracking rods, or special instruments should be used for correction maneuvers.

ABBREVIATIONS

3CO = three-column osteotomy; COR = center of rotation; COWO = closing-opening wedge osteotomy; CWO = closing wedge osteotomy; LIV = lower instrumented vertebra; LL = lumbar lordosis; OV = osteotomy vertebra; OWO = opening wedge osteotomy; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; RKA = regional kyphosis angle; SS = sacral slope; ST = sagittal translation; SVA = sagittal vertical axis; TK = thoracic kyphosis; TLIF = transforaminal lumbar interbody fusion; UIV = upper instrumented vertebra; VCR = vertebral column resection.

Supplementary Materials

    • Figs. E1–E11 (PDF 16,842 KB)

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Koller H, Meier O, Zenner J, et al. Non-instrumented correction of cervicothoracic kyphosis in ankylosing spondylitis: a critical analysis on the results of open-wedge osteotomy C7-T1 with gradual Halo-Thoracic-Cast based correction. Eur Spine J. 2013;22(4):819832.

    • Search Google Scholar
    • Export Citation
  • 2

    McMaster MJ. Osteotomy of the cervical spine in ankylosing spondylitis. J Bone Joint Surg Br. 1997;79(2):197203.

  • 3

    Lenke LG, O’Leary PT, Bridwell KH, et al. Posterior vertebral column resection for severe pediatric deformity: minimum two-year follow-up of thirty-five consecutive patients. Spine (Phila Pa 1976).2009;34(20):22132221.

    • Search Google Scholar
    • Export Citation
  • 4

    Buchowski JM, Bridwell KH, Lenke LG, et al. Neurologic complications of lumbar pedicle subtraction osteotomy: a 10-year assessment. Spine (Phila Pa 1976).2007;32(20):22452252.

    • Search Google Scholar
    • Export Citation
  • 5

    Park JH, Hyun SJ, Kim KJ, Jahng TA. Comparative study between pedicle subtraction osteotomy (PSO) and closing-opening wedge osteotomy (fish-mouth PSO) for sagittal plane deformity correction. Spine (Phila Pa 1976).2017;42(15):E899E905.

    • Search Google Scholar
    • Export Citation
  • 6

    Qian BP, Mao SH, Jiang J, et al. Mechanisms, predisposing factors, and prognosis of intraoperative vertebral subluxation during pedicle subtraction osteotomy in surgical correction of thoracolumbar kyphosis secondary to ankylosing spondylitis. Spine. 2017;42(16):E983E990.

    • Search Google Scholar
    • Export Citation
  • 7

    Qiao J, Xiao L, Sun X, et al. Vertebral subluxation during three-column osteotomy in surgical correction of adult spine deformity: incidence, risk factors, and complications. Eur Spine J. 2018;27(3):630635.

    • Search Google Scholar
    • Export Citation
  • 8

    Li XS, Huang ZF, Deng YL, et al. Computed tomography based three-dimensional measurements of spine shortening distance after posterior three-column osteotomies for the treatment of severe and stiff scoliosis. Spine (Phila Pa 1976).2017;42(14):10501057.

    • Search Google Scholar
    • Export Citation
  • 9

    Hwang CJ, Lenke LG, Sides BA, et al. Comparison of single-level versus multilevel vertebral column resection surgery for pediatric patients with severe spinal deformities. Spine (Phila Pa 1976).2019;44(11):E664E670.

    • Search Google Scholar
    • Export Citation
  • 10

    Bianco K, Norton R, Schwab F, et al. Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus. 2014;36(5):E18.

    • Search Google Scholar
    • Export Citation
  • 11

    Khashan M, Raad M, El Dafrawy MH, et al. Postoperative changes in neurological function after 3-column osteotomy: risk factor analysis of 199 patients. J Neurosur Spine. 2019;30(5):568573.

    • Search Google Scholar
    • Export Citation
  • 12

    Yang C, Zheng Z, Liu H, et al. Posterior vertebral column resection in spinal deformity: a systematic review. Eur Spine J. 2016;25(8):23682375.

    • Search Google Scholar
    • Export Citation
  • 13

    Wang S, Yang Y, Zhang J, et al. Frequent neuromonitoring loss during the completion of vertebral column resections in severe spinal deformity surgery. Spine J. 2017;17(1):7680.

    • Search Google Scholar
    • Export Citation
  • 14

    Zhang BB, Zhang T, Tao HR, et al. Neurological complications of thoracic posterior vertebral column resection for severe congenital spinal deformities. Eur Spine J. 2017;26(7):18711877.

    • Search Google Scholar
    • Export Citation
  • 15

    Li X, Huang Z, Deng Y, et al. Three-dimensional translations following posterior three-column spinal osteotomies for the correction of severe and stiff kyphoscoliosis. Spine J. 2017;17(12):18031811.

    • Search Google Scholar
    • Export Citation
  • 16

    Koller H, Koller J, Mayer M, et al. Osteotomies in ankylosing spondylitis: where, how many, and how much?. Eur Spine J. 2018;27(1)(suppl 1):70100.

    • Search Google Scholar
    • Export Citation
  • 17

    Penning L. Differences in anatomy, motion, development and aging of the upper and lower cervical disk segments. Clin Biomech (Bristol,Avon). 1988;3(1):3747.

    • Search Google Scholar
    • Export Citation
  • 18

    Enercan M, Ozturk C, Kahraman S, et al. Osteotomies/spinal column resections in adult deformity. Eur Spine J. 2013;22(suppl 2):S254S264.

  • 19

    Bogduk N, Mercer S. Biomechanics of the cervical spine. I: Normal kinematics. Clin Biomech (Bristol, Avon). 2000;15(9):633648.

  • 20

    Kawahara N, Tomita K, Baba H, et al. Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine (Phila Pa 1976).2001;26(4):391402.

    • Search Google Scholar
    • Export Citation
  • 21

    Sebastian AS, Ahmed A, Vernon B, et al. Effect of an adjustable hinged operating table on lumbar lordosis during lumbar surgery. Spine (Phila Pa 1976).2018;43(4):302306.

    • Search Google Scholar
    • Export Citation
  • 22

    Xie J, Wang Y, Zhao Z, et al. Posterior vertebral column resection for correction of rigid spinal deformity curves greater than 100°. J Neurosurg Spine. 2012;17(6):540551.

    • Search Google Scholar
    • Export Citation
  • 23

    Iyer RR, Elder BD, Garzon-Muvdi T, et al. Use of an articulating hinge to facilitate cervicothoracic deformity correction during vertebral column resection. Oper Neurosurg (Hagerstown). 2018;15(3):278284.

    • Search Google Scholar
    • Export Citation
  • 24

    Van Royen BJ, De Gast A, Smit TH. Deformity planning for sagittal plane corrective osteotomies of the spine in ankylosing spondylitis. Eur Spine J. 2000;9(6):492498.

    • Search Google Scholar
    • Export Citation
  • 25

    Camargo FP, Cordeiro EN, Napoli MM. Corrective osteotomy of the spine in ankylosing spondylitis. Experience with 66 cases. Clin Orthop Relat Res. 1986;(208):157167.

    • Search Google Scholar
    • Export Citation
  • 26

    Qian BP, Wang XH, Qiu Y, et al. The influence of closing-opening wedge osteotomy on sagittal balance in thoracolumbar kyphosis secondary to ankylosing spondylitis: a comparison with closing wedge osteotomy. Spine (Phila Pa 1976).2012;37(16):14151423.

    • Search Google Scholar
    • Export Citation
  • 27

    Lafage V, Schwab F, Vira S, et al. Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction?. J Neurosurg Spine. 2011;14(2):184191.

    • Search Google Scholar
    • Export Citation
  • 28

    Diebo BG, Lafage R, Ames CP, et al. Ratio of lumbar 3-column osteotomy closure: patient-specific deformity characteristics and level of resection impact correction of truncal versus pelvic compensation. Eur Spine J. 2016;25(8):24802487.

    • Search Google Scholar
    • Export Citation
  • 29

    Koller H, Hitzl W, Meier O, Mayer M. The center of rotation (COR) of cervical 3-column osteotomies (3-CO) for correction of cervical kyphosis. Paper presented at: 32nd Annual Meeting of the Cervical Spine Research Society; May 11–13, 2016;Prague, Czech Republic.

    • Search Google Scholar
    • Export Citation
  • 30

    Belanger TA, Milam RA IV, Roh JS, Bohlman HH. Cervicothoracic extension osteotomy for chin-on-chest deformity in ankylosing spondylitis. J Bone Joint Surg Am. 2005;87(8):17321738.

    • Search Google Scholar
    • Export Citation
  • 31

    Wollowick AL, Kelly MP, Riew KD. Pedicle subtraction osteotomy in the cervical spine. Spine (Phila Pa 1976).2012;37(5):E342E348.

  • 32

    Mehdian S, Arun R. A safe controlled instrumented reduction technique for cervical osteotomy in ankylosing spondylitis. Spine (Phila Pa 1976).2011;36(9):715720.

    • Search Google Scholar
    • Export Citation
  • 33

    Khoueir P, Hoh DJ, Wang MY. Use of hinged rods for controlled osteoclastic correction of a fixed cervical kyphotic deformity in ankylosing spondylitis. J Neurosurg Spine. 2008;8(6):579583.

    • Search Google Scholar
    • Export Citation
  • 34

    Zheng GQ, Song K, Zhang YG, et al. Two-level spinal osteotomy for severe thoracolumbar kyphosis in ankylosing spondylitis. Experience with 48 patients. Spine (Phila Pa 1976).2014;39(13):10551058.

    • Search Google Scholar
    • Export Citation
  • 35

    Chang KW, Chen HC, Chen YY, et al. Sagittal translation in opening wedge osteotomy for the correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. Spine (Phila Pa 1976).2006;31(10):11371142.

    • Search Google Scholar
    • Export Citation
  • 36

    Wang Y, Zhang Y, Mao K, et al. Transpedicular bivertebrae wedge osteotomy and discectomy in lumbar spine for severe ankylosing spondylitis. J Spinal Disord Tech. 2010;23(3):186191.

    • Search Google Scholar
    • Export Citation
  • 37

    Chin KR, Ahn J. Controlled cervical extension osteotomy for ankylosing spondylitis utilizing the Jackson operating table: technical note. Spine (Phila Pa 1976).2007;32(17):19261929.

    • Search Google Scholar
    • Export Citation
  • 38

    Xie J, Wang Y, Zhang Y. Posterior vertebral column resection of severe rigid spinal deformity. Paper presented at: 45th Annual Meeting of the Scoliosis Research Society; September 21–24, 2010;Kyoto, Japan.

    • Search Google Scholar
    • Export Citation
  • 39

    Elnady B, Shawky Abdelgawaad A, El-Meshtawy M. Anterior instrumentation through posterior approach in neglected congenital kyphosis: a novel technique and case series. Eur Spine J. 2019;28(8):17671774.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 216 216 60
Full Text Views 43 43 5
PDF Downloads 75 75 13
EPUB Downloads 0 0 0