SRS-Schwab Grade IV Osteotomy In The Treatment Of Kyphosis Deformity And Surgical Treatment Of Congenital Scoliosis With Spinal Cord Abnormalities

Chapter 1 SRS-Schwab grade IV osteotomy for the treatment of post-traumatic thoracolumbar kyphosisObjective: To evaluate the effectiveness of Grade IV osteotomy in the treatment of post-traumatic thoracolumbar kyphosis(PTK).Methods: From October 2012 to January 2015,a total of 31 patients(12 males,19 females;mean age,42.8±10.1 years)with symptomatic PTK undergoing SRSSchwab grade IV osteotomy were retrospectively reviewed.Radiographic changes were evaluated preoperative,postoperative and follow-up X-ray.The measurements included thoracic kyphosis(TK),lumbar lordosis(LL),focal kyphosis,pelvic incidence(PI),pelvic tilt(PT),sacral slope(SS)and sagittal vertical axis(SVA).Clinical outcome was assessed using the visual analogue scale(VAS),the Oswestry disability index(ODI)and Frankel neurological grade before surgery and during follow-up.Results: All cases were followed-up for a mean of 28.4±5.1 months(range,24-38 months).The TK and LL improved significantly postoperatively from 15.6±7.8°and 67.3±12.2°to 28.1±6.2°(P<0.001)and 48.1±9.3(P<0.001)postoperatively and maintained at 27.3±6.9°and 49.4±7.9°at last follow-up,respectively.The FK improved significantly postoperatively from 36.4±9.5°to 5.6±4.2°(P<0.001),with a mean of 2.3±2.2° correction loss at final follow-up.The correction rate of FK were 84.6%,and with a mean of 49.4±7.9°at last follow-up.No significant difference was observed in terms of the PI,PT,SS and SVA among the preoperative,post-operative and the last follow-up(P>0.05).In addition,the VAS and ODI improved significantly at the final follow-up(P<0.01).Four cases with Frankel D experienced complete neurological recovery at the final follow-up.Radiographic evaluation showed solid bony fusion.No instrument-related complication was observed during the follow up.Conclusions: The SRS-Schwab grade IV osteotomy achieves satisfactory sagittal alignment and good clinical outcomes in patients with PTK.Chapter 2 SRS-Schwab Grade 4 Osteotomy for Congenital Thoracolumbar KyphosisObjective: To evaluate the efficiency and safety of SRS-Schwab Grade 4 osteotomy in CK patients,and to propose its optimal indication.Methods: Thoracolumbar CK patients undergoing SRS-Schwab Grade 4 osteotomy from January 2010 to May 2015 followed up at least 2 years were retrospectively reviewed.On lateral spinal x-rays at pre-operation,post-operation and last follow-up,the thoracic kyphosis(TK),lumbar lordosis(LL),segmental kyphosis(SK)and sagittal vertical axis(SVA)were measured.The comparison between pre-operation and post-operation was performed by paired samples t test.Results: A total of 38 CK patients(17M and 21F)with an average age of 16.5±9.9 years were included.The mean operating time was 242.7±88.1 min and blood loss was 634.5±177.8 ml.The mean follow-up was 38.8±20.3 months.The SK was 49.5±11.7° at pre-operation,6.8±7.4° at post-operation(P<0.001)and 8.0±8.1° at the last follow-up.No significant correction loss during follow-up was found in SK(P=0.125).The SVA was improved from-36.0±18.3 mm at pre-operation to 3.7±17.8 mm at post-operation(P<0.001),and the correction was well maintained during follow-up(P=0.113).Intra-operative complications included one case with incidental dural tear and another with transient root injury.Proximal junctional kyphosis occurred in 3 patients at 6 month post-operation and remained stable during the follow-up.At the last follow-up,all patients were identified to have achieved solid bony fusion.Conclusion: The SRS-Schwab Grade 4 osteotomy,if selected appropriately,could provide satisfying correction of congenital kyphosis.The correction could be well maintained during the longitudinal follow-up.Chapter 3 Do untreated intraspinal anomalies in congenial scoliosis impact the safety and efficacy of corrective surgery?Objective.To investigate the safety and efficacy of spinal correction surgery forcongenital scoliosis(CS)associated with untreated intraspinal anomalies(split cord malformation and/or tethered cord)with intact or stable neurological status.Methods.This retrospective study was performed with the following inclusion criteria:(1)age 10 to 20 years;(2)Cobb angle of main curve being 40° to 90°;(3)undergoing single posterior spinal correction surgery;(4)with pre-operative magnetic resonance imaging(MRI)of whole spine showing intraspinal anomalies including SCM and/or tethered cord;(5)with intact or stable neurological status over the preceding 2 years;and(6)with a minimum of 2 years post-operative follow-up.Patients with previous spinal surgery,neurosurgical intervention for intraspinal anomalies,progressive neurological deficits,chiari malformation,intraspinal tumors or indication for vertebral column resection(VCR)surgery were excluded.The patients were divided into two groups: a group of CS patients with intraspinal anomalies(CS+IA)and a group of CS patients without intraspinal anomalies(CS-IA).The surgical results and complications of correction were compared between the two groups.Results.The CS+IA group included 57 patients,and the CS-IA group included 184 patients.For the CS+IA and CS-IA groups,the mean ages at the time of surgery were 14.1±2.8 years(range,10 to 20 years)and 14.3±2.5 years(range,10 to 20 years),and the mean follow-up times were 30.6±7.9 months(range,24 to 48 months)and 29.2±10.5 months(range,24 to 72 months),respectively.No significant differences were observed in the age,gender,curve pattern,major curve magnitude and flexibility of the major curve between the CS+IA group and the CS-IA group(P>0.05).The postoperative correction rates of the major curve were comparable between the two groups(53.5% vs.55.7%,respectively).Corrections of other radiographic parameters including coronal and sagittal plane balance were similar in both groups(P>0.05).Additionally,no significant difference was observed in the incidence of either implant-related or neurological complications between the groups.No patients in the CS+IA group developed neurological complications from the postoperative period until the latest follow-up,but one patient in the CS-IA group experienced transient weakness of the left lower extremity after surgery.Conclusions.Coexisting intraspinal anomalies(SCM and/or tethered cord)in CS patients with normal or stable neurological status do not increase the risk of neurological complications of corrective scoliosis surgery or influence the long-term surgical results.Prophylactic neurosurgical intervention for intraspinal anomalies before scoliosis correction might be unnecessary for these patients.