Three-column Osteotomy For The Safety And Efficacy Of Scoliosis With Spinal Deformity

BackgroundWith the development of spinal surgery techniques,spinal osteotomy has become a widely used surgical treatment of congenital scoliosis,severe and rigid scoliosis,ankylosing spondylitis and many other diseases.Three-column osteotomy is developed on the basis of the traditional posterior column osteotomy.This operation involves the anterior,middle and posterior column of spine,which can achieve higher correction rate,including vertebrate columun resection,hemivertebra resection,sandwich osteotomy,pedicle subtraction osteotomy,etc.On the other hand,patients with scoliosis are frequently associated with intraspinal anomalies including split spinal cord malformation,tethered spinal cord syndrome and syringomyelia.The treatment of scoliosis with coexisting intraspinal anomalies is a challenge for spine surgeons.Traditional strategy is taking a neurosurgical intervention for intraspinal anomalies before corrective surgery.As the the pathology of intraspinal anomalies has become better understood and the development of techniques,we tried to use three-column osteotomy to treat these patients without neurosurgical intervention.However,is it safe to leave intraspinal anomalies untreated while having a three-column osteotomy?This retrospective clinical study is trying to answer this question.Part Ⅰ:Safety and efficacy of three-column osteotomy for scoliosis associated with Split cord malformation1.MethodsWe enrolled a total of 27 patients(16 female and 11 male)with scoliosis associated with SCM who were undergoing one-stage three-column osteotomy surgery.On the basis of Pang classification,there were 10 cases with Type Ⅰ SCM and 17 patients with Type ⅡSCM.Seven cases with Type Ⅰ SCM have osseous spurs which were located within the correction range.Among them,6 cases received spur resection before correction.The mean follow-up was 27.1 months(range,3 to 67 months).All coronal Cobb angles,sagittal Cobb angels and trunk balance were measured pre-operation,post-operation and at final follow-up.2.ResultsThe average operation time was 5.4h,ranging from 3 to 7.5h.The average blood loss was 1300ml,ranging from 200 to 4500ml.The average fusion segments was 10.1,ranging from 4 to 15.The Cobb angle in the coronal plane was corrected from 67.6° to 26.8°,with a 62.7%correction rate.The kyphosis was corrected from 60.4° to 21.4。,with a 63.4%correction rate.The average trunk shift was 2.7cm pre-operation and 1.7cm post-operation.Four cases had positive changes in MEP during spinal cord monitoring,1 showing temporary lower limbs weakness,bowel and bladder disturbances,while other 3 showing no neurological complications.Sensory deficit and pain of lower limbs was noted in one case,which disappeared after re-adjustment of the pedicle screw.Hemopneumothorax was noted in one case.Seven cases showed neurological deficit before surgery,no one getting worse after surgery.No other complications were found in follow-up.3.ConclusionPatients with scoliosis associated with SCM can safely and effectively undergo one-stage three-column osteotomy.For Type I SCM patients,if their osseous spur is located within the correction range,a spur resection is recommended before correction.For other Type I SCM patients and all Type II SCM patients,no intraspinal intervention is needed.Meanwhile,simultaneous spinal cord monitoring is necessary to avoid spinal cord injuries.Part Ⅱ:Safety and efficacy of three-column osteotomy for scoliosis associated with tethered spinal cord syndrome1.MethodsWe enrolled a total of 16 patients(9 female and 7 male)with scoliosis associated with TCS who were undergoing one-stage three-column osteotomy surgery.The mean follow-up was 22.8 months(range,3 to 72 months).All coronal Cobb angles,sagittal Cobb angels and trunk balance were measured pre-operation,post-operation and at final follow-up.2.ResultsThe average operation time was 5.8h,ranging from 3 to 8.5h.The average blood loss was 1096ml,ranging f’rom 300 to 4500ml.The average fusion segments was 8.5,ranging from 5 to 15.The Cobb angle in the coronal plane was corrected from 55.9° to 18.8°,with a 69.1%correction rate.The kyphosis was corrected from 70.2° to 28.3°,with a 60.1%correction rate.The average trunk shift was 2.7cm pre-operation and 2.2cm post-operation.Three cases had positive changes in MEP during spinal cord monitoring,I showing temporary lower limbs weakness,bowel and bladder disturbances,other 2 showing no neurological complications.Hemopneumothorax was noted in one case.Seven cases showed neurological deficit before surgery,all relieve well during the follow-up.No other complications were found in follow-up.3.ConclusionPatients with scoliosis associated with TCS can safely and effectively undergo one-stage three-column osteotomy.It can also achieve the goal of releasing tethered cord to get the improvement of neurological deficit simultaneously.Meanwhile,MEP positive is an important sign of possible spinal cord injuries,which should be always kept in mind during osteotomy.Part III:Safety and efficacy of three-column osteotomy for scoliosis associated with syringomyelia1.MethodsWe enrolled a total of 15 patients(7 female and 8 male)with scoliosis associated with syringomyelia who were undergoing one-stage three-column-osteotomy surgery.Syringomyelia is located within correction range in 6 cases.The mean follow-up was 19.7months(range,3 to 71 months).All coronal Cobb angle,sagittal Cobb angel and trunk balance were measured before operation,after operation and at final follow-up.2.ResultsThe average operation time was 5.7h,ranging from 3.5 to 8h.The average blood loss was 1393ml,ranging from 300 to 3000ml.The average fusion segments was 11.1,ranging from 6 to 14.The Cobb angle in the coronal plane was corrected from 83.6° to 31.4°,with a 62.7%correction rate.The kyphosis was corrected from 70.0° to 20.9°,with a 72.1%correction rate.The average trunk shift was 2.6cm pre-operation and 1.7cm post-operation.One case had positive changes in MEP during spinal cord monitoring,,showing temporary lower limbs weakness,which disappeared after re-adjustment of the pedicle screw.Other complications included temporary lower limbs weakness and sensory deficit in 1 case,hemopneumothorax in 1 case.Six cases showed neurological deficit before surgery,no one getting worse during the follow-up.No other complications were found in follow-up.3.ConclusionOne-stage three-column osteotomy is a safe and effective procedure for scoliosis patient with coexisting syringomyelia.Incision drainage of syringomyelia is not necessary for these patients.Simultaneous spinal cord monitoring plays an important role in preventing neurological complications.