How Does Thoracic Kyphosis Affect Patient Outcomes in Growing Rod Surgery?

Spine (Phila Pa 1976). 2011 Dec 28;

Authors: Schroerlucke SR, Akbarnia BA, Pawelek JB, Salari P, Mundis GM, Yazici M, Emans JB, Sponseller PD,

Study Design. Retrospective review of a multi-center series.Objective. This study was conducted to specifically identify the complication rate of growing rod surgery in patients with normal (10-40?) versus abnormal thoracic kyphosis.Summary of Background Data. Surgical treatment options for progressive early onset scoliosis include spinal fusion versus growth-sparing techniques. The current most commonly employed growing rod technique involves short fusions at the foundation sites using either hooks or screws as anchors and placement of dual growing rods spanning the deformity. Although the coronal deformity in these patients has been studied extensively, the sagittal profile has received less attention as a possible factor in complication rates and patients outcomes.Methods. Out of 387 patients who underwent surgical placement of growing rods, 90 patients had complete clinical and radiographic data with two-year follow-up after initial surgery. Patients were categorized into three groups based on the magnitude of pre-operative thoracic kyphosis: <10 degrees (K- group), 10-40 degrees (N group) and >40 degrees (K+ group). Patient diagnosis, demographics, surgical information, radiographic measurements and complication types were tabulated and analyzed. A p value of <0.05 was considered significant for all statistical tests.Results. The K- group experienced 27 total complications including 15 general medical complications; the N group had 20 total and 4 general, and the K+ group had 55 total and 22 general complications. Patients in the K+ group were 3.1 times more likely to experience a complication than patients in the N group, which was statistically significant (p<0.05). When considering all types of complications, length of follow-up, T2-T5 proximal kyphosis, post-operative Cobb angle and rod diameter were identified as confounding variables. When the confounding variables were taken into consideration in the analysis, the odds ratios were no longer significant between the N and K+ groups. Patients in the K+ group and K- group were 2.95 and 2.89 times more likely to experience a general medical complication compared to those the N group, respectively (p>0.05). The rate of implant-related complications between the groups did not reach statistical significance, although the K+ group had the most implant complications (n = 34), including 25 rod breakages in 16 patients. Syndromic patients had 2.9 times the risk of having an overall complication when compared to the entire patient series (p<0.05). The number of patients who experienced multiple complications was higher in the K- and K+ groups than in the N group.Conclusion. Patients with thoracic hyper-kyphosis present even more of a challenge with respect to complications, specifically implant-related complications. Our study shows that growing rod surgery in patients with kyphosis >40? have significantly more general and implant complications than patients with normal thoracic kyphosis. Implant complications were more common in hyper-kyphotic (>40?) patients and increased linearly with increasing kyphosis. The most common implant complication was rod breakage. Patients with hyper-kyphotic thoracic spines, particularly syndromic patients, must be monitored closely and parents should be counseled regarding the likelihood of future adverse events.

PMID: 22210014 [PubMed – as supplied by publisher]

The Use of a Transition Rod May Prevent Proximal Junctional Kyphosis in the Thoracic Spine Following Scoliosis Surgery: A Finite Element Analysis.

Spine (Phila Pa 1976). 2011 Dec 28;

Authors: Cahill PJ, Wang W, Asghar J, Booker R, Betz RR, Ramsey C, Baran G

Study Design. Finite element analysisObjective. Via finite element analysis: 1) to demonstrate the abnormal forces present at the top of a scoliosis construct, 2) to demonstrate the importance of an intact interspinous and supraspinous ligament (ISL/SSL) complex, and 3) to evaluate a transition rod (a rod that has a short taper to a smaller diameter at one end) as an implant solution to diminish these pathomechanics, regardless of the integrity of the ISL/SSL complex.Summary of Background Data. The pathophysiology of increased nucleus pressure and increased angular displacement may contribute to proximal junctional kyphosis. Furthermore, high implant stress can be demonstrated at the upper end of the construct, possibly leading to risk of implant failure.Methods. A finite element model was constructed to simulate a thoracic spinal fusion. The model was altered to remove the ISL/SSL complex at the level above the construct. Lastly, the model was altered again by extending the construct one level superior with a transition rod. The angular displacement, the maximum pressure in the nucleus, and stress within the implant were extracted from computational results under two conditions: load control and displacement control. The testing was performed with both titanium and stainless steel implants.Results. Pressure in the nucleus and angular displacement are all increased when the ISL/SSL complex is removed immediately above the instrumented levels, while the screw pull-out force and maximum stress within the screw is decreased. The nucleus pressure increases by over 50%. The angular displacement increases 19-26%. This absence of the ISL/SSL complex simulates the clinical scenario that occurs when these structures are iatrogenically detached. Abnormal mechanics can be restored to normal level by extending the construct rostral one level with a transition rod. Furthermore, the elevated nucleus pressure and angular displacement noted even when the ISL/SSL complex is intact can be avoided with the use of a transition rod. Under the same bending moment (3 Nm), the nucleus pressure at the level immediately cephalad is up to 23% lower than the pressure in a standard construct. The angular displacement is 18-19% less than the standard construct. The maximum implant stress is also decreased by as much as 60%.Conclusions. Finite element modeling suggests that the pathomechanics at the proximal end of a scoliosis construct may be diminished by preserving the ISL/SSL complex and possibly completely eliminated with the use of rods with a diameter transition at the most proximal level.

PMID: 22210013 [PubMed – as supplied by publisher]

Proximal junctional kyphosis in adult reconstructive spine surgery results from incomplete restoration of the lumbar lordosis relative to the magnitude of the thoracic kyphosis.

Iowa Orthop J. 2011;31:199-206

Authors: Mendoza-Lattes S, Ries Z, Gao Y, Weinstein SL

BACKGROUND: PROXIMAL JUNCTIONAL KYPHOSIS (PJK) IS DEFINED AS: 1) Proximal junction sagittal Cobb angle >?10°, and 2) Proximal junction sagittal Cobb angle of at least 10° greater than the pre-operative measurement PJK is a common complication which develops in 39% of adults following surgery for spinal deformity. The pathogenesis, risk factors and prevention of this complication are unclear.
METHODS: Of 54 consecutive adults treated with spinal deformity surgery (age?59.3±10.1 years), 19 of 54 (35%) developed PJK. The average follow-up was 26.8months (range 12 – 42). Radiographic parameters were measured at the pre-operative, early postoperative (4-6 weeks), and final follow-up visits. Sagittal alignment was measured by the ratio between the C7-plumbline and the sacral-femoral distance. Binary logistic regression model with predictor variables included: Age, BMI, C7-plumbline, and whether lumbar lordosis, thoracic kyphosis and sacral slope were present
RESULTS: Patients who developed PJK and those without PJK presented with comparable age, BMI, pelvic incidence and sagittal imbalance before surgery. They also presented with comparable sacral slope and lumbar lordosis. The average magnitude of thoracic kyphosis was significantly larger than the lumbar lordosis in the proximal junctional kyphosis group, both at baseline and in the early postoperative period, as represented by [(-lumbar )lordosis – (thoracic kyphosis)]; no- PJK versus PJK; 6.6°±23.2° versus -6.6°±14.2°; p?0.012. This was not effectively addressed with surgery in the PJK group [(-LL-TK): 6.2°±13.1° vs. -5.2°±9.6°; p?0.004]. This group also presented with signs of pelvic retroversion with a sacral slope of 29.3°±8.2° pre-operatively that was unchanged after surgery (30.4°±8.5° postoperatively). Logistic regression determined that the magnitude of thoracic kyphosis and sagittal balance (C7-plumbline) was the most important predictor of proximal junctional kyphosis.
CONCLUSIONS: Proximal junctional kyphosis developed in those patients where the thoracic kyphosis remained greater in magnitude relative to the lumbar lordosis, and where the sagittal balance seemed corrected, but part of thise correction was secondary to pelvic retroversion.
LEVEL OF EVIDENCE: Prognostic case-control study – Level III.

PMID: 22096442 [PubMed – in process]

Circumferential cervical surgery for spondylostenosis with kyphosis in two patients with athetoid cerebral palsy.

Surg Neurol. 1999 Oct;52(4):339-44

Authors: Epstein NE

Patients with athetoid cerebral palsy may develop severe degenerative changes in the cervical spine decades earlier than their normal counterparts due to abnormal cervical motion.

PMID: 10555838 [PubMed – indexed for MEDLINE]

[Multiplan correction of a 3D deformity : Options and relevance of optimizing the thoracic kyphosis in reconstructive scoliosis surgery].

Orthopade. 2011 Aug;40(8):672-81

Authors: Wiedenhöfer B, Fürstenberg CH, Schröder K, Akbar M

There is presently still no consensus on how to operatively treat adolescent idiopathic scoliosis (AIS), i.e. a clearly reduced thoracic kyphosis. For a long time the primary focus was mostly on correcting the coronal plane while neglecting the sagittal profile. Based on the current literature and own retrospective data a comprehensive review will be given on the optimal correction of the spine and how to avoid secondary complications. Different operative standard procedures are demonstrated with special attention to the sagittal balance and the special parameters sagittal vertical axis (SVA), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), sagittal slope (SSL) and pelvic incidence (PI).

PMID: 21751031 [PubMed – in process]

Neurological complications of anterior spinal surgery for kyphosis with normal somatosensory evoked potentials (SEPs).

J Neurol Neurosurg Psychiatry. 1999 May;66(5):662-4

Authors: Pelosi L, Jardine A, Webb JK

We report a case of neurological complications of anterior release for correction of kyphosis. After the operation, the patient had pyramidal weakness and decreased pain sensation below T5, whereas light touch, proprioception and vibration sensation were intact. Clinical and neurophysiological findings in this patient suggested a partial lesion of the spinal cord probably due to ischaemia in the territory of the anterior spinal artery. Intraoperative and postoperative tibial nerve SEPs remained normal, which stresses the need for recording from the motor pathways.

PMID: 10209183 [PubMed – indexed for MEDLINE]

A case of surgery for kyphosis of the thoracolumbar spine in an elderly patient with Dysphagia.

Acta Med Okayama. 2011 Jun;65(3):211-4

Authors: Nakanishi K, Yamane K, Tanaka M, Misawa H, Saiga K, Ozaki T

Here we report a case of surgery for kyphosis of the thoracolumbar spine in an elderly patient, in whom surgery was performed because the patient had developed intractable digestive symptoms. The case was that of a 76-year-old female with complaints of back pain and dysphagia. When videofluoroscopic examination (VF) of swallowing was performed in the cardia of the stomach, images that indicated stagnation and the reflux of food were observed. It was easier for the patient to swallow food in the extension position. We performed corrective fusion of the posterior spine. After the surgery, the kyphosis angle was improved to 27°, the patient’s back pain was alleviated, and it became easier for the patient to swallow food. VF also showed that the patient’s difficulties with the passage of food had improved. We believe that surgery is a good treatment option for cases of kyphosis with digestive symptoms and deteriorating activities of daily living (ADL), even in the absence of pain and paralysis. VF is also useful for performing evaluations before and after surgery.

PMID: 21709720 [PubMed – in process]

Indications for surgery in so-called “regular” thoracic and thoracolumbar kyphosis.

Eur Spine J. 1997;6(1):25-32

Authors: Gennari JM, Aswad R, Ripoll B, Bergoin M

Idiopathic thoracic, thoracolumbar, and Scheuermann’s kyphosis do not figure in the same global entity. We propose a classification for so-called “regular” kyphosis. This classification is based on the location of the most rigid curvature segment. Segmental kyphosis may be short, in which case we can distinguish between four types: high kyphosis (type I), middle kyphosis (type II), low or thoracolumbar kyphosis (type III), and segmental kyphosis, which can extend along the entire thoracic spine (type IV). The symptomatology and therapeutic indications are different for each type. We report a series of 15 patients (6 female, 9 male), aged between 18 and 33 years (average age 24 years). The mean kyphosis angle (Cobb angle) in type I patients (n = 3) was 75 degrees in type II patients (n = 3) it was 82 degrees, and in type III patients (n = 9) it was 78 degrees. The pain was greater in type III patients. All patients were operated on using a double approach. As the first step, we performed an anterior approach, disc excision, and bone graft. Ten days later, a posterior approach with CD instrumentation was carried out on ten levels. The mean follow-up is 4 years (range 9 months in 7 years). We noticed no neurological complications and one case of late sepsis. Mean angular loss of correction was 6 degrees. The correction obtained depended on the type of kyphosis. We obtained a mean postoperative Cobb angle of 63 degrees in type I curves, 55 degrees in type II, and 45 degrees in type III. The new classification allows a better understanding of regular kyphosis and helps to define clinical and therapeutic approaches. An analysis of the resulting surgical correction can also be made by comparing homogeneous groups of patients.

PMID: 9093824 [PubMed – indexed for MEDLINE]

Is laparoscopic surgery a contraindication in patients with severe senile kyphosis?

Hepatogastroenterology. 2010 Sep-Oct;57(102-103):1095-8

Authors: Sato T, Yamaguchi S, Ozawa S, Ishii T, Tashiro J, Hosonuma T, Koyama I, Gagner M

The japanese population have the longest-life expectancy in the world. Accordingly, older patients with colorectal cancer with senile kyphosis caused by aging or osteoporosis also increase. Laparoscopic surgery is minimally-invasive, and performance on severe kyphotic patients may cause difficulty to approach a narrow abdomen. To determine whether laparoscopic surgery is safe and feasible in patients with severe senile kyphosis.

PMID: 21410038 [PubMed – indexed for MEDLINE]

[Surgery of severe vertebral kyphosis in ankylosing spondylitis].

Rev Rhum Mal Osteoartic. 1987 Mar;54(3):261-7

Authors: Roy-Camille R, Henry P, Saillant G, Doursounian L

12 cases of spinal osteotomy in patients with ankylosing spondylarthritis are reported. It concerns 3 cases of cervical osteotomy and 9 cases of lumbar osteotomy with severe kyphotic deformity. The techniques and the operated cases are analyzed. The indications of this surgery, which is not devoid of neurological risks, are rare. It is only justified in severe deformities in order to restore a normal visual field for the patient.

PMID: 3589455 [PubMed – indexed for MEDLINE]

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