【Abstract】 Objective To investigate the clinical significances of the thoracic pedicle classification determined by inner cortical width of pedicle in posterior vertebral column resection (PVCR) with free hand technique for the treatment of rigid and severe spinal deformities. Methods Between October 2004 and July 2010, 56 patients with rigid and severe spinal deformities underwent PVCR. A total of 1 098 screws were inserted into thoracic pedicles at T2-12. The inner cortical width of the thoracic pedicle was measured and divided into 4 groups: group 1 (0-1.0 mm), group 2 (1.1-2.0 mm), group 3 (2.1-3.0 mm), and group 4 (gt; 3.1 mm). The success rate of screw-insertion into the thoracic pedicles was analyzed statistically. A new 3 groups was divided according to the statistical results and the success rate of screw-insertion into the thoracic pedicles was analyzed statistically again. And statistical analysis was performed between different types of thoracic pedicles classification for pedicle morphological method by Lenke. Results There were significant differences in the success rate of screw-insertion between the other groups (P lt; 0.008) except between group 3 and group 4 (χ2=2.540，P=0.111). The success rates of screw-insertion were 35.05% in group 1, 65.34% in group 2, and 88.32% in group 3, showing significant differences among 3 groups (P lt; 0.017). According to Lenke classification, the success rates of screw-insertion were 82.31% in type A, 83.40% in type B, 80.00% in type C, and 30.28% in type D, showing no significant differences (P gt; 0.008) among types A, B, and C except between type D and other 3 types (P lt; 0.008). In the present study, regarding the distribution of different types of thoracic pedicles, types I, II a, and II b thoracic pedicles accounted for 17.67%, 16.03%, and 66.30% of the total thoracic pedicles, respectively. The type I, II a, and II b thoracicpedicles at the concave side accounted for 24.59%, 21.13%, and 54.28%, and at the convex side accounted for 10.75%, 10.93%, and 78.32%, respectively. Conclusion A quantification classification standard of thoracic pedicles is presented according to the inner cortical width of the pedicle on CT imaging: type I thoracic pedicle, an absent channel with an inner cortical width of 0-1.0 mm; type II thoracic pedicle, a channel, including type IIa thoracic pedicle with an inner cortical width of 1.1-2.0 mm, and type IIb thoracic pedicle with an inner cortical width more than 2.1 mm. The thoracic pedicle classification method has high prediction accuracy of screw-insertion when PVCR is performed.
ObjectiveTo review the advances in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery.MethodsRegular analgesics, drug administrations, and analgesic regimens were reviewed and summarized by consulting domestic and overseas related literatures about perioperative pain management of pediatric and adolescent spinal deformity corrective surgery in recent years.ResultsAs for perioperative analgesis regimens of pediatric and adolescent spinal deformity corrective surgery, regular analgesics include non-steroidal anti-inflammatory drugs, opioids, antiepileptic drugs, adrenergic agonists, and local anesthetic, etc. Besides drug administration by mouth, intravenous injection, and intramuscular injection, the administration also includes patient controlled analgesia, epidural injection, and intrathecal injection. Multimodal analgesia is the most important regimen currently.ConclusionHeretofore, a number of perioperative pain managements of pediatric and adolescent spinal deformity corrective surgery have been applied clinically, but the ideal regimen has not been developed. To design a safe and effective analgesic regimen needs further investigations.
ObjectiveTo systematically review the efficacy and safety of operative treatment versus nonoperative treatment in patients with adult spinal deformity (ASD).MethodsPubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, WanFang Data, and CQVIP databases were searched for controlled studies about operative treatment versus nonoperative treatment for ASD published up till June 2019. ClinicalTrials.gov was searched for grey literatures informally published up till June 2019. Two reviewers independently screened literatures, extracted data, and assessed risk of bias. Meta-analysis was performed by using RevMan 5.3 and Stata 14.0 softwares.ResultsA total of 10 non-randomized controlled studies were included, including 1 601 patients. The pooled results indicated that the operative group was superior to the nonoperative group in ability improvement [the increment of Scoliosis Research Society-22 score: weighted mean difference (WMD)=0.70, 95% confidence interval (CI) (0.69, 0.70), P<0.000 01; the decrement of Oswestry Disability Index score: WMD=11.12, 95%CI (10.74, 11.50), P<0.000 01], pain relief [the decrement of Numeric Rating Scale score: WMD=3.25, 95%CI (3.16, 3.35), P<0.000 01], and Cobb correction [WMD=14.06°, 95%CI (13.60, 14.53)°, P<0.000 01]. The incidence of complications was higher in the operative group than that in the nonoperative group [relative risk=5.38, 95%CI (3.67, 7.88), P<0.000 01].ConclusionsSurgery shows superior efficacy on ability improvement, pain relief, and Cobb correction compared with nonoperative treatment in ASD patients, though its incidence of complications is high. Nonoperative treatment is also an effective treatment for patients with poor physical condition and intolerance to surgery. Due to the limited quantity and quality of included studies, more high-quality studies are required to verify the above conclusions.
ObjectiveTo compare the changes of scoliosis and kyphosis angles after Halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity.MethodsA clinical data of 28 patients with severe rigid spinal deformity between January 2015 and November 2017 was retrospectively analyzed. Sixteen patients were treated by Halo-pelvic traction with posterior spinal osteotomy (group A) and 12 patients were treated with posterior spinal osteotomy only (group B). There was no significant difference between the two groups (P>0.05) in gender, age, body mass index, and preoperative pulmonary function, coronal and sagittal Cobb angles, and flexibility. The operation time, intraoperative blood loss, and complications were recorded. The coronal and sagittal Cobb angles were measured on X-ray films before operation (before traction in group A), at 10 days after operation, at last follow-up in the two groups and after traction in group A. The improvement rate of deformity after traction in group A, the correction rate of deformity after operation, and the loss rate of correction at last follow-up were calculated.ResultsAll patients were followed up 24-30 months (mean, 26.5 months). The operation time and intraoperative blood loss were significantly less in group A than in group B (t=7.629, P=0.000; t=8.773, P=0.000). In group A, 1 patient occurred transient numbness of both legs during continuous traction and 2 patients needed ventilator support for more than 12 hours. In group B, 7 patients needed ventilator support for more than 12 hours, including 1 patient with deep incision infection. The incidence of complications was 18.75% (3/16) in group A and 58.33% (7/12) in group B, and the difference between the two groups was significant (χ2=4.680, P=0.031). The coronal and sagittal improvement rates of deformity after traction in group A were 40.47%±3.60% and 40.70%±4.20%, respectively. There was no significant difference between the two groups (P>0.05) in the coronal and sagittal Cobb angles at 10 days after operation and at last follow-up, in the correction rate of deformity after operation, and in the loss rate of correction at last follow-up.ConclusionFor the severe rigid spinal deformity, Halo-pelvic traction with posterior spinal osteotomy and simple posterior spinal osteotomy can obtain the same orthopedic effect and postoperative deformity correction. However, the Halo-pelvic traction can shorten operation time, reduce blood loss and incidence of perioperative complications.
Objective To investigate the feasibility of predicting proximal junctional kyphosis (PJK) in adults after spinal deformity surgery based on back-forward Bending CT localization images and related predictive indicators. Methods A retrospective analysis was performed for 31 adult patients with spinal deformity who underwent posterior osteotomy and long-segment fusion fixation between March 2017 and March 2020. There were 5 males and 26 females with an average age of 62.5 years (range, 30-77 years). The upper instrumented vertebrae (UIV) located at T5 in 1 case, T6 in 1 case, T9 in 13 cases, T10 in 12 cases, and T11 in 4 cases. The lowest instrumented vertebrae (LIV) located at L1 in 3 cases, L2 in 3 cases, L3 in 10 cases, L4 in 7 cases, L5 in 5 cases, and S1 in 3 cases. Based on the full-length lateral X-ray film of the spine in the standing position before and after operation and back-forward Bending CT localization images before operation, the sagittal sequence of the spine was obtained, and the relevant indexes were measured, including thoracic kyphosis (TK), lumbar lordosis (LL), local kyphosis Cobb angle (LKCA) [the difference between the different positions before operation (recovery value) was calculated], kyphosis flexibility, hyperextension sagittal vertical axis (hSVA), T2-L5 hyperextension C7-vertebral sagittal offset (hC7-VSO), and pre- and post-operative proximal junctional angle (PJA). At last follow-up, the patients were divided into PJK and non-PJK groups based on PJA to determine whether they had PJK. The gender, age, body mass index (BMI), number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, osteotomy grading, and related imaging indicators were compared between the two groups. The hC7-VSO of the vertebral body with significant differences between groups was taken, and the receiver operating characteristic curve (ROC) was used to evaluate its accuracy in predicting the occurrence of PJK. Results All 31 patients were followed up 13-52 months, with an average of 30.0 months. The patient’s PJA was 1.4°-29.0° at last follow-up, with an average of 10.4°; PJK occurred in 8 cases (25.8%). There was no significant difference in gender, age, BMI, number of fusion segments, number of cases with coronal plane deformity, bone mineral density (T value), UIV position, LIV position, operation time, intraoperative blood loss, and osteotomy grading between the two groups (P>0.05). Imaging measurements showed that the LL recovery value and T8-L3 vertebral hC7-VSO in the PJK group were significantly higher than those in the non-PJK group (P>0.05). There was no significant difference in hyperextension TK, hyperextension LL, hyperextension LKCA, TK recovery value, LL recovery value, kyphosis flexibility, hSVA, and T2-T7, L4, L5 vertebral hC7-VSO (P>0.05). T8-L3 vertebral hC7-VSO was analyzed for ROC curve, and combined with the area under curve and the comprehensive evaluation of sensitivity and specificity, the best predictive index was hC7-L2, the cut-off value was 2.54 cm, the sensitivity was 100%, and the specificity was 60.9%. Conclusion Preoperative back-forward Bending CT localization image can be used to predict the occurrence of PJK after posterior osteotomy and long-segment fusion fixation in adult spinal deformity. If the patient’s T8-L2 vertebral hC7-VSO is too large, it indicates a higher risk of postoperative PJK. The best predictive index is hC7-L2, and the cut-off value is 2.54 cm.