Objective To compare perioperative and complication outcomes, focusing on the prevention of sagittal translation (ST), between a novel “prioritized correction with multiple-rod construct” (PC-MRC) technique and traditional multiple-rod constructs (M-RC) in adult spinal deformity (ASD) patients undergoing 3-column osteotomies (3-COs).
Methods In this retrospective study, 101 ASD patients with a minimum 2-year follow-up after 3-COs were divided into 2 groups: PC-MRC (n=65) and M-RC (n=36). The PC-MRC technique involved initial osteotomy closure with short rods followed by global alignment correction with long rods. Radiographic and clinical parameters were assessed preoperatively, postoperatively, and at final follow-up.
Results The PC-MRC group had significantly shorter operation time and lower estimated blood loss (p=0.045 and p=0.007, respectively). Major coronal and kyphotic deformity correction rates were similar between groups. No significant correction loss occurred at the final follow-up. Crucially, the incidence of ST was significantly lower in the PC-MRC group (1.5% vs. 25.0%, p<0.001). Correspondingly, the overall rate of neurological injury was lower in the PC-MRC group (7.7% vs. 22.2%, p=0.037).
Conclusion The PC-MRC technique offers a versatile and rigid fixation for 3-COs in ASD patients, facilitating significant correction of global deformity. This straightforward technique effectively prevents massive blood loss and ST caused by 3-COs, while minimizing the risk of neurological complication.
Objective To analyze long-term clinical and radiological outcomes after multilevel anterior osteotomy with posterior instrumentation in patients with ossification of posterior longitudinal ligament (OPLL)-induced myelopathy and cervical kyphosis.
Methods Patients who underwent multilevel anterior osteotomy with posterior instrumentation for OPLL-induced myelopathy and cervical kyphosis and had a minimum of 5-year follow-up were included. Clinical outcomes (Japanese Orthopaedic Association score system for cervical myelopathy [C-JOA], 12-item Short Form health survey [SF-12], Neck Disability Index [NDI]) and radiological parameters (C2–7 lordosis, center of gravity of the head [CGH]-C7 sagittal vertical axis [SVA], T1 slope) were analyzed at the preoperative, immediate postoperative, and latest follow-up timepoints.
Results Twenty-eight patients were included. The average follow-up period was 66.4 months. All clinical outcome parameters showed significant improvement. C-JOA, SF-12, and NDI showed significant improvement at latest follow-up (p<0.001). C2–7 lordosis increased significantly immediately postoperatively (-6.0°±10.4°) compared to preoperatively (+9.2°±9.6°), and was largely maintained at latest follow-up (-5.7°±9.4°). T1 slope significantly increased between the immediate postoperative timepoint (21.9°±7.7°) and latest follow-up (24.2°±9.5°) (p=0.046). CGH-C7 SVA significantly increased between the immediate postoperative timepoint (22.7±14.8 mm) and latest follow-up (32.2±22.6 mm) (p=0.046).
Conclusion Multilevel anterior osteotomy with posterior instrumentation is a safe and effective surgical option for OPLL-induced myelopathy with kyphotic cervical alignment. Future studies are required to investigate the forward tilting of cervical spine over time after surgery.
Objective To compare the clinical outcomes and biomechanical characteristics of 1-, 2-, and 3-level pedicle subtraction osteotomy (PSO), and establish selection criteria based on preoperative radiographic parameters.
Methods Patients undergone PSO to treat ankylosing spondylitis from February 2009 to May 2019 in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were enrolled. According to the quantity of osteotomy performed, the participants were divided into group A (1-level PSO, n = 24), group B (2-level PSO, n = 19), and group C (3-level PSO, n = 11). Clinical outcomes were assessed before surgery and at the final follow-up. Comparisons of the radiographic parameters and quality-of-life indicators were performed among and within these groups, and the selection criteria were established by regression. Finite element analysis was conducted to compare the biomechanical characteristics of the spine treated with different quantity of osteotomies under different working conditions.
Results Three-level PSO improved the sagittal parameters more significantly, but resulted in longer operative time and greater blood loss (p < 0.05). Greater stress was found in the proximal screws and proximal junction area of the vertebra in the model simulating 1-level PSO. Larger stress of screws and vertebra was observed at the distal end in the model simulating 3-level PSO.
Conclusion Multilevel PSO works better for larger deformity correction than single-level PSO by allowing greater sagittal parameter correction and obtaining a better distribution of stress in the hardware construct, although with longer operation time and greater blood loss. Three-level osteotomy is recommended for the patients with preoperative of global kyphosis > 85.95°, T1 pelvic angle > 62.3°, sagittal vertical alignment > 299.55 mm, and pelvic tilt+ chin-brow vertical angle > 109.6°.
A novel pre-contoured V-shaped rod in one-level pedicle subtraction osteotomy for the treatment of rigid lumbar kyphosis caused by ankylosing spondylitis: technical note and case series Hongtao Ding, Cheng Zeng, Andrew Y. Xu, Audrey Y. Su, Jeffrey J. Yeung, Xin Chen, Huadong Wang, Yanbin Zhang, Kai Yan, Yonggang Xing, Da He, Bin Xiao BMC Musculoskeletal Disorders.2025;[Epub] CrossRef
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Objective Osteotomies are required for the mobilization of spinal segments in patients with revisional scoliosis surgery with a fusion mass; however, only a few techniques have shown efficacy and safety, and their mid- and long-term outcomes remain unelucidated. This study aimed to analyze long-term outcomes of the posterior multilevel crack osteotomy (PMCO) technique for revisional surgery for scoliosis with a fusion mass.
Methods Data from 18 patients who underwent revisional scoliosis surgery using PMCO between 2009 and 2015 and had more than 5-year follow-up were retrospectively reviewed. The Cobb angle and coronal and sagittal balance parameters were examined preoperatively, postoperatively, and during the final follow-up. Perioperative parameters and complications were also assessed.
Results Preoperative and postoperative Cobb angles were 60.5° and 29.9°, respectively (p < 0.001); this improvement was maintained until the final follow-up (33.4°, p = 0.058). The difference in preoperative and postoperative coronal balance was statistically significant (15.9 mm and 9.2 mm, respectively; p < 0.001); this was maintained until the final follow-up (p = 0.071). There was no change in sagittal balance parameters over the 3 measurement periods. Only 1 patient showed PMCO-related motor weakness, but he spontaneously recovered 3 months after postsurgery. Pseudarthrosis was not observed during the follow-up period.
Conclusion Incomplete osteotomy using PMCO provided satisfactory deformity correction without severe complications during revisional surgery for scoliosis with a fusion mass. It may be a less invasive procedure that maintains cortical continuity, preserves soft tissues, and provides sufficient mobility for the correction of spinal segments.
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Objective This retrospective cohort study has been aimed at evaluating the incidence of complications after vertebral body sliding osteotomy (VBSO) and analyzing some cases. Furthermore, the complications of VBSO were compared with those of anterior cervical corpectomy and fusion (ACCF).
Methods This study included 154 patients who underwent VBSO (n = 109) or ACCF (n = 45) for cervical myelopathy and were followed up for > 2 years. Surgical complications, clinical and radiological outcomes were analyzed.
Results The most common surgical complications after VBSO were dysphagia (n = 8, 7.3%) and significant subsidence (n = 6, 5.5%). There were 5 cases of C5 palsy (4.6%), followed by dysphonia (n = 4, 3.7%), implant failure (n = 3, 2.8%), pseudoarthrosis (n = 3, 2.8%), dural tears (n = 2, 1.8%), and reoperation (n = 2, 1.8%). C5 palsy and dysphagia did not require additional treatment and spontaneously resolved. The rates of reoperation (VBSO, 1.8%; ACCF, 11.1%; p = 0.02) and subsidence (VBSO, 5.5%; ACCF, 40%; p < 0.01) were significantly lower in VBSO than in ACCF. VBSO restored more C2–7 lordosis (VBSO, 13.9° ± 7.5°; ACCF, 10.1° ± 8.0°; p = 0.02) and segmental lordosis (VBSO, 15.7° ± 7.1°; ACCF, 6.6° ± 10.2°; p < 0.01) than ACCF. The clinical outcomes did not significantly differ between both groups.
Conclusion VBSO has advantages over ACCF in terms of low rate of surgical complications related to reoperation and significant subsidence. However, dural tears may still occur despite the lessened need for ossified posterior longitudinal ligament lesion manipulation in VBSO; hence, caution is warranted.
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Objective The objective of this study is to assess differences in complication profiles between 3-level posterior column osteotomy (PCO) and single-level pedicle subtraction osteotomy (PSO) as both are reported to provide similar degrees of sagittal correction.
Methods The PearlDiver database was queried retrospectively using International Classification of Disease, 9th and 10th edition and Current Procedural Terminology codes to identify patients who underwent PCO or PSO for degenerative spine disease. Patients under age 18 or with history of spinal malignancy, infection, or trauma were excluded. Patients were separated into 2 cohorts, 3-level PCO or single-level PSO, matched at a 1:1 ratio based on age, sex, Elixhauser comorbidity index, and number of fused posterior segments. Thirtyday systemic and procedure-related complications were compared.
Results Matching resulted in 631 patients for each cohort. PCO patients had decreased odds of respiratory (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.43–0.82; p = 0.001) and renal complications (OR, 0.59; 95% CI, 0.40–0.88; p = 0.009) compared to PSO patients. There was no significant difference in cardiac complications, sepsis, pressure ulcer, dural tear, delirium, neurologic injuries, postoperative hematoma, postoperative anemia, or overall complications.
Conclusion Patients who undergo 3-level PCO have decreased respiratory and renal complications compared to single-level PSO. No differences were found in the other complications studied. Considering both procedures achieve similar sagittal correction, surgeons should be aware that 3-level PCO offers an improved safety profile compared to single-level PSO.
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Neurospine 2021;18(4):816-823. Published online October 21, 2021
Objective To compare the radiological and functional outcomes and complications of adult spinal deformity patients who underwent a pedicle subtraction osteotomy (PSO) below L2 but categorized according to their construct where either 2-rod or multiple-rod construct is applied.
Methods Sixty-seven patients met the inclusion criteria, and were categorized into 3 groups: 2 rods (2R), multiple rods around the PSO (MRP), multiple rods around the PSO and lumbosacral junction (MRL). Demographic data, operative parameters, spinopelvic parameters, functional outcomes, and complications were collected.
Results Health-related quality of life scores showed a better outcome at 6 months and last follow-up visits in the MRP and MRL groups which were noted on different domains of Scoliosis Research Society-22 questionnaire, 36-item Short Form Health Surve, and Oswestry Disability Index scores (p < 0.05). The 3 groups showed similar rates of rod-related complications with no significant difference (p = 0.95). And inside each group, distribution of complications between pseudarthrosis with revision and rod fracture without revision was also similar (p = 0.99).
Conclusion The use of multiple rods across the PSO did not show a better outcome when compared to single rods in terms of incidence and types of mechanical complications. However, better postoperative coronal alignment and health-related quality of life scores in the multiple rods group could be seen demonstrating an improved functional outcome.
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Pedikel-Subtraktions-Osteotomie: Zwei- versus Mehr-Stab-Fixierung
Objective The objective of this study was to compare the biomechanical differences of different rod configurations following anterior column realignment (ACR) and pedicle subtraction osteotomy (PSO) for an optimal correction technique and rod configuration that would minimize the risk of rod failure.
Methods A validated spinopelvic (L1-pelvis) finite element model was used to simulate ACR at the L3–4 level. The ACR procedure was followed by dual-rod fixation, and for 4-rod constructs, either medial/lateral accessory rods (connected to primary rods) or satellite rods (directly connected to ACR level screws). The range of motion (ROM), maximum von Mises stress on the rods, and factor of safety (FOS) were calculated for the ACR models and compared to the existing literature of different PSO rod configurations.
Results All of the 4-rod ACR constructs showed a reduction in ROM and maximum von Mises stress compared to the dual-rod ACR construct. Additionally, all of the 4-rod ACR constructs showed greater percentage reduction in ROM and maximum von Mises stress compared to the PSO 4-rod configurations. The ACR satellite rod construct had the maximum stress reduction i.e., 47.3% compared to dual-rod construct and showed the highest FOS (4.76). These findings are consistent with existing literature that supports the use of satellite rods to reduce the occurrence of rod fracture.
Conclusion Our findings suggest that the ACR satellite rod construct may be the most beneficial in reducing the risk of rod failure compared to all other PSO and ACR constructs.
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Objective The posterolateral extradural suboccipital approach can be used to reach the anterior epidural space and the retro-odontoid regions. The extent of necessary bone removal of the atlas vertebra (C1) has not yet been defined. We studied the changes in the size of the horizontal and vertical surgical windows using stepwise bone removal of C1. A representative case is shown.
Methods The anatomical study was performed bilaterally on five Thiel-fixed human cadavers (mean age, 83.7 years). The surgical window (horizontal × vertical) required to access the retro-odontoid region via a posterolateral approach was measured for an intact C1 posterior arch, after a semicircular inferior partial resection of the C1 arch, after resection of the unilateral hemiarch of C1, and finally after drilling approximately 3 mm from the medial aspect of the lateral mass of C1.
Results The intact C1 resulted in a very narrow surgical window of 6.3 mm × 9.7 mm (horizontal × vertical). The vertical window increased to a 13 mm after the semicircular inferior partial resection of the C1 arch and to 17.3 mm in the case of removal of the ipsilateral C1 posterior arch. The bone removal from the medial aspect of the C1 lateral mass resulted in a widening of the horizontal surgical window to 10.3 mm. The final size of the surgical window was 10.3 mm × 17.3 mm. The patient with severe kyphoscoliosis of the craniocervical spine was successfully operated on using odontoid and C1–2 facet osteotomies.
Conclusion If only the anterior epidural space or the base of the odontoid needs to be reached, the semicircular inferior partial resection of the C1 arch allows for an adequate surgical window. The tip of the odontoid could only be reached if the ipsilateral posterior arch is resected.
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Although cervical spinal deformity (CSD) can have a profoundly negative impact on an individual’s quality of life and there have been many advances in surgical treatment of CSD in recent years, there exists no comprehensive classification system of surgical treatment that categorizes anterior and posterior surgery separately according to the grade of surgery. The objective of this study is to introduce the new classification system of various surgical treatments for CSD. We developed a new classification system (SOF system) for CSD surgery that describes the sequence of surgical approach (S), the grade of osteotomy (O), and the information of fixation (F) using alphanumeric codes. This new classification system can provide a consistent description of the various osteotomies performed in CSD surgery. Especially, regarding research, there has been a clear benefit to this classification. Having a standardized classification that allows for common frame for cervical deformity correction surgery, communication between surgeons and the evaluation of the CSD surgeries make it possible to conduct global comparative research about surgical outcome.
Adult cervical deformity (ACD) has been shown to have a substantial impact on quality of life and overall health, with moderate to severe deformities resulting in significant disability and dysfunction. Fortunately, surgical management and correction of cervical sagittal imbalance can offer significant benefits and improvement in pain and disability. ACD is a heterogenous disease and specific surgical correction strategies should reflect deformity type (driver of deformity) and patient-related factors. Spinal rigidity is one of the most important considerations as soft tissue releases and osteotomies play a crucial role in cervical deformity correction. For ankylosed, fixed, and severe deformity, 3-column osteotomy (3CO) is often warranted. A 3CO can be done through combined anteriorposterior (vertebral body resection) and posterior-only approaches (open or closed wedge pedicle subtraction osteotomies [PSOs]). This article reviews the literature for currently published studies that report results on the use of 3CO for ACD, with a special concentration on posterior based 3CO (open and closed wedge PSO). More specifically, this review discusses the indications, radiographic corrective ability, and associated complications.
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This study aims to describe the surgical management of cervical deformity arising from outside the cervical spine because of upper thoracic malalignment, using pedicle subtraction osteotomy (PSO). Cervical spine deformity is a complex topic and it can be generally divided into 2 categories, the first category is when the primary deformity is inside the cervical spine and the treatment will focus on the cervical spine itself, whereas the second category is when the primary deformity is outside the cervical spine usually in the adjacent upper thoracic area, the cervical deformity is a compensation for the adjacent malalignment, and thus in this situation, the management will occur in the upper thoracic area. Description of a single surgeon’s technique for performing PSO to treat rigid upper thoracic deformity. PSO in the upper thoracic spine is a safe and effective procedure and can result in satisfying clinical and radiological outcome with indirect correction of the compensatory cervical deformity. Cervical deformity arising from upper thoracic malalignment should be dealt with by treating the problem at its origin outside the cervical spine by performing a PSO in the upper thoracic spine.
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