Shuo Cao and Xin Chen contributed equally to this study as co-first authors.
To report concave-side distraction technique to treat congenital cervical scoliosis in lower cervical and cervicothoracic spine. To evaluate and compare clinical and radiographic results of this procedure with classic hemivertebra resection procedure.
This study reviewed 29 patients in last 13 years. These patients were divided into convex-side resection group (group R) and concave-side distraction group (group D). Radiographic assessment was based on parameter changes preoperatively, postoperatively and at last follow-up. Demographic data, surgical data and complications were also evaluated and compared between the 2 groups.
In group R, mean age was 8.9 ± 3.3 years and follow-up was 46 ± 18 months. Operation time and blood loss averaged 500 ± 100 minutes, 703 ± 367 mL. In group D, mean age was 9.9 ± 2.8 years and follow-up was 34 ± 14 months. Operation time and blood loss averaged 501 ± 112 minutes, 374 ± 181 mL. Structural Cobb angle was corrected from 29.4° ± 12.5° to 5.3° (2.1°–18.1°) (p = 0.001) and 33.7° ± 14.1° to 12.8° ± 11.4° (p < 0.001) in groups R and D. Compensatory Cobb angle had a spontaneous correction rate of 59.6% (40.0%–80.8%) and 59.7% ± 23.0% in groups R and D. Mandibular incline, clavicle angle and spine coronal balance were significantly improved at last follow-up in both groups. All correction rates were not statistically different between groups. However, group D had significant less blood loss (p < 0.001) and operation time (p = 0.004) per vertebra than group R. Seven patients developed C5 nerve root palsy and recovered by 6 months of follow-up.
Both surgical procedures are safe and effective in correcting congenital cervical scoliosis. But concave-side distraction technique has less blood loss and time-consuming during surgery, which provides a better option for the treatment of congenital cervical scoliosis.
Congenital cervical scoliosis is caused by multiple defects of segmentation or formation of vertebra, including hemivertebra, wedged vertebra, butterfly vertebra, block vertebrae, and unilateral bar [
Deformed vertebra in cervical region is unusual and the incidence is low compared to that in the thoracic and lumbar regions [
Inclusion criteria was patients with the presence of torticollis caused by congenital cervical scoliosis (defined as a Cobb angle of > 10°) in lower cervical and cervicothoracic spine; Operation and follow-up were performed in our hospital. The indication for surgery is patients with severe disfiguring deformity or patients with proven or expected deterioration deformities.
Exclusion criteria included (1) Patients with congenital cervical scoliosis caused by deformed vertebra in cranial-cervical junction or other causes of torticollis appearance, such as muscular torticollis, ocular torticollis, neurogenic torticollis, etc.; (2) Patients with other spinal deformity or disease, such as cervical kyphosis or kyphoscoliosis, congenital deformity of middle and lower thoracic spine, lumbar spine, ankylosing spondylitis, severe ossification of cervical posterior longitudinal ligament, etc.; (3) Cervical infectious diseases, cervical primary, or metastatic tumor; (4) Have a history of spinal trauma or surgery; (5) Imaging data are incomplete or follow-up time less than 24 months.
We reviewed 76 cases from congenital cervical scoliosis database in our department from January 2009 till now. According to inclusion and exclusion criteria, 29 patients were included in this study. According to different surgical procedures, we divided these 29 patients into 2 groups, convex-side resection group (group R), which was performed before 2016, and concave-side distraction group (group D), which was performed after 2016. These 2 surgical procedures had same surgical indication. The details of patients’ demographic and operative data were recorded in
This study protocol was approved by the Medical Science Research Ethics Committee of the Peking University Third Hospital (approval number: 2015269) and written evidence of informed consent was obtained from patients’ parents.
Photos and radiographic images were captured on each patient at a relaxed standing position, with no correction of torticollis. Computed tomography (CT) was performed to provide the details of osseous malformation. Computed tomographic angiography (CTA) was used before operation to evaluate for vertebral and carotid artery malformations. Radiographic parameters were measured independently by 2 surgeons before surgery, 3 months after surgery, and at last follow-up. We recorded the average of each measurement.
On coronal reconstruction view of CT scan, we recorded structural Cobb angle, which is the large curve in the segments with vertebral deformities causing clinical asymmetry or head deviation and needs to be surgically corrected. It is shown as the angle between the lines drawn parallel to the superior endplate of the most cranial vertebra and to the inferior endplate of the most caudal vertebra in the curve.
On standing posteroanterior radiographs of the spine, we measured 4 parameters to describe scoliosis: (1) Compensatory Cobb angle, the small curve without vertebral deformities. It is compensatory to the structural curve and is shown as the angle between the lines drawn parallel to the superior endplate of the most cranial vertebra and to the inferior endplate of the most caudal vertebra in the curve; (2) Mandible incline, the angle between horizontal line and the line through mandibular angles on both sides; (3) Clavicle angle, the angle between horizontal line and the line through the clavicular distal end on both sides; and (4) Spine coronal balance, the distance between a vertical line drawn from the apex of the odontoid process and the vertical line through the midpoint of superior endplate of sacrum. The details are shown in
All parameters were obtained from the PACS (picture archiving and communication system) of the hospital, with an accuracy of 0.1 mm or 0.1°. The postoperative correction rate was calculated using [(preoperation parameter–postoperation parameter)/preoperation parameter]× 100%.
In our department, convex-side resection and concave-side distraction procedure were used before and after 2016. The details of surgical techniques were introduced as follows.
A sterilized 3-dimensional (3D)-printed model was prepared to assist the surgeon to make preoperative surgical plan and recognize anatomical malformations during operation. Neurophysiological monitoring of the spinal cord was done throughout the procedure by measuring somatosensory evoked and motorevoked potentials.
Resection of the cervical hemivertebra was performed using an anterior-posterior-anterior combined approach (
The main procedures consist of 3 steps. Step 1: The hemivertebra body and adjacent discs were entirely dissected and the anterior part of transverse process was removed through an anterior approach. The vertebral artery and nerve root were exposed and protected. Step 2: The lamina, lateral mass with pedicle and the posterior part of the transverse process were removed through a posterior approach. The spinal cord, vertebral artery and nerve root were exposed. Pedicle screws and rods were placed and the gap between adjacent levels after resection was closed by bending the head to convex side under Mayfield traction. Step 3: A polyetheretherketone (PEEK) cage contained auto bone graft was placed into the intervertebral space and titanium plate was placed.
Distraction and lateral opening on concave side to correct cervical scoliosis was also performed using an anterior-posterior-anterior combined approach (
Step 1: Patient was placed in supine position and then given general anesthesia. Conventional anterior cervical approach was used to reach prevertebral space. According to preoperative plan, the intervertebral discs and cartilage plate were removed by curettage and nucleus pulposus forceps. Musculi longus cervicis was dissected subperiosteally and released to the lateral side of uncovertebral joint. The upper or lower level disc was excised and the epiphyseal plates of the upper and lower segments were scraped off to the lateral side of uncovertebral joint. Posterior longitudinal ligament was released and drainage was placed and the incision was closed temporarily.
Step 2: Patient was then placed in the prone position. The lamina, lateral masses on both sides and facet joints were exposed. Pedicle screws were placed in the adjacent upper and lower segments under navigational guidance and fixation rods were placed. After pedicle screws were distracted on concave side under simultaneous Mayfield traction, a valley gap between facet joint on concave side was created. The cartilage of the facet joint was completely removed and cortical bone was roughened. According to the degree of distraction, a well-reshaped and polished PEEK cage or a 3D-printed customized titanium alloy spacer was placed between the upper and lower facet joints and make sure it was in close contact with the cortical bone of the facet joints. After satisfactory position was confirmed under fluoroscopy, nail rod system was locked. Allograft bone grafting was performed around cage, on facet joint, lateral mass, and lamina. Drainage was placed and the incision was closed.
Step 3: Then the patient was placed in supine position for anterior fusion with plate fixation. The upper and lower cartilage plates of the adjacent vertebral bodies were completely removed and the cortical bone was roughened. A PEEK cage or a 3D-printed customized titanium alloy spacer was grafted into the intervertebral space on concave side, above which a titanium plate was placed. At last drainage was placed and the incision was closed.
After surgery, patients were given sufficient analgesia (intravenous nonsteroidal anti-inflammatory drugs and analgesic drugs combined with weak opioids) and prevention of infection (cephalosporin, intravenous infusion for 48 hours). When the drainage flow was less than 50 mL/24 hours, the drainage tube was removed. After the anterior and posterior drainage tubes were removed, the patient was able to move to the ground. Postoperative neck brace braking was not required but within 6 weeks after operation, collar protection should be applied when going out for activities.
An adaptation of Shapiro-Wilk test was used to examine whether the data were normally distributed. Continuous variables with normal distribution were presents as mean± standard deviation; nonnormal variables were reported as median (interquartile range). Categorical variables were analyzed by chi-square test. Mean of 2 continuous normally distributed variables between the 2 groups were compared by 2-independent samples t-test; nonnormal variables were assessed with the Mann-Whitney U-test. Mean of 2 continuous normally distributed variables before and after operation were compared by paired sample t-test in each group; nonnormal variables were assessed with Wilcoxon sign rank test. The data were analysed by IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA). A p-value of <0.05 was considered significant.
No patient presented neurologic deficit before surgery in these 2 groups. Convex-side resection group (group R) contained 15 patients (7 males and 8 females) with an average age of 8.9± 3.3 years (range, 4−15 years) at surgery. All cases in group R were resected one hemivertebra or wedged vertebra totally or partially. The mean operation time was 500± 100 minutes (range, 279–670 minutes) with an average blood loss of 703± 367 mL (range, 100–1,500 mL). The mean follow-up was 46± 18 months (range, 24–72 months) (
Because of the different number of surgical segments in 2 groups, total operation time and total blood loss during surgery cannot make good comparison between groups. Except for the procedure of resection and distraction, pedicle screw placement is the most influential procedure for intraoperative bleeding and operation time. Thus, these 2 data were divided by the number of pedicle screw placed vertebra in each patient. The vertebra of screw placement was shown in
In group R, the mean structural Cobb angle was 29.4°± 12.5° before surgery and 5.3° (range, 2.1°–18.1°) after surgery (Z = -3.408, p=0.001) with an average correction rate of 81.7% (range, 38.0%–90.3%) and 4.2° (range, 1.5°–14.6°) at the last follow-up (Z= -2.544, p= 0.057). The distal compensatory curve averaged 19.3°±11.6° before surgery and 8.7°±6.8° after surgery (t=4.129, p = 0.001) with a mean spontaneous correction rate of 59.6% (range, 40.0%–80.8%) and it was 7.7°± 6.3° at the last follow-up (t= 1.019, p= 0.325). In terms of head tilt and shoulder balance, mandibular incline was corrected from 7.4°± 5.1° to 2.5° (range, 2.1°–4.3°) (Z= -2.386, p= 0.017) and clavicle angle was corrected from 4.8°±3.2° to 1.1° (range, 0.5°–2.3°) (Z=-1.875, p=0.035). Spine Coronal balance changed from 30.3 mm (range, 18.0–46.4 mm) to 10.0 mm (range, 6.7–29.0 mm) (Z= -2.101, p= 0.036).
In group D, the mean structural Cobb angle was 33.7°± 14.1° before surgery and 12.8°±11.4 °after surgery (t=11.197, p<0.001) with an average correction rate of 66.7%±23.4% and 12.5°±11.0° at the last follow-up (t= 0.493, p= 0.630). The distal compensatory curve averaged 19.9° ± 8.6°before surgery and 8.9° ± 7.7° after surgery (t= 8.473, p< 0.001) with a mean spontaneous correction rate of 59.7% ± 23.0% and it was 8.7° ± 7.1° at the last follow-up (t= 0.819, p= 0.427). In terms of head tilt and shoulder balance, mandibular incline was corrected from 4.5°± 2.6° to 1.6° (range, 0.3°–4.4°) (Z= -2.543, p= 0.011) and clavicle angle was corrected from 4.0°±2.0° to 2.0°±1.7° (t=3.140, p=0.008). Spine Coronal balance changed from 25.9± 15.4 mm to 8.5 mm (range, 6.3–22.1 mm) (Z= -3.006, p= 0.010). Details were shown in
In demographic and operative data, group D had less operation time per vertebra (t= 3.146, p= 0.004) and less blood loss per vertebra (t= 4.408, p< 0.001) than group R. The other data showed no statistical difference between the 2 groups. Meanwhile, there was no statistical difference in correction rate of each radiological parameter between the 2 groups (
In group R, 3 of 15 patients developed a postoperative C5 nerve root palsy with a decrease in deltoid muscle strength. Two cases had palsy on convex side and the other one had it on concave side. In group D, 4 of 14 patients developed a postoperative C5 nerve root palsy. Two cases had palsy on convex side and the other 2 had it on concave side (
Congenital cervical scoliosis is a rare but severe spinal deformity. It usually detected incidentally and radiographs are taken only when the patients develop decompensated head and neck tilt that proves recalcitrant to physical therapy [
There is little possibility for compensation above the deformity region in cervical spine [
Surgical treatment should be considered in patients with severe disfiguring deformity or poor prognosis. Posterior arthrodesis in situ of the affected part in spine [
Although this technique can obtain satifatory clinical outcome [
The principle of convex-side resection technique is to remove the hemivertebra or the triangle portion of unsegmented vertebrae. We named this procedure as “peak-cut” procedure because it can rebulit the parallel position of upper and lower vertebrae and correct the torticollis. The concave-side distraction technique can be named as “Valley-fill” procedure. Because this procedure creates a gap like a valley between 2 facets and fill this valley with a spacer, it easily rebulits the paralle position of upper and lower vertebrae and correct the torticollis. To perform a “Valley-fill” procedure, we do not need to expose the neurovascular structure. All the process are carried out within the intervertebral space like disc and facet. Therefore it is easier, safer and faster than “peak-cut” procedure. One additional benifit that patient will obtain from this precedure is his/her body height will be taller immdiately after the surgery.
As shown in
Correction rates of all radiological parameters between the 2 groups have no statistical difference, which indicate these 2 methods have similar orthopedic effect (
Regarding complications, all patients with postoperative C5 nerve root palsy completely recovered by 6 months of follow-up. Hence we believe that intraoperative traction or transient ischemia of the nerve root could be the main cause for this complication.
Our study has some limitations. First, it had a small sample size and included only certain types of deformities and thus was not fully representative of the complexity of congenital cervical scoliosis since this condition is extremely rare. However, to the best of our knowledge, this is the first study to introduce a novel technique to treat congenital cervical scoliosis. Second, given the young age of our patients,the follow-up duration is still relatively short. Thus, a longterm follow-up study should be conducted in the future. Third, additional clinical results, like patients and parents satisfaction degree, are needed to better evaluate these 2 surgical techniques in the further studies.
By means of these 2 surgical techniques, a sufficient correction of cervical scoliotic deformity is achieved and the head tilt is corrected. Concave-side distraction technique has less operation time and blood loss during surgery and similar correction rates compared to hemivertebra resection precedure. It is a better and safer option to treat congenital cervical scoliosis.
The authors have nothing to disclose.
Application Research and Promotion of Clinical Characteristics in Beijing (Z161100000516004).
Conceptualization: XC, SP, YD, YZ, TX, WL, FZ, YS; Data curation: SC, YD, TX, WL, YS; Formal analysis: SC, XC, TX, WL, YS; Funding acquisition: XC, SP, YD, YZ, WL, FZ, YS; Methodology: SC, XC, YD, TX, WL, FZ, YS; Project administration: SC, XC, SP, YD, YZ, TX, FZ, YS; Visualization: SC, XC, SP, YZ, WL, FZ, YS; Writing - original draft: SC; Writing - review & editing: SC, YS
Radiographic assessment parameters. (A) On the coronal reconstruction view of computed tomography scan, structural Cobb angle (a) is the large curve with vertebral deformities and is shown as the angle between the lines drawn parallel to the superior endplate of the most cranial vertebra and to the inferior endplate of the most caudal vertebra in the curve. (B) On the standing posteroanterior radiographs of the spine, Compensatory Cobb angle (b) is the small curve without vertebral deformities and is compensatory to the structural curve; Mandible incline (c) is the angle between the horizontal line and the line through the mandibular angles on both sides; Clavicle angle (d) is the angle between the horizontal line and the line through the clavicular distal end on both sides; Spine coronal balance (e) is the distance between a vertical line drawn from the apex of the odontoid process and the vertical line through the midpoint of superior endplate of sacrum.
Photographs and radiographs from case 6, group R (convex-side resection group). A 6-year-old boy with left C4 fully segmented hemivertebra. (A) A preoperative photograph shows obvious torticollis and head tilt. (B, C, F) Posteroanterior radiographs and computed tomography (CT) scan on coronal reconstruction view show mandible incline angle is 6.1°, clavicle angle is 1.3° and spine coronal balance is 18.0 mm. Structural and compensatory Cobb angle are 31.6°, 25.4°. (D, E) Three-dimensional (3D) reconstruction on CT scan and 3D-printed model. (G) Photographs after surgery show obvious improved appearance. (H, I, L) Posteroanterior radiographs and CT scan show mandible incline angle is 0.4°, clavicle angle is 1.4° and spine coronal balance is 25.2 mm. Structural and compensatory Cobb angle are 7.7°, 14.7°. (J, K) Photographs show a sterilized 3D printed model is prepared to assist the surgeon in recognizing anatomical malformations during operation. A gap is showed after left C4 hemi lamina resection (green arrow) and intraoperative fluoroscopy.
Photographs and radiographs from case 2, group D (concave-side distraction group). A 9-year-old girl with right C5 fully segmented hemivertebra and C2–3 block vertebra. (A) A preoperative photograph shows obvious torticollis and head tilt. (B–D) Posteroanterior radiographs and computed tomography (CT) scan on coronal reconstruction view show mandible incline angle is 6.3°, clavicle angle is 2.1°, spine coronal balance is 15.3 mm. Structural and compensatory Cobb angle are 35.4°, 11.0°. (D, E) Three-dimensional (3D) printed model and designed surgical plan show C5 right hemivertebra and 3D-printed metal spacers are placed between left C4–6 vertebral bodies and left C4–6 facet joint to distract concave side. (G) Photographs after surgery show obvious improved appearance. (H, I, J) Posteroanterior radiographs and CT scan show mandible incline angle is 0.1°, clavicle angle is 5.2°, spine coronal balance is 7.2 mm. Structural and compensatory Cobb angle are 4.9°, 1.7°. Two 3D-printed metal spacers between left C4–6 vertebral bodies and left C4–6 facet joint are placed as surgical plan.
Diagram of each surgical process for concave-side distraction technique. (A) Anterior approach, the initial status before surgery. (B) Soft tissue release on intervertebral disc and uncovertebral joint. (C) Posterior approach, the initial status before surgery. (D) Soft tissue release on facet joint capsule and ligamentum flavum. (E) Place a 3-dimensional (3D)-printed customized spacer between the facet joint on concave side to correct scoliosis. (F) Anterior approach, place a 3Dprinted customized spacer between the vertebral bodies on concave side to correct scoliosis.
Demographic data for patients
Group | Patient No. | Sex | Age (yr) | Deformity types | VA anomaly | Follow-up period (mo) |
---|---|---|---|---|---|---|
R | 1 | M | 5 | Left C5 fully segmented HVB; C2–3 right unilateral bar | None | 54 |
2 | F | 10 | Left T2 fully segmented HVB; C2–3, C5–T1 block vertebra | None | 48 | |
3 | F | 10 | Left C3 semi segmented WVB; C2–3, C6–7 block vertebra | Right twisted VA | 72 | |
4 | M | 7 | Right C6 fully segmented HVB; Occipitalization of atlas; C3–5 block vertebra | Right fine VA | 72 | |
5 | F | 12 | Right T1 fully segmented HVB; C2–4, C5–6 block vertebra | Right fine VA | 60 | |
6 | M | 6 | Left C4 fully segmented HVB | None | 24 | |
7 | F | 9 | Right C3 semi segmented WVB; Occipitalization of atlas; C2–3 block vertebra | Left fine VA | 24 | |
8 | M | 14 | Right C3 semi segmented WVB; C2–4 block vertebra | None | 28 | |
9 | F | 8 | Left C6 fully segmented WVB | None | 60 | |
10 | M | 12 | Right C3 fully segmented WVB | None | 72 | |
11 | M | 9 | Right C4 fully segmented HVB; C2–3 block vertebra; dysplasia of occipital condyle and atlas | None | 24 | |
12 | F | 7 | Left C4 semi segmented WVB; Occipitalization of atlas, Atlantoaxial subluxation; C5–6 right unilateral bar | Left fine VA | 6 | |
13 | F | 4 | Left C4 non segmented butterfly VB; C2–5 block vertebra; C6–7 right unilateral bar | None | 48 | |
14 | M | 6 | Left C3 non segmented HVB; C1–4 block vertebra | None | 48 | |
15 | F | 15 | Left C4 semi segmented HVB; C1–4 block vertebra | None | 36 | |
D | 1 | F | 10 | Left C3 semi segmented WVB; C3–4 block vertebra | None | 24 |
2 | F | 9 | Right C5 fully segmented HVB; C2–4 block vertebra | None | 31 | |
3 | M | 6 | Left C3 fully segmented HVB | Left fine VA | 30 | |
4 | M | 7 | Left C3 fully segmented WVB; C2–3 right unilateral bar | None | 24 | |
5 | M | 10 | Left C4 nonsegmented HBV; C2–5 block vertebra | None | 24 | |
6 | F | 6 | Left C3 nonsegmented WBV; C2–3–4 block vertebra | Right fine VA | 26 | |
7 | F | 6 | Right T1 fully segmented HVB; C5–7, T2–3 block vertebra | None | 60 | |
8 | M | 10 | Right C3 semi segmented WVB; C2–3 block vertebra | None | 48 | |
9 | F | 9 | Left C3 semi segmented HVB; C2–3 right unilateral bar | None | 25 | |
10 | F | 13 | Left C3 nonsegmented WBV; C2–6 block vertebra; C2–3 right unilateral bar | Right fine VA | 24 | |
11 | M | 13 | Left C3,C5 non segmented WVB; C2–6 block vertebra | None | 72 | |
12 | M | 13 | Left C5 nonsegmented HVB, C2–3,C4–5–6 block vertebra | None | 24 | |
13 | M | 14 | Right C3 fully segmented HVB, left T2 fully segmented HVB | None | 48 | |
14 | M | 13 | Right C5 fully segmented HVB; C2–4, C6–7 block vertebra; T1 butterfly vertebra | None | 24 |
Group R, convex-side resection group; group D, concave-side distraction group; VA, vertebral artery; HVB, hemivertebra; WVB, wedged vertebra; VB, vertebra.
Surgical details for patients
Group | Patient No. | Surgical details | Resected VB or distracted segment | Fusion levels | VB of screw placement | Surgical time (min) | Blood loss (mL) | Complications |
---|---|---|---|---|---|---|---|---|
R | 1 | A: C5 hemivertebrectomy P: C5 laminectomy; left C4–6 facetectomy; C4, C6 pedicle screw fixation and fusion A: C4–6 bone fusion with plate fixation | C5 | C4–6 | C4, C6 | 570 | 500 | None |
2 | A: T2 hemivertebrectomy P: T2 laminectomy; left T1–2–3 facetectomy; T1, T3 pedicle screw fixation and fusion A: T1–3bone fusion with plate fixation | T2 | T1–3 | T1, T3 | 550 | 900 | None | |
3 | A: C3 partial wedged vertebrectomy P: C3 laminectomy; left C2–3 facetectomy; C2, C3 pedicle screw fixation and fusion A: C2–3 bone fusion with plate fixation | C3 | C2–3 | C2, C3 | 510 | 900 | None | |
4 | A: C6 hemivertebrectomy P: C6 laminectomy; left C5–6 facetectomy; C5, T1 pedicle screw fixation and fusion A: C5–7 bone fusion with plate fixation | C6 | C5–T1 | C5, T1 | 670 | 600 | None | |
5 | A: T1 hemivertebrectomy P: T1 laminectomy; left C7–T2 facetectomy; C7, T2 pedicle screw fixation and fusion A:C7–T2 bone fusion with plate fixation | T1 | C7–T2 | C7, T2 | 600 | 750 | C5 verve root palsy on convex side | |
6 | A: C4 hemivertebrectomy P: C4 laminectomy; left C3–5 facetectomy; C3, C5 pedicle screw fixation and fusion A:C3–5 bone fusion with plate fixation | C4 | C3–5 | C3, C5 | 358 | 1,100 | None | |
7 | A: C3 partial wedged vertebrectomy P: C3 laminectomy; right C2–4 facetectomy; C2, C4 pedicle screw fixation and fusion A: C2–4 bone fusion with plate fixation | C3 | C2–4 | C2, C4 | 500 | 700 | None | |
8 | A: C3 wedged vertebrectomy P: C3 laminectomy; right C2–4 facetectomy; C2, C4 pedicle screw fixation and fusion A:C2–4 bone fusion with plate fixation | C3 | C2–4 | C2, C4 | 500 | 1,500 | None | |
9 | A: C6 partial wedged vertebrectomy P: C6 partial laminectomy; left C5–6 facetectomy; C5, C7 pedicle screw fixation and fusion A: C5–6 bone fusion with plate fixation | C6 | C5–7 | C5, C7 | 483 | 100 | None | |
10 | A: C3 partial wedged vertebrectomy P: Right C2–3 laminectomy and facetectomy; C2, C3 pedicle screw fixation and fusion A: C2–3 bone fusion with plate fixation | C3 | C2–3 | C2, C3 | 279 | 150 | None | |
11 | A: C4 hemivertebrectomy P: C4 laminectomy; right C3–5 facetectomy; C2, C6 pedicle screw fixation and fusion A: C3–5 bone fusion with plate fixation | C4 | C2–6 | C2, C6 | 360 | 700 | C5 verve root palsy on convex side | |
12 | A: C4 partial wedged vertebrectomy P: C4 partial laminectomy; left C3–5 facetectomy; Occipital screws and C3, C5, C7 pedicle screw fixation and fusion A: C3–5 bone fusion with plate fixation | C4 | C0–7 | C3, C5, C7 | 572 | 850 | C5 verve root palsy on concave side | |
13 | A: C4 butterfly vertebrectomy P: C4 laminectomy; left C3–5 facetectomy; C3,C5 pedicle screw fixation and fusion A: C3–5 bone fusion with plate fixation | C4 | C3–5 | C3, C5 | 528 | 400 | None | |
14 | A: C3 hemivertebrectomy P: C3 laminectomy; left C2–4 facetectomy; C2, C4 pedicle screw fixation and fusion A: C2–4 bone fusion with plate fixation | C3 | C0–4 | C2, C4 | 494 | 400 | None | |
15 | A: C4 hemivertebrectomy P: C4 laminectomy; left C3–5 facetectomy; C2, C6 pedicle screw fixation and fusion A: C3–6 bone fusion with plate fixation | C4 | C2–6 | C2, C6 | 523 | 1,000 | None | |
D | 1 | A: C4–5 discectomy, soft tissue release P: right C4–5 facetectomy and distraction, 3D spacer inserted; C4, C5 pedicle screw fixation and fusion A: C4–5 bone fusion with plate fixation | C4–5 | C4–5 | C4, C5 | 326 | 125 | None |
2 | A: C4–6 discectomy, soft tissue release P: left C4–6 facetectomy and distraction, 3D spacer inserted; C4, C6 pedicle screw fixation and fusion A: C4–6 bone fusion with plate fixation | C4–6 | C4–6 | C4, C6 | 402 | 110 | C5 verve root palsy on concave side | |
3 | A: C3–4 discectomy, soft tissue release P: C3 laminectomy, C3–4 facetectomy and right C3–4 distraction, cage inserted; C2, C4 pedicle screw fixation and fusion A: C2–4 bone fusion with plate fixation | C3–4 | C2–4 | C2, C4 | 424 | 260 | None | |
4 | A: C3–4 discectomy, soft tissue release P: right C3–4 facetectomy and distraction, cage inserted; C2, C4 pedicle screw fixation and fusion A: C3–4 bone fusion with plate fixation | C3–4 | C2–4 | C2, C4 | 394 | 240 | None | |
5 | A: C5–6 discectomy, soft tissue release P: right C5–6 facetectomy and distraction, cage inserted; C5, C6 pedicle screw fixation and fusion A: C5–6 bone fusion with plate fixation | C5–6 | C5–6 | C5, C6 | 603 | 500 | C5 verve root palsy on concave side | |
6 | A: C4–5 discectomy P: right C4–5 facetectomy and distraction, cage inserted; C2, C5 pedicle screw fixation and fusion A: C4–5 bone fusion with plate fixation | C4–5 | C2–5 | C2, C5 | 344 | 115 | None | |
7 | A: C7–T1 discectomy P: left C7–T2 distraction, cage inserted; C5, C7, T2, T4 pedicle screw fixation and fusion A: C7–T2 bone fusion with plate fixation | C7–T2 | C5–T4 | C5, C7, T2, T4 | 514 | 500 | None | |
8 | A:C3–4 discectomy P: left C2–4 facetectomy and distraction, cage inserted; C2, C4 pedicle screw fixation and fusion A: C2–4 bone fusion with plate fixation | C2–4 | C2–4 | C2, C4 | 447 | 200 | None | |
9 | A: C3-4-5 discectomy, soft tissue release P: right C3-4-5 facetectomy and distraction, two cages inserted; C2, C4, C5 pedicle screw fixation and fusion A: C3-4-5 bone fusion with plate fixation | C3–4,C4–5 | C2–5 | C2, C4, C5 | 589 | 430 | C5 verve root palsy on convex side | |
10 | A: C4-5-6-7 discectomy, soft release P: right C5-6-7 facetectomy and distraction, two cages inserted; C4, C6, C7 pedicle screw fixation and fusion A: C4-5-6-7 bone fusion with plate fixation | C5–6,C6–7 | C4–7 | C4, C6, C7 | 660 | 500 | None | |
11 | A: Osteotomy among C3–4–5, soft release P: Osteotomy among C3-4-5 lamina, right C2–4, C4–6 distraction, two cages inserted; C2, C4, C6 pedicle screw fixation and fusion A: C2-4-6 bone fusion with plate fixation | C2–4,C4–6 | C2–6 | C2, C4, C6 | 604 | 600 | None | |
12 | A: C3–4, C6–7 discectomy, soft tissue release P: right C3–4, C6–7 facetectomy and distraction, 2 cages inserted; C3, C4, C6, C7 pedicle screw fixation and fusion A: C3–4, C6–7 bone fusion with plate fixation | C3–4,C6–7 | C3–4, C6–7 | C3, C4, C6, C7 | 450 | 550 | None | |
13 | A: C2–4, T1–3 discectomy, soft tissue release P: left C2–4, right T1–3 facetectomy and distraction, two cages inserted; C2, C4, C7, T1, T3, T4 pedicle screw fixation and fusion A: C2–4, T1–3 bone fusion with plate fixation | C2–4,T1–3 | C2–4, C7–T4 | C2, C4, C7, T1, T3, T4 | 652 | 510 | None | |
14 | A: C4–5–6, C7–T1 discectomy P: left C4–6, C7–T1 facetectomy and distraction, 2 cages inserted; C2, C4, C6, C7, T1, T3 pedicle screw fixation and fusion A: C4–6, C7–T1 bone fusion with plate fixation | C4–6, C7–T1 | C2–T3 | C2, C4, C6, C7, T1, T3 | 606 | 600 | C5 verve root palsy on convex side |
Group R, convex-side resection group; group D, concave-side distraction group; VB, vertebra; A, anterior approach; P, posterior approach.
Correction results for 2 groups
Group | Parameter | Preoperation | Postoperation | Correction rate after operation (%) | p-value (preop vs. postop) | LFU | Correction rate at LFU (%) | p-value (postop vs. LFU) |
---|---|---|---|---|---|---|---|---|
R | Structural Cobb angle (°) | 29.4 ± 12.5 | 5.3 (2.1,18.1) | 81.7 (38.0–90.3) | Z = -3.408, p = 0.001 |
4.2 (1.5–14.6) | 81.7 (46.7–92.2) | Z = -2.544, p = 0.057 |
Compensatory Cobb angle (°) | 19.3 ± 11.6 | 8.7 ± 6.8 | 59.6 (40.0–80.8) | t = 4.129, p = 0.001 |
7.7 ± 6.3 | 70.0 (36.9–89.9) | t = 1.019, p = 0.325 | |
Mandibular incline (°) | 7.4 ± 5.1 | 2.5 (2.1–4.3) | 53.7 (20.7–77.0) | Z = -2.386, p = 0.017 |
2.2 ± 1.7 | 77.8 (49.2–90.0) | Z = -1.789, p = 0.074 | |
Clavicle angle (°) | 4.8 ± 3.2 | 1.1 (0.5–2.3) | 56.2 (5.7–88.9) | Z = -1.875, p = 0.035 |
1.5 (0.5–2.3) | 65.7 (16.2–71.2) | Z = -0.881, p = 0.378 | |
Spine coronal balance (mm) | 30.3 (18.0–46.4) | 10.0 (6.7–29.0) | 52.2 (-5.3–77.6) | Z = -2.101, p = 0.036 |
12.4 (5.4–22.3) | 67.2 (0.0–78.8) | Z = -0.596, p = 0.551 | |
D | Structural Cobb angle (°) | 33.7 ± 14.1 | 12.8 ± 11.4 | 66.7 ± 23.4 | t = 11.197, p < 0.001 |
12.5 ± 11.0 | 67.7 ± 23.0 | t = 0.493, p = 0.630 |
Compensatory Cobb angle (°) | 19.9 ± 8.6 | 8.9 ± 7.7 | 59.7 ± 23.0 | t = 8.437, p < 0.001 |
8.3 ± 7.1 | 63.7 ± 20.8 | t = 0.819, p = 0.427 | |
Mandibular incline (°) | 4.5 ± 2.6 | 1.6 (0.3–4.4) | 44.2 ± 48.1 | Z = -2.543, p = 0.011 |
2.5 ± 1.8 | 55.3 (6.2–82.9) | Z = 0.183, p = 0.858 | |
Clavicle angle (°) | 4.0 ± 2.0 | 2.0 ± 1.7 | 40.0 (23.6–85.9) | t = 3.140, p = 0.008 |
1.3 ± 1.2 | 73.7 (44.3–94.4) | t = -1.749, p = 0.080 | |
Spine coronal balance (mm) | 25.9 ± 15.4 | 8.5 (6.3–22.1) | 28.7 ± 57.7 | Z = --3.006, p = 0.010 |
7.1 (4.6–17.8) | 61.1 (15.1–82.8) | Z = 0.600, p = 0.559 |
Values are presented as mean±standard deviation or median (interquartile range).
Group R, convex-side resection group; group D, concave-side distraction group; LFU, last follow-up.
p<0.05.
Comparison between the 2 groups
Variable | Group R (15 cases) | Group D (14 cases) | p-value |
---|---|---|---|
Sex, male:female | 7:8 | 8:6 | X2 = 0.318, p = 0.715 |
Age (yr) | 8.9 ± 3.3 | 9.9 ± 2.8 | t = -0.863, P= 0.396 |
Operation time per vertebra (min) | 243 ± 51 | 181 ± 55 | t = 3.146, p = 0.004 |
Blood loss per vertebra (mL) | 342 ± 183 | 123 ± 55 | t = 4.408, p < 0.001 |
Complication cases | 3/15 | 4/14 | X2 = 0.291, p = 0.682 |
Correction rate at LFU (%) | |||
Structural Cobb angle (°) | 81.7 (46.7–92.2) | 67.7 ± 23.0 | Z = -0.415, p = 0.683 |
Compensatory Cobb angle (°) | 70.0 (36.9–89.9) | 63.7 ± 20.8 | Z = -0.153, p = 0.879 |
Mandibular incline (°) | 77.8 (49.2–90.0) | 55.3 (6.2–82.9) | Z = -1.616, p = 0.106 |
Clavicle angle (°) | 65.7 (16.2–71.2) | 73.7 (44.3–94.4) | Z = -1.223, p = 0.234 |
Spine coronal balance (mm) | 67.2 (0.0–78.8) | 61.1 (15.1–82.8) | Z = -0.284, p = 0.777 |
Values are presented as mean±standard deviation or median (interquartile range).
Group R, convex-side resection group; group D, concave-side distraction group; LFU, last follow-up.
p<0.05.