Role of Pedicle Subtraction Osteotomy in the treatment of Kyphotic Deformity of the Spine.
Abstract
Objective: To determine the functional and radiological outcome of Pedicle Subtraction Osteotomy (PSO) in the treatment of kyphotic deformity of the spine.
Methods: This descriptive study was conducted in Orthopaedic unit Karnali Academy of Health Sciences, Jumla Nepal and Orthopaedic and Spine unit Lahore General Hospital from 23rd March 2017 to 23rd March 2020.All patients with kyphotic deformity and sagittal imbalance fulfilling the inclusion criteria were treated with PSO. Post operative functional and neurological outcome was assessed with Oswestry Disability Index(ODI) Questionnaire and Frankel Grade system while radiological outcome was evaluated by measuring the Kyphotic angle. Patients were graded as per ODI results as having minimal disability (0 to 20% score), moderate (21% to 40%), severe (41% to 60%), crippled (61% to 80%) and bed bound (81% to 100%) disability. Neurological categorization of the patients were done as per Frankel Grade system from A(Complete motor and sensory deficit) to E (Complete motor and sensory recovery).Comparison of pre operative and post operative ODI and Frankel Grade system was done and P value was calculated with paired Sample-t test and Chi-square test and. P value <0.05 was considered significant.
Results: We operated 15 patients with PSO. The mean age of our patients was 21.6±8.5 years. Female patients were 9(60%) and males were 6(40%). The mean pre-operative ODI of 44.6% (Sever disability) was statistically improved (P<0.05) to 18.66% (Minimal disability) post operatively at one year follow up. The mean pre-operative and post-operative kyphotic angles were 34.72°±4.34° and 1.88°±21.13° (P<0.05) respectively. Neurological deficit improved from Frankel Grade D to E in 1(6.66%) patient while 1(6.66%) patient had post-operative neurological deficit with Frankel grade C at one year follow up.
Conclusion: Pedicle subtraction osteotomy is a safe and valid surgical technique for the correction of kyphotic deformity of the spine as shown by excellent functional and radiological outcome achieved in majority of our patients.
References
Perriman DM, Scarvell JM, Hughes AR, Ashman B, Lueck CJ, Smith PN. Validation of the flexible electrogoniometer for measuring thoracic kyphosis. Spine (Phila Pa 1976). 2010; 35 (14): 633-640.
Ulmar B, Guhring M, Schmalzle T, Weise K, Badke A, Brunner A. Inter- and intra-observer reliability of the Cobb angle in the measurement of vertebral, local and segmental kyphosis of traumatic lumbar spine fractures in the lateral X-ray. Arch Orthop Trauma Surg. 2010; 130(12): 1533-1538.
Macagno AE, O'Brien MF. Thoracic and thoracolumbar kyphosis in adults. Spine (Phila Pa 1976). 2006; 31 (19 Suppl): S161-170.
Shelton YA. Scoliosis and kyphosis in adolescents: diagnosis and management. Adolesc Med State Art Rev.2007; 18(1): 121-139.
Atici Y, Balioglu MB, Kargin D, Mert M, Albayrak A, Kaygusuz MA. Analysis of complications following posterior vertebral column resection for the treatment of severe angular kyphosis greater than 100 degrees. Acta Orthop Traumatol Turc. 2017; 51(3): 201-208.
Qiu J, Peng Y, Qiu X, Gao W, Liang T, Zhu Y, et al. Comparison of anterior or posterior approach in surgical treatment of thoracic and lumbar tuberculosis: a retrospective case-control study. BMC Surg.2022; 22(1): 161. doi: 10.1186/s12893-022-01611-1.
Suk S-I, Kim J-H, Kim W-J, Lee S-M, Chung E-R, Nah K-H. Posterior Vertebral Column Resection For Severe Spinal Deformities. Spine. 2002; 27(21): 2374-2382
Hu FQ, Hu WH, Zhang H, Song K, Wang Y, Wang TH, et al. Pedicle Subtraction Osteotomy with a Cage Prevents Sagittal Translation in the Correction of Kyphosis in Ankylosing Spondylitis. Chin Med J. 2018; 131(2): 200-206.
Thomasen E: Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop Relat Res1985; 194: 142-152.
Sciubba DM, Gallia GL, McGirt MJ, Woodworth GF, Garonzik IM, Witham T, et al. Thoracic kyphotic deformity reduction with a distractible titanium cage via an entirely posterior approach. Neurosurgery. 2007; 60 (4 Suppl 2): 223-230.
Cho WJ, Kang CN, Park YS, Kim HJ, Cho JL. Surgical Correction of Fixed Kyphosis: Asian Spine J. 2007; 1(1): 12-18.
Smith-Petersen MN, Larson CB, Aufranc OE. Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. Clin Orthop Relat Res. 1969; 66:6-9.
Gupta MC, Gupta S, Kelly MP, Bridwell KH. Pedicle Subtraction Osteotomy. JBJS Essent Surg Tech. 2020; 10(1): e0028.1-11. doi: 10.2106/JBJS.ST.19.00028.
Kirshblum S, Botticello A, Benedetto J, Donovan J, Marino R, Hsieh S, et al. Comparison of Diagnostic Stability of the ASIA Impairment Scale Versus Frankel Classification Systems for Traumatic Spinal Cord Injury. Arch Phys Med Rehabil. 2020; 101(9): 1556-1562.
Werneke M, Hayes D, Deutscher D. Clinical utility of the Oswestry Disability Index for measuring the function of patients with low back pain. Spine J. 2018; 18(4): 712-713.
Hyun SJ, Kim YJ, Rhim SC. Spinal pedicle subtraction osteotomy for fixed sagittal imbalance patients. World J Clin Cases. 2013; 1(8): 242-248.
Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients: a long-term follow-up data. J Korean Neurosurg Soc. 2010; 47: 95-101.
Heary RF, Bono CM. Pedicle subtraction osteotomy in the treatment of chronic, posttraumatic kyphotic deformity. J Neurosurg Spine. 2006; 5(1): 1-8.
Lin G, Wang S, Yang Y, Su Z, Du Y, Xu X, et al. The effect of pedicle subtraction osteotomy for the correction of severe Scheuermann thoracolumbar kyphosis on sagittal spinopelvic alignment. BMC Musculoskelet Disord. 2021; 22: 165. Doi:https://doi.org/10.1186/s12891-020-03942-7
El-Sharkawi MM, Koptan WM, El-Miligui YH, Said GZ. Comparison between pedicle subtraction osteotomy and anterior corpectomy and plating for correcting post-traumatic kyphosis: a multicenter study. Eur Spine J. 2011; 20 (9): 1434-1440.
Berven SH, Deviren V, Smith JA, Emami A, Hu SS, Bradford DS. Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy. Spine (Phila Pa 1976) 2001; 26 (18): 2036-2043
Bridwell KH, Lewis SJ, Edwards C, Lenke LG, Iffrig TM, Berra A, et al. Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine (Phila Pa 1976). 2003 Sep 15; 28 (18): 2093-2101.
Ahn UM, Ahn NU, Buchowski JM, Kebaish KM, Lee JH, Song ES, et al. Functional outcome and radiographic correction after spinal osteotomy. Spine (Phila Pa 1976). 2002 Jun 15; 27 (12): 1303-1311.
Daubs MD, Brodke DS, Annis P, Lawrence BD. Perioperative Complications of Pedicle Subtraction Osteotomy. Global Spine J. 2016; 6 (7): 630-635.
Ames CP, Barry JJ, Keshavarzi S, Dede O, Weber MH, Deviren V. Perioperative Outcomes and Complications of Pedicle Subtraction Osteotomy in Cases With Single Versus Two Attending Surgeons. Spine Deform. 2013; 1 (1): 51-58.