Management of delayed posttraumatic cervical kyphosis

We describe three patients with misdiagnosed unstable fractures of the cervical spine, who were treated conservatively and developed kyphotic deformity, myelopathy, and radiculopathy. All three patients were then managed with closed reductions by crown halo traction, followed by instrumented fusions. Their neurologic function was regained without permanent disability in any patient. Unstable fractures of the cervical spine will progress to catastrophic neurologic injuries without surgical fixation. Posttraumatic kyphosis and the delayed reduction of partially healed fracture dislocations by preoperative traction are not well characterized in the subaxial cervical spine. The complete evaluation of any subaxial cervical spine fracture requires CT scanning to assess for bony fractures, and MRI to assess for ligamentous injury. This allows for assessment of the degree of instability and appropriate management. In patients with delayed posttraumatic cervical kyphosis, preoperative closed reduction provided adequate realignment, facilitating subsequent operative stabilization.     

Straight Back Syndrome: positive response to spinal manipulation and adjunctive therapy – A case report

Straight Back Syndrome (SBS) has been recognized for over 50 years. Not to be confused with flat back syndrome in the lumbar spine, SBS patients present with an obvious loss of the thoracic kyphosis accompanied by apparent heart symptoms. The main purpose of this article is to describe a patient diagnosed with SBS, whose symptoms were successfully managed using spinal manipulative therapy as well as ancillary modalities. The use of diagnostic and laboratory tests are essential to differentially diagnose cardiac disease from SBS. Genesis and incidence of this condition is also discussed as well as roentgenometric analysis. A suggested diagnostic algorithm is presented as well.     

Hyperkyphosis and back pain are not associated with prevalent vertebral fractures in women with osteoporosis

Abstract

Vertebral fractures (VFs) are the clinical consequence of spinal osteoporosis and may be associated with back pain and aggravated kyphosis. However, the relative importance of VFs as an underlying cause of kyphosis and chronic back pain is not known. The aim of this study was to investigate the relationship between prevalent VFs and the size of kyphosis, and back pain in osteoporotic women. Thirty-six women, aged 74.6?±?8.3 years, were consecutively recruited from the osteoporosis unit at Uppsala University Hospital. The patients had 1–9 radiographic verified VFs. Tragus wall distance (TWD) and numeric rating scale were used to measure kyphosis and pain. All patients had a hyperkyphosis (TWD?≥?10?cm). Notably, there were no associations between numbers or location of VFs versus size of kyphosis (ρ?=?0.15, p?=?0.4; ρ?=??0.27, p?=?0.12) or severity of back pain (ρ?=??0.08, p?=?0.66; ρ?=?0.16, p?=?0.35). Furthermore, no association was evident between kyphosis and back pain (ρ?=??0.02, p?=?0.89). There was, however, an association between size of kyphosis and age (R?=?0.44, p?=?0.008). In conclusion, these data suggest that prevalent VFs are not significantly associated with kyphosis or chronic back pain, in patients with manifest spinal osteoporosis.     

蛋壳技术在强直性脊柱炎并脊柱后凸畸形矫形中的应用

[目的]观察腰椎后路经椎弓根椎体楔形截骨的蛋壳技术在治疗强直性脊柱炎后凸畸形中的临床效果.[方法] 34例强直性脊柱炎后凸畸形患者,平均年龄为34.6岁,男性27例,女性7例.根据术前测量的颌眉垂线角,采用后路经L2或L2及L3椎弓根的椎体楔形截骨.[结果]所有患者都能很好的耐受手术.手术时间为150～ 210min,出血量为1 000～2 400 ml.无神经系统并发症发生.颌眉垂线角由术前的平均41°矫正为术后的平均为5°.所有患者能够平视行走,矢状面平衡和步态得到明显改善.随访中植骨均获骨性融合,无断钉及内固定失效发生.[结论]腰椎后路经椎弓根的蛋壳技术,能够在充分保护脊髓和神经根的前提下实现椎体的楔形截骨,对于强直性脊柱炎后凸畸形具有良好的治疗效果.     

半椎体切除术治疗先天性脊柱侧后弯畸形

目的分析一期后路半椎体切除治疗先天性脊柱侧后凸畸形的手术效果,并探讨手术固定融合节段方案的选择。方法回顾分析15例由半椎体引起侧后凸畸形的患儿,其中男9例,女6例,年龄3～17岁,平均13.5岁。均行后路半椎体切除、矫形内固定及情骨融合手术。结果随访15～68个月,平均40.5个月。术后矫形效果满意,侧凸畸形由术前平均45.3°改善至11.4°（矫正率达68.7%）;后凸畸形由术前的平均35.5°,矫正至11.4°（矫形率达67.9%）,远期矫形丢失率低,植骨融合良好,无内固定物断裂松动等并发症。结论一期后路半椎体切除、椎弓根钉棒系统矫形内固定和植骨融合手术,可以有效矫正青少年脊柱结构性侧后凸畸形。     

肋椎关节损害对强直性脊柱炎胸腰椎后凸畸形患者肺功能的影响

目的:分析强直性脊柱炎(ankylosing spondylitis,AS)胸腰椎后凸畸形患者肺功能损害的模式,探讨其肺功能与肋椎关节损害程度的相关性。方法:2004年4月~2011年12月采用截骨矫形术治疗45例AS胸腰椎后凸畸形患者,男41例,女4例,年龄22~60岁,平均34.6岁;病程3~37年,平均13.5年。后凸Cobb角55°~120°,平均83.5°。患者术前均行肺功能检测;根据患者术前CT评估其肋椎关节损害程度,并分为0、1、2、3、4共5级,对存在肺功能障碍伴肋椎关节损害的患者根据关节损害程度分组,1、2级为A组,3、4级为B组,对两组间肺功能参数进行比较;并对肋椎关节损害程度与术前Cobb角、年龄、病程和肺功能参数进行相关性分析。结果:7例肺功能正常;38例(84.4%)伴有不同程度的肺功能障碍,其中轻度13例,中度22例,重度3例;限制性通气功能障碍23例,阻塞性2例,混合性13例。41例(91.1%)患者出现不同程度的肋椎关节损害,其中1级7例,2级13例,3级18例,4级3例。B组患者肺活量(VC)、用力肺活量(FVC)及30倍第1秒用力肺活量(FEV1*30)等肺功能参数的实际值与预测值的百分比明显低于A组患者(P<0.05)。肋椎关节损害程度与后凸Cobb角呈正相关(r=0.43,P=0.024),而与患者年龄和病程无明显相关性(r=0.08,0.44,P>0.05);VC、FVC及FEV1*30等参数的实际值与预测值的百分比均与肋椎关节损害程度有负相关性(r=-0.49,-0.35,-0.39,P<0.05)。结论:AS胸腰椎后凸畸形患者肺功能障碍较为常见,损害程度以中度通气功能障碍为主,损害类型以限制性通气功能障碍为主。肋椎关节损害是AS胸腰椎后凸畸形患者肺功能损害的一个影响因素。     

Children with acute Perthes' disease have asymmetrical lower leg growth and abnormal collagen turnover

Background?Abnormalities in distal growth and low levels of insulin–like growth factor (IGF)–I have been reported in children with Perthes' disease. Our aim was to establish whether the acute phase of Perthes' disease is associated with abnormalities of growth, of bone or of collagen turnover.

Methods?We performed a cross–sectional study of 15 children (3–11 years of age, 13 boys) at acute presentation and a longitudinal cohort study of 9 children. We measured (1) the lengths of both lower legs (by knemometry) at weeks 1, 2, 6 and 12, (2) height and weight at presentation and at the second–year follow–up, and (3) levels of IGF–I, IGFBP–3, collagen markers and bone alkaline phosphatase at weeks 1 and 12, and in year 2.

Results?Height SD scores were normal at presentation but declined thereafter. Lower leg growth was not impaired at presentation but was asymmetrical, ceased during weeks 2–6, and then resumed symmetrically. Patients had persistently low IGF–I, low soft tissue collagen synthesis and enhanced collagen breakdown compared with age– and sex–related reference data. Markers of bone formation increased during follow–up.

Interpretation?Acute changes in lower leg growth reflected differential weight bearing, then immobilization and remobilization. Persistently low IGF–I may have contributed to low soft tissue collagen synthesis and growth. Changes in bone formation markers most likely reflected bone healing.

?     

Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis: a morphological classification of 120 cases

Purpose

To analyze the relationship between the cervical spine and global spinal-pelvic alignment in young patients with idiopathic scoliosis based on a morphological classification, and to postulate the hypothesis that cervical kyphosis is a part of cervico-thoracic kyphosis in them.

Methods

120 young patients with idiopathic scoliosis were recruited retrospectively between 2006 and 2011. The following values were measured and calculated: cervical angles (CA), cervico-thoracic angles (CTA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), spinal sacral angle (SSA), hip to C7/hip to sacrum, thoracic kyphosis (TK), lumbar lordosis (LL), Roussouly sagittal classification, Lenke Type Curve and Lumbar Modifier. The cervical curves were classified as lordosis, straight, sigmoid and kyphosis. They were categorized into four groups as cervical non-kyphosis group (CNK Group), cervical kyphosis group (CK Group), cervical-middle-thoracic kyphosis group (CMTK Group), and cervical-lower-thoracic kyphosis group (CLTK Group) according to their morphological characters of sagittal alignments. All parameters were compared and analyzed among groups.

Results

The incidence of cervical kyphosis was 40 % (48/120). The CA and the CTA were in significant correlation (r = 0.854, P = 0.00). The cervical spine alignments were revealed to be significantly different among groups (r = 85.04, P = 0.00). Significant differences among groups in CA, CTA and TK were also detected. A strong correlation between the group type and Lenke Lumbar Modifier was still seen (P < 0.05). Fisher’s exact test revealed that the individual vertebral body kyphosis and wedging were directly related to the overall cervical kyphosis (P = 0.00, respectively).

Conclusion

The cervical kyphosis is correlated with global sagittal alignment, and is a part of cervico-thoracic sagittal deformity in young patients with idiopathic scoliosis. Despite the deformity in cervical alignment, the global spine could still be well-balanced with spontaneous adjustment. The correlation between our grouping based on the morphological characteristics of the sagittal alignments and Lenke Lumbar Modifier suggests that the coupled motion principle be appropriate to explain the modifications both in coronal and sagittal planes.     

Outcomes and Complications following Posterior Long Lumbar Fusions Exceeding Three Levels

The outcomes and complications of posterior-only lumbar instrumented long fusions exceeding three segments with selective segmental transforaminal lumbar interbody fusion for the treatment of degenerative lumbar scoliosis, kyphosis, or both combined with spondylolisthesis were analyzed to investigate risk factors associated with surgical instrumentation failure. Fifteen consecutive patients with degenerative lumbar scoliosis, kyphosis, or both combined with spondylolisthesis were studied retrospectively. There were 5 male and 10 female patients, with a mean age of 71.8 years. All the patients were followed for a mean duration of 19.4 months postoperatively. Radiographic evaluation included coronal Cobb angle, lumbar lordosis (LL) angle, pelvic incidence (PI), and pelvic tilt (PT). The clinical outcomes were assessed by means of Japanese Orthopedic Association (JOA) score. Patients were divided into two groups: group 1—7 patients with surgical complications; group 2—8 patients without complications. The preoperative and postoperative coronal Cobb''s angle were not significantly different between groups 1 and 2. The LL highly correlated with developing surgical complications. There were statistically significant differences in preoperative and postoperative LL and the mean difference between PI and the LL (PI–LL) between groups 1 and 2. Linear correlation and regression analysis showed that there was no correlation between JOA score and the coronal Cobb angle in degenerative scoliosis patients. However, we found a positive correlation between JOA and LL. Our series of long lumbar fusions had a high complication and instrumentation failure. Creating adequate LL angle in harmony with PI was a key to prevent surgical complications and attain neurological improvement.     

不同截骨节段重建ⅢA型强直性脊柱后凸矢状面平衡的生物力学分析

背景:强直性脊柱后凸畸形的矫形技术已较为成熟,术者也可根据患者的弯曲类型、弯曲度数等选择不同的截骨术式,但由于缺少被广泛认可的分型系统,导致强直性脊柱后凸畸形的描述和手术策略制定都较为混乱。目的:应用计算机辅助软件建立强直性脊柱炎后凸截骨三维有限元模型,分析其生物力学特性。方法:获取1例301分型ⅢA型强直性脊柱后凸畸形患者的影像资料,建立强直性脊柱后凸畸形三维有限元模型,测量T12、L1、L2和L34个不同节段截骨角度,模拟去松质骨截骨术,对截骨矫形后的模型进行钉棒系统固定,分析其生物力学特性。结果与结论:①截骨节段越靠近尾端螺钉应力越大,螺钉应力分布大小的顺序为L3>L2>L1>T12,不同截骨节段的螺钉应力分布特点相同,都集中在截骨节段的相邻上/下2个节段的螺钉上,明显大于其他节段的螺钉应力;②钛棒的应力大小顺序为L2>L3>L1>T12;③截骨节段越靠近头端截骨接触面应力越大,截骨接触面应力大小顺序为T12>L1>L2>L3;④结果表明对于ⅢA型强直性脊柱后凸畸形,选择L2截骨节段可获得较佳的矫形程度、降低内固定应力分布集中导致的并发症发生。