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Closing-opening wedge osteotomy for the treatment of sagittal imbalance or kyphotic deformity
|關鍵字:||kyphotic deformity;駝背畸型;osteotomy;sagittal imbalance;sagittal malalignment;截骨術;矢狀面失衡;矢狀面排列不正||出版社:||生物產業機電工程學系所||引用:|| DeWald RL. Osteotomy of the thoracic/lumbar spine. In: Bradford DS, ed. Master techniques in Orthopaedic Surgery, The Spine. Philadelphia: Lippin¬cott-Raven, 1997:229-48.  Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size: a prospective controlled clinical study. Spine 1994;19:1611-8.  Bernhardt M, Bridwell KI-1. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989;14:717-21.  Jackson RP, Hales C. Congruent spinopelvic alignment on standing lateral radiographs of adult volunteers. Spine 2000;25:2808-15.  White AA, Panjabi MM. Practical biomechanics i1t scoliosis and kyphosis. In: White AA, Panjabi MM, eds. Clinical Biomechanics of the Spine. 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Kyphotic deformity can produce sagittal malalignment and imbalance. Patients can not move or stand erect without overwork of musculature because of compromising the biomechanical advantage. The result is muscle fatigue and activity-related pain. During reconstructive surgery, restoration of the best possible sagittal balance is crucial for obtaining satisfactory clinical results. However, there are two problems for this. The first, there is no way to control and predict the quality or outcomes of the reconstructed sagittal balance before or during operation. The second, there is no an osteotomy through posterior-only approach for the large and rigid kyphosis to allow three-column release and large range of correction.
A method was developed to determine the lumbosacral curve which theoretically would bring spinal sagittal balance to an ideal state by calculation and simulation for each patient preoperatively and a template and blueprint was made accordingly for operative procedures to follow. Also a new osteotomy, closing-opening wedge osteotomy(COWO), to provide three-column release through a posterior-only approach was developed and could make rigid kyphotic deformity flexible enough to be adequately manipulated to match the template and to obtain optimal correction of sagittal imbalance.
The objective of this study is to investigate the feasibility of controlling quality of reconstructed sagittal balance for sagittal imbalance and to evaluate the safety and efficacy of the new method and surgical procedures to reconstruct an optimal sagittal balance for patients with sagittal imbalance or kyphotic deformity.
The report contained two studies. In study 1, thirty-one patients with degenerative lumbar kyphoscoliosis (mean age, 72.3 years; range, 65-78 years) treated with the method and COWO were followed up for a mean of 4.1 years. Their preoperative, 2-month postoperative, and final follow-up radiographs were assessed and a questionnaire to measure changes in pain, function, self-image, patient satisfaction with surgery administered was. Postoperative complications was analyzed. In study 2, eighty-three consecutive patients treated for sagittal imbalance with the method and COWO with a minimum follow-up of two years were analyzed. Radiographic analysis included assessment of thoracic kyphosis, lumbar lordosis, lordosis through COWO site, and sagittal balance. Outcomes analysis utilized the Scoliosis Research Society questionnaire. Complications and radiographic findings were analyzed.
In study 1, final radiographs showed increased L1-S1 lordosis from 11.3° to -50.5° (increase of 61.8°), correction of kyphotic deformity from 64.3° to -14.1°, and correction of scoliotic deformity from 48.9° to 8.3°. Sagittal imbalance significantly improved from 68.8 to 27.1 mm, whereas the sacrofemoral distance decreased from 59.3 to -5.1 mm, and the sacral inclination angle increased from 9.7° to 34.3°. Subjective pain was significantly and persistently reduced. Most patients maintained good correction and had good clinical results. No major complication occurred. Eight patients (26%) developed junctional kyphosis. In study 2, the average increased in lordosis and improved sagittal balance were 81.9o and 17.1 cm. Mean correction through the osteotomy site was 42.2o (range 31-55o). No vascular injury occurred. While three patients developed lumbosacral pseudarthrosis, the COWO area was unaffected in all patients. Nine patients developed cephalad junctional kyphosis and two patients developed caudad junctional kyphosis. Most patients reported improvement in terms of pain, self-image, and function as well as overall satisfaction with the procedure.
Analysis of all radiographic datas showed the mean estimated values of L1-S1 lordosis, sacral inclination angle (SIA), sacrofemoral distance (SFD), and distribution of L1-S1 lordosis at the closing-opening wedge osteotomy (COWO) site and L4-S1 segments were -30.8o, 24.6o, 0 mm, 16.1% (-5o), and 62% (-19o), respectively. The mean reconstructed values were -41.1o, 23.3o, 3.9 mm, 41% (-17o), and 46% (-19o), respectively. There were significant differences between estimated and reconstructed values of L1-S1 lordosis and percent of distributions, however, there was no significant difference between the estimated and reconstructed magnitude of L4-S1 lordosis, SIA, and SFD. A properly oriented pelvis can be brought nearly directly above the hip axis. The mean sagittal global balance, represented by the distance between the vertical line through the hip axis and sacral promontory, improved from 61.4 mm before surgery to 3.9 mm 2 months after surgery. Normal sagittal global balance was reconstructed. The mean sagittal spinal balance measured as the horizontal distance between the C7 sagittal plumb line and the posterior superior corner of S1 improved from 97.4 mm before surgery to 11 mm 2 months after surgery. Normal sagittal spinal balance was reconstructed.
Quality control of the reconstructed sagittal balance for sagittal imbalance is possible. Correctly orienting the pelvis reconstructed by restoration of enough L1-S1 lordosis with adequate distribution at L4-S1 segments is a matter of critical importance for optimizing reconstructed sagittal balance. Preventing junctional fracture and persistent rehabilitation of surgically injured lumbar extensor musculature are crucial for maintaining the reconstructed sagittal balance. COWO is a safe and useful procedure for patients with sagittal imbalance the level of patient satisfaction was high after more than two years of follow-up, with most patients having improved resolution of pain, increased self-image, and greater function. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in lumbosacral fusion, and junctional kyphosis.
研究結果兩組病患x光資料分析顯示第一組病患最終隨訪的x光片顯示腰1至薦1前曲角度由後凸11.3度矯正至前曲50.5度(矯正61.8度)，後凸畸型由64.3度矯正至前曲14.1度，側凸畸型由48.9度矯正至8.3度，矢狀面平衡由68.8㎜，矯正至27.1㎜，薦股距(sacrofemoral distance)由59.3㎜減至-5.1㎜，薦椎傾斜角度(sacral inclination angle)由9.7度增至34.3度，疼痛感明顯及持續的減輕，大部份病例都可維持良好的矯正及臨床結果，沒有大的併發症發生，有8例(26%)的病例發生交界後凸(junctional kyphosis)。第二組病患最終隨訪的x光片顯示，平均前曲角度之增加為81.9度，矢狀面平衡改善17.1公分，截骨節段平均矯正度為42.2度(範圍：31~55度)，沒有血管損傷發生，在截骨節段沒有假關節形成，有三例在腰薦節段有假關節形成，有11例產生交界處駝背畸型，大部分的病患在疼痛，自體形象感，功能及滿意度均改善。
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