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13 Osteotomy forTraumatic Spinal Deformity
Fig. 13.2 Laminae and spinous process have been resected, leaving only part of the articular process and pedicle. (a) Lateral view; (b) axial view
189
Fig. 13.3 Pedicle has been removed, and it can be seen that the posterior edge of the vertebral body protrudes into the spinal canal and compresses
the dural canal. (a) Lateral view; (b) axial view
verse processes, and the anterior lateral edge of the exposed
vertebral body is exposed to the anterior along the lateral
edge of the vertebral body with Anonymous osteotome (an
instrument in the Tian’s osteotome set) (Fig.13.5). It must
be strictly carried out under the periosteum, especially
when the vertebral body is exposed, the elevator should
advance along the waist of the vertebral body to avoid damaging the segmental blood vessels. Then change to the
lever and lever off the soft tissue around the vertebral body
and segment blood vessels, and expose the whole vertebral
body (Fig.13.6). Scope of vertebral body expose: includ-
Fig. 13.4. Wedge resection includes the posterior arch and upper 3/4
of the vertebral body of the compression fracture level and the lower 1/5
of the upper vertebra and the disc involved in the fracture-dislocation of
the spine.
ing the whole wedge vertebral body with compression
fracture and the inferior edge of the upper vertebral body
and disc of the upper vertebral body (see Fig.13.4).
190
Fig. 13.5 Use the anonymous elevator to elevate along the waist of the
vertebral body, strictly under the periosteum, directly to the anterior
edge of the vertebral body, so as to avoid damaging the segmental blood
vessels
H. Tian et al.
Fig. 13.8 The lateral part of the vertebral body is excised with straight
osteotome in layers, hemostasis with bone wax
Fig. 13.6 Change to the lever to lever off the soft tissue around the
vertebral body and segment blood vessels, exposing the whole vertebral
body
Fig. 13.7 Protect the spinal nerve roots of the superior level outside
the operation eld with a nerve root retractor to facilitate corpectomy
The fourth step: retract the spinal nerve root. The spinal nerve roots exiting through the upper intervertebral
foramen are retracted and protected outside the operation
eld with the nerve root retractor (Fig.13.7).
Fig. 13.9 The central part of the vertebral body is excised with a
shovel and the crescent osteotome, and the bone fragments protruding
from the posterior edge of the vertebral body into the vertebral canal are
reserved for the nal step
The fth step: vertebral osteotomy. First, remove the lateral part of the vertebral body (Fig.13.8) with straight osteotome layer by layer. For the bleeding of cancellous bone
sinus, stop the bleeding by applying bone wax. Apply hard
bone wax after each cut. The surface must be smooth so as to
play a real hemostasis role. Then, the central part of the vertebral body is excised with a shovel and a crescent osteotome.
The central part of the vertebral body (Fig.13.9) is excised
rst, and the fragments protruding into the spinal canal are
temporarily retained. The central part of the vertebral body is
cut through on both sides, and only the fragments protruding
into the spinal canal are left for the nal treatment.
The sixth step: posterior edge resection. The posterior
edge of the vertebral body and the bone fragments protruding into the vertebral canal are left for nal treatment until
most of the vertebral bodies are excised. The methods of
resection of posterior edge of vertebral body and fragments
protruding into vertebral canal are as follows. First, use the
posterior longitudinal ligament elevator to separate a gap
13 Osteotomy forTraumatic Spinal Deformity
Fig. 13.10 Use the pusher to pull down the posterior edge of the vertebral body and the bone fragments protruding into the vertebral canal
191
Fig. 13.12 Reduction and internal xation have been completed. The
cancellous bone of the vertebral body is facing the cancellous bone surface, so no interbody bone grafting is needed. Only grafting with bone
chips on top of the lamina is needed
5. Postoperative management:
The patient should lie in a atbed when returned to the
ward. The drainage tube is connected with a negative
pressure drainage bottle, the drainage tube is removed
24–48h later, and the suture was removed 10 days later.
After removing the suture, the patient is allowed to ambulate. A plaster vest is applied with traction by occipitalmandible belt suspending on a vertical frame.
Fig. 13.11 Fingers palpation to check whether the bone fragments in
front of the dura mater has been completely removed, and whether the
dural sac has been relaxed and expanded, so as to check before closing
the osteotomy space
from the posterior bone sheet, then use the pusher to push
down the posterior bone sheet of the vertebral body and the
fragments protruding into the spinal canal (Fig. 13.10).
Remove the bone fragments with the nucleus pulposus forceps. Pay attention to protect the integrity of the dural canal,
prevent dural tear and CSF leakage. After resection of the
posterior edge of the vertebral body and the fragments protruding into the spinal canal, if there are no residual fragments in the osteotomy space by palpation (Fig.13.11), the
osteotomy space shall be closed immediately.
The seventh step: reduction and internal xation.
Generally, the osteotomy space of traumatic kyphosis is not
wide, and the commonly used instrumentation is by screw–
rod xation. Generally, 2–3 screws on each side above and
below the osteotomy space are adequate, or, 8–12 screws and
2 rods in total (Fig.13.12). In some cases, distal extension
and proximal compression may be performed as required.
The eighth step: place the drainage tube and close the
incision. Place T-shaped drainage tube, close the incision
by layers to complete the operation.
13.2.3 Typical Cases
• Case 1. A 16-year-old female, traumatic kyphosis. She
was treated with a U-shaped rod and wiring internal xation in other hospitals. The wire broke after the operation
and the correction failed. The patient came to our hospital
for a revision surgery. A thorough examination was done
after admission. The preoperative Cobb angle was 75°.
Vertebral column resection plus proximal compression
and distal distraction and internal xation were performed. The operation went smoothly. After the operation, the Cobb angle of X-ray lm became 1°, the height
increased by 3cm, and the body shape improved signicantly (Fig.13.13a–f).
• Case 2. A 36-year-old male was admitted to the emergency department because of a lumbar and back injury
in a trafc accident. After X-ray and CT examination,
he was diagnosed with an L1 exion compression fracture with kyphosis deformity, with a Cobb angle of 33°.
On the 5th day after admission, T12-L1 kyphosis osteotomy under general anesthesia with endotracheal intubation and internal xation with screw–rod system was
performed. The operation went smoothly. Postoperative
kyphosis was corrected, Cobb angle was 2° (Fig.13.14a–
i), and the patient was discharged after 10 days when
the suture was removed.
192
a
c
H. Tian et al.
b
d
e
f
Fig. 13.13 Traumatic angular kyphosis. (a) Angular kyphosis was evi-
dent before operation. (b) Kyphosis was corrected after surgery. (c)
Preoperative anteroposterior X-ray, (d) Kyphosis was 75° in the preop-
erative lateral X-ray, (e) posterior X-ray lms after total spinal osteotomy, (f) postoperative lateral X-ray showed Cobb angle changed to 1°
a
c
13 Osteotomy forTraumatic Spinal Deformity
193
b
d
g
e
h
f
i
Fig. 13.14 Typical cases 2: (a) L1 compression fracture in the antero-
posterior radiograph; (b) lateral radiograph kyphosis deformity Cobb
angle 33°; (c) posterior vertebral fracture seen on preoperative CT.The
fragment protruded slightly back into the spinal canal without neurological symptoms; (d) CT coronal showed a comminuted fracture at the
upper edge of L1 vertebra; (e) CT sagittal showed a comminuted frac-
ture at the upper edge of L1 vertebra. Posterior fragments protruded
into the spinal canal, compression of anterior vertebral body, kyphosis
deformity Cobb angle 33°; (f) preoperative CT three-dimensional
reconstruction; (g) scope of vertebral column resection. (h) Orthotopic
radiograph of screw–rod system internal xation; (i) Cobb angle
changed to 2° after total spinal osteotomy
194
H. Tian et al.
Suggested Reading
1. Tian H.Surgical treatment of kyphosis kyphosis. Chin J Orthop.
1992;12(3):162–5.
2. Tian H, Yuan T, Tian S.Posterior invasion and vertebral osteotomy.
Spinal Deformation. 1992;7(1):4–11.
3. Tian H, Li F.Spinal deformity and osteotomy. Xi’an: World Book;
2001. p.377–735.
4. Tian H. Spinal surgeons should be good at using rongeurs and
osteotome. Chin J Mod Oper Surg. 2002;6(1):67–8.
5. Tian H.Application of “Tian’s spinal bone knife” in orthopaedic
surgery. Chin J Orthop. 2003;11(15):1073–5.
6. Tian H.Report of 25 cases of traumatic paraplegia treated with posterior spinal decompression by posterior approach. Chin J Orthop.
2006;07:549–50.
7. Tian H, Lv X, Ma Y.Treatment of severe spinal curvature with total
spine osteotomy and internal xation with head-sleeve ring. Chin J
Orthop. 2007;15(3):167–72.
8. Tian H, Liu S, Ma Y. Practical spine surgery. Guangzhou:
Guangdong Science and Technology Press; 2008. p.87–409.
9. Tian H, Liu S, Ma Y.Practical spine surgery illustration. Beijing:
People’s Military Medical Press; 2008. p.152–675.
10. Tian H.History of treatment of spinal deformity in China. Chin J
Orthop. 2009;17(9):706–7.
11. Tian H, Li M, Ma Y.Spinal deformity osteotomy orthopedics, vol.
5. Beijing: People’s Medical Publishing House; 2011. p.3–339.
12. Tian H.A brief history and popularization of spinal osteotomy with
thin blade bone knife. Chin J Orthop. 2012;20(23):2207–8.
13. Tian H, Zhang H, Liang Y.Surgical treatment of spinal deformity.
Guangzhou: Guangdong Science and Technology Press; 2012.
p.1–483.
14. Tian H, Li M, Wang Z.Key points and diagrams of thoracolumbar surgery. Beijing: People’s Medical Publishing House; 2012.
p.1–470.
15. Tian H, Ma Y, Xie J. Spinal osteotomy orthopedics. Guangzhou:
Guangdong Science and Technology Press; 2018. p.2–541.