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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_31_библиотеки_им_акад_М_И_Перельмана
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Post-Traumatic Kyhphosis
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51
MericEnercan andAzmiHamzaoglu
51.1 Definition
Post-traumatic kyphosis (PTK) is dened as painful kyphotic angulation of the
post-traumatic spine. PTK most often presents after major trauma resulting in spinal
column fracture but can also present following minor trauma in patients with poor
bone quality.
51.2 Natural History
PTK can involve untreated patients, patients with failed conservative treatment, and
patients with unsuccessful surgery. Regardless of the etiology or the initial treatment,
the most common complaints are (i) progressive deformity, (ii) increasing neurologic
decit, (iii) sagittal and/or coronal plane imbalance, (iv) increasing pain, and (v) cosmetic and functional deterioration. There are many factors that dene the characteristics of PTK deformity. The level and the magnitude of the injury are the main
contributors. The PTK deformity typically occurs at the thoracic and thoracolumbar
spine. Compression fractures are unlikely to produce a progressive deformity since the
middle and posterior columns are left intact. If the local kyphosis exceeds 20°, concomitant injury of the posterior ligamentous structures may lead to progressive deformity. If the injury is more severe, such as a severe burst fracture or a exion-distraction
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_51].
M. Enercan (*) · A. Hamzaoglu
Istanbul Spine Center at Istanbul Florence Nightingale Hospital, Istanbul, Turkey
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_51
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M. Enercan and A. Hamzaoglu
injury in which the anterior, middle, and posterior columns are disrupted, PTK is likely
to be greater and progressive in nature (Chap. 7). PTK patients present with two different types of sagittal deformity. Type I sagittal deformity is characterized by normal
overall sagittal balance with a focal kyphosis; type II sagittal deformity is characterized
by focal kyphotic deformity with global sagittal imbalance (Chap. 50).
The progression of PTK can cause a new or worsening neurologic decit by
direct compression of the neural elements, tenting of the neural elements across the
angular kyphosis, and mechanical stress on the spinal cord. The development of
post-traumatic syringomyelia also leads to the development or progression of the
neurologic decit. Up to 50% of patients develop spinal cystic changes, and 21–28%
of the patients may develop a syrinx even 30years after the initial spinal cord injury.
Post-traumatic syringomyelia usually presents with segmental pain and sensory
loss, followed by progressive asymmetrical weakness.
Pain is one of the most common symptoms of PTK, and it is generally secondary to
abnormal spine biomechanics at the apex of the kyphotic deformity; it results in altered
forces acting on the soft tissues and surrounding structures. Patients with a focal kyphotic
deformity greater than 20° are at increased risk to develop chronic pain with poor functional tolerance. Pain may also be secondary to canal stenosis or neural foramen compromise, nonunion, instability, and adjacent compensatory changes that occur above or
below the kyphotic deformity. Hyperlordosis in the lumbar spine or hypokyphosis/thoracic lordosis above the deformity may be a source of chronic fatigue and pain.
PTK often presents in two different patterns, malunion or nonunion, with different courses. Malunion is essentially a stable late deformity that carries the risk of
spinal stenosis. Nonunion or pseudoarthrosis is more similar to unstable late deformity with risks of acute instability (Chap. 47). Table51.1 outlines fracture-related
risk factors for malunion and nonunion (Table51.1).
51.3 Physical Examination
A detailed history and physical examination must be performed in every patient.
Injury patterns and previous treatment interventions should be noted. The patient
should be observed undressed while standing and walking. Any compensatory
Table 51.1 Fracture-related risk factors for PTK with malunion and nonunion
Fracture-related risk factors for PTK
with malunion Fracture-related risk factors for PTK with nonunion
• Sagittal index >20° • Burst fractures with vertebral body height loss >50%
• Vertebral body height loss >30% • Extension-type fractures effecting three columns
• Local kyphosis angle >30° • Dead bone sign in traumatic osteoporotic fractures
• Posterior ligamentous complex and
posterior osseous injuries
• Severe posterior ligamentous ligament injury
• Signicant posterior distraction or lateral translation
on plain radiographs
51 Post-Traumatic Kyhphosis
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alignment changes and contractures of the hips and knees should be noted.
Neurologic examination should include sensory, motor power, deep tendon reexes,
nerve root tension signs, and gait pattern (Video 51.4). Video recording of patients’
gait gives more details about the gait pattern and enables comparison with postoperative gait. Photographs should be taken from the front, back, and sides in standing
position for preoperative coronal and sagittal plane balance analyses (Chap. 50).
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51.4 Imaging
1. Sagittal and coronal spinal parameters should be assessed with standing anteroposterior and lateral full-length spine radiographs. Local kyphosis angle should
be measured between the superior end plate of the adjacent cranial vertebra and
the inferior end plate of the adjacent caudal vertebra (Video 51.6). The sagittal
index is obtained by the difference in degrees of the kyphotic deformity minus
the normal contour in the corresponding area. Hyperextension fulcrum or prone
lateral radiographs can be used to assess the exibility of the kyphotic deformity.
Dynamic lateral radiographs can be helpful in detecting instability, pseudoarthrosis, hardware failure, and adjacent segment disease.
2. Computerized tomography (CT) is used for dening the bony anatomy, including the degree and pattern of fracture healing and fusion status. CT is also helpful to assess bony anatomy with previous surgery. Three-dimensional (3D) CT
scan reconstruction can be helpful in preoperative planning.
3. Magnetic resonance imaging (MRI) is used to evaluate the posterior osteoligamentous complex, to determine the integrity of the spinal cord, and to assess
the integrity of the surrounding intervertebral discs and the presence of disc
herniation.
4. CT myelography is indicated when MRI is contraindicated (e.g., cardiac pacemaker) or not possible due to previous instrumentation.
51.5 Differential Diagnosis
Other etiologies of the kyphosis including postinfectious kyphosis (Chap. 52), congenital kyphosis (Chap. 24), and Scheuermann kyphosis (Chap. 22) should be
excluded.
51.6 Treatment Options
The goals of surgery are to obtain a satisfactory balance in both sagittal and coronal
planes, to attain a solid fusion with balanced spine, to relieve pain, to improve neurologic decits if present, and to prevent further deformity. In order to successfully
address a PTK, the surgeon must consider the areas of neural compression, the
magnitude of the focal PTK, the overall sagittal and coronal balance/alignment, the
exibility and character of the deformity, and the location of the deformity.
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M. Enercan and A. Hamzaoglu
Surgical options are all-anterior, simultaneous combined anterior-posterior surgery,
or posterior-only surgery. All anterior approaches allow direct access to the anterior
and middle column and anterior decompression. Morbidity related to anterior surgery
is the major limitation. In the presence of the signicant and rigid deformity, the correction will be limited. Combined anterior-posterior surgery imposes three stages; the
rst stage includes posterior instrumentation, posterior release, and temporary posterior xation. The second stage includes anterior decompression and anterior column
restoration with or without anterior instrumentation. The third stage involves nal posterior reduction and xation. In recent years, posterior-only surgery is being preferred
to combined approaches. Posterior osteotomy options are posterior-column osteotomy
(Ponte) or three-column osteotomies. Three-column osteotomy options are pedicle
subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO), and posterior vertebral column osteotomy (PVCR). Flexible global kyphosis can be managed with single
or multiple posterior-column osteotomies, whereas patients with sharp angular kyphosis with major sagittal imbalance require three-column osteotomies (Videos 51.3 and
51.6). The PVCR osteotomy provides the most complete mobilization of the spine for
deformity correction in all planes, enables anterior column reconstruction, and is useful
for rigid deformities with very signicant sagittal or coronal imbalance.
51.6.1 Correction Technique forRigid Sharp Angular Kyphosis
Following PVCR
The correction should be applied in a stepwise manner. Placing a temporary cage will
prevent sudden shortening, dural buckling, and iatrogenic neurologic decit. When
the sharp angular kyphotic deformity is corrected by 30% to 50%, temporary mesh
cage is removed and replaced by a lamina spreader. The osteotomy site is distracted
and lengthened anteriorly with the lamina spreader, while simultaneous compression
is applied posteriorly. When the anterior gap is lengthened 50% or more compared to
the initial status, an expandable cage is placed anteriorly at the osteotomy site. The
expansion of the expandable cage provides additional anterior lengthening, and nal
correction is achieved by posterior compression maneuvers. Anterior lengthening
and posterior compression will be continued until ideal sagittal alignment is achieved
(Fig.51.1). PTK secondary to malunion and nonunion can be managed successfully
with the PVCR technique (Figs.51.2 and 51.3).
Fig. 51.1 Correction technique of PTK correction following PVCR with sequential posterior
compression and simultaneous anterior column lengthening technique
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Fig. 51.2 A 30-year-old female patient with PTK due to malunion. She had a previous failed
surgery and signicant neurologic decit due to post-traumatic syringomyelia. Following L1
PVCR, sequential posterior compression and simultaneous anterior column lengthening technique
was performed for deformity correction
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Fig. 51.3 A 42-year-old female patient with PTK presented with nonunion. PVCR was performed, and an expandable cage was used in order to reconstruct anterior column support and
restore the ideal thoracolumbar sagittal alignment
51.7 Expected Outcomes
If a post-traumatic kyphosis is left untreated, there is a high risk of chronic back
pain, and this risk increases in the patients whose kyphosis is located in the lumbar
region. A progressive post-traumatic kyphosis can be related to neurologic compromise. The outcome of the surgical treatment is satisfactory if the treatment is performed in highly specialized centers.
51.8 Potential Complications
PTK surgery is technically challenging and prone to complications. Various studies
reported a more than 60% rate of overall complication rate with a 10% reoperation
rate. The most commonly reported complications are neurological complications,
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M. Enercan and A. Hamzaoglu
pulmonary and urinary complications, bleeding, dural tear, pseudoarthrosis, implant
failure, and infection (Chap. 66). The neurological complications occur in 6.3–15.8%
and are transient in most cases. Patients with preoperative neurologic decits had a
higher risk of postoperative permanent decits.
51.9 What Should Patient andFamily Know?
Treatment of PTK is often challenging, and successful treatment depends on careful
patient selection and appropriate surgical intervention. Surgical treatment should
address decompression of neural elements and restoration of ideal sagittal alignment and achieve solid fusion. In recent years, posterior-only surgery is being preferred to anterior or combined approaches. Among posterior osteotomies, PVCR
provides the most complete mobilization of the spine for deformity correction.
Proper correction techniques should be performed to achieve ideal correction and
prevent complications.
Further Readings
Adogwa O, etal. Delayed posttraumatic deformity presentation and management. In: Bridwell
KH, Gupta MC, editors. Bridwell and DeWald’s textbook of spinal surgery. 4th ed. Wolters
Kluwer: Philadelphia, PA; 2020. p.1309–16.
Buchowski JM, Kuhns CA, Bridwell KH, Lenke LG.Surgical management of posttraumatic tho-
racolumbar kyphosis. Spine J. 2008;8:666–77.
Munting E.Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications
and technical aspects. Eur Spine J. 2010;19(Suppl 1):69–73.
Post-Infectious Deformity
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52
ShahnawazHaleem
52.1 Definition
Post-infectious kyphosis is the loss of sagittal alignment caused by destruction of
intervertebral discs or adjoining vertebral bodies due to infective process.
52.2 Natural History
Spinal infections (pyogenic and non-pyogenic) can occur either due to blood-borne
infections or local inoculation peri-operatively (Chap. 66), followed by increased
pain in the affected area. Haematogenous infection in capillary loops induces the
inammatory cascade which leads to bony destruction and collapse. The infection
can spread in all directions leading to paravertebral and epidural abscesses and adjacent disc involvement. The patients’ symptoms and signs will depend specically
on the primary site of infection, its area of spread, the duration of infection, any
ongoing infection, the organism involved and immune status of the patient.
While pain and fever are usually present, involvement of the epidural space can
affect neural structures and loss of stability due to softening of vertebral bones causing a collapse (due to pathological fracture) and resultant cord compression which
can lead to a neurological decit. The onset of paralysis may occur early or late.
Delayed onset of paralysis may be due to the vertebral destruction causing either
bony impingement or a kyphotic deformity.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_52].
S. Haleem (*)
Royal Orthopaedic Hospital, Spinal House, Northeld, Birmingham, UK
e-mail: shahnawaz.haleem@nhs.net
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_52
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The clinical picture may be varied and lead to a delay in diagnosis and therefore
correct appropriate antibiotic management and surgical intervention. The most
common organisms are S. aureus and S. epidermidis with Pseudomonas aeruginosa
being most commonly seen in intravenous drug users (Chap. 65). Mycobacterium
tuberculosis is the most common non-pyogenic organism (Chap. 64).
S. Haleem
52.3 Physical Examination
Symptoms and signs depend on any ongoing infection. The majority of patients present with pain (on any form of movement), night sweats, intermittent fever, anorexia
and weight loss. Paralysis is not an early presentation in most patients but when present is rapidly progressive. Occasionally, patients present with myelopathy due to the
stretched spinal cord at the apex of sharp kyphosis so-called gibbus. Gibbus is a
sharp-angled kyphosis and pathognomonic for post-tuberculous kyphosis.
Physical signs included localised tenderness, muscle spasm (paraspinal and torticollis depending on site of infection), hamstring spasm and generalised weakness.
A pointing abscess is rare, and straight leg raise (SLR) test may elicit back pain and
rarely radiculopathy (Video 52.4).
The location/level of the infective process may dictate the physical signs as
deformity occurring in the cervical and thoracic spine with cause increased neurological decit as compared to the thoracolumbar spine. The patient therefore may
present with upper motor neurone (UMN) signs in higher lesions with a sensory
level or accid weakness in lower motor neurone (LMN) lesions depending on the
level of cord compression. Previous cord injury due to infection can lead to central
cord/anterior cord syndromes with their features on examination. Central cord syndrome presents with increased weakness in the upper limbs as compared to the
lower limbs, and anterior cord syndrome affects the anterior two-thirds of the spinal
cord resulting in motor paralysis below the level of the lesion and loss of pain and
temperature at and below the level of the lesion.
It is therefore imperative to include ASIA (American Spinal Cord Injury
Association) chart scoring from the rst examination as a written record to ensure
any improvement or decit is correctly monitored (Appendix G). Any new decit
will then require repeat imaging to gain further information and guide appropriate
management.
52.4 Imaging
Radiographs are not very sensitive to early spinal involvement, and the rst radiographic nding may be seen 2weeks to 3months after infective onset. These are
usually endplate erosions. Other early changes include loss of endplate normal
contour, subchondral bone defects and sclerotic bone formation. Late radiographic
changes may reveal collapse of vertebrae, bony column decits, segmental
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kyphosis and bony ankylosis (fusion). Standing long-cassette anteroposterior and
lateral radiograms should be taken for better evaluation of the spinal alignment
(Video 52.6).
Computed tomography (CT) can identify paravertebral collections, show bony
changes (endplate destruction) and lytic/sclerotic features and dene neural
impingement (Appendix Q). CT-guided biopsy may help obtain deep specimens to
rule out any ongoing infection. Magnetic resonance imaging (MRI) can reveal any
ongoing infection (especially with gadolinium enhancement), neurological injury
(including cord infarction) and ongoing impingement due to gibbus. T2-weighed
images are valuable for demonstrating myelopathy as a hyperintense lesion. All
neurological decits need to have up-to-date scans.
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52.5 Differential Diagnosis
The differential diagnosis of post-infectious kyphosis should include congenital
kyphosis, primary and metastatic tumours (Chap. 63), pathological fractures caused
by metabolic bone disease, rheumatoid arthritis and ankylosing spondylitis (Chap.
54), Charcot spinal arthropathy and any other infective process causing bony
destruction and kyphosis.
52.6 Treatment Options
The rst step is to make sure the causative pathogen has been correctly identied
and proper treatment (especially for tuberculosis, TB) initiated. It is presumed that
the patient has no ongoing infective issues in this treatment plan which would then
depend on the presence of pain, neurological decit (time since onset and progression), patient mobility status and comorbidities. Nonoperative options in a neurologically intact patient presenting only with pain and no or limited deformity would
include pain relief, brace application, physiotherapy and mobilisation. Operative
indications are due to presenting and progressive neurological decit. Here the priority is to relieve the cord compression, improve malalignment (Chap. 50) and stabilise the spine. This may involve surgical decompression, realignment with
osteotomies and stabilisation (posteriorly and/or anteriorly) (Videos 52.3, 52.4, 52.6
and 52.7). The length of the pedicle screw and rod construct (number of levels
fused) should be carefully planned preoperatively to ensure optimal outcomes
depending on the neurological status and degree of kyphosis to ensure that optimal
spinopelvic parameters are achieved.
Figure 52.1a and b show postinfectious deformity in a 14-year-old boy suffering
from TB since the age of 3years. He presented with no neurological decit and only
progressive deformity. Figure52.2a and b show deformity on CT and MR imaging.
He underwent a successful stabilisation and remains neurologically intact at latest
follow-up (Fig.52.3a and b).
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S. Haleem
a
Fig. 52.1 (a and b) Show a kyphoscoliotic deformity in a 14-year-old boy with a history of TB at
rst presentation in 2014 [Courtesy of Prof. Alpaslan Şenköylü]
b
52.7 Expected Outcomes
This depends on the preoperative neurological status and degree of kyphosis. Early
surgical intervention is required if the patient presents with neurological decit.
Early surgical intervention involving judicious decompression, optimal realignment
and stabilisation (with front and back surgery) will ensure a good outcome. However,
once paralysis sets in with a patient who has other comorbidities, then recovery can
be poor, and further management will involve rehabilitation in a spinal cord
injury centre.
52.8 Potential Complications
These can include infection, bleeding, nerve injury, paralysis, spinal uid leak,
blood clots (legs and lungs), malpositioned metalwork, failure to fuse, metalwork
failure, continued symptoms, post-junctional kyphosis and risks of anaesthesia,
COVID infection and death.
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