1. Posterior Closing Wedge Osteotomy,Posterior Closing Wedge Osteotomy, Decancellation and Instrumentation for theDecancellation and Instrumentation for the Correction of Kyphotic Deformity ofCorrection of Kyphotic Deformity of Osteoporotic Spinal FractureOsteoporotic Spinal Fracture JUI-KUO HUNG MD.MHAJUI-KUO HUNG MD.MHA Changhua Christian Hospital, Changhua, TaiwanChanghua Christian Hospital, Changhua, Taiwan MD.& MHA.MD.& MHA. //

2. Osteoporotic spinal fractureOsteoporotic spinal fracture High challenge Thoracolumbar kyphosis Back pain Instability Neurological deficit Conservative treatment Surgical treatment Variable modalities 3. Study Design & ObjectivesStudy Design & Objectives Retrospective review Osteoporotic spinal fracture with kyphotic deformity Posterior closing wedge osteotomy Decancellation Instrumentation Functional, neurological and radiological assessment 4. MATERIALS AND METHODSMATERIALS AND METHODS 5. Demographics of PatientsDemographics of Patients 1998 ~ 2004, 27 patients 3 Deaths 2424 patients 6, 18 66 Y/O 57 ~ 80 Follow-up 36.5 months 24 ~ 60 6. DiagnosisDiagnosis 18 6 0 2 4 6 8 10 12 14 16 18 Burst Fx Burst Fx Compression Fx Comp. Fx 7. Angular LevelAngular Level 1 2 9 10 2 0 1 2 3 4 5 6 7 8 9 10 T10 T11 T12 L1 L2 T10 T11 T12 L1 L2 8. Surgical IndicationsSurgical Indications Progressive kyphotic deformity Kyphosis 30 degree Compromise of horizontal balance Progressive neurological deficit Inability to maintain an erect posture and ambulation Intractable pain 9. Surgical MethodSurgical Method -- Posterior Closing Wedge Osteotomy/Decancellation ---- Posterior Closing Wedge Osteotomy/Decancellation -- 10. Surgical MethodSurgical Method -- Posterior Closing Wedge Osteotomy/Decancellation ---- Posterior Closing Wedge Osteotomy/Decancellation -- 11. Radiographic EvaluationRadiographic Evaluation -- T-L Segmental Kyphosis ---- T-L Segmental Kyphosis -- 12. Functional EvaluationFunctional Evaluation -- Oswestry Disability Index-- Oswestry Disability Index Verson 2.0Verson 2.0 ---- Pain intensity Personal care Lifting Walking Sitting Standing Sleeping Sex life Social life Traveling Total 50, Exclude Sex Life 45 13. RESULTSRESULTS 14. Operation Time/Blood LossOperation Time/Blood Loss Operation Time (min) 298 (220~540) Blood Loss (ml) 1988 (400~6000) 15. Neurological ResultsNeurological Results A B C D E Pre- OP A - - - - - - B - - - - - - C - - 2 9 1 12 D - - - 2 8 10 E - - - - 2 2 Post- OP - - 2 11 11 24 No neurological compromiseNo neurological compromise Average neurological recovery:Average neurological recovery: 0.86 grade0.86 grade 16. Kyphosis CorrectionKyphosis Correction Pre-OP Post- OP Final F/U Net Correction Kyphosis 33.34.6 (26~52) 3.752 (2~18) 83.1 (4~20) 25.3 17. Kyphosis CorrectionKyphosis Correction 33.3 3.75 8 0 10 20 30 40 Pre-OP Post-OP Final F/U Kyphosis 18. Functional ResultsFunctional Results -- Oswestry Disability Index ---- Oswestry Disability Index -- 40 18.5 0 5 10 15 20 25 30 35 40 Pre-OP Final F/U Pre-OP Final F/U 19. ComplicationsComplications Pneumonia 1 Ileus 2 Paresthesia 1 Urine retention 4 Dura tear 2 Pressure sores 1 20. Junctional FractureJunctional Fracture 6 patients (20%) 4 without anti-resorption agents 2 with Fosamax 1 with Evista Mean duration 8 months (4~14) Continue labor work 2 with vertebroplasty 4 with conservative treatment 21. CASE PRESENTATIONCASE PRESENTATION 22. 70Y/O L1 Lesion Pre-OPPre-OP KyphosisKyphosis 3535 Post-OPPost-OP KyphosisKyphosis 77 F/U 34 monF/U 34 mon KyphosisKyphosis 1010 23. 74Y/O L1 Lesion Pre-OPPre-OP KyphosisKyphosis 5252 Post-OPPost-OP KyphosisKyphosis 1616 F/U 42 monF/U 42 mon KyphosisKyphosis 1818 24. DISCUSSIONDISCUSSION 25. Kyphosis CorrectionKyphosis Correction -- Surgical Modality ---- Surgical Modality -- Ant. opening wedge osteotomy Smith-Petersen Post. closing wedge osteotomy Decancellation Pedicle subtraction osteotomy Transpedicular body augmentation Cement, bone grafts, cage 26. Posterior Closing Wedge OsteotomyPosterior Closing Wedge Osteotomy DecancellationDecancellation Michele and Krudger in 1949 Diagnosis of vertebral lesions Heinig in 1984 Egg-shell procedure Correction of rigid deformity Protection of neurological elements and vascular structures 27. Posterior Closing Wedge OsteotomyPosterior Closing Wedge Osteotomy DecancellationDecancellation 1986~1991, 13 patient, 57 months F/U Kyphotic deformity Postsurgical, AS, idiopathic and infectious Lumbar lordosis 15.5 45.7 Sagittal C7 plumb line 14.5cm 4.2 cm Functional outcome 93% satisfaction Sigurd HB et al, Spine, 2001 28. Posterior Closing Wedge OsteotomyPosterior Closing Wedge Osteotomy DecancellationDecancellation 1995~2002, 33 patients, >2 years F/U Fixed sagittal imbalance Degenerative sagittal imbalance (62Y/O) Posttraumatic kyphosis (45.5Y/O) Ankylosing spondylitis (55Y/O) Kyphosis correction 28 Thoracic kyphosis 19.6 31.8 Lumbar lordosis 14.8 47.7 Good functional recovery Bridwell KH et al, Spine, 2003 29. Junctional FracturesJunctional Fractures Common events Long spinal fusion and instrumentation Vertebroplasty and kyphoplasty Complication Pain with fracture and junctional kyphosis Neurological deficit Prevention Construct modification, screw hook External protection and PT strengthening Anti-resorption or anabolic agents Prophylactic vertebroplasty 30. Junctional Fractures after Long InstrumentationJunctional Fractures after Long Instrumentation 38 patients, 16 22, 72.4 Y/O Long instrumentation at least 5 levels 30 months F/U Junctional compression fracture 8/38 (5-cephalic, 3-caudal) Overall 21% Prevention Use hook Cement augmentation Medication Advanced junctional kyphosis Extend instrumentation Dewald CJ et al, Spine, 2006 31. CONCLUSIONCONCLUSION 32. Posterior Closing Wedge Osteotomy / DecancellationPosterior Closing Wedge Osteotomy / Decancellation -- Advantage ---- Advantage -- Wide correction level From thoracic to lumbar spine Creation of a large, shared neural foramen, avoid nerve stretch Correction of kyphotic angle Average 30 Decrease of ant. structures injury Enhance osteotomy site healing 33. Posterior Closing Wedge Osteotomy / DecancellationPosterior Closing Wedge Osteotomy / Decancellation -- Disadvantage ---- Disadvantage -- Prolong operation time Large amount of blood loss High technique demand High perioperative morbidity High stress to surgeons 34. Alternative OptionsAlternative Options -- No shortening, No lengthening, Just recovery ---- No shortening, No lengthening, Just recovery -- Body reconstruction Transpedicle grafting Vertebroplasty Kyphoplasty Body augmentator Cage TpBA Implant dislodgement Pedicle subtraction osteotomy May decrease its importance in the future 35.