Decision Making Algorithm for Adult Spinal Deformity Surgery

Kim, Yongjung J.,Hyun, Seung-Jae,Cheh, Gene,Cho, Samuel K.,Rhim, Seung-Chul The Korean Neurosurgical Society 2016 Journal of Korean neurosurgical society Vol.59 No.4

Adult spinal deformity (ASD) is one of the most challenging spinal disorders associated with broad range of clinical and radiological presentation. Correct selection of fusion levels in surgical planning for the management of adult spinal deformity is a complex task. Several classification systems and algorithms exist to assist surgeons in determining the appropriate levels to be instrumented. In this study, we describe our new simple decision making algorithm and selection of fusion level for ASD surgery in terms of adult idiopathic idiopathic scoliosis vs. degenerative scoliosis.

Pedicle Screw Placement in the Thoracolumbar Spine Using a Novel, Simple, Safe, and Effective Guide-Pin : A Computerized Tomography Analysis

현승재,Yongjung J. Kim,임승철,Gene Cheh,Samuel K. Cho 대한신경외과학회 2015 Journal of Korean neurosurgical society Vol.58 No.1

Objective : To improve pedicle screw placement accuracy with minimal radiation and low cost, we developed specially designed K-wire with a marker. To evaluate the accuracy of thoracolumbar pedicle screws placed using the novel guide-pin and portable X-rays. Methods : Observational cohort study with computerized tomography (CT) analysis of in vivo and in vitro pedicle screw placement. Postoperative CT scans of 183 titanium pedicle screws (85 lumbar and 98 thoracic from T1 to L5) placed into 2 cadavers and 18 patients were assessed. A specially designed guide-pin with a marker was inserted into the pedicle to identify the correct starting point (2 mm lateral to the center of the pedicle) and aiming point (center of the pedicle isthmus) in posteroanterior and lateral X-rays. After radiographically confirming the exact starting and aiming points desired, a gearshift was inserted into the pedicle from the starting point into the vertebral body through the center of pedicle isthmus. Results : Ninety-nine percent (181/183) of screws were contained within the pedicle (total 183 pedicle screws : 98 thoracic pedicle screws and 85 lumbar screws). Only two of 183 (1.0%) thoracic pedicle screws demonstrated breach (1 lateral in a patient and 1 medial in a cadaver specimen). None of the pedicle breaches were associated with neurologic or other clinical sequelae. Conclusion : A simple, specially designed guide-pin with portable X-rays can provide correct starting and aiming points and allows for accurate pedicle screw placement without preoperative CT scan and intraoperative fluoroscopic assistance.

Pedicle Screw Placement in the Thoracolumbar Spine Using a Novel, Simple, Safe, and Effective Guide-Pin : A Computerized Tomography Analysis

Hyun, Seung-Jae,Kim, Yongjung J.,Rhim, Seung-Chul,Cheh, Gene,Cho, Samuel K. The Korean Neurosurgical Society 2015 Journal of Korean neurosurgical society Vol.46 No.4

Objective : To improve pedicle screw placement accuracy with minimal radiation and low cost, we developed specially designed K-wire with a marker. To evaluate the accuracy of thoracolumbar pedicle screws placed using the novel guide-pin and portable X-rays. Methods : Observational cohort study with computerized tomography (CT) analysis of in vivo and in vitro pedicle screw placement. Postoperative CT scans of 183 titanium pedicle screws (85 lumbar and 98 thoracic from T1 to L5) placed into 2 cadavers and 18 patients were assessed. A specially designed guide-pin with a marker was inserted into the pedicle to identify the correct starting point (2 mm lateral to the center of the pedicle) and aiming point (center of the pedicle isthmus) in posteroanterior and lateral X-rays. After radiographically confirming the exact starting and aiming points desired, a gearshift was inserted into the pedicle from the starting point into the vertebral body through the center of pedicle isthmus. Results : Ninety-nine percent (181/183) of screws were contained within the pedicle (total 183 pedicle screws : 98 thoracic pedicle screws and 85 lumbar screws). Only two of 183 (1.0%) thoracic pedicle screws demonstrated breach (1 lateral in a patient and 1 medial in a cadaver specimen). None of the pedicle breaches were associated with neurologic or other clinical sequelae. Conclusion : A simple, specially designed guide-pin with portable X-rays can provide correct starting and aiming points and allows for accurate pedicle screw placement without preoperative CT scan and intraoperative fluoroscopic assistance.

Adolescent Idiopathic Scoliosis Treatment by a Korean Neurosurgeon : The Changing Role for Neurosurgeons

현승재,Woong-Beom Kim,Young-Seop Park,Ki-Jeong Kim,장태안,Yongjung J. Kim 대한신경외과학회 2015 Journal of Korean neurosurgical society Vol.58 No.1

Objective : The purpose of this study was to evaluate radiographic/clinical outcomes of adolescent idiopathic scoliosis (AIS) patients treated by a Korean neurosurgeon. Methods : Ten AIS patients were treated by a single neurosurgeon between January 2011 and September 2013 utilizing segmental instrumentation with pedicle screws. Basic demographic information, curve pattern by Lenke classification, number of levels treated, amount of correction achieved, radiographic/clinical outcomes [by Scolisis Resarch Society (SRS-22r) questionnaire] and complications were evaluated to determine the surgical results. Pulmonary function test was utilized to assess forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before and after surgery. Results : The average percentage of correction of the major structural curve was 73.6% (ranged from 64% to 81.5%). Preoperative and final postoperative absolute FVC averaged 3.03 L and 3.76 L (0.73 L increase, p=0.046), and absolute FEV1 averaged 2.63 L and 3.49 L (0.86 L increase, p=0.021). Preoperative and final postoperative average self-image and function scores of SRS-22r were, 2.6±0.5, 3.3±0.1, 4.0±0.5, and 4.6±0.0, respectively. There was a significant improvement of the self-image and function scores of SRS-22r questionnaires before and after surgery (p<0.05). There was no case of neurological deficit, infection and revision for screw malposition. One patient underwent a fusion extension surgery for shoulder asymmetry. Conclusion : Radiographic/clinical outcomes of AIS patients treated by a Korean neurosurgeon were acceptable. Fundamental understanding of pediatric spinal deformity is essential for the practice of AIS surgery.

Adolescent Idiopathic Scoliosis Treatment by a Korean Neurosurgeon : The Changing Role for Neurosurgeons

Hyun, Seung-Jae,Kim, Woong-Beom,Park, Young-Seop,Kim, Ki-Jeong,Jahng, Tae-Ahn,Kim, Yongjung J. The Korean Neurosurgical Society 2015 Journal of Korean neurosurgical society Vol.46 No.4

Objective : The purpose of this study was to evaluate radiographic/clinical outcomes of adolescent idiopathic scoliosis (AIS) patients treated by a Korean neurosurgeon. Methods : Ten AIS patients were treated by a single neurosurgeon between January 2011 and September 2013 utilizing segmental instrumentation with pedicle screws. Basic demographic information, curve pattern by Lenke classification, number of levels treated, amount of correction achieved, radiographic/clinical outcomes [by Scolisis Resarch Society (SRS-22r) questionnaire] and complications were evaluated to determine the surgical results. Pulmonary function test was utilized to assess forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before and after surgery. Results : The average percentage of correction of the major structural curve was 73.6% (ranged from 64% to 81.5%). Preoperative and final postoperative absolute FVC averaged 3.03 L and 3.76 L (0.73 L increase, p=0.046), and absolute FEV1 averaged 2.63 L and 3.49 L (0.86 L increase, p=0.021). Preoperative and final postoperative average self-image and function scores of SRS-22r were, $2.6{\pm}0.5$, $3.3{\pm}0.1$, $4.0{\pm}0.5$, and $4.6{\pm}0.0$, respectively. There was a significant improvement of the self-image and function scores of SRS-22r questionnaires before and after surgery (p<0.05). There was no case of neurological deficit, infection and revision for screw malposition. One patient underwent a fusion extension surgery for shoulder asymmetry. Conclusion : Radiographic/clinical outcomes of AIS patients treated by a Korean neurosurgeon were acceptable. Fundamental understanding of pediatric spinal deformity is essential for the practice of AIS surgery.

Clinical and Radiological Outcomes of Posterior Vertebral Column Resection for Severe Spinal Deformities

Lee, Byoung Hun,Hyun, Seung-Jae,Kim, Ki-Jeong,Jahng, Tae-Ahn,Kim, Yongjung J.,Kim, Hyun-Jib The Korean Neurosurgical Society 2018 Journal of Korean neurosurgical society Vol.61 No.2

Objective : The aim of this study was to investigate clinical and radiological outcomes of patients who underwent posterior vertebral column resection (PVCR) by a single neurosurgeon in a single institution. Methods : Thirty-four consecutive patients with severe spinal deformities who underwent PVCR between 2010 and 2016 were enrolled. The radiographic measurements included a kyphotic angle of PVCR levels (VCR angle), sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis (LL), and spinopelvic parameters. The data of surgical time, estimated blood loss, duration of hospital stay, complications, intraoperative neurophysiologic monitoring, and the Scoliosis Research Society (SRS)-22 questionnaire were collected using a retrospective review of medical records. Results : The VCR angle, LL, and SVA values were significantly corrected after surgery. The VCR and LL angle were changed from the average of $38.4{\pm}32.1^{\circ}$ and $-22.1{\pm}39.1^{\circ}$ to $-1.7{\pm}29.4^{\circ}$ (p<0.001) and $-46.3{\pm}23.8^{\circ}$ (p=0.001), respectively. The SVA was significantly reduced from $103.6{\pm}88.5mm$ to $22.0{\pm}46.3mm$ (p=0.001). The clinical results using SRS-22 survey improved from $2.6{\pm}0.9$ to $3.4{\pm}0.8$ (p=0.033). There were no death and permanent neurological deficits after PVCR. However, complications occurred in 19 (55.9%) patients. Those patients experienced a total of 31 complications during- and after surgery. Sixteen reoperations were performed in twelve (35.3%) patients. The incidence of transient neurological deterioration was 5.9% (two out of 34 patients). Conclusion : Severe spinal deformities can be effectively corrected by PVCR. However, the PVCR technique should be utilized limitedly because surgery-related serious complications are relatively common.

Restoration of Sagittal Balance in Spinal Deformity Surgery

Makhni, Melvin C.,Shillingford, Jamal N.,Laratta, Joseph L.,Hyun, Seung-Jae,Kim, Yongjung J. The Korean Neurosurgical Society 2018 Journal of Korean neurosurgical society Vol.61 No.2

The prevalence of patients with adult spinal deformity (ASD) has been reported as high as 68%. ASD often leads to significant pain and disability. Recent emphasis has been placed on sagittal plane balance and restoring normal sagittal alignment with regards to the three dimensional deformity of ASD. Optimal sagittal alignment has been known to increase spinal biomechanical efficiency, reduce energy expenditure by maintaining a stable posture with improved load absorption, influence better bony union, and help to decelerate adjacent segment deterioration. Increasingly positive sagittal imbalance has been shown to correlate with poor functional outcome and poor self-image along with poor psychological function. Compensatory mechanisms attempt to maintain sagittal balance through pelvic rotation, alterations in lumbar lordosis as well as knee and ankle flexion at the cost of increased energy expenditure. Restoring normal spinopelvic alignment is paramount to the treatment of complex spinal deformity with sagittal imbalance. Posterior osteotomies including posterior column osteotomies, pedicle subtraction osteotomies, and posterior vertebral column resection, as well anterior column support are well known to improve sagittal alignment. Understanding of whole spinal alignment and dynamics of spinopelvic alignment is essential to restore sagittal balance while minimizing the risk of developing sagittal decompensation after surgical intervention.

청년군과 고령군의 시상면상 흉추 및 흉요추 만곡의 비교

강규복(Gyu-Bok Kang),안영준(Young-Joon Ahn),김용정(Yongjung J. Kim),김영배(Youngbae B. Kim),고영록(Young-Rok Ko) 대한정형외과학회 2016 대한정형외과학회지 Vol.51 No.1

목적: 흉추 후만은 연령 변화에 따른 시상면상 균형과 수술의 범위를 결정하는 주요 인자이다. 그러나 이의 세부 변화에 대하여 알려진 바가 없어 분석하고자 하였다. 대상 및 방법: 326명의 척추와 하지의 질환이나 수술 등의 과거력이 없는 정상 성인 남성들을 연령에 따라 1군(평균, 21.2±1.7세) 및 2군(평균, 64.1±6.4세)으로 나누고 기립 측면 촬영에서 시상면상 척추 골반 지표들을 측정하였다. 흉추 및 흉요추 후만은 A (제7경추-제5흉추), B (제5-10흉추), C (제10-12흉추) 및 D (제12흉추-제2요추)의 4개 구간으로 세분하였다. 결과: 2군에서 흉추 후만각(21.1°±7.7° vs. 30.0°±8.8°, p<0.001), B구간(15.8°±6.1° vs. 18.1°±7.9°, p=0.003) 및 C구간(5.3°±5.1° vs. 11.8°±6.5°, p<0.001) 등이 증가하였다. A구간(12.1°±6.4° vs. 9.8°±6.4°, p=0.001)에서는 1군에서 큰 값을 보였다. D구간에서는 유의한 차이를 보이지 않았다. 결론: 흉추 후만의 증가는 고령군에서 중, 하부 흉추에서 증가를 보였다. 이는 청년군과 고령군의 정상 척추 해부학의 이해와 수술적 치료에 대한 중요한 참고 자료가 될 것이다. Purpose: Little is known with respect to changes in the segmental thoracic and thoracolumbar kyphosis, which are major parameters influencing sagittal balance of the spine. The authors investigated the detailed segmental changes of those parameters by ageing. Materials and Methods: A total of 326 normal asymptomatic males were divided into 2 groups; group 1 (mean age, 21.2±1.7; n=175) and group 2 (mean age, 64.1±6.4; n=151). After taking a standing sagittal radiograph, the sagittal spinal and pelvic parameters were measured. Thoracic and thoracolumbar kyphosis were classified according to segments A, C7 UEP (upper end vertebra)–T5 UEP; B, T5 UEP–T10 UEP; C, T10 UEP–T12 LEP (lower end vertebra); and D, (T12 LEP–L2 LEP), and analyzed between 2 groups, respectively. Results: Thoracic kyphosis (21.1°±7.7° vs. 30.0°±8.8°, p<0.001), segment B (15.8°±6.1o vs. 18.1°±7.9°, p=0.003), and segment C (5.3°±5.1° vs. 11.8o±6.5°, p<0.001) were increased in group 2. In group 2 segment A showed decreased kyphosis (12.1°±6.4° vs. 9.8°±6.4°, p=0.001). In segment D no significant difference was observed between groups. Conclusion: Increased thoracic kyphosis was observed in the middle and lower thoracic regions. The authors provided important references of sagittal parameters to determine the expected ranges of kyphosis for a normal asymptomatic male of a given age.