A Clinical Analysis of Surgical Treatment of Lumbar Degenerative Kyphosis

Eung-Ha Kim; Seung-Kwan Han; Hyun-Jung Kim

doi:10.4184/jkss.2001.8.3.210

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Kim, Han, and Kim: A Clinical Analysis of Surgical Treatment of Lumbar Degenerative Kyphosis

Original Article

Journal of Korean Spine Surg 2001;8(3):210-218.

Published online: 21 February 2001

DOI: https://doi.org/10.4184/jkss.2001.8.3.210

A Clinical Analysis of Surgical Treatment of Lumbar Degenerative Kyphosis

Eung-Ha Kim, M.D., Seung-Kwan Han, M.D., Hyun-Jung Kim, M.D.

Department of Orthopedic Surgery, National Medical Center, Seoul, Korea

Address reprint requests to Eung-Ha Kim, M.D. Department of Orthopedic Surgery, National Medical Center 18-79 Ulchiro-6-ga, Choong-gu, Seoul 100-799, Korea Tel : 82-2-2260-7193, Fax : 82-2-2278-9570, E-mail : eungha@unitel.co.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

A retrospective study.

Objective

To analyse associated preoperative conditions and postoperative causes of sagittal imbalance and to analyze clinical results of surgical treatment of lumbar degenerative kyphosis.

Summary of Literature Review

There have been many controversies and high possibility of unsatisfactory results in surgical treatment of symptomatic degenerative lumbar kyphosis, which was complicated condition usually needed multi- level operation in old age.

Materials and Methods

We analyzed 24 patients who complained of long standing stooping as one of main symptoms with radiologically measured lumbar kyphosis and underwent surgical restoration of lumbar lordodsis with long segmental spinal fusion from 1995 to 1999. Mean followup was 31.9months(from 24 to 48 months). Operative treatments were posterolateral fusion with pedicular screw(15 cases), anterior and posterior interbody fusion(5 cases), posterior interbody fusion with cage(1 case) and decancellation osteotomy(3 cases). Cases divided into 2 groups(Group A : improved stooping, Group B: recurred stooping) were evaluated by radiological measurement of changes in surgically restored lumbar lordosis correlated with clinical improvement of stooping. Overall clinical results were evaluated according to Kirkaldy-Willis criteria.

Results

The associated conditions of preoperative lumbar kyphosis were recognized as multiple disc degeneration, segmental instability, degenerative vertebral wedging and pseudospondylolisthesis. Postoperative stooping recurred in 5 cases and caused by adjacent kyphosis in 2 cases, loss of correction in 1 case and both in 2 cases. Loss of correction was associated with pseudarthrosis in 1 case, screw loosening in 3 cases and allograft collapse in 2 cases. A ccording to Kirkaldy-Willis, 8 cases of unsatisfactory clinical results consisted of 3 cases of pseudarthrosis out of 19 cases of Gruop A and all cases(5 cases) in group B. Most of correction loss occurred at lower lumbar spine(L3- S1) and was closely related to postoperative sagittal imbalance.

Conclusion

Maintenance of well corrected lumbar lordosis for sagittal balance and prevention of pseudarthrosis were manda-tory for good clinical outcome in surgical treatment of lumbar degenerative kyphosis.

Keywords: Lumbar degenerative kyphosis, Sagittal imbalance, Pseudarthrosis, Surgical treatment

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Figures and Tables%

Fig. 1.

Parameter which represent spinal alignment.

Fig. 2-A.

Preoperative lateral radiography of 68-year-old man shows disc degeneration of L2-3 L3-4 L4-5 L5-S1, and rigid kyphosis in flexion-extension view. Fig. 2-B. Postoperative lateral radiography with L2-S1 posterolateral fusion with pedicular screw and pedicle subtraction osteotomy on L4 shows increased lumbar lordosis angle by 16˚. Postoperative 28-months followup lateral radiography of lumbar spine shows correction loss(L1-S1) by 8˚, but shows maintenance of lumbar lordosis and relief of stooping.

Fig. 3-A.

Preoperative lateral radiography of 64-year-old woman shows disc degeneration of L4-5 L5-S1, wedge vertebrae L4 L5, and segmental instability L3-4 L4-5 in flexion-extension view. Fig. 3-B. Postoperative lateral radiography with L2-S1 posterolateral fusion with pedicular screws and L2-5 anterior interbody fusion with allograft shows increased lumbar lordosis angle by 15˚. Postoperative 33-months followup lateral radiography of lumbar spine shows compression fx L1 with correction loss(L1-S1) by 4˚, but showed maintenance of lumbar lordosis and relief of stooping.

Fig. 4-A.

Preoperative lateral radiography of 66-year-old woman shows disc degeneration of L2-3 L4-5 L5-S1, wedge vertebrae L5 and pseudospondylolisthesis L3 on 4. Fig. 4-B. Postoperative lateral radiography with L2-S1 posterolateral fusion with pedicular screw and posterior lumbar interbody fusion with cage L4-5 shows increased lumbar lordosis angle by 11˚. Postoperative 33-months followup lateral radiography of lumbar spine shows correction loss(L1-S1) by 4˚, but showed maintenance of lumbar lordosis and relief of stooping.

Table 1.

Radiologic Results in Improved stooping group (Group A)

	Preop	IPO	F/U	Loss of Correction
FSA*(In-fusion)	9.8	24.7	21.3	3.4
TLLA^†(L1-S1)	14.1	30.3	26.2	4.1
HLSA^‡(L1-L3)	–7.5	0.1	–2.1	2.2
LLSA^§(L3-S1)	18.6	30.8	28.4	2.4
SI^\|\|(ß-Angle)	19.8	34.3	32.1	2.2

^∗ FSA : fusion segmental angle

^† TLLA : Total lumbar lordosis angle

^‡ HLSA : High lumbar segmental angle

^§ LLSA : Low lumbar segmental angle

^|| SI : Sacral inclination

Table 2.

Radiologic Results in Persistent stooping group (Group B)

	Preop	IPO	F/U	Loss of Correction
FSA(In-fusion)	4.4	25.6	16.2	9.4
TLLA(L1-S1)	10.9	31.3	19.8	11.5
HLSA(L1-L3)	–2.4	2.6	0.2	2.4
LLSA(L3-S1)	16.8	26.8	16.0	10.8
SI(ß-Angle)	24.0	35.8	26.2	9.6

Table 3.

Associated conditions for lumbar kyphosis

Cause	Case(%)
Multiple Disc Degeneration	24 case(100)
Wedge or Collapsed vertebrae	7 case(29.1)
Segmental Instability	8 case(33.3)
Pseudospondylolisthesis	4 case(16.6)

Table 4.

Causes of Postoperative Sagittal Imbalance

Cause	Case(%)	Location
Pseudarthrosis	1 case(4.1)	1 case(L5-S1)
Screws Loosening	3 cases(12.5)	3 cases(L3-S1)
Allograft collapse	2 cases(8.3)	2 cases(L3-S1)
Adj^∗. Disc Degeneration	3 cases(12.5)	2 cases(L5-S1),1 case(L1-2)

^∗ Adj. : Adjacent

Table 5.

Associated neural compression

Cause	Case(%)
Spinal stenosis	20 cases(83.3)
HNP	14 cases(58.3)

Table 6.

Clinical Results(Kirkaldy-Willis, 1974)

	Group A	Group B
Excellent	5(26.3%)	0(0%)
Good	11(57.8%)	0(0%)
Fair	3(15.7%)	4(80.0%)
Poor	0(0%)	1(20.0%)

Table 7.

Clinical Results(Loss of cardinal sign)

	Group A	Group B
Loss of forward stooping	19(100%)	0(0%)
Restore ability of climbing slope	13(68.4%)	1(20.0%)
Relief of Low back pain	16(84.2%)	1(20.0%)
Relief of all cardinal sign	8(42.1%)	0(0%)

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