Loss of Sagittal Balance and Clinical Outcomes following Corrective Osteotomy for Lumbar Degenerative Kyphosis

Ki-Tack Kim; Sang Hun Lee; Kyung-Soo Suk; Jung-Hee Lee; Yang-Sun Im; Eun-Min Seo

doi:10.4055/jkoa.2009.44.1.83

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Kim, Lee, Suk, Lee, Im, and Seo: Loss of Sagittal Balance and Clinical Outcomes following Corrective Osteotomy for Lumbar Degenerative Kyphosis

Original Article

Journal of the Korean Orthopaedic Association

Journal of the Korean Orthopaedic Association 2009; 44(1): 83-92.

Published online: 23 February 2009

DOI: https://doi.org/10.4055/jkoa.2009.44.1.83

Loss of Sagittal Balance and Clinical Outcomes following Corrective Osteotomy for Lumbar Degenerative Kyphosis

Ki-Tack Kim, M.D., Sang Hun Lee, M.D., Kyung-Soo Suk, M.D., Jung-Hee Lee, M.D., Yang-Sun Im, M.D., Eun-Min Seo, M.D.

Department of Orthopedic Surgery, East-West Neo Medical Center, College of Medicine, Kyung Hee University, Seoul, Korea.

Address reprint requests to Sang Hun Lee, M.D. Department of Orthopedic Surgery, East-West Neo Medical Center, Kyung Hee University, 149, Sangil-dong, Gangdong-gu, Seoul 134-090, Korea. Tel: +82.2-440-6152, Fax: +82.2-440-7494, shl6@khu.ac.kr

Abstract

Purpose

To report the loss of correction of a sagittal imbalance and the clinical outcomes after a corrective osteotomy for lumbar degenerative kyphosis.

Materials and Methods

This study analyzed the radiological parameters, surgical techniques, and clinical outcomes of 23 patients, who underwent corrective osteotomy for lumbar degenerative kyphosis. The patients were divided into groups I (>5 cm loss of correction of sagittal imblance, 12 patients) and II (<5 cm, 11 patients) to compare the patients with the correction preserved with those with the correction lost. In terms of the clinical outcome, group A (high satisfaction score group >3.5 out of 5, 11 patients) was compared with group B (low satisfaction score group <3.5 out of 5, 12 patients).

Results

The sagittal imbalance was corrected by performing a Smith-Petersen osteotomy (SPO) in 11 cases and Pedicle subtraction osteotomy (PSO) in 12. The mean preoperative sagittal imbalance was improved from 26.4 cm to 4.05 cm, postoperatively, and 11.2 cm at the last follow up. The mean loss of correction was 11.2 cm in group I and 2.3 cm in group II. The mean satisfaction score was 4.56 in group A and 2.18 in group B. The presence of an old compression fracture was found to be related to the loss of correction, and the preoperative symptomatic spinal stenosis was related to poor clinical outcomes.

Conclusion

After mean 45 month follow up, the mean loss of sagittal correction was 38.3%, which mainly occurred at the proximal unfused segment. The clinical success rate was 45.5%, regardless of the loss of sagittal balance correction.

Keywords: Lumbar degenerative kyphosis, Sagittal imbalance

Figures and Tables

Fig. 1

Radiographs after the Smith-Peterson osteotomy with anterior lumbar interbody fusion (A) and Pedicle subtraction osteotomy (B) in lumbar degenerative kyphosis patients.

Fig. 2

Schematic diagram showing a sagittal imbalance (SI), SI1 and SI2.

Fig. 3

Radiographs showing LDK patients with reactive thoracic lordosis (A) and without reactive thoracic lordosis (B).

Fig. 4

Serial radiographs of a 72-year-old female patient showing loss of sagittal balance. (A) Preoperative radiograph showing severe sagittal imbalance (35.5 cm). (B) Immediate postoperative radiographs showing a restoration of the sagittal balance (4.5 cm). Note the line from the posterosuperior corner of S1 to the center of the T12/L1 disc passes in front of T1. (C) Two years after surgery, the sagittal balance was lost (19.2 cm). The same line of (B) passes in back of T1. This suggests that a significant loss of correction occurred at the proximal unfused segments.

Fig. 5

Serial radiographs of a 74-year-old female patient showing severe loss of correction 46 months after surgery. Most of the loss occurred at proximal unfused segment with degenerative changes.

Table 1

Radiographic Parameters of the Patients

^*PI, Pelvic incidence; ^†SS, Sacral slope; ^‡SI, Sagittal imbalance; ^§SI 1, Sagittal imbalance T1-T12-L1; ^∥SI 2, Sagittal imbalance T12-L1-S1; ^¶PVM, Paravertebral muscle cross-section area ^**BDM, Mean lumbar spine bone densitometry.

Table 2

Analysis of the Related Factors in the Patients Showing a Preserved (Group I) and Loss (Group II) of Sagittal Balance

^*SI, sagittal imbalance; ^†PI, pelvic incidence; ^‡SS, sacral slope; ^§PVM, paravertebral muscle cross-section area; ^∥OCF, old compression fracture; ^¶BDM, Mean lumbar spine bone densitometry; ^**SPO, Smith-Peterson Osteotomy; PSO, Pedicle subtraction osteotomy; ^**BDM, Mean lumbar spine bone densitometry; ^††MSRSI, Modified Spine Research Society Instrument; ^‡‡RTL, Reactive thoracic lordosis.

Table 3

Analysis of the Related Factors in the Patients Showing Good (Group A) and Poor (Group B) Satisfaction

^*MSRSI, Modified Spine Research Society Instrument; ^†PI, Pelvic Incidence; ^‡SS, Sacral Slope; ^§SI, Sagittal Index; ^∥PVM, Paravertebral Muscle Cross-section Area; ^¶OCF, Old Compression Fracture; ^**BDM, Mean Lumbar Spine Bone Densitometry; ^††SPO, Smith-peterson Osteotomy; PSO, Pedicle Subtraction Osteotomy; ^‡‡RTL, Reactive Thoracic Lordosis.

Notes

^*This paper was partly supported by research sponsorship from AO spine Korea.

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