J Korean Neurosurg Soc.  2022 Jan;65(1):84-95. 10.3340/jkns.2021.0147.

Clinical Efficacy and Safety of Controlled Distraction-Compression Technique Using Expandable Titanium Cage in Correction of Posttraumatic Kyphosis

• Kang D
• Lewis SJ
• Kim DH

• KMID: 2523916
• DOI: http://doi.org/10.3340/jkns.2021.0147

Abstract

Objective
: To investigate the clinical efficacy and safety of the controlled distraction-compression technique using an expandable titanium cage (ETC) in posttraumatic kyphosis (PTK).
Methods
: We retrospectively studied and collected data on 20 patients with PTK. From January 2014 to December 2017, the controlled distraction-compression technique using ETC was consecutively performed in 20 patients with PTK of the thoracolumbar zone (range, 36–82 years). Among them, nine were males and 11 were females and the mean age was 61.5 years. The patients were followed regularly at 1, 3, 6, and 12 months, and the last follow-up was more than 2 years after surgery.
Results
: The mean follow-up period was 27.3±7.3 months (range, 14–48). The average operation time was 286.8±33.1 minutes (range, 225–365). The preoperative regional kyphotic angle (RKA) ranged from 35.6° to 70.6° with an average of 47.5°±8.1°. The immediate postoperative mean RKA was 5.9°±3.8° (86.2% correction rate, p=0.000), and at the last follow-up more than 2 years later, the mean RKA was 9.2°±4.9° (80.2% correction rate, p=0.000). The preoperative mean thoracolumbar kyphosis was 49.1°±9.2° and was corrected to an average of 8.8°±5.3° immediately after surgery (p=0.000). At the last follow-up, a correction of 11.9°±6.3° was obtained (p=0.000). The preoperative mean back visual analog scale (VAS) score was 7.9±0.8 and at the last follow-up, the VAS score was improved to a mean of 2.3±1.0 with a 70.9% correction rate (p=0.000). The preoperative mean Oswestry disability index (ODI) score was 32.3±6.9 (64.6%) and the last follow-up ODI score was improved to a mean of 6.85±2.9 (3.7%) with a 78.8% correction rate (p=0.000). The overall complication was 15%, with two of distal junctional fractures and one of proximal junctional kyphosis and screw loosening. However, there were no complications directly related to the operation.
Conclusion
: PVCR through the controlled distraction-compression technique using ETC showed safe and good results in terms of complications, and clinical and radiologic outcomes in PTK. However, to further evaluate the efficacy of this surgical procedure, more patients need long-term follow-up and there is a need to apply it to other diseases.

Keyword

Controlled distraction; Vertebral column resection; Kyphosis; Cage, expandable

Figure

• 

  Fig. 1. Pedicle screw fixation (A), and laminectomy and its limits (B and C). Laminectomy extent is between dashed lines (C). Partial discectomy and corpectomy with an osteotome and pituitary forceps (D), and removal of the remnant posterior vertebral body wall under the dura done with a reverse-angled curette (E). If the cap of the temporary rod was loosened temporarily before inserting the expandable titanium cage, the partial reduction of kyphosis by gravity could be confirmed (F). An expandable titanium cage (ETC) was inserted into the empty space in a collapsed state (G). After placement, we expanded the ETC along with sagittal alignment until the anterior vertebral height was nearly similar to the posterior vertebral height with a temporary rod fixed (H). The short temporary rod was exchanged for a pre-bent and suitably sized permanent rod (I). Once the cage was expanded, a large amount of additional allogenous and autogenous bone chips were packed into the expanded cage and between the ETC and residual cortical shell (J and K).

• 

  Fig. 2. Comparison of the extent of bone removal. The affected rib was transected about 1–1.5 cm from the lateral border of the transverse process (TP) (lower), unlike conventional surgery which removes ribs 5–6 cm from the lateral border of the TP (upper). Only one-third to one-half of the lateral wall of the vertebral body was removed to secure enough space for the expandable titanium cage. Blue color : removed bone, dark blue : rib, red : remnant cortical shell.

• 

  Fig. 3. The expandable titanium cage can be inserted into the corpectomy site in a direction perpendicular to the dura and rotated to expand for lumbar lesions.

• 

  Fig. 4. Case 2. The whole spine X-ray (A) shows focal kyphosis in the thoracolumbar junction without global sagittal imbalance. The dynamic views (B-D) show rigid kyphosis with a 70° regional kyphosis angle (RKA) and 67° of thoracolumbar kyphosis (TLK). All RKA and TLK were improved to 6° immediate postoperatively (E). Although one patient developed a distal junctional fracture 3 months postoperatively (F, red arrow), the patient recovered well with conservative treatment.

• 

  Fig. 5. Immediate postoperative computed tomography (CT; A and B). The remaining thin rim of the cortical shell acts as a surrounding mechanical barrier for fitting and impaction of the bone graft and is advantageous for bone union (A and B). Last follow-up CT shows fused state of corpectomy site (C-E). The red line (B) indicate the remaining cortical rim and the yellow arrow indicates the resected rib and the red one is the remnant rib.

Reference

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