Objective:To investigate the impact of correcting rotational subluxation through circumferential fusion and transforaminal lumbar interbody fusion (TLIF) on postoperative coronal plane imbalance in degenerative scoliosis.Methods:A retrospective analysis was conducted on the data of 108 patients with type A degenerative scoliosis in the Nanjing classification who underwent primary multi-segment posterior column osteotomy (PCO) with deformity correction and internal fixation at Nanjing Gulou Hospital from June 2017 to June 2021. Patients were divided into two groups based on the presence of preoperative rotational subluxation: the rotational subluxation group and the non-rotational subluxation group. The rotational subluxation group consisted of 60 patients, with 8 males and 52 females, aged 63.7±5.5 years (range, 56-75 years). The non-rotational subluxation group included 48 patients, with 5 males and 43 females, aged 64.4±5.2 years (range, 53-72 years). Within the rotational subluxation group, depending on whether TLIF was performed on the rotational subluxation segment, they were further categorized into the TLIF group and the PCO group. The TLIF group comprised 28 patients, while the PCO group had 32 patients. Full-spine anteroposterior and lateral X-rays were taken preoperatively, postoperatively, and at the last follow-up to measure coronal balance types and radiographic parameters. The differences in the lumbar Cobb angle, coronal balance distance (CBD), and the Cobb angle of the lumbosacral curve (Cobb-Fra angle) were compared between the rotational subluxation group and the non-rotational subluxation group, as well as between the TLIF group and the PCO group.Results:The average surgery duration ranged from 200 to 310 min, with a mean of 235±47 min. The intraoperative blood loss ranged from 700 to 2,400 ml, with an average of 950±355 ml. The number of fused segments in the rotational subluxation group was 7.6±2.1, ranging from 5 to 11 segments, while in the non-rotational subluxation group, it was 7.4±2.0, ranging from 5 to 10 segments. Postoperatively, 13%(8/60) of patients in the rotational subluxation group developed type C coronal imbalance, significantly higher than the 2%(1/48) in the non-rotational subluxation group. The immediate postoperative and final follow-up lumbar Cobb angles, CBD, and Cobb-Fra angles in the rotational subluxation group were 20.60°±10.73° and 20.33°±10.92°, 22.53±16.45 mm and 18.53±17.31 mm, 13.14°±4.40° and 11.23°±4.92°, respectively, which were higher than those in the non-rotational subluxation group (13.92°±7.02° and 12.92°±6.64°, 18.62±17.44 mm and 8.83±8.95 mm, 11.91°±3.03° and 9.52°±3.30°), with statistical significance ( P<0.05).. Among patients in the rotational subluxation group, the probability of new-onset coronal imbalance postoperatively was 4%(1/28) in the TLIF group, which was lower than the 22%(7/32) in the PCO group, with a statistically significant difference (χ 2=4.330, P=0.037). The immediate postoperative and final follow-up lumbar Cobb angles, CBD, and Cobb-Fra angles in the PCO group were 25.63°±11.00° and 25.13°±11.04°, 27.37±18.95 mm and 25.25±18.67 mm, 15.50°±3.62° and 14.08°±4.77°, respectively, which were significantly higher than those in the TLIF group (14.86°±6.96° and 14.86°±5.37°, 17.08±10.94 mm and 10.86±7.86 mm, 10.14°±3.37° and 8.46°±2.66°), with statistical significance ( P<0.05). Conclusion:For patients with Type A degenerative scoliosis combined with rotational subluxation according to the Nanjing classification, performing a 360-degree circumferential release and interbody fusion at the segment with rotatory subluxation can reduce the risk of developing new postoperative coronal imbalances.

Adolescent idiopathic scoliosis(AIS)is a complex three-dimensional deformity involving coronal,sagittal,and axial planes,with a prevalence that should not be overlooked.With advancements in technology and in-depth research,an increasing number of hospitals and physicians are exploring standardized diagnostic and treatment approaches for AIS.Comprehensive and in-depth understanding is required for AIS,including its etiology,screening and diagnosis,classification,assessment and examination,treatment options,exploration of current focus,and evaluation of quality of life.Such understanding ensures that the diagnostic and treatment are scientific,standardized,and timely.Based on the principles of evidence-based medicine,a consensus on the diagnosis and treatment of AIS is reached after multiple discussions among spinal surgery experts,aiming to provide reference and guidance for clinical practice.

Objective:To investigate the impact of correcting rotational subluxation through circumferential fusion and transforaminal lumbar interbody fusion (TLIF) on postoperative coronal plane imbalance in degenerative scoliosis.Methods:A retrospective analysis was conducted on the data of 108 patients with type A degenerative scoliosis in the Nanjing classification who underwent primary multi-segment posterior column osteotomy (PCO) with deformity correction and internal fixation at Nanjing Gulou Hospital from June 2017 to June 2021. Patients were divided into two groups based on the presence of preoperative rotational subluxation: the rotational subluxation group and the non-rotational subluxation group. The rotational subluxation group consisted of 60 patients, with 8 males and 52 females, aged 63.7±5.5 years (range, 56-75 years). The non-rotational subluxation group included 48 patients, with 5 males and 43 females, aged 64.4±5.2 years (range, 53-72 years). Within the rotational subluxation group, depending on whether TLIF was performed on the rotational subluxation segment, they were further categorized into the TLIF group and the PCO group. The TLIF group comprised 28 patients, while the PCO group had 32 patients. Full-spine anteroposterior and lateral X-rays were taken preoperatively, postoperatively, and at the last follow-up to measure coronal balance types and radiographic parameters. The differences in the lumbar Cobb angle, coronal balance distance (CBD), and the Cobb angle of the lumbosacral curve (Cobb-Fra angle) were compared between the rotational subluxation group and the non-rotational subluxation group, as well as between the TLIF group and the PCO group.Results:The average surgery duration ranged from 200 to 310 min, with a mean of 235±47 min. The intraoperative blood loss ranged from 700 to 2,400 ml, with an average of 950±355 ml. The number of fused segments in the rotational subluxation group was 7.6±2.1, ranging from 5 to 11 segments, while in the non-rotational subluxation group, it was 7.4±2.0, ranging from 5 to 10 segments. Postoperatively, 13%(8/60) of patients in the rotational subluxation group developed type C coronal imbalance, significantly higher than the 2%(1/48) in the non-rotational subluxation group. The immediate postoperative and final follow-up lumbar Cobb angles, CBD, and Cobb-Fra angles in the rotational subluxation group were 20.60°±10.73° and 20.33°±10.92°, 22.53±16.45 mm and 18.53±17.31 mm, 13.14°±4.40° and 11.23°±4.92°, respectively, which were higher than those in the non-rotational subluxation group (13.92°±7.02° and 12.92°±6.64°, 18.62±17.44 mm and 8.83±8.95 mm, 11.91°±3.03° and 9.52°±3.30°), with statistical significance ( P<0.05).. Among patients in the rotational subluxation group, the probability of new-onset coronal imbalance postoperatively was 4%(1/28) in the TLIF group, which was lower than the 22%(7/32) in the PCO group, with a statistically significant difference (χ 2=4.330, P=0.037). The immediate postoperative and final follow-up lumbar Cobb angles, CBD, and Cobb-Fra angles in the PCO group were 25.63°±11.00° and 25.13°±11.04°, 27.37±18.95 mm and 25.25±18.67 mm, 15.50°±3.62° and 14.08°±4.77°, respectively, which were significantly higher than those in the TLIF group (14.86°±6.96° and 14.86°±5.37°, 17.08±10.94 mm and 10.86±7.86 mm, 10.14°±3.37° and 8.46°±2.66°), with statistical significance ( P<0.05). Conclusion:For patients with Type A degenerative scoliosis combined with rotational subluxation according to the Nanjing classification, performing a 360-degree circumferential release and interbody fusion at the segment with rotatory subluxation can reduce the risk of developing new postoperative coronal imbalances.

Rigid spinal kyphosis deformity is typically characterized by a large kyphotic Cobb angle (≥70°) and a significant decrease of intervertebral flexibility (bending flexibility<30°), due to primary spinal disease, spinal trauma or other diseases. Severe kyphotic deformity leads to a poor posture and spinal cord or neurological impairment. Three-column osteotomy, including pedicle subtraction osteotomy (PSO) and its modified methods, is the only effective treatment for such patients. For example, asymmetrical PSO (APSO) could not only achieve successful realignment of spinal biplanar balance, but also realize complete closure of osteotomy gap, which is conducive to realize solid bony fusion and provide better stability. In partial pedicle subtraction osteotomy (PPSO), the remaining cortical shell of pedicle could decrease the risk of neural injury without significant loss of correction amount, so PPSO could be a viable surgical option for spinal deformity. Besides, modified partial pedicle subtraction osteotomy (MPPSO) is commonly used for post-traumatic thoracolumbar kyphosis with an injured disc. The potential superiorities of MPPSO are that it not only increases regional stability by reserving the integrity of the lower facet joint, but also promotes direct interbody fusion in the upper disc space. For closing-opening wedge osteotomy (COWO), it could obtain more kyphotic corrections by closing posterior column and opening anterior column simultaneously. Modified closing-opening wedge osteotomy (MCOWO) is an ideal option in treating cases of thoracolumbar posttraumatic kyphosis with flat discs or wedge-shape vertebra, because great correction results were observed at follow-up with postero-superior triangular corner primarily resected. Although technically difficult and demanding, bone-disc-bone osteotomy (BDBO) is still a good option for achieving "bone-to-bone" closure of the osteotomy site to yield higher fusion rates and decrease the risk of pseudoarthrosis. A full understanding of the osteotomy range, correction effects and advantages for each type of modified PSO is essential for preoperative plans, optimal spinal sagittal reconstructions and excellent prognosis.

Sagittal translation(ST) was defined as any measurable sagittal displacement more than 5 mm between the posterior inferior edge of the cranial vertebral body and the posterior superior edge of the caudal body at the osteotomized vertebrae(OV). Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by enthesitis and heterotopic ossification affecting sacroiliac joints and vertebral column. In the late stage, the poor quality of life caused by inability to lie supine or look straight ahead were the chief reasons for spinal osteotomy. Intraoperative ST secondary to AS thoracolumbar kyphosis contributed to improvement of sagittal vertical axis (SVA) partly. However, severe ST leaded to a huge bony step in front of dura, which was prone to vascular injury, neurologic deficit and cerebrospinal fluid leakage, thus affecting surgical outcomes. Prior research indicated there were significant correlations between intraoperative ST and inappropriate maneuver, the degree of ankylosis, the kyphosis curve pattern and correction, early fracture of the anterior cortex of the OV, excessive or insufficient decancellation of the OV, mismatch between the center of correcting forces and the center of rotation, incorrect application of cantilever technique. The use of anti-ST appliances, intraoperative fluoroscopy and nerve monitoring could prevent the occurrence of ST effectively. For AS patients with ST, relevant measures or decompressive laminectomies could be taken on the basis of neurological function to prevent neurologic deficit. Due to the strong osteogenic ability in AS patients, favorable bony reconstruction and fusion could be available during follow-up after adopting corresponding treatment involving ST. A thorough understanding of mechanism and risk factors of sagittal translation was essentially instructional to spinal surgeons thereby the incidence of intraoperative ST and complications could be decreased.

With the popularization of minimally invasive concept in the treatment of lumbar degenerative disease,minimally invasive lumbar interbody fusion has gradually developed into the mainstream technique of lumbar fixation and fusion.At present,there are many types of minimally invasive lumbar interbody fusion. In this paper, four kinds of minimally invasive lumbar interbody fusion (anterior lumbar interbody fusion,minimally invasive transforaminal lumbar interbody fusion,extreme lateral interbody fusion,oblique lumbar interbody fusion),which are widely used in clinical practice,are systematically described from the aspects of indication selection,technical characteristics, clinical efficacy and prevention of complications.In order to obtain the best treatment effect with the least trauma,it is necessary for the surgeons to formulate detailed surgical strategies on the basis of strictly grasping the indications,and choose the operation according to their own clinical experience and skills,so as to maximize the advantages of different minimally invasive lumbar interbody fusion.

With the popularization of minimally invasive concept in the treatment of lumbar degenerative disease,minimally invasive lumbar interbody fusion has gradually developed into the mainstream technique of lumbar fixation and fusion.At present,there are many types of minimally invasive lumbar interbody fusion. In this paper, four kinds of minimally invasive lumbar interbody fusion (anterior lumbar interbody fusion,minimally invasive transforaminal lumbar interbody fusion,extreme lateral interbody fusion,oblique lumbar interbody fusion),which are widely used in clinical practice,are systematically described from the aspects of indication selection,technical characteristics, clinical efficacy and prevention of complications.In order to obtain the best treatment effect with the least trauma,it is necessary for the surgeons to formulate detailed surgical strategies on the basis of strictly grasping the indications,and choose the operation according to their own clinical experience and skills,so as to maximize the advantages of different minimally invasive lumbar interbody fusion.

Objective:To evaluate long-term results of growth friendly non-fusion technique (GF) in the treatment of early-onset scoliosis (EOS).Methods:From August 2008 to October 2019, a total of 26 EOS patients (mean age 7.2±2.4 years old) who had completed surgery with GF treatment, including 12 males and 14 females, were reviewed retrospectively. Among them, 16 patients underwent growing rod treatment while 10 patients underwent vertical expandable prosthetic titanium rib (VEPTR) treatment. All patients had minimum 2 lengthening procedure during distraction period and over 2-year follow-up after graduation. Radiographic data were collected before and after index surgery as well as at graduation and the latest follow-up. Complications were also recorded during distraction period and after graduation.Results:A total of 145 lengthening procedures were performed in 26 patients, averagely 5.6 procedures per patient. The mean age at graduation was 12.6±1.6 years old. The average follow-up was 4.7±1.4 years duringdistraction period, and 2.9±0.9 years after graduation.The main Cobb angle was significantly decreased from 81.2°±17.3° to 41.1°±13.1°( t=8.124, P<0.001)after the index surgery, but slightly increased to 48.8°±15.4° at the end of distraction. After definitive spinal fusion, the main Cobb angle was notably decreased from 52.8°±16.1° to 45.4°±14.8° in 16 patients( t=2.415, P=0.035), with an average correction rate of 14.1%±9.4%. At the latest follow-up, the main Cobb angle was 45.2°±15.6° and the average correction rate was 44.3%±15.5% when comparing with the value before the index surgery. The thoracic and spinal height were significantly increased after initial surgery. During distraction period, the average gain of thoracic and spinal height was 3.3±0.9 cm and 5.6±1.9 cm, with the growth rate of 0.6±0.3 cm and 1.0±0.4 cm per distraction, respectively. A total of 36complications were recorded in 14 patients. There were 27 complications occurred during distraction period and 9 after graduation. Conclusion:Surgical management of EOS with growing rod and VEPTR could effectively correct the spinal deformity and maintain spinal growth. The complication rate after graduation was relative lower than distraction period. However, the correction of definitive spinal fusion during graduation was relative lower.

Objective:To investigate the outcome of posterior correction surgery for severe kyphoscoliosis secondary to spinal Gorham disease, further to explore the countermeasure in such complicated condition.Methods:From January 2005 to December 2019, a total of 12 consecutive patients were diagnosed with spinal Gorham disease. Four patients who had undergone correction surgery were reviewed retrospectively. There were 3 males and 1 female. The median age of surgery was 14.5 years (11.5 years, 27.5 years), with the median of Cobb angle of scoliosis and kyphosis 29° (21.5°, 78.0°) and 94° (78.0°, 103.0°), respectively. After Halo-gravity traction, one-stage posterior correction surgeryand Schwab grade I or II osteotomy, with pedicle screw fixation bridging the diseased vertebrae was performed. Drug therapy of bisphosphonate was recommended after surgery. The Cobb angle of scoliosis and kyphosis, coronal and sagittal balance were measured on the standing upright radiographs of the spine. CT and MRI were used to give precise evaluation of spinal and peripheral soft tissue involvement.Results:After Halo-gravity traction of 3 months (2.5 months, 3.5 months), the median of Cobb angle of scoliosis decreased to 23.5° (15.5°, 77.0°) and kyphosis decreased to 65° (57°, 83.5°) respectively. Two patients underwent facetectomyand 2 received Ponte osteotomy. The median operative time and blood loss were 5.5 h (5.1 h, 5.9 h) and 3 095ml (2 950 ml, 3 320 ml), with the fusion segment of 13.5 (12.5, 14.5) and the fixation density of 47.8% (40.9%, 57.3%). After surgery, the median of Cobb angle of scoliosis and kyphosis decreased to 18° (10.5°, 38.5°) and 59° (42.0°, 78.0°). Compared to the values before traction, the median of correction rates of scoliosis and kyphosis after surgery were 46.7% (33.1%, 59.5%) and 35% (12.3%, 51.1%) respectively. Moreover, the median of coronal balance decreased from 15.5 mm (9.0 mm, 21.0 mm) to 6.5 mm (4.0 mm, 9.0 mm), while the median of sagittal balance decreased from 14 mm (-18.0 mm, 27.5 mm) to 5.5 mm (-5.5 mm, 12.5 mm). During a median of follow-up of 2.8 years (2.0 years, 3.5 years), no complication was detected except one patient whounderwent revision surgery for rod broken.Conclusion:One-stage posterior correction surgery combined with preoperative halo-gravity tractionand postoperative anti-osteoporosis therapydemonstratedto be safe and effective for severe kyphoscoliosis secondary to spinal Gorham disease. More attention should be paid to the failure of internal fixation after surgery.

Objective: To evaluate the clinical outcome and health related quality of life in degenerative patients with kyphoscoliosis who underwent S₂AI placement and identify the potential risk factors of pelvic incidence variation postoperative and at last follow-up. Methods: The present study reviewed degenerative patients with kyphoscoliosis who accepted surgery utilized S₂AI screw between January 2015 and January 2019. 25 patients were included in our study, 4 males and 21 females, among these patients, the mean age were 58.84±6.03 years, range from 50-68 years. All patients were conducted long fusion distal to pelvis utilizing S₂AI screws. According to the variation of pelvic incidence at last follow-up, we divided patients into two subgroups: 1) Group I: Patients' pelvic incidence increased more than 5 degree compared with post-operation. 2) Group S: Patients' pelvic incidence varied less than 5 degree compared with post-operation. 13 patient (2 male, 11 female; mean age: 57.23±6.06 years) were categorized into group I, and 12 patients (2 male, 10 female; mean age: 60.58±5.73 years) were categorized into group S.Cobb′s angle, lumbar lordosis(LL), regional kyphosis(RK), sagittal vertical axis(SVA), pelvic incidence(PI), pelvic tilt(PT), sacral slop(SS) were recorded at pre-operation, post-operation and last follow up. The MOS item short from the health survey(SF-36) and Oswestry disability index (ODI) were also recorded at pre-operation and last follow up. Results: There was no statistical difference in gender, age, preoperative Cobb angle, SVA between two groups. In group I, pelvic incidence were decreased postoperatively and increased at the last follow-up (56.92°±14.47° vs 42.69°±14.23° vs 51.62°±14.53°, P<0.05). In group S, pelvic incidence were decreased postoperatively (46.21°±12.26° vs 37.08°±12.99°, P<0.05) and remained stable at the last follow up (37.08°±12.99° vs 37.17°±13.34°, P>0.05). Cobb angle (46.08°±20.52° vs 19.96°±12.64° vs 20.28°±12.01°), RK (32.88°±15.28° vs-12.16°±17.75° vs-11.64°±17.29°), SVA (94.61±92.59 mm vs 25.49±23.89 mm) were improved significantly after surgery and remained stable at the last follow-up. HRQoL score was improved significantly in all patients at the last follow-up compared with preoperative (SF-36 PCS: 36.88±10.89 vs 67.91±10.46, P<0.05; SF-36 MCS: 33.48±10.96 vs 60.19±8.10, P<0.05; ODI: 46.00%±13.54% vs 23.40%±8.86%, P<0.05). Conclusion Pelvic fixation utilizing S2AI screw can provide substantial correction and patients' HRQoL can be improved significantly after surgery. Meanwhile, PI changed at the last follow-up in partial patient. The variation of PI may be associated with the preoperative sagittal malalignment.