In total, 10 severe rigid thoracolumbarspine deformity patients received a PEO. The three-dimensional model provided accurate diagnostic and better surgical options. The kyphosis and scoliosis correction rates reached averages of 77.1 ± 8.9% and 76.9 ± 7.1%, intraoperative bleeding 1990 ± 1010 ml and operation time 7.12 ± 3.88 h. Osteotomies were all performed at T12 or L1. Three patients had typical symptoms of L1 nerve root injury. Specifically, knee extension and hip flexion of lower limb exhibited weakness, and the inner thigh felt numb (Table 1). Table 2 shows the results for these patients’ SF–36 scores according to preoperative and one-year postoperative. One year after surgery, the SF–36 scores of physical function, role-physical, bodily pain, general health, vitality, social function, role-emotional and mental health from 60 ± 30, 47 ± 33, 44 ± 30, 32 ± 18, 50 ±30, 46 ± 29, 26 ± 40 and 52 ± 20 to 81 ± 16, 69 ± 19, 73 ± 11, 66 ± 21, 74 ± 16, 74 ± 24, 63 ± 37 and 76 ± 12, RESPECTIVELY (P < 0.01). The quality of life has improved significantly in patients with PEO one year later.
However, although the clinical effect of the PEO technique was obvious, the complications were unavoidable. Three patients with L1 nerve roots injure occurred, with abnormal SEP and MEP waveforms during the operation and confirmed by the lower limb EMG after surgery. The symptoms of L1 nerve roots injure were significantly improved through therapy of mannitol, methylprednisolone and nutritional neurotherapy. And we could see that the L1 nerve roots function was obviously improved by the continuous monitoring of both lower limb EMG. Meanwhile, 1 case of hemopneumothorax, repair was effective without any leakage, and a closed thoracic drainage tube was placed post operation. One patient experienced paralytic ileus who have been healed after gastric decompression, promote intestinal motility and symptomatic medical treatment. Through one year follow-up of the patients, we did not find any other complications, such as dura laceration, superficial infection, nonunion/rod broken, distal screw loosening and adjacent segment kyphosis (Table 3).
Case 1
Female, 33y, housewife, with waist deformity for 18 years, increased over the last year. The spine deformity was serious. In the flexion test, the left side of the waist was raised 10 cm, muscle strength of both lower limbs was grade V grade, and the patient was feeling normal. The preoperative diagnosis was severe rigid thoracolumbar deformity, kyphosis Cobb 85° and scoliosis Cobb 67° was determined by X-rays after bending (Figure 2A). Osteotomy was performed at T11 and T12, and the upper and lower end vertebrae were T8 and L4 (Figure 2B). Due to position variation, we carelessly mistakenly identified L1 as the T12 nerve root, and damaged the L1 nerve root on the convex side of the side bend with abnormal waveforms by SEP and MEP during the operation (Figure 2D). Despite postoperative kyphosis and scoliosis correction to Cobb 12° and 15° (Figure 2C), knee extension and hip flexion of left lower limb were weak grade Ⅲ, and the inner thigh was feeling numb. We reconfirmed L1 nerve root damage by the lower limb EMG after surgery. After a period therapy of mannitol, methylprednisolone and nutritional neurotherapy, muscle strength of left lower limb had recovered to grade IV, and the symptom of numbness had been relieved before leaving the hospital. One year follow-up after surgery, the patient still had symptom of left lower limb weakness, which had an impact on daily life.
Case 2
Male, 21y, delivery man, with waist deformity for 10 years, increased over 4 year. In the flexion test, the left side of the waist was raised 8 cm, muscle strength of both lower limbs was grade V grade with no numbness. The preoperative diagnosis was severe rigid thoracolumbar deformity, kyphosis Cobb 90° and scoliosis Cobb 130° was determined by X-rays after bending (Figure 2A). Osteotomy was performed at T12 and L1, and the upper and lower end vertebrae were T5 and L5 (Figure 2B). Due to high tension, we carelessly mistakenly damaged the L1 nerve root on the convex side with abnormal waveforms by SEP and MEP during the operation (Figure 2D). Despite postoperative kyphosis and scoliosis correction to Cobb 25° and 40° (Figure 2C), knee extension and hip flexion of left lower limb were grade II, and the inner thigh was feeling numb. After surgery, the L1 nerve root damage was confirmed again by the EMG. After a period therapy, muscle strength of left lower limb had recovered to grade IV, and significant improvement in numbness before leaving the hospital. However, after one year of follow-up, the patient could not go up the stairs smoothly, which had an impact on his work.
Case 3
Male, 22y, had waist deformity for 8 years, increased over the two years. In the flexion test, the left side of the waist was raised 14 cm, muscle strength of both lower limbs was grade V, but feeling was normal, indicating the spine deformity was serious (Figure 3A). Preoperative diagnosis was severe rigid thoracolumbar kyphosis, with a kyphosis Cobb 102° and scoliosis Cobb 118°, as judged by X-rays after bending (Figure 3B, 3C and 3D). Osteotomy was performed at L1 and L2, and the upper and lower end vertebrae were T8 and S1. During the operation, we observed that the L1 nerve roots on the convex side of the scoliosis were pulling tension and easy damaged (Figure 3E). We tried to use nerve strippers to separate and protect the L1 nerve root while maintaining normal waveforms by SEP and MEP during the operation (Figure 3F). The L1 nerve roots were slack and floating in the gap (Figure 3E). The postoperative patient’s kyphosis and scoliosis were corrected to Cobb 32° and 35°, respectively (Figure 3G). Postoperative, patient had no referable symptoms of nerve roots damage.