Surgical treatment of posttraumatic kyphosis of the lumbar spine: compensatory changes and dynamics of sagittal balance

Objective. To analyze clinical and radiological results of staged surgical interventions in the treatment of patients with posttraumatic kyphosis of the lumbar spine and to identify a mechanism of deformity compensation.
Material and Methods. The data obtained from the case histories of 42 patients operated on for clinically significant posttraumatic kyphosis at the L3 and L4 vertebral levels were studied. Patients underwent staged surgical interventions in one surgical session. Demographic data and radiological results of surgical treatment were evaluated.
Results. As a result of surgical interventions, local kyphosis was corrected on average by 29.66° ± 13.83° from 15.48° ± 13.04° to
-14.19° ± 8.85°. After correction of posttraumatic kyphosis, statistically significant changes in the parameters of sagittal curvatures of the spine were revealed: an increase in thoracic kyphosis (TK) and lumbar lordosis (LL), changes in the parameters of the spinopelvic balance PT and SS with a p-level < 0.05, as well as in the global angle (p < 0.001) were noted. According to the GAP scale, 26 (61.9 %) patients
moved to a more balanced category. A correlation (r = 0.45; p < 0.05) was found between the indices of local kyphosis and the GAP scores before surgery. The total duration of all surgical stages was 318 [150; 600] minutes, and blood loss was 677 [150; 1800] ml. In 9 (21.4 %) patients, 12 intra- and postoperative complications were noted.

Conclusion. The main compensatory mechanisms of posttraumatic deformities with the apex at L3 and L4 vertebrae are a decrease in thoracic kyphosis, the thoracolumbar lordosis and pelvic retroversion. Staged surgical treatment for posttraumatic spinal deformities significantly improves the parameters of the spinopelvic and global sagittal balance. It ameliorated the sagittal profile of patients in 61.9 % of cases and was accompanied by moderate duration of surgery and intraoperative blood loss and an acceptable number of complications.

1. De Gendt EEA, Muijs SPJ, Benneker LM, Oner FC. Term and definition of a deformity after a spine trauma: Results of an international Delphi study. Brain Spine. 2024;4:102749. DOI: 10.1016/j.bas.2024.102749.

2. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994;3:184–201. DOI: 10.1007/BF02221591.

3. Duval-Beaupere G, Schmidt C, Cosson P. A Barycentremetric study of the sagittal shape of spine and pelvis: the conditions required for an economic standing position. Ann Biomed Eng. 1992;20:451–462. DOI: 10.1007/BF02368136.

4. Vaz G, Roussouly P, Berthonnaud E, Dimnet J. Sagittal morphology and equilibrium of pelvis and spine. Eur Spine J. 2002;11:80–87. DOI: 10.1007/s005860000224.

5. Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, Ames C, Smith JS, Shaffrey CI, Glassman S, Farcy JP, Lafage V. The comprehensive anatomical spinal osteotomy classification. Neurosurgery. 2014;74:112–120. DOI: 10.1227/NEU.0000000000000182o.

6. Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstück F, Pérez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A. Global Alignment and Proportion (GAP) score: development and validation of a new method of analyzing spinopelvic alignment to predict mechanical complications after adult spinal deformity surgery. J Bone Joint Surg Am. 2017;99:1661–1672. DOI: 10.2106/JBJS.16.01594.

7. Charles YP, Bauduin E, Pesenti S, Ilharreborde B, Prost S, Laouissat F, Riouallon G, Wolff S, Challier V, Obeid I, Boissiere L, Ferrero E, Solla F, Le Huec JC, Bourret S, Faddoul J, Abi Lahoud GN, Fiere V, Vande Kerckhove M, Campana M, Lebhar J, Giorgi H, Faure A, Sauleau EA, Blondel B. Variation of global sagittal alignment parameters according to gender, pelvic incidence, and age. Clin Spine Surg. 2022;35:E610–E620. DOI: 10.1097/BSD.0000000000001321.

8. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. DOI: 10.1097/01.sla.0000133083.54934.ae.

9. Obeid I, Boissiere L, Yilgor C, Larrieu D, Pellise F, Alanay A, Acaroglu E, Perez-Grueso FJ, Kleinstuck F, Vital JM, Bourghli A. Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J. 2016;25:3644–3649. DOI: 10.1007/s00586-016-4649-3.

10. Cavagnaro MJ, Tavolaro C, Orenday-Barraza JM, Farhardi D, Baaj AA, Bransford R. Burst fractures of the fifth lumbar vertebra: Case series and systematic review. J Clin Neurosci. 2022;103:163–171. DOI: 10.1016/j.jocn.2022.07.017.

11. Moawad CM, Arzi H, Naik A, Bashir R, Arnold PM. Short-segment pedicle fixation of traumatic low lumbar fractures (L3–L5): report of 36 cases. Clin Spine Surg. 2022;35:E590–E595. DOI: 10.1097/BSD.0000000000001324.

12. Alsayed MA, Elaal MA. Surgical management of posttraumatic thoracolumbar kyphosis: A review. J Family Med Prim Care. 2024;13:814–818. DOI: 10.4103/jfmpc.jfmpc_689_23.

13. Munting E. Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications and technical aspects. Eur Spine J. 2009;19 Suppl 1(Suppl 1):S69–S73. DOI: 10.1007/s00586-009-1117-3.

14. Yaman O, Zileli M, Senturk S, Paksoy K, Sharif S. Kyphosis after thoracolumbar spine fractures: WFNS Spine Committee Recommendations. Neurospine. 2021;18:681–692. DOI: 10.14245/ns.2142340.170.

15. Barrey C, Roussouly P, Perrin G, Le Huec JC. Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanisms? Eur Spine J. 2011;20 Suppl 5(Suppl 5):626–633. DOI: 10.1007/s00586-011-1930-3.

16. Lamartina C, & Berjano P. Classification of sagittal imbalance based on spinal alignment and compensatory mechanisms. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2014;23:1177–1189. DOI: 10.1007/s00586-014-3227-9.

17. Шульга А.Е., Зарецков В.В., Островский В.В., Бажанов С.П., Лихачев С.В., Смолькин А.А. Особенности сагиттального баланса пациентов при посттравматических деформациях грудного и поясничного отделов позвоночника // Гений ортопедии. 2021. Т. 27. № 6. С. 709–716. [Shulga А, Zaretskov V, Ostrovskij V, Bazhanov S, Likhachev S, Smolkin A. Peculiarities of the sagittal balance of patients with post-traumatic deformities of the thoracic and lumbar spine. Genij Ortopedii. 2021;27(6):709–716]. DOI: 10.18019/1028-4427-2021-27-6-709-716.

18. Gupta MC, Yilgor C, Moon HJ, Lertudomphonwanit T, Alanay A, Lenke L, Bridwell KH. Evaluation of global alignment and proportion score in an independent database. Spine J. 2021;21:1549–1558. DOI: 10.1016/j.spinee.2021.04.004.

19. Sun X, Sun W, Sun S, Hu H, Zhang S, Kong C, Lu S. Which sagittal evaluation system can effectively predict mechanical complications in the treatment of elderly patients with adult degenerative scoliosis? Roussouly classification or Global Alignment and Proportion (GAP) Score. J Orthop Surg Res. 2021;16:641. DOI: 10.1186/s13018-021-02786-8.

20. Pizones J, Moreno-Manzanaro L, Sanchez Perez-Grueso FJ, Vila-Casademunt A, Yilgor C, Obeid I, Alanay A, Kleinstuck F, Acaroglu ER, Pellise F. Restoring the ideal Roussouly sagittal profile in adult scoliosis surgery decreases the risk of mechanical complications. Eur Spine J. 2020;29:54–62. DOI: 10.1007/s00586-019-06176-x.

21. Suk SI, Kim JH, Lee SM, Chung ER, Lee JH. Anterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fracture. Spine. 2003;28:2170–2175. DOI: 10.1097/01.BRS.0000090889.45158.5.

22. Oneill KR, Lenke LG, Bridwell KH, Hyun SJ, Neuman B, Dorward I, Koester L. Clinical and radiographic outcomes after 3-column osteotomies with 5-year follow-up. Spine. 2014;39:424–432. DOI: 10.1097/BRS.0000000000000156.

23. Lazennec JY, Neves N, Rousseau MA, Boyer P, Pascal-Mousselard H, Saillant G. Wedge osteotomy for treating post-traumatic kyphosis at thoracolumbar and lumbar levels. J Spinal Disord Tech. 2006;19:487–494. DOI: 10.1097/01.bsd.0000211296.52260.9c.

24. Bianco K, Norton R, Schwab F, Smith JS, Klineberg E, Obeid I, Mundis G Jr, Shaffrey CI, Kebaish K, Hostin R, Hart R, Gupta MC, Burton D, Ames C, Boachie-Adjei O, Protopsaltis TS, Lafage V. Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients. Neurosurg Focus. 2014;36:E18. DOI: 10.3171/2014.2.FOCUS1422.

25. Mundis GM, Jr, Turner JD, Kabirian N, Pawelek J, Eastlack RK, Uribe J, Klineberg E, Bess S, Ames C, Deviren V, Nguyen S, Lafage V, Akbarnia BA. Anterior column realignment has similar results to pedicle subtraction osteotomy in treating adults with sagittal plane deformity. World Neurosurg. 2017;105:249–256. DOI: 10.1016/j.wneu.2017.05.12.

26. Turgut M, Turgut AT, Dogra VS. Iatrogenic ureteral injury as a complication of posterior or lateral lumbar spine surgery: a systematic review of the literature. World Neurosurg. 2020;135:280–296. DOI: 10.1016/j.wneu.2019.12.107.