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MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF DEFENSE

CLINICAL MEDICINE SCIENCE RESEARCH INSTITUTE
108 MILITARY CENTRAL HOSPITAL

PHAM TRONG THOAN

RESEARCH ON CLINICAL FEATURES, X-RAY IMAGE
AND EVALUATION ON THE RESULTS OF ADOLESCENT
IDIOPATHIC SCOLISIS CORRECTION SURGERY

Major: Trauma Orthopedic
Code: 62720129

A SUMMARY OF MEDICAL PH.D DISSERTATION

HANOI, 2019


WORKS COMPLETED AT:
CLINICAL MEDICINE SCIENCE RESEARCH INSTITUTE - 108

MILITARY CENTRAL HOSPITAL

Supervisors:
1. Ass. Prof .Pham Hoa Binh
2. Ph.D. Phan Trong Hau

Reviewer 1:……………………………………
Reviewer 2……………………………………..
Reviewer 3………………………………………

The dissertation will be defended in front of the Revewing Council at
the Institute level at: ……... day…..month….year…

Find out at:
1. National Library
2. Library of Clinical Medicine Science Research Institute – 108
Military Central Hospital


1
BACKGROUND
Adolescent idiopathic scoliosis accounts for the highest
proportion (2-4% of adolescents). The characteristics of the disease are
physical body deformities that cause the spine to curl to one side and
rotate the vertebrae on three planes. Spinal deformities occur on a
normal healthy body, if severe and untreated, such deformities may
lead to complications, sequelae: backache, cardiopulmonary function
impairment, physical body deformities, psychological insecurity,
patients lose confidence when they integrate into the community.
Scoliosis appears silently and become severe in puberty, continues to
change until adulthood. The complications and sequelae have a very
different impact and effect for each individual. Scoliosis correction
surgery is often very difficult and complex with many risks, future
results may change without meeting the expectations of patients and
their families. Decision on surgery, selection on surgical techniques
must be carefully considered and accurately planned based on a process
of monitoring, detailed assessment of clinical and x-ray characteristics
as well as the evolution of curves, rate of growing and synthesizing
prognostic factors.
Until now in Vietnamese medical literature, there has not been a
study of in-depth analysis of reference data on Vietnamese people such as
clinical features and x-ray images to serve as basis for the designation and
selection of the most appropriate surgical techniques for each case of
scoliosis in adolescents, no work has reported the application of direct
rotation of vertebral body in scoliosis correction surgery. We study the
subject: “Research on clinical features, x-ray image and evaluation
on the results of adolescent idiopathic scoliosis correction
surgery”with 2 objectives:
1. Survey the clinical features and x-ray images of unknowncause scoliosis of the adolescence age as a basis for surgery
designation.
2. Evaluate the results of scoliosis surgery by direct rotation of
the vertebral body.


2
CHAPTER 1
OVERVIEW
1.1 Outline of idiopathic scoliosis
1.1.1. Functional anatomy characteristics of the thoracic and lumbar
spine
The thoracic and lumbar spines are spinal segments from T1 to L5
with two opposite physiological curves. With lumbar spine, spinal
functional unit consists of two vertebral bodies, intervertebral disc
connecting the two vertebral bodies and the soft parts that links them.
Biomechanical studies assessing the role of components in lumbar
spinal function units by Abumi showed that supraspinous ligament and
interspinous ligament did not affect the firmness and movement
amplitude of the spinal unit. However, the joints and intervertebral disc
are important and directly affect the instability of the lumbar spinal
movement unit. For the thoracic spine surrounded by the rib cage,
sternum and back muscles, the anatomical structure and the
biomechanical role of the relevant factors have many differences from
the lumbar spine. The thoracic spine is connected to the rib through
costa joints, including the transverse costal joint and articulation of
head of rib (or cost central articulations). Costa joints are surrounded
by ligaments such as transverse ligaments, wing ligaments and internaljoint ligaments. Takeuchi's research on experiment showed that the
costa joint and the intervertebral disc are important components in the
thoracic spinal function unit.
1.1.2. Clinical features of idiopathic scoliosis.
1.1.2.1. Objective symptoms.
Objective symptoms of scoliosis patients depend on the location
and magnitude of the curve. The patient's age at onset is significant in
assessing the flexibility of the spine and predicting the risk of
progression of the curve. Changing gait of scoliosis patients can be
observed when the scoliosis angle is large or causing nerve damage.
For scoliosis in the chest if the top vertebrae rotate much, it will cause
imbalance of the rib cage - convex side and concave side, the clinical
examination may show that the posterior rib cage - convex side is
higher than the concave side due to the protrusion of the ribs. Scoliosis
patients may have two disproportionate shoulders, the protrusion of the
left or right shoulder is an important factor for determining the screw
position and fixation for each type of curve.


3
1.2.The role of X-ray imaging and CT scanning in scoliosis
assessment
1.2.1. The role of X-ray imaging in scoliosis assessment
To comprehensively assess scoliosis patients, the x-ray image of
the entire spine plays an important role. On animated X-ray films, it can
be assessed the flexibility of each spinal curve, the film tilting into one
side is important in assessing curves, the basis for determining the
extent of bone welding and has an important role to for the high
thoracic curves and lumbar thorax. Films with deviated peak padding,
neck pulls or deviated peak push-press contribute to analyzing and
evaluating spinal flexibility, predicting correction ability, determining
bone welding position. None of the films has superior superiority in
assessing factors related to location diagnosis, flexibility and
determination of bone fixation location, so it is necessary to take
enough films to serve as the basis for analyzing and evaluating the
preparation before surgery.
1.3. Surgical treatment for scoliosis patients.
1.3.1.Scope, screwing position for curves according to Lenke's
classification.
Lenke's classification system is designed for doctors to plan
surgery based on the classification of curves. The principle is that the
main curves and the real curves need to be fixed to the bone, the offset
curve can adjust itself after surgery.
1.3.1.1. For the main thoracic curve, Lenke type 1.
Lenke’s type 1A curve at the position LIV may stop at the
intermediate vertebrae, the position UIV depends on the shoulder
balance and characteristics of the high thoracic curve. When selecting
the position LIV higher than the intermediate vertebrae, the risk of
losing offset is very likely to occur.
1.3.2. scoliosis surgery by direct rotation of the vertebral body.
A scoliosis correction system when applied in surgery needs to
achieve factors such as creating the strongest correction force,
max.correction of the spinal deformities with the number of vertebrae
bolted and bone-welded is as few as possible.
Principles and techniques of direct rotation of the vertebral body
have been studied, introduced and applied in clinical practice.
When implementing vertical rod derotation technique, scoliosis
correction has two impact force vectors. The first is the vector of


4
vertical rod rotation force; this force element directly affects the back
and side of the vertebrae. This force corrects deformities on the plane of
the forehead plane and the vertical plane but has no impact element on
the horizontal plane. At the same time, when rotating, the vertical rod
itself also rotates around its axis 90 degrees which is the next force
vector. This can affect the vertebral body rotation of scoliosis patients.
For scoliosis patients with large Cobb angle and without the
flexibility of the curve, there is a large friction force between the
vertical rod and the pedicle screw during the vertical rod rotation. In
that case the rotating force of the vertical rod will increase the rotation
degree of the curve deformity. If there is no friction between the screw
and the vertical rod, the screw will slide on the vertical rod. In this
situation, the rotational deformity correction depends on the angle of
the pedicle screw and the vectors of the vertical rod rotation force.
Clinically, the effect of rotational deformity correction of vertical rod
rotation technique is negligible because it always exists a large friction
between the vertical rod and the screw during the vertical rod rotation.
The concept of direct vertebral rotation is to correct the deformity
of the vertebral body by a direct force opposite the back of the curve
deformity. The pedicle screw is taken from the back of the vertebral
body through the peduncle and to the front of the vertebral body; with
this position of the pedicle screw, it can transmit force into the
deformed vertebral body and perform the rotational correction. Fixed
tools such as steel wires, hooks do not perform this transmission force
because the means only lie behind the vertebra. The direct rotation of
the vertebral body is carried out on the opposite side of the rotational
deformity, the opposite direct rotation force can correct the rotational
deformity on the horizontal plane and correct the deformity in threedimensional space.


5

Directvertebral rotation

Slide between screw and vertical rod

Figure 1.1. The principle of direct rotation of the vertebral body


6
CHAPTER 2
SUBJECTS AND METHODS OF RESEARCH
2.1. Research subjects
Subjects include 40 adolescent idiopathic scoliosis patients who
are undergoing surgical treatment with Lenke's scoliosis correction
method by a system of pedicle screws via peduncle in the Faculty of
Trauma Orthopedic Spine, 108 Military Central Hospital from August
2009 to July 2016.
2.1.1.Criteria for selecting patients.
(According to the recommendation of World Scoliosis Society).
-Idiopathic scoliosis patient
- Cobb angle > 40 degrees
- Adolescence age
- Eligible for anesthesia, resuscitation
- Records of sufficient data and follow-up time.
2.2. Research Method
2.2.1. Research Method
A prospective study describes vertical clinical prospect, without a
control group. The study is based on examination for patients, analysis
of subclinical test results (mainly conventional x-ray films), surgical
treatment, and monitoring and evaluation of results.
2.2.3.Clinical scoliosis research criteria.
- Iliac crest balance
- Shoulder balance
- Bodybalance
- Balance the rib cage and bone….
2.2.4.Research criteria on x-ray film.
- Difference of spine rib angle.
- Balance the collarbone…..
2.2.5. Surgical method
2.2.5.1. Pre-surgerical preparation.
Determine the tactic of screwing according to Lenke as following:
Type 1: Main thoracic curve
- The vertebrae position of the bottom screw is the intermediate
vertebra for the 1A, 1B curve. The vertebrae position of the top screw
of the curve: patients with the right shoulder higher than the left
shoulder will put the screw to T4, patients with the two shoulders


7
balancing before the surgery will put the screw on T3, and patients with
the left shoulder higher than the right shoulder will put the screw to T2.
- Curve type 1C: the position of the bottom screw extends to the
lumbar spine 2 levels under intermediate vertebra.
Type 2: Double curve of the thoracic spine
- Determine the vertebra to put the top screw on the top: if the left
shoulder is higher, put the screw up to T2; if the right shoulder is
higher, put the screw T3; if two shoulders are balanced, put the screw
on T4. The vertebrae position to be put the bottom screw is as type 1.
2.2.7.3. Criteria for evaluating treatment results.
Evaluating the treatment results is based on the following criteria.
- The effectiveness of correcting scoliosis according to Harrington.
- Evaluate according to SRS-24 criteria.
- Evaluate complications during and after surgery.
2.2.8. Data processing methods.
Use the software SPSS 22.0 for medical statistics.
- Results of qualitative variables and quantitative variables with
subgroups are presented in the form of frequency and percentage.
- Results of quantitative variables are presented as: average +/- standard
deviation or the median (smallest-largest).
- To compare the relationship between qualitative variables,
percentages or quantitative variables with subgroups, we use ChiSquared tests.
- To compare the relationship among quantitative variables with normal
distribution and qualitative variables with two values, we use the T test
for two independent groups.
- The difference is considered statistically significant when the value of
p is <0.05.


8
CHAPTER 3. RESEARCH RESULTS
3.1.Clinical features of the research patient group
Table 3.1.Classification by patient’s age.
Age
Number of patient
Rate (%)
< 10
01
2.5
10-18
35
87.5
>18
4
10.0
Age
Oldest: 21
Youngest: 08
Total
40
100%
The oldest patient is 21 years old and the youngest is 8 years old,
of which the age of 10-18 years accounts for 85%, there are 4 patients
older than 18 years old. These patients were examined and found out at
adolescence age when monitoring periodically. Due to objective and
subjective conditions of patients, when she was older than 18 years, she
could afford to carry out a surgery. An 8-year-old patient underwent
surgery because at the time of the examination, the patient had iliac
crest ossification developed to Risser III, the patient had menstruation,
deformity of the lumbar misalignment greater than 4.8 cm, large iliac
crest imbalance, large rib cage deformity, comparing Cobb angles after
one year, we see a rapid progression (Cobb angle after one year of
follow-up from 25 degrees to 68 degrees). Considering the above
factors of patients, we decided to make surgical intervention.

Figure 3.1. Picture of an 8-year-old patient before surgery, the arrow
pointing her body curve 4.8cm to the side and rib cage difference of 16
degrees.


9
3.1.2. Clinical features.
Table 3.3. Clinical features of surgical patients group.
Clinical features
Average value
Bilateral iliac crest balance
0.09 ± 0.1 cm
Bilateral body balance
4.63 ± 1.37 cm
Bilateral cage balance
13.25 ± 5.74 degree
Bilateral shoulder balance
0.93 ± 0.64 cm
Total number of patient
N=40
Clinically, the scoliosis patient group indicated for surgery has an
imbalance in the body, and the iliac crest and rib cage. Of which, for
the deformity of the rib cage, the difference of both sides is 13.25
degrees, the body imbalance of 4.63 cm, the average shoulder
imbalance of 0.93 cm, the patient had a physical change from the
shoulder to the waist and the whole body.
3.2. X-ray image features of research patient group.
Table 3.6.Features on the straight X-ray film.
Indicators in X-ray image
Average value
Misalignment of top vertebrae of thoracic spine
5.33 ± 2.44 cm
Misalignment of top vertebrae of lumbar spine
1.48 ± 1.86 cm
Spinal angle difference
25.4 ± 13.09
degree
Bilateral collar bone difference
5.75 ± 4.26 degree
Bilateral collar bone difference of rib cage
8.31 ± 6.44 degree
The deflection angle of the disc under the position
15.48 ± 6.72
fixed with horizontal plane
degree
Total number of patient
N=40
Scoliosis patient group indicated for surgery has with many
deformities on straight x-ray film, bilateral clavicle imbalance,
imbalance of spinal ribs, rib cage in which deformity of spinal rib
difference is up to 25.4 degrees, Misalignment of top vertebrae of
thoracic spine of 5.33cm.
3.2.2. Characteristics on inclined x-ray film.
Table 3.9. Characteristics on inclined x-ray film
Indicators in inclined X-ray image
Average value
Spinal axis difference via C7
1.16 ± 0.16 cm
Kyphotic angle of thoracic spine T5-T12
19.45 ± 10.6 degree
Kyphotic angle of lumbar spine T10-L2
5.68 ± 5.87 degree
Lumbosacral curvature (L1S1) - angle
35.95
±
11.42


10
degree
Total number of patient
N=40
The patient had an average kyphotic angle of the thoracic spine of
19.45 degrees, the average kyphotic angle transition area of 5.68
degrees. The kyphotic angle deformities T5-T12 are in normal values
(from 10 degrees to 40 degrees).
3.3 Treatment results
3.3.1. Near results of treatment after surgery.
A total of 40 postoperative patients had a scar healing in the first
period, no infection. Two patients had complications immediately after
surgery, of which one patient had a hemothorax, one patient put the
screw in wrong position which made through the left peduncleT7 into
the spinal canal and showed signs of spinal marrow injury.
3.3.1.1. Clinically near treatment results.
Table 3.16. Results of clinical spinal correction immediately after
surgery
Indicator
Pre-surgery
Post-surgery
P value
Shoulder balance
0.93 ± 0.64 cm
0.28 ± 0.17 cm
P<0.001
Body balance
4.63 ± 1.37 cm
0.95 ±0.36 cm
P<0.001
Iliac crest balance
0.09± 0.1 cm
0.09 ± 0.1 cm
P>0.05
Rib cage balance
13.25±
5.74
4.07 ±3.29
P<0.001
degree
degree
Total number of
40
patient
Patients had shoulder imbalance before surgery of 0.93 cm on
average. The effect of correcting and restoring the patient's shoulder
balance reached an average of 0.28cm. The level of body balance
recovery over the patient's waist is significantly improved compared to
pre-surgery. The body imbalance over the patient's waist before surgery
is 4.63 cm on average. The body balance restored after surgery was
0.95 cm that was statistically significant with p <0.001.
Changing the patient’s physique through indicators such as the shoulder
balance, body balance over the waist and rib cage has a clear difference from
pre-surgery.


11
3.3.1.2. Height change after surgery.
Table 3.17. Height change immediately after surgery (n = 40
patients)(unit: cm)
Patient’s height
Average
Deflection
P value
Height before surgery
154.50
8.269
Height after surgery
159.92
8.160
p<0.001
Height increase
5.425
0.812
The patient had a remarkable height change after surgery. The
average height of the patient before surgery was 154.50 cm. After surgery
the average height increased by 5.425 cm.
3.3.1.3 Kết quả điều trị gần trên hình ảnh x-quang.
Table 3.18. Results of the spinal correction on straight x-ray image
right after surgery.
Indicator
Pre-surgery Post-surgery P value
Misalignment of top vertebrae of 5.33 ± 2.44
1.2 ± 0.85 cm p<0.001
thoracic spine
cm
Misalignment of top vertebrae of 1.48 ± 1.86 0.46 ± 0.35
p<0.01
lumbar spine
cm
cm
Spinal angle difference
25.4 ± 13.09 8.2 ± 4.45
p<0.001
degree
degree
Bilateral collar bone difference
5.75 ± 4.26 2.9 ± 2.02
p<0.001
degree
degree
Bilateral collar bone difference of 8.31 ± 6.44 3.24 ± 2.05
p<0.001
rib cage
degree
degree
Rotation value of peduncle
3.62 ± 2.22 0.55 ± 0.76
p<0.001
degree
degree
The deflection angle of the disc
15.48 ± 6.72 3.75 ± 3.53
under the position fixed with
p<0.001
degree
degree
horizontal plane
Total number of patient
40
Preoperative patients had a mean misalignment of the top vertebral of
5.33 cm on average. After surgery of scoliosis correction, the average d
misalignment was 1.20 cm. The average rotation value of peduncle
before surgery was 3.6 according to Nash-Moe classification. The study
results showed that the rotation value of peduncle after surgery was
significantly improved with reliability p <0.001.


12
Table 3.19. Effect of Cobb angle correction on straight x-ray image
after surgery.
Cobb angle Cobb angle
Curve
Correction
before
after
P value
position
effect
surgery
surgery
T2-T5
14.65 ± 8.15 4.47 ± 3.82
67.39 ± 20.85 p<0.001
degree
degree
(%)
T5-T12
43.45 ± 17.90 9.55 ± 7.60
78.54 ± 13.76 p<0.001
degree
degree
(%)
L1-S1
28.40 ± 13.34 5.62 ± 6.15
79.40 ± 17.55 p<0.001
degree
degree
(%)
Main
55.6 ±12.70 11.5 ± 7.56
79.68±11.72
p<0.001
curve
degree
degree
(%)
Total
40 patients
Surgery with a full- pedicle screw configuration could correct the
high thoracic spine curve to be 67.39%. The main thoracic curve after
surgery improved 79.68%. The change of Cobb angle before and after
surgery was statistically significant with p <0.001.
Table 3.20. Correction of the spine on inclined x-ray film right after
surgery.
Indicator
Pre-surgery Post-surgery P value
Spinal axis difference via C7
1.16 ± 0.16
0.34± 0.11 p<0.001
(cm)
(cm)
Kyphotic angle of thoracic spine 19.45 ± 10.6 22.6 ± 5.98 p<0.01
T5-T12
(degree)
(degree)
Kyphotic angle of lumbar spine 5.68 ± 5.87
3.6 ± 1.65 p<0.001
T10-L2
(degree)
(degree)
Lumbosacral curvature (L1S1) - 35.95±11.43 41.3± 13.8 p<0.05
angle
(degree)
(degree)
Deflection angle of disc under the 16.48±9.36
13.53±9.76 p<0.001
position of bone welding
(degree)
(degree)
Total number of patient
40 patients
The effect of recovering the kyphotic angle of the thoracic spine
T5-T12 is statistically significant, the average kyphotic angle right after
surgery is 22.6 degrees. The lumbar spine maintains a physiological
curvature of 41.3 degrees.


13
3.3.1.5. Complications after scoliosis surgery.
Early complications after surgery.
Among total 40 patients undergoing surgery, we had 2 patients
who had early complications after surgery. Patient Nguyen Nhat T. was
diagnosed to be idiopathic scoliosis with the curve type 2A. Scoliosis
correction surgery was from the back of the spine and screw through
the fixed peduncle, bone graft. During the surgery to screw the left
thoracic spine T7, the screw was put in the wrong position. After
surgery, the patient showed signs of spinal marrow injury, and then
experienced a CT scan. Surgery to remove the T7 screw on the left.
Spinal marrow injury recovered after 3 months.

A

B

Before surgery
After surgery
Figure 3.4. T7 on the left in the wrong position (A)
Source of research patients: [NC16]
The second patient Nguyen Thi O [NC23]. Scoliosis correction
surgery was from the back of the spine. After surgery, the patient
showed clinical signs of pleural effusion which were detected on x-ray
image and the ultrasound result showed pleural effusion on the right.
The patient was treated with pleural drainage after 5 days of
withdrawal. In the last re-examination, the patient the patient did not
have difficulty breathing, respiratory function and spinal movement
function were normal. Ultrasound results had no pleural effusion.


14

A

B

C
Figure 3.5. Complications of pleural effusion
A. Images of right pleural effusion; B. Place the right pleural
drainage;
C. After withdrawing the drainage.
3.3.3. Far treatment results at the average time of follow-up 33.55 ±
22.52 months.
3.3.3.1. Far clinical treatment results.
A total of 40 patients showed scar healing, no pain, no sign of late
surgical infection, no nerve damage. There were no signs of
postoperative decompensation, no broken or loosened screw.


15
Table 3.26. Clinical correction results after surgery 33.55 ± 22.52
months
Indicator
Pre-surgery
Post-surgery
P value
Shoulder balance
0.93 ± 0.64 cm
0.3 ± 0.17 cm
p<0.001
Body balance
4.63 ± 1.37 cm
0.95 ±0.38 cm
p<0.001
Iliac crest balance
0.09± 0.1 cm
0.09 ± 0.1 cm
p>0.05
Rib cage balance
13.25±
5.74
4.12 ±3.28
p<0.001
degree
degree
Total
number
of
40
patient
At the time of the last follow-up, the patient's shoulder balance,
thoracic deformity, body balance was maintained, the difference
compared to pre-surgery was statistically significant with p <0.001.
3.3.3.2. Treatment results on X-ray image.
Table 3.27. Correction results on straight x-ray image after 33.55 ±
22.52 months
Indicator
Pre-surgery
PostP value
surgery
Misalignment of top vertebrae 5.33 ± 2.44 1.2 ± 0.85
p<0.001
of thoracic spine
cm
cm
Misalignment of top vertebrae 1.48 ± 1.86 0.46 ± 0.35
P<0.01
of lumbar spine
cm
cm
Spinal angle difference
25.4 ± 13.09 8.3 ± 4.42
p<0.001
degree
degree
Bilateral collar bone difference 5.75 ± 4.26 3.0 ± 2.35
p<0.001
degree
degree
Bilateral collar bone difference 8.31 ± 6.44 3.44 ± 2.35
p<0.001
of rib cage
degree
degree
Rotation value of peduncle
3.62 ± 2.22 0.55 ± 0.75
p<0.001
degree
degree
The deflection angle of the disc
15.48 ± 6.72
3.8 ±
under the position fixed with
P<0.001
degree
3.61degree
horizontal plane
Total number of patient
40
Table 3.28. The correction effect on straight x-ray image after 33.55 ±
22.52 months
Curve
Cobb angle
Cobb angle Correction effect P value


16
position

before
after surgery
surgery
T2-T5
14.65 ± 8.15
5.17 ± 5.38 66.6 ± 20.82 (%) p<0.001
degree
degree
T5-T12 43.45 ± 17.90 9.77 ± 7.85
78.15 ± 13.82 p<0.001
degree
degree
(%)
L1-S1
28.40 ± 13.34 5.82 ± 6.16
78.75 ± 17.56 p<0.001
degree
degree
(%)
Main
55.6 ±12.7 12.37 ± 7.69
78.15± 11.68(%) p<0.001
curve
degree
degree
Total
40 patients
The correction effect of the curves was maintained after surgery
33.55 ± 22.52 months; the results were statistically significant with the
maintenance effect of 78.15%.
Table 3.29. Correction results on inclined x-ray image after 33.55 ± 22.52
months
Indicator
Pre-surgery
Post-surgery P value
Spinal axis difference
0.34± 0.11
1.16 ± 0.16 (cm)
p<0.001
via C7
(cm)
Kyphotic angle of
19.45 ± 10.6
22.15±
p<0.01
thoracic spine T5-T12
(degree)
5.87(degree)
Kyphotic angle of
3.6 ±
5.68 ± 5.87(degree)
p<0.001
lumbar spine T10-L2
1.65(degree)
Lumbosacral
40.58±
curvature (L1-S1) - 35.95±11.43(degree)
p<0.001
13.11(degree)
angle
Deflection angle of
disc
under
the
13.55±9.78
16.48±9.36 (degree)
P<0.001
position of
bone
(degree)
welding
Total number of
40 patients
patient
Patients after surgery 33.55 ± 22.52 months, the kyphotic angle of
thoracic spine T5-T12 still maintained and improved 22.15 degrees
compared to pre-surgery. The results were statistically significant.
3.3.3.4. Evaluation results according to SRS-24.


17
Table 3.32. Treatment results according to SRS-24 at the time of followup 33.55 ± 22.52 months.
Evaluation indicator
according to SRS-24

Average
score before
surgery
3.57 ± 0.63
3.39 ± 0.75
4.12 ± 0.83

Average score
12 months
after surgery
4.38 ± 0.45
4.12 ± 0.59
4.32 ± 0.46

P value

Backache
<0.001
Physique
<0.001
Movement/manoeuvre
<0.01
function
Movement level
4.25 ± 1.06
4.41 ± 0.82
0.564
Satisfaction level
4.87 ± 0.05
At the time of the last follow-up, the patient was satisfied with the
surgery results, the average score of 4.87 showed the high level of
satisfaction of the patient.
3.3.3.5. Correlation between correction of the main curve with some
relevant factors
Table 3.33. Compare the effect of the main curve correction by
gender
Effect of the main
Average
Deflection
p
curve correction
Male (n=8)
72.88
14.46
p>0.05
Female (n=32)
79.46
10.75
There is no difference in the effect of the main curve correction
between male and female.
Table 3.34. Correlation coefficients between the effect of the main
curve correction and some relevant factors
Correlation
Factors
coefficient r
p
(spearman)
Age
-0.434
0.005
Main curvature angle before
-0.204
0.206
surgery
Iliac crest ossification
-0.187
0.248
Rotation value of peduncle Nash-0.132
0.418
Moe
Number of screw
0.197
0.222


18

Figure 3.1. Graph expressing the correlation between the effect of the
main curve correction and the age of the research patient
The study results showed that there is a strong inverse correlation
between the effect of the main curve correction and the patient’s age.
The correction effect is higher when the age is lower (the correlation
coefficient r = -0.434, p <0.01).
There is no correlation between the correction effect and other
factors such as the main curvature angle, iliac crest ossification,
rotation value of peduncle and the number of screws during the surgery
(p> 0.05).


19
CHAPTER 4. DISCUSSION
4.1. Clinical features of scoliosis patient group related to surgery.
4.1.2 The patient’s shoulder balance.
4.1.2.1 Method of evaluating the shoulder balance.
Shoulder balance plays an important role in determining the
position of the upper screw of the curve, affecting the patient's physique
and the patient's satisfaction after surgery. To assess the patient's
shoulder imbalance before surgery, we rely on clinical and x-ray
measurements. Clinical research results showed that patients with twoshoulder difference was 0.93 ± 0.64 cm on average, the deflection angle
of collar bone was 5.75 ± 4.26 degrees. For thoracic curves when fixing
the structure curve part, the remaining vertebrae not fixed and the body,
the shoulder spondylosis can correct and offset itself. In order to
evaluate the shoulder balance before and after surgery, there are many
different methods that can be based on factors such as Coracoid height
difference, Clavical angle difference, Clavicle – rib intersection
difference, Radiographical shoulder height, Clavicle chest cage angle
difference, Apex vertebral rotation T1 compared to the horizontal
plane.
4.1.2.2. Shoulder balance in scoliosis correction surgery.
In the group of 40 patients, we usually choose UIV on the last
vertebra of the curve the same level in case bilateral shoulder balance
or the right shoulder higher than the left shoulder. In case the left
shoulder is higher than the right shoulder, we choose UIV at T3. During
the surgery when correcting, we examined patients directly, if there is a
phenomenon of right shoulder after surgery higher, we will increase the
compression on the right and limit the tension on the left and vice versa
to maintain the shoulder balance after surgery. The study results
showed that the average preoperative shoulder imbalance of patients
was 0.93 cm on average. Postoperative results showed that the
correction of shoulder imbalance improved remarkably, reduced to 0.3
cm. The difference was statistically significant.


20

Before surgery
5 years after surgery
Figure 4.5. Shoulder balance before and after surgery. Research
patients [NC14]
We believe that the two basic elements of UIV bone welding
position and correction techniques during surgery are two factors that
affect shoulder balance after surgery. The research of the two authors
Tran Quang Hien and Nguyen Hoang Long have not mentioned this
yet.
4.2 . The value of x-ray image in scoliosis correction surgery
4.2.3. Role of x-ray image of the entire spine in surgical tactics.
In the surgery to treat idiopathic scoliosis, comprehensive
assessment of patients before surgery is important. For a
comprehensive assessment, patients must be examined throughout the
body and do subclinical tests. Conventional x-ray imaging is carried out
on a standard specialized camera to take the image of the entire spine
from the low neck area to the far end of pelvis. Patients were taken in
straight position, inclined position, straight when inclining to the left
and right at maximum, straight when pulling the neck at maximum,
straight when put the round pad at the top of the curvature angle. The
studies of Kuklo and Potter show high reliability when using
conventional x-ray image to identify factors in scoliosis assessment. On
straight and inclined x-ray image, the Cobb angle of the high thoracic
spine, the main thoracic spine, the lumbar spine, the rotation value of
top vertebrae according to Nash-Moe, misalignment of the top vertebra
compared to the spinal axial line via C7, spinal imbalance on the
straight image, rotation of the last vertebra with the horizontal plane,
the iliac crest ossification according to Risser, assessing the kyphotic


21
angle T5-T12, T10-L2, T12 -S1, shoulder balance, rotation of vertebrae
T1, the top vertebrae and last vertebrae of the curve, stable vertebrae,
intermediate vertebrae. On moving films, it is possible to assess the
flexibility of each spinal curve, determine the position of the top and
last vertebrae of the curve required to be fixed by screw and required to
be bone-welded.
4.3. Issues related to surgical results
4.3.1. Direct rotation of the vertebral body related to the scoliosis
correction results.
We have applied Lenke's technique - the direct rotation of
vertebral body – to 40 idiopathic scoliosis patients, the research results
showed that the correction effect was very good. The average Cobb
angle before surgery is 55.6 ± 12.7 degrees, the average Cobb angle
after surgery at the last time of follow-up is 12.37 ± 7.69 degrees. The
correction effect reaches 78.15 ± 11.68 (%).The effect of correcting the
thoracic deformity of the rib cage and the rotation of the top vertebrae
improved remarkably before and after surgery. The thoracic deformity
level of the rib cage when surveyed by scoliometter before surgery is
13.25 degrees, reduced to only 4.12 degrees after surgery using direct
rotation of the vertebral body. The average rotation value of the
peduncle evaluated according to Nash-Moe before surgery was 3.62
degrees, reduced to below 1.2 degrees at the last follow-up time. The
change was statistically significant. The average kyphotic angle of
thoracic spine before surgery was 19.45, after surgery was 22.15 with p
<0.05. The correction effectiveness of Tran Quang Hien is 57.8%,
while the research result of Nguyen Hoang Long reaches 72.5%.
In the study of Lee and his associates comparing the effect of
correcting the scoliosis of two groups of patients, one group was
operated by conventional rod derotation technique while the other
group used the direct rotation of vertebrae. Research results showed
that the direct rotation technique improved the rotation of the vertebral
body on the CT scan by 42.5%, the difference was statistically
significant with p <0.001 compared with conventional correction
techniques. The self-correction effect of the lumbar spine reached
80.5%, the results improved markedly compared with 62.2% of the
self-correction effect of the lumbar spine when using the vertical rod
derotation.


22
4.3.2. Role of pedicle screw in the scoliosis correction results
In our study there were 40 patients undergoing fixed surgery with
a full pedicle screw configuration, screwing and scoliosis correction
techniques according to the instructions of Lenke and Suk. Although
there was no treatment experience in this field, the correction effect was
very good on three planes. The correction effect on the forehead plane
reached 78.15%, the degree of horizontal movement of the top
vertebrae of the thoracic spine was recovered from 5.33 cm to 1.2 cm at
the last time of follow-up, the body balance over the waist was
recovered at the last time of follow-up from 4.63 cm to 0.95 cm on
average, the shoulder balance was recovered with an average difference
reducing from 0, 93cm to 0.3cm, the reliability was statistically
significant. There was no case of false joints at the last time of followup. The correction effect of Tran Quang Hien reached 57.8%, of
Nguyen Hoang Long reached 72.5%.


23
CONCLUSION
After making a research on 40 idiopathic scoliosis patients, we draw
some conclusions as below.
1. Clinical features, x-ray image.
1.1. Clinical features
- Bilateral iliac crest balance: 0.09 ± 0.1 cm
- Shoulder balance on average: 0.93 ± 0.64 degree.
- Bilateral rib cage balance on average: 13.25 ± 5.74 degree.
- Bilateral body balance: 4.63 ± 1.37 cm
2.2. X-ray image
2.2.1. X-ray image on straight film.
- Iliac crest ossification level 3, 5 mainly accounts for 70%.
- Rotation of peduncle according to Nash-Mia on average: 3.62 ±
2.22 degree.
- The bilateral thoracic clavicle difference: 8.31 ± 6.44 degree.
- Bilateral misalignment of the top vertebrae of the thoracic spine:
5.33 ± 2.44 cm
- Bilateral clavicle difference: 5.75 ± 4.26 degree.
- The curvature angle of the main curve on average: 55.6 ± 12.7
degree.
2.2.2. X-ray image on inclined film.
- Kyphotic angle of the thoracic spine T5-T12 on average: 19.45 ±
2.96 degree
- Lumbosacral curvature L1S1- angle on average: 39.95 ± 11.42
degree
2.2.3. Classification by Lenke
- Classification by Lenke curve type 1 is mainly: 28/40 accounting
for 70%
- Type A variant account mainly for: 57.5%
- Kyphotic angle of the normal thoracic spine accounts for: 97.5%.
2. Surgical result
- The effect of correcting scoliosis by direct rotation of the
vertebral body reached 78.15% according to Harrington's calculation.
- Of 40 patients, 38 patients achieved good results, accounting for
95%, 2 patients achieved an average result, accounting for 5%.
- Patients were satisfied with the surgery results with an average
score of 4.87 ± 0.05


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