Posterior vertebral column resection at the apical vertebra versus subapical vertebra for tuberculotic angular kyphosis: 100 patients with a minimum 2-year follow-up.
OBJECTIVE The authors of this study aimed to compare the surgical outcomes and complication profiles of posterior vertebral column resection (pVCR) performed at the apical vertebra (AV) versus the subapical vertebra (SAV) in patients with rigid tuberculotic angular kyphosis (TAK). They hypothesized that an SAV resection would reduce the incidence of neurological complications without compromising radiographic correction. METHODS They conducted a retrospective analysis of patients with TAK who underwent single-level pVCR (Schwab grade 5 osteotomy) between June 2010 and June 2023. Patients were divided into 2 groups, an AV group and SAV group. Demographic, surgical, radiographic, and health-related quality of life (HRQOL) data were collected. Radiographic parameters included sagittal Cobb angle, pelvic incidence, lumbar lordosis, and sagittal vertical axis. HRQOL outcomes were assessed using the visual analog scale, Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) functional assessment, and SF-36. Complications, including dural tears, intraoperative neuromonitoring (IONM) alerts, neurological deficits, etc., were recorded and compared. RESULTS One hundred patients were eligible for study inclusion, of whom 65 were included in the AV group and 35 in the SAV group. Both groups attained and maintained significant correction of the sagittal Cobb angle postoperatively, with no significant differences in radiographic outcomes between groups. However, the SAV group demonstrated significantly lower rates of dural tears (11.4% vs 29.2%, p = 0.044), IONM alerts (22.9% vs 44.6%, p = 0.032), and neurological complications (17.1% vs 36.9%, p = 0.040), particularly motor deficits (11.4% vs 29.2%, p = 0.044). HRQOL outcomes showed better ODI and JOA scores in the SAV group at the final follow-up (both p < 0.001). CONCLUSIONS This study provides clinical evidence that the SAV constitutes a safer and more strategic resection site, as it avoids the severely pathological kyphotic apex and facilitates a more physiologically tolerable correction. Therefore, the subapical VCR strategy is recommended as a viable alternative for managing severe TAK, one that prioritizes patient safety without substantially compromising deformity correction.