Mean Postoperative Cobb Angle Research Articles

Outcome of the surgical treatment of adolescent idiopathic scoliosis using the Scoliosis Research Society outcome questionnaire

Background Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine. Posterior deformity correction represents the gold standard of the surgical treatment of AIS. The fixation technique was shifted from hybrid fixation to the all pedicle screw construct, which could produce superior deformity correction. Patient-oriented outcome questionnaires have become an important measure of the success of surgical correction. This study was conducted to assess the outcome of all pedicle screw constructs in treating AIS using the Scoliosis Research Society (SRS)-24 outcome questionnaire. Patients and methods Seventy-nine AIS patients were included with a minimum 2-year follow-up. Clinical and radiographic measurements were evaluated at preoperative, postoperative, and final follow-up periods. Complications and results of the SRS-24 questionnaire were analyzed. Sex, Lenke classification, levels of the lowest instrumented vertebra, curve magnitude, and percentage of curve correction were correlated with the SRS-24 questionnaire results. Results There were 59 females and 20 males. The mean age of the patients was 14.2 ± 2.5 years. According to Lenke classification, the majority of the curves were type 1 (57 patients), followed by type 5 (11 patients), type 2 (six patients), type 3 (three patients), type 6 (two patients), and no type 4. The mean preoperative major curve Cobb angle was 59.3 ± 9.045° and the mean postoperative Cobb angle was 5.82 ± 5.932°. The average score for SRS-24 was 4.17. The mean preoperative pain score was 3.29, which improved to 4.30 after at least 2 years of follow-up (P˂0.005). Statistically significant improvement was seen in the general self-image, function from back condition, and level of activity. After surgery, the mean score for self-image was 4.19, and for function was 3.55. The postoperative function was the lowest, while the postoperative satisfaction score was the best of all domains, with a mean score of 4.55. About 90% of patients were satisfied with the results of their surgical correction. Magnitude of curve and amount of correction did not significantly alter the SRS scores. Conclusion All pedicle screw construct is an efficient and safe method in AIS correction. The surgical treatment in our AIS patients has resulted in a perceived benefit in all domains of SRS-24 questionnaire.

Temporary Flexible Rods for Correction of Severe Pediatric Spinal Deformity.

Surgical correction of large, rigid scoliotic and kyphotic curves carries an increased risk of perioperative complications, such as neurological injury and excessive blood loss, compared with correction of less severe curves. Titanium temporary flexible rods (TFRs), designed for pediatric long bone fracture fixation, may be helpful as adjuncts to achieve gradual, stepwise intraoperative correction of severe pediatric spinal deformities. A retrospective review was conducted of spinal fusion cases for pediatric scoliosis or kyphosis at our institution that used TFRs as a correction technique from 2007 to 2019. Patients underwent posterior spinal fusion with predominantly pedicle screw instrumentation. Intraoperatively, a non-contoured titanium elastic nail was temporarily positioned in the screws unilaterally to achieve partial correction while the contralateral side was instrumented. Then, the TFR was removed and replaced with a permanent rod. Thirty-four patients with severe spinal deformities underwent posterior spinal fusion. Seventeen had scoliosis (mean major Cobb angle, 89.3°) and 17 had kyphosis (mean T5-T12 kyphosis, 73.8°). Idiopathic deformity was the most common etiology; neuromuscular, syndromic, and postsurgical causes contributed to the remainder of cases. All patients had Ponte osteotomies. Four patients (11.8%) had neuromonitoring alerts, 1 of which was related to insertion of the TFR; all were reversible. For patients with scoliosis, the mean postoperative Cobb angle measured 40.2° (53.6% correction). For patients with kyphosis, the mean postoperative T5-T12 angle measured 43.3° (30.4° of correction). TFRs appear to be helpful adjuncts for correction of severe pediatric spinal deformities, facilitating gradual intraoperative correction in a single-stage operation. Neuromonitoring alerts are common but reversible. [Orthopedics. 2023;46(4):234-241.].

Surgical outcome of scoliosis in patients with Marfan syndrome.

To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. IV.

The implant density does not change the correction rate of the main and the accompanying curves: A comparison between consecutive and intermittent pedicle screw constructs.

The aim of this study was to evaluate the clinical outcomes and the coronal correction rate of the main and accompanying curves of adolescent idiopathic scoliosis (AIS) corrected with pedicle screws inserted consecutively or intermittently. The prospectively collected data of 60 patients (8 men and 52 women; mean age: 14.6±2.5 years) who underwent corrective surgery for AIS between January 2010 and December 2015 were reviewed retrospectively. Two groups were constituted according to the pedicle screw construct type: consecutive pedicle screw construct (CPSC) and intermittent pedicle screw construct (IPSC) groups. The preoperative, early postoperative, and 24-month follow-up radiographs and the Scoliosis Research Society-22 (SRS-22) scores were reevaluated. The Cobb angle of the main and accompanying curves, the correction rate, and the flexibility of the curves were calculated. The mean preoperative Cobb angles were 57.03° and 57.46°, the mean postoperative Cobb angles were 14.93° and 14.4°, and the mean correction rates were 76.22% and 75.31% in IPSC and CPSC groups, respectively (p>0.05). The preoperative and postoperative accompanying curve magnitudes and correction rates were similar (p>0.05). These radiographic outcomes were also consistent with the SRS-22 scores. Both the pedicle screw constructs had satisfactory outcomes following the surgery, which were confirmed by both the SRS-22 scores and radiographs taken perioperatively and at follow-ups. The IPSC and CPSC groups did not demonstrate a significant change in the correction rate of the main and minor or major accompanying structural and nonstructural curves, and also in the SRS-22 scores. Level III, Retrospective comparative study.

A QUALIDADE DE VIDA É PIOR EM PACIENTES COM ESCOLIOSE IDIOPÁTICA DO ADOLESCENTE SUBMETIDOS A FUSÕES MAIS LONGAS? ACOMPANHAMENTO DE DOIS ANOS

ABSTRACT Objective: To compare quality of life in patients with longer fusions with that of those who have short fusions 2 years of after surgery. Methods: This is a retrospective comparative cohort study (Level of Evidence III) involving patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion with pedicle screws with a 2-year follow-up. The primary outcome was quality of life assessed using the SRS-30 questionnaire. Participants were divided according to Lenke and stratified into those with major (Lenke 3 and Lenke 6) and minor (Lenke 1 and Lenke 5) fusions. Results: Forty-one patients, 34 of whom were women, were evaluated: Lenke 1 (17 patients), Lenke 3 (15 patients), Lenke 5 (3 patients), and Lenke 6 (6 patients). The mean age was 13.8 years, the mean preoperative and postoperative Cobb angles were 56.48 degrees and 10.49 degrees, respectively, and the mean surgical Cobb reduction was 45.54 degrees. All patients in the sample showed an overall improvement in quality of life after surgery (p&lt;0.0001). There was no difference between groups A (long fusions) and B (short fusions) in relation to the domains in general (p&gt;0.05). Although pain was improved in the overall sample, this was not the case for the group with structured double curves and longer fusions (p = 0.03). Conclusion: There was no difference in quality of life between patients with long and short fusions with a 2-year follow-up. Level of Evidence III; Retrospective cohort.

Inclusion of the fractured level into the construct of short segment fixation in patients with thoracolumbar fractures: clinical and radiological outcome

BackgroundThoracolumbar fractures represent a widespread injuries that can cause significant disability and strain the healthcare system. Different surgical approaches are described in the literature. This study was conducted to evaluate the fractured level inclusion in short-segment fixation of thoracolumbar junction spine fractures.ResultsPreoperative neurological deficit was reported in seven patients ranging from ASIA grade C to D. All of these patients improved to grade E by the end of the follow-up period, except for one patient who improved from grade C to D. The mean Oswestry Disability Index was 19.87%. The mean postoperative Cobb angle was 11.77° which significantly improved compared to a preoperative value of 19.37°. There was a significant improvement in the postoperative anterior and posterior vertebral body height compared to the preoperative values. The vertebral body compression ratio significantly improved during the postoperative period to a mean of 84% compared to 76% preoperative.ConclusionsThere was significant improvement of the postoperative values of the mean Cobb angle, the anterior and the posterior vertebral body height as well as the vertebral body compression ratio compared to the preoperative values.

Radiological outcomes of the selective spinal fusion for lenke type 5C adolescent idiopathic scoliosis

Objective: To determine the short term radiological outcomes of Lenke type 5C adolescent idiopathic scoliosis in terms of Cobb angle correction and coronal balance after selective posterior segmental spinal instrumentation with pedicle screws. Methods: This retrospective cohort study was conducted in the department of Orthopaedic at tertiary care public hospital of Mumbai, India. The medical records of patients from 17th April 2015 to 29th October 2019 who underwent a selective spinal fusion with pedicle screws for Lenke type-5C adolescent idiopathic scoliosis were reviewed. Preoperative radiographs were evaluated for Cobb angle of the lumbar or thoracolumbar curve as well as a sagittal and lumbar modifier on anteroposterior and lateral standing films. The curve correction, implant density, number of segment fused and coronal balance was assessed on postoperative radiographs. The pre and postoperative comparison of important study variables was done and P-value was calculated with the help of the chi-square test. P-value &lt;0.05 was considered statistically significant. Results: The total number of patients was 34. Majority (94.1%, n=32) were females while only 2(5.9%) were males. The mean age at the time of operation was 14.35±2.19 years (range 8 to 19 years). Mean pre-operative and post-operative Cobb angles were 61.790±13.120 (range 400 to 850) and 10.550±8.710 (range 00 to 300) respectively (P-value 0.00). The mean percentage of curve correction and percentage of fulcrum flexibility was 83.35±13.07 % (range 55% to 100%) and 59.56%±15.07 (range 28.57% to 84.60%) respectively (P value 0.469). Mean implant density and fusion mass was 66.03±7.94% (range 53 to 79%) and 10.32±2.8 (range 7 to 15%) segments respectively. The coronal balance was achieved in all patients. No major complication was noted. Conclusion: Near normal Cobb angle correction and coronal balance was achieved in all patients of Lenke type 5C adolescent idiopathic scoliosis treated with posterior segmental spinal instrumentation utilizing pedicle screws.

A Retrospective Study of Factors Associated with Restoration of Thoracic Kyphosis in 43 Patients with Adolescent Idiopathic Scoliosis with Lenke Type 1 Curvature.

BackgroundThis retrospective study aimed to identify the factors associated with successful surgical correction of thoracic kyphosis (TK) in 43 patients with adolescent idiopathic scoliosis (AIS) with Lenke type 1 curvature, in which the major curve with the largest Cobb angle was mainly in the thoracic region.Material/MethodsWe collected data from patients with Lenke 1 AIS. The following parameters were measured: Cobb angle, side-bending Cobb angle, cervical lordosis (CL), TK, lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), the sagittal vertical axis (SVA), the center of a C7 plumb line to the center sacral vertical line (C7-CSVL), correction rate, Ponte osteotomy, flexibility, and screw density. Univariate analysis and multivariate logistic regression analyses were performed.ResultsAmong the 43 cases analyzed, the mean postoperative Cobb angle at the last follow-up, C7-CSVL, SVA, CL, TK, LL, PI, SS, and PT were respectively 21.33±9.47°, 10.41±8.45 mm, 19.68±14.33 mm, 16.19±7.45°, 23.12±7.45°, 50.33±11.37°, 49.70±9.83°, 39.42±8.11°, and 10.16±6.63°. Univariate analysis suggested that preoperative TK, preoperative LL, and Ponte osteotomy were statistically significant (P<0.05), and multivariate analysis suggested that preoperative LL and Ponte osteotomy were statistically significant (P<0.05).ConclusionsThe results of this study demonstrated that preoperative TK, preoperative LL, and Ponte osteotomy were related factors for maintaining normal TK. Multivariate analysis suggested that preoperative LL and the use of Ponte osteotomy with full-thickness segmental resection of the spinal posterior column resulted in the successful surgical correction of TK in patients with AIS with Lenke type 1 curvature.

Perioperative outcome of severe rigid idiopathic scoliosis: Single-staged posterior spinal fusion utilizing a dual attending surgeon strategy. A report of 41 patients.

Various surgical strategies including combined approach and spinal osteotomies in severe rigid scoliosis had been reported with significant perioperative complication rates. The use of single-staged posterior spinal fusion (PSF) utilizing a dual attending surgeon strategy for severe rigid scoliosis has not been widely reported. This was a retrospective study aimed to evaluate the perioperative outcome of single-staged PSF in severe rigid idiopathic scoliosis patients (Cobb angle ≥90° and ≤30% flexibility). Forty-one patients with severe rigid idiopathic scoliosis who underwent single-staged PSF were included. The perioperative outcome parameters were operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, transfusion rate, patient-controlled anesthesia morphine usage, length of postoperative hospital stay, and perioperative complications. Radiological parameters included preoperative and postoperative Cobb angle, correction rate, side-bending flexibility, and side-bending correction index. The mean age was 16.9 ± 5.6 years. The mean preoperative Cobb angle was 110.8 ± 12.1° with mean flexibility of 23.1 ± 6.3%. The mean operation duration was 215.5 ± 45.2 min with mean blood loss of 1752.6 ± 830.5 mL. The allogeneic blood transfusion rate was 24.4%. The mean postoperative hospital stay was 76.9 ± 26.7 h. The mean postoperative Cobb angle and correction rate were 54.4 ± 12.8° and 50.9 ± 10.1%, respectively. The readmission rate in this cohort was 2.4%. Four perioperative complications were documented (9.8%), one somatosensory evoke potential signal loss, one superficial infection, one lung collapse, and one superior mesenteric artery syndrome. Severe rigid idiopathic scoliosis treated with single-staged PSF utilizing a dual attending surgeon strategy demonstrated an average correction rate of 50.9%, operation duration of 215.5 min, and postoperative hospital stay of 76.9 h with a 9.8% perioperative complication rate.

Impact of metal density on deformity correction in posterior fusions for adolescent idiopathic scoliosis: A retrospective cohort study.

IntroductionOptimal implant density for posterior spinal fusion in adolescent idiopathic scoliosis (AIS) remains controversial. We aimed to examine radiographic outcomes of AIS cases treated with limited density pedicle screw constructs.MethodsThis is a retrospective analysis of 96 patients (89 females and 7 males with mean age of 13.8 ± 4.4 years) with AIS who underwent posterior spinal instrumentation at Ghurki Trust Teaching Hospital between 2014 and 2016. Construct characteristics and radiographic measurements were compared preoperatively and at 2 year follow-up using paired t-test. Pearson's correlation coefficient between curve characteristics and metal density was calculated.ResultsPreoperative coronal Cobb angle was 68.5 ± 6.9°. Flexibility of the curve was 47.5 ± 10.3% based on push-prone films. The mean number of vertebrae in the fusion was 10.7 ± 1.6. The implant density was 62%. The mean postoperative Cobb angle was 18.6 ± 4.2°, giving a mean correction of 72.5 ± 6.8%. Metal density was not correlated with preoperative coronal or sagittal radiographic variables; MT Cobb angle (r = 0.02, p = 0.847), MT curve flexibility (r = 0.129, p = 0.210), preoperative thoracic kyphosis (r = -0.119, p = 0.247) or lumbosacral lordosis (r = −0.048, p = 0.645). There was a significant correlation between the flexibility of the curve as assessed by push-prone radiographs with the percentage correction achieved (r = 0.368, p < 0.0001) as well as absolute correction in degrees (r = 0.643, p < 0.0001). No significant correlations were present between metal density and MT curve coronal correction rate/percentage (r = 0.086, p = 0.407) or postoperative Cobb angle (r = 0.098, p = 0.344).ConclusionMetal density does not influence the coronal and sagittal correction of AIS. Neither larger nor stiffer curves necessitate high metal density.Level of evidenceIV.

Complication rates for preexisting baclofen pumps and ventricular shunts following scoliosis correction: a preliminary study.

OBJECTIVE Many patients undergoing spinal fusion for neuromuscular scoliosis have preexisting neurosurgical implants, including ventricular shunts (VSs) for hydrocephalus and baclofen pumps (BPs) for spastic cerebral palsy. Recent studies have discussed a possible increase in implant complication rates following spinal fusion, but published data are inconclusive. The authors therefore, sought to investigate: 1) the rate of implant complications following fusion, 2) possible causes of these complications, and 3) factors that place patients at higher risk for implant-related complications. METHODS Cases involving pediatric patients with a preexisting VS or BP who underwent spinal fusion for scoliosis correction between 2005 and 2016 at a single tertiary children's hospital were retrospectively analyzed. Patient demographics, implant characteristics, spinal fusion details, neurosurgical follow-up, and implant complications in the 180 days following fusion were recorded and analyzed. RESULTS Overall, 75 patients who underwent scoliosis correction had preexisting implants: 39 had BPs, 31 VSs, and 5 both. The patients' mean age at fusion was 13.49 ± 2.78 years (range 3.62-18.81 years), and the mean time from the most recent previous implant surgery to fusion was 5.70 ± 4.65 years (range 0.10-17.3 years). The mean preoperative and postoperative Cobb angles were 62.4° ± 18.9° degrees (range 20.9°-109.0°) and 23.5° ± 13.3° degrees (range 2.00°-67.3°), respectively. No VS complications were identified. Two patients with BPs were found to have complications (unintentional cutting of their BP catheter during posterior spinal fusion) within 180 days postfusion. There were no recorded neurosurgical implant infections, failures, fractures, or dislodgements. Although 10 patients required at least 1 surgical procedure for irrigation and debridement of the spine wound following fusion, there were no abdominal or cranial implant wound infections requiring revision, and no implants required removal. CONCLUSIONS The results of this study suggest that spinal fusion for scoliosis correction does not increase the rates of complications involving previously placed neurosurgical implants. A large-scale, prospective, multicenter study is needed to fully explore and confirm this finding.

Severe rigid Scheuermann kyphosis in adult patients; correction with posterior-only approach.

Scheuermann kyphosis is the most common structural kyphosis among adolescence and young people. Surgical treatment may be performed through combined anterior and posterior or posterior-only approaches; to our knowledge, the efficacy of posterior-only approach as less invasive procedure is not well studied in case of severe rigid Scheuermann kyphosis. Eighteen patients with severe rigid Scheuermann kyphosis operated through only posterior approach from 2013 to 2016 were evaluated. All information regarding demographic data, curve size before and after the surgery, surgical time, amount of blood loss, correction loss during follow-up and also complications was collected. There were six females and 12 males. Mean age of the patients was 22.4years (range 17-38). Mean kyphosis angle before surgery was 87.2° (range 85-105), and that reduced to 47.4° (range 45-55) after the surgery. Mean curve size in hyperextension view was 73.8°. Mean postoperative Cobb angle was 50-55 percent of preoperative curves. Mean hospital admission duration was 3.5days after the index surgery (range 3-5days). Mean blood loss during the surgery was 250ml. Mean surgical duration time was 150min. Mean follow-up period was 9months (range 8-48months). No complication was found among the patients. Posterior-only approach using advanced osteotomy techniques and posterior release is a safe and reliable approach for treatment of patients suffering from severe rigid Scheuermann kyphosis and provides acceptable deformity correction.

Single-stage deformity correction in children with neurogenic kyphoscoliosis: nuances and a proposal for risk stratification.

OBJECTIVE Neurogenic kyphoscoliosis in pediatric patients has varied causes and diverse management options. The most common management strategy is to stage the orthopedic and neurosurgical aspects of the correction at an interval of 3-6 months from each other. The aim of this study was to report the authors' experience with correction of deformity in children with associated neurological abnormalities requiring intervention as a single-stage surgical treatment. METHODS Of 591 pediatric patients with scoliosis treated at the Amrita Institute of Medical Sciences and Research Centre between January 2001 and January 2011, the authors identified all patients with neurogenic kyphoscoliosis who underwent deformity correction and a neurosurgical procedure in the same surgical session when they were younger than 15 years. Data regarding the demographic details, preoperative Cobb angle/kyphotic angle, surgical details, postoperative complications, cost of the procedure, and long-term neurological outcome were collected for each case and analyzed. Based on the results of this analysis, the authors propose a 2-category risk stratification system for the timing of deformity correction depending on the primary neurogenic etiology. RESULTS Ten cases involving patients with neurogenic kyphoscoliosis requiring both deformity correction and neurosurgical procedure met the criteria and were included in the analysis. All 10 patients were younger than 15 years; their mean age was 10.8 years. The average Cobb angle was 59.5°. Five patients underwent foramen magnum decompression, 5 patients underwent spinal cord detethering, and 1 patient had intraspinal intradural tumor excision. The mean estimated blood loss was 1177 ml (range 700-1550 ml), and the mean operative time was 4.4 hours (range 3-5.5 hours). There were no intraoperative complications. None of the patients had any new postoperative neurological deficits. The mean postoperative Cobb angle of the main thoracic curve was 12.6°. CONCLUSIONS Simultaneous deformity correction along with a definitive neurosurgical procedure in patients with neurogenic kyphoscoliosis can be performed without added morbidity and avoids both the added costs and the risk of complications associated with a second surgery. The risk stratification system proposed in this paper may serve as a guideline for case selection and help to optimize outcome.

Scoliosis after pectus excavatum correction: does it improve or worsen?

Scoliosis is associated with pectus excavatum. However, the change in the degree of scoliosis after pectus excavatum correction has not been clarified. This study examined how the correction of pectus excavatum influences the status of pre-existing scoliosis. A total of 779 pectus excavatum patients operated between 2007 and 2011 using the pectus bar were retrospectively analysed. Preoperative severity and postoperative change of scoliosis in accordance with the severity of pectus excavatum were evaluated. Cobb angle, Haller index and sternal tilt degree were measured from pre- and postoperative whole-spine anteroposterior radiographs and chest computed tomography. Sixty-three (8%) patients had scoliosis (Cobb angle >10°). No significant correlation was noted between postoperative changes in Cobb angle, Haller index or sternal tilt angle. Preoperative severity of scoliosis showed a positive correlation with postoperative changes in Cobb angle ( r = 0.527, P < 0.001). In analyses between groups with mild and moderate scoliosis (Cobb angle <15° and >15°, respectively), the mean postoperative Cobb angle was decreased in mild scoliosis (-2.88°) but was increased in moderate scoliosis (3.86°; P < 0.001). Regarding the 'improvement' and 'aggravation' of scoliosis after pectus correction, preoperative severity of scoliosis was the only significant factor in univariable and multivariable analysis. Pectus excavatum repair using a pectus bar may improve scoliosis, but when the preoperative Cobb angle exceeds 15°, scoliosis may be aggravated. Therefore, pectus excavatum with concomitant moderate scoliosis requires extra caution during repair. This preliminary result suggests further investigation into the effect of chest cage remodelling on spine dynamics.

Conversion of Implant Failure in Early Onset Scoliosis to Magnetic Growing Rod. A Series of Five Cases

Introduction Conventional growing systems allow spinal growth to continue and prevent curve progression but need multiple interventions that increase the risk of infection, complications of anesthesia. A more advanced, less invasive method is the remotely distractible, magnetically controlled growing rod (MCGR) system which has been developed to allow frequent non-invasive distractions. This is the first series focusing on the conversion of failed growing implant to MCGR. Materials and Methods A prospective single center study from 11/2012 to 8/2015 with consecutive patients with progressive deformity and implant failure. Five children have been converted to MCGR; one boy and 4 girls; mean age 11.9 years. The scoliosis was infantile in two and neuromuscular in 3 cases. Four patients had VEPTR and one had a conventional growing rod. Results Mean preoperative Cobb angle was 56.6°, thoracic kyphosis 59.6° and spinal length (T1-S1) 339mm. The upper fixation level was T3-T5 with a lower fixation to T11 and L2 in the infantile scoliosis and L3 in two neuromuscular cases. One neuromuscular scoliosis was fixed with hooks to the iliac crest. Mean operative time was 135 minutes and blood loss 217 ml. Mean postoperative Cobb angle was 48.1°, thoracic kyphosis of 49.8% and spinal length 379mm. During this study a total of 15 distractions have been performed to all children. At final FU (mean of 21.8m), mean Cobb angle was 48° (total additional correction of 2.5°), thoracic kyphosis of 51.5° (total additional correction of 3.2°) and spinal length of 387 mm (total spinal growth of 33 mm). One case reached to final fusion after 2 distractions. Double rods have been the rule with exception of one neuromuscular case. This single rod was broken after 6 months and replaced by a double rod system. The other complication was a proximal junctional kyphosis (PJK) that occurred primarily after VEPTR and again after magnetic rod. Conclusion Although conversion of implant failure from VEPTR and growing rod systems to MCGR is a good option to allow growth of the instrumented segment, this gives limited results when performed at a relatively older age. The postoperative correction in these cases is relatively limited due to prior correction by the older systems. One complication related to the implant occurred with single rod construct. Correction by MCGR will face the same challenge to prevent PJK, like other growing rod systems. The new technique provided a non-surgical repeated (sometimes outpatient) distractions.

The Convex Manipulation: An Alternative Technique in Surgical Treatment of Adolescent Idiopathic Scoliosis

Introduction Concave derotation is the traditional correction maneuver in adolescent idiopathic scoliosis surgery. However, the positioning of thoracic pedicle screws at concave side of the curve can be quite challenging, because of the small pedicle size and the wide variation in its morphological characteristics, due to the vertebral dystrophy observed in scoliotic patients. Then, to reduce risks of neural damages, and ensure the same strenght of derotation maneuver, a convex manipulation through an all-level pedicle screws convex instrumentation can be performed. We report perioperative and 2-year results in a consecutive series of patients treated by convex manipulation through an all-level pedicle screws convex instrumentation. Material and Methods From January 2013 to January 2015 we surgical treated 36 consecutive patients (28 F, 8 M, mean age 13 years) affected by thoracic adolescent idiopathic scoliosis (Lenke type 1, 27 patients, and Lenke type 2, 9 patients). Mean pre-operative Cobb angle was 56°±6° in Lenke type 1 group and 51°±4° plus 32°±3° in Lenke type 2 group. We performed a posterior access only in all patients using polyaxial pedicle screws at each level on the convex side of the curve. Derotation and manipulation maneuvers were performed on the convex prebent rod. In all cases motor-evoked potentials monitoring was used. Mean follow-up time was 27 months. Results The average percentage of coronal correction was 76 ± 5% (mean post-operative Cobb angle 15°±4°), with no neurological complications. Concerning the post-operative kyphosis, we observed a slight decrease of mean values compared with pre-operative measurements (mean reduction of thoracic kyphosis 5°±2°). At 2-year follow-up no changes in coronal nor in sagittal plane were observed. The mean operative time was 210 ± 30 minutes, with a mean blood loss of 500 ± 100 ml. Using the free-hand technique, the mean time of pedicle screws positioning in the thoracic area on the convex side was 2 ± 1 minutes from T6 to T12, and 4 ± 1 minutes from T3 to T5. Whenever included in the area of arthrodesis, T2 was usually instrumented with the Universal Clamps, to reduce the stiffness of the construct. Instead, T1 has never been included in the arthrodesis area. Conclusion This case-series study shows the effectiveness and the safety of convex manipulation in Lenke type 1 and type 2 scoliosis. The coronal correction obtained with this technique is comparable to that obtained with the traditional concave derotation. Other advantages are the short operative time, the low intra-operative blood loss and, mostly, a lower risk of neurological complications.

Magnetic controlled growing rods for early-onset scoliosis: a 4-year follow-up

Background ContextThere have been no studies with medium-term follow-up of magnetic controlled growing rods (MCGRs). PurposeThis study aimed to report our single center experience of a magnetic growing rod system with an average of 4 years' follow-up. Study Design/SettingA retrospective case series was carried out. Patient SampleThe sample comprised patients with early-onset scoliosis treated with magnetic controlled growth rods who were operated in 2011. Outcome MeasuresCobb angle, spinal growth rate, complications, and revision were the outcome measures. MethodsClinical case notes and radiographs were reviewed. ResultsThere were 8 patients (5 dual-rod construct, 3 single-rod construct) who had a minimum of 44 months' follow-up and average of 48 months (44–55 months). Mean age at surgery was 8.2 years (range 3–10). Mean preoperative Cobb angle was 60° (34–94), whereas mean postoperative Cobb angle was 42° (32–63). The average number of extensions was 13.8 (range: 12–20). There were 6 patients (75%) who required 8 revision surgeries: rod problems (N=4), proximal screw pull-out (N=3), and development of proximal junction kyphosis (N=1). All three patients who had single-rod construct underwent revision procedure. Currently, four patients (50%) still have the magnetic rods in situ. The mean duration of MCGR in the patient in the removed group was 39 months (range: 34–46). ConclusionsMedium-term results of MCGR are not as promising as previously reported early results. Hence, MCGRs should be used with caution. Single-rod constructs should definitely be avoided. The role of MCGRs in revision cases still remains unknown.

Minimally invasive iliac screw fixation in treating painful metastatic lumbosacral deformity: a technique description and clinical results.

Pelvic fixation via iliac screws is a crucial technique in stabilizing metastatic lumbosacral deformity. MIS iliac screw fixation avoids complications of an open approach and is a viable palliative option in treating patients with painful instability and advanced disease, unsuited for major reconstruction. In this paper we describe the use of MIS iliac screw fixation in treatment of painful metastatic LSJ deformity, highlighting our treatment rationale, selection criteria, technical experience and outcomes. Five patients with lumbosacral metastatic deformity who underwent MIS lumbopelvic stabilization using iliac screws were prospectively studied. Patients had severe axial back pain in erect posture with significant resolution when supine. All patients had advanced disease with unfavorable tumor scores for major spinal reconstruction. Mean cohort age was 62years. Median pre-op SIN and Tokuhashi scores were 13 and 9, respectively. All patients were instrumented successfully without conversion to open technique. Mean preoperative and postoperative Cobb angle was 11° and 5.4°, respectively. There were no neurological deficits or wound complications postop. Postoperative CT scans showed no iliac screw and sacroiliac joint bony violation. Mean time for commencement of adjuvant therapy was 2.8weeks. Average follow-up was 13.2months. No screw breakage, wound complication, symptomatic implant prominence and SI joint pain were noted at last follow-up. MIS iliac screw fixation is feasible, reproducible and can be employed without complications in metastatic spine. This opens a new avenue of surgical management for metastatic lumbosacral disease patients, who otherwise may be inoperable and provide better soft tissue control and earlier postoperative adjuvant treatment opportunity.

Assessment of Rib Hump Deformity Correction in Adolescent Idiopathic Scoliosis With or Without Costoplasty Using the Double Rib Contour Sign

Level III-therapeutic study. The purpose of this study was to determine whether the addition of costoplasty in adolescent idiopathic scoliosis surgery improved correction of the rib hump deformity. Trunk deformity is comprised of vertebral rotation, posterior vertebral element, and rib deformities. Surgical correction of the rotational deformity has been performed by segmental spinal instrumentation with vertebral derotation, but complete correction of the rib hump by derotation is rarely achieved. A multicenter registry database for adolescent idiopathic scoliosis was reviewed with the inclusion criteria of Lenke type I curves treated with posterior spinal fusion with or without costoplasty, instrumented with pedicle screws or hybrid constructs, with a minimum follow-up of 2 years. The first group (group I) was treated with pedicle screws, direct vertebral rotation, and no costoplasty, whereas the second group (group II) was treated with pedicle screws, vertebral rotation, and costoplasty. The rib index (RI), calculated from the double rib contour sign, and Cobb angle were measured radiographically and compared between groups. The groups comprised 36 subjects in group I and 40 subjects in group II. The mean preoperative Cobb angles for groups I and II were 49.7 and 49.8 degrees, respectively, whereas the mean postoperative Cobb angles were 10.2 and 10.9 degrees, respectively. There was no difference in preoperative and postoperative values when comparing both groups (P=0.48 and 0.96, respectively). Before spine surgery, RI for groups I and II was 1.61 and 1.80, respectively. Postoperatively, the rib indices were 1.39 for group I and 1.29 for group II. These differences were found to be statistically significant (P=0.002 and 0.006, respectively). The amounts of correction of RI were 0.23 and 0.51 for groups I and II, respectively. This difference was found to be statistically significant (P<0.0001). The correction percentages were 13.7% and 28.3%, respectively. This difference was also found to be statistically significant (P<0.0001). Costoplasty combined with pedicle screws and vertebral derotation may significantly improve rib hump deformity as opposed to pedicle screws and vertebral derotation alone.

Effectiveness and Safety of Convex Derotation in Thoracic Adolescent Idiopathic Scoliosis

Introduction Concave derotation is the traditional correction maneuver in adolescent idiopathic scoliosis surgery. However, the positioning of thoracic pedicle screws at the concave side of the curve can be quite challenging, because of the small pedicle size and the wide variation in its morphological characteristics, due to the vertebral dystrophy observed in scoliotic patients. Then, to reduce risks of neural damages and ensure the same strength of derotation maneuver, a convex derotation through an all-level pedicle screws convex instrumentation can be performed. We report perioperative and 1-year results in a consecutive series of patients treated by convex derotation through an all-level pedicle screws convex instrumentation. Materials and Methods From January 2013 to January 2014, we surgically treated 24 consecutive patients (18 female patients and 6 male patients, mean age 13 years) affected by thoracic adolescent idiopathic scoliosis (Lenke Type 1, 19 patients, and Lenke Type 2, 5 patients). Mean preoperative Cobb angle was 56 ± 6 degrees in Lenke Type 1 group and 51 ± 4 degrees plus 32 ± 3 degrees in Lenke Type 2 group. We performed a posterior access only in patients using polyaxial pedicle screws at each level on the convex side and two sublaminar acrylic loops (universal clamps) at the upper instrumented vertebra, to reduce the stiffness of the construct. Derotation maneuver was performed on the convex prebent rod. In all cases, motor-evoked potential monitoring was used. Mean follow-up time was 15 months. Results The average percentage of coronal correction was 76 ± 5% (mean postoperative Cobb angle 15 ± 4 degrees), with no neurological complications. Regarding the postoperative kyphosis, we observed a slight decrease in mean values compared with preoperative measurements (mean reduction of thoracic kyphosis 5 ± 2 degrees). At 1-year follow-up, no changes in coronal or sagittal plane were observed. The mean operative time was 210 ± 30 minutes, with a mean blood loss of approximately 500 ± 100 mL. Using the free-hand technique, the mean time of pedicle screws positioning in the thoracic area on the convex side was approximately 2 ± 1 minutes from T6 to T12 and approximately 4 ± 1 minutes from T3 to T5. Whenever included in the area of arthrodesis, T2 was usually instrumented with the universal clamps. Instead, T1 has never been included in the arthrodesis area. Conclusion This case-series study shows the effectiveness and safety of convex derotation in Lenke Type 1 and 2 scoliosis. The coronal correction obtained with this technique is comparable to that obtained with the traditional concave derotation. Other advantages are short operative time, low intraoperative blood loss, and, mostly, a reduced risk of neurological complications.