Rigid Scoliosis Research Articles

315. Sequential correction with satellite rods in severe rigid thoracic scoliosis

BACKGROUND CONTEXT The treatment of severe and rigid thoracic scoliosis was challenging. We employed Ponte osteotomy followed by sequential correction technique with satellite rods construction to treat severe rigid thoracic scoliosis aiming to achieve better correction with less complications. This technique could reduce the difficulty of rod installation by separated maneuvers and multi-rods system. Satisfactory correction rate and less correction loss during the longitudinal follow-up could be expected in this cohort. PURPOSE The objective of this study was to evaluate the safety and efficacy of this technique. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE A total of 32 patients (12 M, 20F) with severe rigid thoracic scoliosis (Cobb angle>100°) who underwent sequential correction technique with satellite rod construction between October 2012 and October 2016 and with more than 2 years follow-up were retrospectively reviewed. OUTCOME MEASURES Cobb angle of major curve, apex vertebral translation, trunk shift, thoracic kyphosis and lumbar lordosis were measured through standing X-ray imaging preoperatively, postoperatively and at final follow-up. The duration of operation, blood loss and complication were recorded. SRS-22 questionnaire was measured to evaluate the clinical outcomes. METHODS Cobb angle of major curve, apex vertebral translation, trunk shift, thoracic kyphosis and lumbar lordosis were measured through standing X-ray imaging preoperatively, postoperatively and at final follow-up. The duration of operation, blood loss and complication were recorded. SRS-22 questionnaire was measured to evaluate the clinical outcomes. RESULTS The average age was 21.3±10.8 years (range 17 to 46 years) and the average follow-up was 34.3±8.9 months. The mean preoperative Cobb angle of major curve was 117.8±9.8° (range 104° to 131°) with a mean flexibility of 13.9% and the mean thoracic kyphosis was 65.5±18.7° (range 48° to 87°) . The mean duration of operation was 267.4±42.3min and the mean blood loss was 895.4±103.1ml. The coronal main curve was corrected to 54.4±10.9° with a mean correction rate of 53.9%±9.3% and the mean thoracic kyphosis was corrected to 35.6±12.0°, which were both significantly improved (p CONCLUSIONS Sequential correction technique with satellite rods construction was a safe and effective strategy in the treatment of severe rigid thoracic scoliosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Ventilation/perfusion SPECT/CT in patients with severe and rigid scoliosis: An evaluation by relationship to spinal deformity and lung function

ObjectiveStructural changes of the spine and chest wall associated with SRS result in poor cardiopulmonary function. Comprehensive assessment of pulmonary function is extremely important for patients with SRS before a correction operation. We explore the changes of distribution of lung ventilation and perfusion function in patients with SRS using SPECT/CT and describe the relation between these changes with Cobb angle and FVC%. Patients and methodsFrom March 2015 to August 2016, 16 consecutive SRS patients with a mean age of 20.1 years(range 11–36 years) were included in the study. Scoliotic parameters on radiographs were analyzed. FVC% were obtained by spirometry test. Lungs ventilation/perfusion single photon emission computed tomography scans was performed preoperatively in all patients to explore pulmonary ventilation and perfusion function changes. These changes were measured as the deviation form the normal perfusion and ventilation function distribution in right and left lung and correlated with the Cobb angle of main curve and FVC%. ResultsThe regional lung ventilation and perfusion function defects were not found in all SRS patients. Ventilation function deviation was a mean 5.7%(range, −3.6% to 10.1%), significantly less than perfusion function deviation of 8.2%(range, −0.3% to 22.2%) (P = 0.015, t = −2.732). Lung ventilation and/or perfusion function deviation did not correlated with Cobb angle and FVC%, respectively. There was significant correlation between lungs ventilation and perfusion function deviation(P = 0.001, r = 0.753). ConclusionThe ventilation and perfusion function distribution were favourable in convex and concave side lung of SRS. Deformity bring about greater lungs perfusion function changes than ventilation function. The measurement of lung ventilation and perfusion function changes may represents an additional functional feature to assess pulmonary function of SRS more comprehensively.

Erratum to: Magnetically controlled growing rods for rigid scoliosis : An alternative to halo-gravity traction in preparing for definitive correction?

Erratum to: Orthopäde 2018 https://doi.org/10.1007/s00132-018-3631-7 Dear Reader,Unfortunately, an incorrect subtitle was published in the online version of the article.We kindly ask you to use the correct title:"Magnetically controlled growing rods for rigid scoliosis.An alternative to halo-gravity ….

Skull-femoral traction after posterior release for correction of adult severe scoliosis: efficacy and complications

BackgroundIt is a great challenge for spine surgeons to correct severe rigid scoliosis. We developed a three- staged correction (one stage posterior release and screw placement, two stage skull-femoral traction and three stage posterior instrumentation) for adult severe scoliosis. The objective of this study is to investigate safety and efficacy of a three- staged correction for adult severe scoliosis.MethodsA retrospective review was performed for patients with severe scoliosis receiving three- staged correction (one stage posterior release and screw placement, two stage skull-femoral traction and three stage posterior instrumentation) from June 2001 to October 2014. The inclusion criteria were as follows: [1] age more than 18 years; [2] main curve larger than 90°; [3] a minimum 2-year follow-up. Patients were excluded if they had a history of surgery or anterior release or receiving three column osteotomies.ResultsA total of 63 patients were included (37 female and 26 male), with a mean age of 22.7 years (range: 18–30 years) and follow-up of 42.6 months (range: 24–108 months). The aetiology was congenital in 27 patients, neuromuscular in 18, idiopathic in 11, neurofibromatosis-1 in 4 and Marfan syndrome in 3. The mean traction weight was 28.4 kg (range: 18–32 kg), equal to 57.2% of patients’ body weight (range: 42.7–72.3%). The mean traction time was 22.7 days (range: 12–44 days). Postoperative correction rate was 55% (range: 38–78%) for scoliosis and 51% (range: 32–75%) for kyphosis. Contribution of traction to correction was 51% (range: 36–70%) for scoliosis and was 43% (range: 34–55%) for kyphosis.ConclusionsThree- staged correction (one stage posterior release and screw placement, two stage skull-femoral traction and three stage posterior instrumentation) could effectively correct adult severe scoliosis. The incidence of complications of skull-femoral traction was not low, but transient and could be successfully managed.

Surgical treatment for severe and rigid scoliosis: a case-matched study between idiopathic scoliosis and syringomyelia-associated scoliosis

Background ContextTreatment guidelines for severe and rigid syringomyelia-associated scoliosis (SRSMS) are limited. Typically, surgeons apply practice guidelines for severe and rigid idiopathic scoliosis (SRIS) to treat SRSMS. No study has directly compared the results of surgical treatment between patients with SRSMS and those with SRIS. PurposeThe present study was performed to compare the outcomes of surgical correction of SRSMS and SRIS from clinical and radiographic perspectives. Study DesignThis is a retrospective, case-matched, single-center, institutional review board-approved study. Patient SampleA total of 26 patients with SRSMS or SRIS treated by an anterior and posterior vertebral column resection approach or an internal distraction approach were enrolled. Outcome MeasuresThe SRSMS and SRIS groups were compared on the following variables: fusion length, screw number, operation time, estimated blood loss, follow-up duration, different radiological parameters (including main thoracic curve, cranial compensatory curve, caudal compensatory curve, thoracic kyphosis, lumbar lordosis, thoracic apical vertebral translation, coronal balance, and sagittal vertical axis), Scoliosis Research Society (SRS)-22 scores, and complication rate. MethodsThirteen patients with SRSMS were matched with patients with SRIS on curve magnitude, the flexibility of the main curve, surgical procedure, age, and gender. All patients had a minimum of 2 years of follow-up. The radiographic parameters and demographic data from patients were evaluated before surgery, immediately after surgery, and at the latest follow-up. ResultsThe case matches were relatively ideal except one pair with the main curve in the opposite direction. There was no significant difference in fusion length, screw number, operation time, estimated blood loss, or follow-up duration between the two groups. No significant differences were found between the two groups in the main curve or caudal compensatory curve before surgery, immediately after the operation, or at the final follow-up. The correction of thoracic apical vertebral translation in the SRIS group was better than that in the SRSMS group. The SRSMS group had a larger preoperative, postoperative, and final follow-up cranial compensatory curve and a lower correction rate than did the SRIS group. There was no significant difference in preoperative coronal balance between the two groups. After surgery, the coronal balance in the SRSMS and SRIS groups averaged 24.4±13.2 mm and 12.1±7.9 mm, respectively, which was significantly different (p=.04). At the most recent follow-up, the coronal balance in the SRSMS group improved to 14.8±12.6 mm, and it was 11.8±8.6 mm in the SRIS group. No significant difference was found between the two groups (p=.56). There was no significant difference in thoracic kyphosis, lumbar lordosis, or sagittal vertical axis before surgery, immediately after the operation, or at the final follow-up. Before surgery and at the final follow-up, the two groups had similar scores on function, pain, self-image, mental health, and satisfaction. There was no significant difference in complication rates between the two groups. ConclusionsTypically, surgical correction outcomes are similar in patients with SRSMS and SRIS. Patients with SRIS tended to have a smaller cranial compensatory curve and better correction of the cranial compensatory curve and thoracic apical vertebral translation. Patients with SRSMS tended to have a higher proportion and greater amount of postoperative coronal imbalance, which may be improved during follow-up.

Gastrointestinal Complications After Surgical Correction of Neuromuscular Scoliosis: A Retrospective Cohort Study.

A retrospective cohort study of consecutively operated neuromuscular scoliosis patients. Surgical correction of neuromuscular scoliosis can be complicated by early gastrointestinal complications, but data on the extent and severity of them is scarce. The aim of the study was to determine the incidence, course, and risk factors of gastrointestinal complications after neuromuscular scoliosis correction. Ninety-one patients (<21 years of age) were consecutively operated on for neuropathic neuromuscular scoliosis during 2000-2011. Patients who developed marked postoperative gastrointestinal complications were identified and clinical, operative, and radiographic records, death certificates, and post-mortem reports were examined. The average age at surgery was 14.5 (SD 2.9) and follow-up time was 4.9 (SD 2.3) years. Gastrointestinal complications occurred in 12 (13%) patients and included prolonged paralytic ileus (7%, 6/91), dysphagia (7%, 6/91), and gastroparesis (1%, 1/91). Hospital stay was 22 (SD 11) days in patients with gastrointestinal complications and 16 (SD 20) days in non-complicated patients (p = 0.005). Dysphagia required permanent feeding gastrostomy in one patient whereas other complications were transient and none caused death. The risk factors for postoperative gastrointestinal complications were preoperative main curve correction <30% in traction/bending radiographs (Relative Risk (RR) = 28 (95% Confidence Interval (CI) 4.4-180); p < 0.001), preoperative main curve >90° (RR = 5.5 (95% CI 1.3-23); p = 0.020), disturbance in intraoperative spinal cord monitoring (RR = 6.0 (95% CI 1.1-34); p = 0.043), and intravenous opioid medication over 5 days postoperatively (RR = 7.9 (95% CI 1.8-35), p = 0.006). Gastrointestinal complications occurred in 13% of patients after neuromuscular scoliosis correction. Marked gastrointestinal complications extended postoperative hospitalization period, but they were transient in majority (92%) of cases and none caused death. Rigid scoliosis was the most significant risk factor for gastrointestinal complications. Gastrointestinal complications appear to be less frequent after posterior only spinal fusion with total pedicle screw instrumentation and Ponte osteotomies.

Comparison of anterior and posterior vertebral column resection versus anterior and posterior spinal fusion for severe and rigid scoliosis

Background ContextMany different correction methods have been reported to treat severe and rigid scoliosis. In the past, anterior and posterior spinal fusion (APSF), which included an anterior release followed by posterior instrumented fusion, was widely applied. In recent years, anterior/posterior vertebral column resection (APVCR) is used to treat severe and rigid scoliosis. PurposeWe aimed to compare the clinical results of APSF and APVCR for severe and rigid scoliosis. Study DesignThis is a retrospective, one-center, institutional review board-approved study. Patient SampleA total of 48 patients with severe and rigid scoliosis treated by APSF or APVCR were enrolled. Outcome MeasuresComparisons between groups were made regarding the following variables: age at surgery, gender, etiology, flexibility of main curve, anterior release length, posterior fusion length, screw number, operation time, estimated blood loss, hospitalization time, follow-up duration, different radiological parameters, complication rate, and Scoliosis Research Society (SRS)-22 scores. MethodsAccording to the operating technique, 48 patients with severe and rigid scoliosis were divided into two groups. In the first group, 26 patients were treated by APSF. In the second group, 22 patients were treated by APVCR. All patients had a minimum 2-year follow-up. The radiographic parameters as well as anterior release length, posterior fusion length, screw number, operation time, estimated blood loss, hospitalization time, complication rate, and demographic data were analyzed. ResultsThere was no significant difference in age, gender, etiology, flexibility of main curve, anterior release length, posterior fusion length, screw number, and follow-up between the two groups. The APVCR group had longer operation and hospitalization time, and more blood loss. There was no significant difference in the preoperative main curve between the two groups, but the APVCR group had smaller main curve at postoperation and final follow-up, and higher correction rate at immediate postoperation and final follow-up. There was no significant difference in the preoperative, postoperative, and final follow-up thoracic kyphosis, and coronal and sagittal balance between the two groups. There was no significant difference in complication rate between the two groups. Analysis of the preoperative SRS-22 questionnaire revealed no difference between the two groups. At final follow-up, APSF and APVCR groups had similar scores in the function, pain, self-image, mental health, and satisfaction with the treatment domains. ConclusionsCompared with APSF, treating severe and rigid scoliosis by APVCR means longer operation and hospitalization time, and more blood loss, but it allows better correction rate of main curve. Furthermore, SRS-22 questionnaire improvement scores were similar for both correction methods.

Severe Rigid Scoliosis: Review of Management Strategies and Role of Spinal Osteotomies.

Severe rigid curves pose a considerable challenge to the treating spine surgeon. In our practice, approximately 30%–40% of patients with scoliosis present late with severe rigid scoliosis (>90° and <30% correction on bending films). Controversy still exists with regard to the ideal surgical strategy for correcting these rigid curves. Rigid scoliosis often presents in the form of either sharp angular or rounded deformities. Rounded deformities can be effectively managed with an anterior release to loosen the apex and posterior instrumentation (with osteotomies, if required). In contrast, severe rigid scoliosis, which is a sharp angular deformity, is not very amenable to anterior release and is best managed by posterior-only vertebral column resection and posterior instrumentation.

CLINICAL APPLICATION OF A DRILL GUIDE TEMPLATE FOR PEDICLE SCREW PLACEMENT IN SEVERE SCOLIOSIS.

ABSTRACTObjective: To evaluate the accuracy and the effect of drill guide template for pedicle screw placement in severe scoliosis.Method: Eight patients with rigid scoliosis were enrolled, five males and three females, ranging from nine to 23 years old. A three-dimensional CT scan of the spine was performed and saved as a DICOM file type. The multi-level template was designed by Mimics software and manufactured according to the part of the most severe deformity. The drill template was placed on the corresponding vertebral surface. Pedicle screws were carefully inserted across the trajectory of the template. Postoperatively, the positions of the pedicle screws were evaluated by CT scan and graded for validation.Results: No spinal cord injury or nerve damage occurred. All patients had satisfactory outcomes. The abnormalities and the measures observed during operation were the same as those found in the preoperative period. The position of the pedicle screws was accurate, according to the postoperative X-ray and CT scan. The rate of scoliosis correction was 60%. Compared with controls, surgery time, blood loss and radiation were significantly lower.Conclusion: With the application of multi-level template, the placement of pedicle screws shows high accuracy in scoliosis with shorter surgical time, less blood loss and less radiation exposure. Level of Evidence III, Retrospective Comparative Study.

Distal Adding-on and Risk Factors in Severe and Rigid Scoliosis.

A retrospective study. The aim of this study was to identify associated risk factors of distal adding-on in severe and rigid scoliosis. Previous work has evaluated the challenges in the treatment of patients with severe and rigid scoliosis and the risks of complications. Furthermore, although several studies have investigated postoperative distal adding-on and attendant risk factors in Lenke type 1A scoliosis, very few have focused on distal adding-on in severe and rigid scoliosis. In this study, 48 consecutive patients with severe and rigid scoliosis underwent posterior spinal fusion surgery. The parameters of preoperative, immediately postoperative, and minimum 2-year follow-up radiographs were evaluated. The patients were classified as positive or negative for distal adding-on at follow-up, and risk factors were comparatively analyzed in the two groups. The average Cobb angle and flexibility of the main thoracic curve (MTC) were 107.4° ± 15.9° and 16.4% ± 10.2%, respectively, before surgery. Distal adding-on was observed in 12 patients (25.0%) at follow-up. Univariate analysis identified several factors significantly associated with distal adding-on. Furthermore, significant independent risk factors identified by stepwise logistic regression analysis included the correction rate of the MTC immediately after surgery (odds ratio: 1.107, 95% confidence interval: 1.024-1.197, P = 0.011) and the difference between the lower instrumented vertebra (LIV) and last touching vertebra (LTV) levels (odds ratio: 0.121, 95% confidence interval: 0.028-0.518, P = 0.004). In severe and rigid scoliosis, a high correction rate of the MTC immediately after surgery and the LIV level above the LTV were significantly associated with distal adding-on. 3.

Preliminary application of a multi-level 3D printing drill guide template for pedicle screw placement in severe and rigid scoliosis

Accurate implantation of pedicle screw in spinal deformity correction surgeries is always challenging. We have developed a method of pedicle screw placement in severe and rigid scoliosis with a multi-level 3D printing drill guide template. From November 2011 to March 2015, ten patients (4 males and 6 females) with severe and rigid scoliosis (Cobb angle >70° and flexibility <30%)were included. Multi-level template was designed and manufactured according to the part (two or three levels) of the most severe deformity. The drill template was then placed on the corresponding vertebral surface. Then, pedicle screws were carefully inserted along the trajectories. The other screws were placed in free hand. After surgery, the positions of the pedicle screws were evaluated by CT scan and graded for validation. 48 screws were implanted using templates, other 104 screws in free hand, and the accuracies were 93.8 and 78.8%, respectively, with significant difference. The deformity correction ratio was 67.1 and 41.2% in coronal and sagittal plane post-operatively, respectively. The average operation time was 234.0±34.1min, and average blood loss was 557±67.4ml. With the application of multi-level template, the incidence of cortex perforation in severe and rigid scoliosis decreased and this technology is, therefore, potentially applicable in clinical practice.

Analysis of the rate of orthopaedic contribution of strong halo-femoral traction in the treatment of severe rigid idiopathic scoliosis

Objective To analyze the rate of orthopaedic contribution of strong halo-femoral traction in the treatment of severe rigid idiopathic scoliosis and discuss its meaning. Methods All of 27 cases of severe rigid idiopathic scoliosis patients treated with strong halo-femoral traction, hospitalized in our department from December 2008 to August 2010, were retrospectively analyzed. All patients underwent preoperative Halo-femoral traction. After 2-4 weeks' traction, one-stage posterior instrumentation and fusion was performed with intraoperative traction. The Cobb angles in coronal plane of the major curve before surgery, on bending film, on fulcrum film, after traction and immediately after surgery were measured. The rate of absolute and relative contribution of every orthopaedic element (Bending, fulcrum, traction, surgery) were compared. Results The duration of follow-up was (51.8±7.7) months on average (range, 40-68 months). The mean coronal Cobb angle of major curve were 105.1°±11.1°(88°-131°), the mean coronal Cobb angle of major curve on Bending film were 84.6°±12.6°(69°-115°), and the mean coronal Cobb angle of major curve on fulcrum film were 75.8°±10.5°(62°-97°). The mean coronal Cobb angle of major curve after traction were 66°±11.7°(50°-90°). The mean coronal Cobb angle of major curve after posterior surgery were 43.1°±8.8°(23°-58.1°). The mean correction rate after traction was 37.5%±6.4%(28.6%-54%) ,the correction rate after surgery was 57.2%±6.7% (51.5%-67.7%) on the aver-age. The rate of absolute and relative contribution of Bending were 19.8%±4.4%(12.2%-28.1%) 、33.8%±7.6%(21.4%-46.2%). The rate of absolute and relative contribution of fulcrum were 8.2%±4.3%(2.9%-24.8%) 、13.3%±6.9%(1.1%-35.5%). The rate of absolute and relative contribution of traction were 9.5%±4.7%(2%-20%) 、16.2%±8.2%(3.4%-36.5%). The rate of absolute and relative contribution of surgery were 21.7%±7.0% (5.9%-37.2%) 、36.7%±10.7%(11.6%-55.6%). In the process of traction one patient had the right little finger numb and two other patients experienced stiff knee and hip, there were no other related complications occurring in the process of traction. No death or respiratory failure or paralysis occurred intra- and post-operatively. No screw or rod fracture was found during the follow-up. Conclusion The study indicates that the XiangYa gradual strong halo-femoral traction makes relatively prominent role in the treatment of severe rigid idiopathic scoliosis, meanwhile makes the correction diversification, reduces the risk of operation, effectively avoids many unnecessary VCR, and is a safe and effective way for the treatment of severe rigid idiopathic scoliosis. Key words: Scoliosis; Traction; Spinal Fusion

HF10 Therapy for Chronic Back Pain in Patients with Nonoperated Kyphoscoliosis: The Importance of Preoperative Assessment

Dear Editor, Severe kyphoscoliosis is a deformity with fixed spinal vertebrae that does not allow traction, suspension, or side bending of the spine [1]. Treatment of rigid scoliosis in adults involves correction of complex three-dimensional deformities and restoring balance to the spine but is challenging due to a high rate of associated neurological complications [2]. Spinal cord stimulation (SCS) involves a minimally invasive procedure and might be an alternative pain-relieving therapeutic option with lower risks than spinal correction surgery, especially in patients with increased preoperative risk factors [3]. SCS delivered at 10kHz (HF10) may be preferable over conventional SCS for treatment of back pain [4], but studies examining its use in patients with kyphoscoliosis are lacking. We describe a patient with severe kyphoscoliosis who suffered from back pain for many years but refused spinal correction surgery. A treatment with high-frequency SCS diminished the burden of pain, and the patient was able to return to work. To our knowledge, this is the first report of an “unoperated back” patient who was efficiently treated with high-frequency SCS. A woman age 57 years presented with severe idiopathic kyphoscoliosis and progressive therapy-resistant back pain …

Staged Anterior Release and Posterior Instrumentation in Correction of Severe Rigid Scoliosis (Cobb Angle >100 Degrees)

PurposeSevere rigid curves present a big challenge to the treating spine surgeon. We evaluated the outcome of staged anterior release and posterior instrumentation for rigid scoliosis. MethodsTwenty-one patients with an average age of 14.4 years (range 11–17) having a rounded severe rigid scoliosis (Cobb angle >100 degrees) underwent surgical correction. Six patients had congenital scoliosis, 13 idiopathic scoliosis, and 2 syndromic. All patients underwent anterior release in Stage I with one or more Ponte osteotomies and in Stage II with all pedicle screw instrumentation, and 13 of the patients underwent an asymmetric pedicle subtraction osteotomy at the apex. Patients were assessed for deformity correction, operative time, blood loss, and any complications. ResultsThe preoperative Cobb angle of 116.6 degrees (range 101–124 degrees) improved to 74.0 degrees (range 54–86 degrees) after anterior release: 29.4% correction and the final postoperation Cobb angle after posterior instrumentation was 26.5 degrees (range 22–32 degrees), with final 76% correction. The average blood loss in anterior release was 585.95 mL (range 400–980 mL; % estimated blood volume = 19.5%), whereas the mean operative time was 223 minutes (165–315 minutes). One patient had prolonged chest drain and two, basal atelectasis following anterior release. The mean operative time for the posterior procedure was 340 minutes (range 280–420 minutes) and average blood loss was 2,066 mL (range 1,200–3,200 mL). The mean apical axial rotation of 56 degrees (range 26–79 degrees) improved to 28 degrees (range 9–42 degrees) (p < .05). There was loss of motor evoked potential signal in one and hook pullout, superficial infection, and local skin necrosis one case each. ConclusionThe staged approach to the management of severe, rigid scoliosis helps get an excellent correction. Anterior release loosens up the rigid apex and provides with nearly 30% correction so that the extent of the osteotomies in the second stage from the back is substantially reduced, allowing for a final good correction.

Comparison of internal distraction with traditional anterior release and posterior correction in the treatment of severe and rigid scoliosis

Objective To compare clinical results between internal distraction and traditional anterior release and posterior correction in the treatment of severe and rigid scoliosis. Methods 40 cases with severe and rigid scoliosis who had surgery from April 2008 to May 2013 were retrospectively analyzed. According to whether internal dis-traction was applied. They were divided into internal distraction group and traditional group. In internal distraction group, anterior release, internal distraction and staged posterior correction was applied. There were 5 males and 15 females in internal distraction group with an average age of 17.5±2.8, among were 16 cases of idiopathic scoliosis and 4 cases of neuromuscular scoliosis. In traditional group, traditional anterior release and posterior correction was performed. There were 4 males and 16 females in traditional group with an average age of 17.2±2.6, among them there were 17 cases of idiopathic scoliosis and 3 cases of neuromuscular scoliosis. Operation time, estimated blood loss, Cobb angle of major curve, kyphosis angle, coronal trunk shift, and sagittal vertical axis were compared between two groups. Results The time of first surgery in internal distraction group was longer than that of traditional group, but no significant increment in estimated blood loss was found. The time of posterior correction surgery in internal distraction group was shorter than that of traditional group, and estimated blood loss in internal distraction group was also less than that of traditional group. The follow-up duration averaged(28.1±5.7)months(24-36 months). After surgery and at final follow-up, Cobb angle of major curve in traditional group was much bigger than that of internal distraction group. The correction rate of major curve in internal distraction group averaged 73.7%. The decline of wave amplitude of somatosensory evoked potential(SEP)was found in one patient in traditional group when rods were connected to screws in posterior correction surgery. The rods were removed immediately, and SEP amplitude was restored. The rods were bent more and refixed, and the surgery was completed without alert. The decline of wave amplitude of SEP was found in 1 patient in internal distraction group when distraction was applied to 4.5 cm. The distraction was released and SEP amplitude was restored. Atelectasis after anterior release was found in 2 patients in traditional group and internal distraction group respectively, and it recovered after respiratory exercise. Medial breach 2-4 mm around the apical region was found in 2 patients in traditional group and 1 patient in internal distraction group. 2 patients in internal distraction group had pain in concave side in distal compensative curve after the first surgery. It was considered as soft-tissue injury resulting from internal distraction, and resolved after treatment. There no significant difference in complication rate between 2 groups. Conclusion Internal distraction, which can improved the correction rate of severe and rigid scoliosis, but not increased operation time, estimated blood loss, and complication rate, is a safe and reliable technique. Key words: Scoliosis; Traction; Spinal fusion; Orthopedic procedures

EXPERIENCE OF HALOPELVIC TRACTION IN THE TREATMENT OF SEVERE SPINE DEFORMITY: A CASE SERIES

AbstractBackground:Severe and rigid scoliosis and kyphosis are difficult to treat but with the advent of new spinal operative techniques and implants, it has become man-ageable in expert hands. However these implants are too expensive for developing countries like us. The Halo-pelvic traction is a relatively cheaper device sys-tem used to treat such deformities. Moreover, rapid curve correction and one stage surgery may lead to permanent neurological deficit.Objective:To evaluate treatment outcome of Halo-pelvic Traction in the treatment of severe scoliosis and kyphosis.Methodology:This descriptive study was conducted in the department of Orthopedics surgery and traumatology unit I, King Edward Medical University, Mayo Hospital Lahore from September 2010 to August 2012. The patients with severe spinal deformity which could not be corrected at a single stage were included. A Performa was made for each patient and results were statistically analyzed by using SPSS version 20.Results:Total no. of 07 patients were treated, out of them 04 scoliosis patients having mean Cobbs angle of 77.25 5.31 before treatment, improved significantly to 45 5.35 after surgery (p?0.0001), 03 kyphosis patients with mean Kyphus angle of 96.67 24.66 improved to 58.33 17.56 (p?0.0001). Two major complications i.e. one paraplegia which recovered incompletely and one had CSF discharge from cranial pin that was also revived thoroughly after changing the position of the pin.Conclusion:Halopelvic traction device can help in treating the patients of severe scoliosis and kyphosis.Keywords:Kyphosis, Halo-Pelvic, Kyphus angle, Cobbs angle.

Two-stage posterior correction in the treatment of severe rigid neuromuscular scoliosis: Case report

Background: Treatment of severe rigid scoliosis is challenging. Traditional methods such as combined anterior and posterior surgery with or without perioperative halo-gravity traction, or more aggressive one-stage posterior correction methods carry many drawbacks and potential risks. To overcome this, a staged posterior approach was raised. We report a patient successfully treated with this new method. Case Report: A 15-year-old boy was diagnosed to have neuromuscular scoliosis of unknown origin. The Cobb angle was 110 degrees at T9- L4, and 77 degrees at T2- T9. The preoperative pelvic tilt was 16 degrees. Bending views showed the flexibility about 10%. Two-stage correction was performed. The major curve magnitude reduced 40 degrees or 36.3% after the first-stage surgery, and 25 degrees or 35.7% after the second-stage surgery. The final correction rate was 59.1%. The postoperative pelvic tilt reduced to 6 degrees. No complication such as infection, neurological injury or respiratory compromise was found. Discussion: This two-stage approach has many advantages, including preventing pulmonary function deterioration, no need of halo traction, avoiding too much manipulation of the spinal cord during each surgery, and facilitating curve correction. However, we should also take into consideration of its large blood loss, nutritional demand and potential risk of infection. Conclusion: Two-stage posterior correction is a reasonable and suitable alternative correction strategy in the treatment of severe rigid scoliosis. However, further study is needed to verify its validity and safety.

The Impact of Posterior Temporary Internal Distraction on Stepwise Corrective Surgery for Extremely Severe and Rigid Scoliosis

The Impact of Posterior Temporary Internal Distraction on Stepwise Corrective Surgery for Extremely Severe and Rigid Scoliosis

Multiple derotation plus costotransversectomy for severe and rigid scoliosis

To explore the outcomes of multiple derotation plus costotransversectomy for patients with severe and rigid scoliosis. Clinical analyses were conducted for the clinical data of operative duration, blood loss volume and SRS-22 scale. Radiographic data included Cobb angle of coronal curves, apical vertebral translation, coronal balance and sagittal balance. All measurements were taken pre-operation, post-operation and during the final follow-up period. The mean follow-up period was 4.1 ± 0.7 (3-5.5) years, mean operative duration 33 ± 8.4 min and mean blood loss volume 2303.5 ± 9.0 ml. Preoperative major curves ranged from 65° to 110° Cobb angle. Coronal plane correction of major curve from 10° to 41° Cobb angle (mean 30.8 ± 9.8°). And there was a mean loss of correction of 3.6% during the final follow-up. The magnitudes of thoracic kyphosis and lumbar lordosis were 31.1 ± 12.4°, 45.5 ± 10.5° pre-operation, 25.6 ± 5.5°, 33.43 ± 5.45° post-operation and 28.6 ± 6.1°, 35.26 ± 4.2° during the final follow-up. The apical vertebral translation of major curve was corrected by 73.2%. The coronal imbalance, sagittal imbalance and apical vertebral translation indifferently was 3.2 ± 1.1, 2.3 ± 1.1, 6.35 ± 1.65 cm pre-operation, 0.9 ± 1.0, 0.4 ± 0.5, 2.4 ± 1.2 cm post-operation and 1.2 ± 1.1, 0.6 ± 0.5, 2.6 ± 1.4 cm during the final follow-up. Incomplete thoracic nerve dysfuction occurred in one case and superficial dermatoedge necrosis in another recovered within 2 weeks. Neither malposition of pedicle screw nor complication of instrumentation was found. Excellent outcomes were obtained according to SRS-22 score. For patients with severe and rigid scoliosis, the technique of multi-rod-derotation and rib resection may achieve a good correction of scoliosis without serious complications and avoid a resection of vertebral column.

The impact of posterior temporary internal distraction on stepwise corrective surgery for extremely severe and rigid scoliosis greater than 130°.

To investigate the efficacy and safety of temporary internal distraction corrective surgery for extremely severe scoliosis. Eleven scoliosis patients (3 males and 8 females) with curves ≥130° (mean 148.8°; range 130°-157°) who underwent a two-stage surgery, including a posterior temporary internal distraction correction and definitive posterior spinal correction with posterior pedicle screw instrumentation from 2008 to 2011 were retrospectively reviewed. Minimum follow-up was 2-years (mean 41.8months; range 27.0-63.0months). The analysis focused on the impact of temporary internal distraction on curve correction, pulmonary function tests (PFTs), complications and surgical outcomes. Neurosurveillance of sensory (somatosensory-evoked potentials) and motor (motor-evoked potentials) potential was performed in all cases. Posterior instrumentation was used in all patients. After the use of internal distraction, the preoperative major curve (mean 148.8°; range 130°-157°) was corrected to a mean of 79° (range 63°-87°), the T5-T12 kyphosis Cobb angle (mean 79°; range 30°-97°) was corrected to a mean of 59° (range 20°-75°), the coronal imbalance (mean 0.8cm; range -3.6 to 2.8cm) was improved to a mean of 0.6cm (range -1.5 to 2.0cm), the forced vital capacity percentage (FVC%) was improved from 59.3±11.6 to 68.7±13.7, and the forced expiratory volume in 1s (FEV1%) was improved from 61.4±13.6 to 71.3±9.3. The average increase in body height was 6.7cm, and the dorsum razor was corrected to 3-5cm. During definitive surgery, the final major curves were corrected to a mean of 55° (range 32°-72°), the T5-T12 kyphosis Cobb was corrected to 35° (range 15°-68°), the coronal imbalance was improved to 0.5cm (range -1.2 to 1.8cm), the FVC% was improved to 71.2±8.3, the FEV1% was improved to 76.3±16.7, the increase in body height was 3.1cm, and the dorsum razor was corrected to 1-3cm. The mean interval time between the two surgeries was 3.5months. None of the patients exhibited postoperative neurologic deficits or infections. No instrument complications were found during the final follow-up. Temporary internal distraction in a two-stage corrective surgery provided patients who had extremely severe and rigid scoliosis, an effective and safe solution for scoliosis without significant complications.