Secondary Scoliosis Research Articles

Thoracic Synostosis Associated with Secondary Scoliosis in Arabian Horse Foal

Thoracic Synostosis Associated with Secondary Scoliosis in Arabian Horse Foal

The Complex Spine in Children with Spinal Muscular Atrophy: The Transforaminal Approach-A Transformative Technique.

Spinal muscular atrophy, a genetic disease resulting in loss of motor function, presents from in utero to adulthood. Depending on progression and secondary scoliosis, spinal stabilization may be necessary. When planning intrathecal access in these patients, spinal anatomy is the most important factor. Therefore, when planning intrathecal nusinersen injections, we subdivided patients with spinal muscular atrophy into simple-versus-complex spine subgroups. Our purpose was to present our experience with our first 42 transforaminal intrathecal nusinersen injections. We reviewed 31 consecutive patients with spinal muscular atrophy types 1-3 who presented for intrathecal nusinersen injections from March 2017 to September 2018. Nine children had complex spines (ie, spinal instrumentation and/or fusion) and required preprocedural imaging for route planning for subarachnoid space access via transforaminal or cervical approaches. A total of 164 intrathecal nusinersen injections were performed in 31 children 4-226 months of age, with 100% technical success in accessing the subarachnoid space. Nine patients with complex spinal anatomy underwent 45 intrathecal nusinersen injections; 42 of 45 procedures were performed via a transforaminal approach with the remaining 3 via cervical techniques. There were no complications. Our initial experience has resulted in a protocol-driven approach based on simple or complex spinal anatomy. Patients with simple spines do not need preprocedural imaging or imaging-guided intrathecal nusinersen injections. In contrast, the complex spine subgroup requires preprocedural imaging for route planning and imaging guidance for therapy, with the primary approach being the transforaminal approach for intrathecal nusinersen injections.

Preoperative Pulmonary Function Test Results Are Not Associated With Postoperative Intubation in Children Undergoing Posterior Spinal Fusion for Scoliosis: A Retrospective Observational Study

Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion. The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes. The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively. Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.

Hip-Spine Syndrome: The Coronal Alignment of the Lumbar Spine and Pelvis in Patients with Ankylosed Hips.

Introduction Fixed abduction and/or adduction deformities of the hip joint may cause pelvic obliquity with subsequent development of secondary lumbar scoliosis. However, the relationships between the magnitude of a fixed angle (either abduction or adduction) of the hip and the direction of pelvic tilt and lumbar scoliosis remain unclear. The purpose of this study was to investigate the coronal alignment of the lumbar spine and pelvis in patients with ankylosed hips. Methods A total of 56 patients were analyzed, including 17 males and 39 females, with an average age of 65 years (range: 45 to 80 years). Regarding the coronal spinopelvic alignment, the following parameters were measured: the degree of lumbar scoliosis (LS; Cobb angle), pelvic obliquity (PO), and ankylosed hip angle (AHA). The PO and AHA were defined as the angle between the inter-teardrop line and a horizontal line, respectively, and the long axis of the femur on the side of the ankylosed hip. For each parameter, correlations between the parameters were evaluated using a regression analysis. A P value of <0.05 was considered significant. Results Positive linear correlations were observed between the AHA and direction of the PO angles (r = 0.831, p<0.01), the AHA and direction of the LS angles (r = 0.770, p<0.01), and the directions of the PO and LS angles (r = 0.832, p<0.01). Conclusions This study provides evidence to suggest that, in patients with ankylosed hips, the abduction position is positively correlated with the downward PO and the convexity of the LS toward the AH side. In contrast, the adduction position is positively correlated with these results on the opposite side.

Positional disappearance of motor evoked potentials is much more likely to occur in non-idiopathic scoliosis.

PurposeThis study evaluates intraoperative disappearance of motor waveforms related to patient positioning in neurologically asymptomatic patients with spinal deformity.MethodsThis is a retrospective review of 190 neurologically asymptomatic patients aged seven to 17 years planned for posterior instrumentation under neuromonitoring. There were 159 patients with adolescent idiopathic scoliosis and 31 patients with secondary scoliosis. Patients underwent surgery with transcranial electric stimulation motor evoked potentials (TES-MEPs). In case of abnormal findings, surgery was temporarily discontinued and necessary measures undertaken. In case of permanent signal disappearance surgery was definitively discontinued.ResultsSix patients showed permanent loss of signal during early stages of surgery. These patients had a mean major curve of 64° Cobb angle and a mean thoracic kyphosis (D2 to D12) of 72°. The 184 remaining patients had a mean major curve of 50° Cobb angle and a thoracic kyphosis of 35°. A retrospective descriptive review of the patients’ radiographs shows hyperkyphosis to be the common ground between the six secondary scoliosis cases. Gradual preoperative traction maintained during the surgery applied in two of these patients taken back to surgery six months later was associated with maintenance of TES-MEP signals throughout the surgery.ConclusionThis study shows that positional permanent loss of neuromonitoring signals is more likely to occur in patients with secondary scoliosis and hyperkyphosis shown to have sharper spine deformity and suspected to have a more vulnerable spinal cord. Gradual skeletal traction performed in two of these patients and maintained during surgery showed promising results.Level of EvidenceIV

Secondary Cervicothoracic Scoliosis in Congenital Muscular Torticollis.

BackgroundAlthough secondary cervicothoracic scoliosis frequently occurs in patients with congenital muscular torticollis (CMT), the relationship between scoliosis and CMT has not been evaluated. This study aims to evaluate the effects of surgical release of sternocleidomastoid (SCM) muscle on secondary cervicothoracic scoliosis in patients with CMT and determine factors affecting the improvement of scoliosis after surgical release of SCM muscle.MethodsEighty-seven of the 106 patients, confirmed as having secondary cervicothoracic scoliosis with CMT with a minimum 1-year follow-up, were included in this study. Preoperative and last follow-up radiologic outcomes were assessed for the cervicomandibular angle (CMA), Cobb angle of the cervicothoracic scoliosis, and direction of convexity in the scoliosis curve. Patients were divided into two groups to assess the improvement of Cobb angle according to residual growth potential; age ≤ 15 years and > 15 years. The improvement of Cobb angle after surgical release was compared in the two groups. Correlation analysis and multivariable regression analysis were performed to determine the factors affecting the improvement of scoliosis.ResultsAll the radiologic parameters, such as the Cobb angle and CMA, improved significantly after surgical release (p < 0.001). The improvement of Cobb angle was significantly higher in age ≤ 15 years than in age > 15 years (p < 0.001). The improvement of Cobb angle was significantly correlated with age (r = −0.474, p < 0.001) and the preoperative Cobb angle (r = 0.221, p = 0.036). In multivariable regression analysis, age and preoperative Cobb angle were shown to be predisposing factors affecting the improvement of scoliosis.ConclusionsThe results showed that SCM release can be a beneficial treatment for secondary cervicothoracic scoliosis. The improvement of scoliosis was greater when the SCM release was performed before the patient reached the end of growth.

Benefits and complications of halo-gravity traction in adolescents with severe idiopathic or secondary scoliosis prior to vertebral fusion. Series of 16 cases

In the treatment of severe scoliosis, pre-surgical halo-gravity traction (HGT) achieves an increase in curve flexibility and in preoperative pulmonary function as well as a neurologic risk reduction following final surgery. Our aim was to describe the benefits and complications of HGT in adolescents with idiopathic scoliosis or secondary scoliosis while awaiting vertebral fusion. A descriptive and retrospective study. Sixteen patients admitted to hospital and carrying a HGT between January 2014 and December 2017 were included. The main judgment criteria were the height gain, the final weight of traction, the decrease in the Cobb angle, the gain in the forced vital capacity (FVC) and the description of complications. There were eight teenagers with an idiopathic scoliosis aged-mean (SD) 12.1(1.9) years old, a height gain of 7.6(2.3)cm, a final weight of traction of 13.7(3.9)kg corresponding to 37.2(7.5)% of body weight. Cobb angle mean(SD) of 97.5(8)° was reduced of 26.9(11.1)° at the end of traction. And a FVC gain mean (SD) of 12.4(8.8)%. Likewise, eight adolescents with a secondary scoliosis aged-mean(SD) 12.8(1.2) years old, a height gain of 9.2(2.8)cm, a final weight of traction of 12.7(1.3)kg corresponding to 38.9(11.6)% of body weight. Cobb angle mean(SD) of 100(13.8)° was reduced of 26.5(8.4)° at the end of traction. And a FVC gain mean(SD) of 7.1(9.7)%. The most frequent complications in the group of idiopathic scoliosis ( n = 8) were neck pain (75%), headache (37.5%), pin pain (25%), visual disorders, thorax pain and pin infection (12.5%). In the group of secondary scoliosis ( n = 8), neck pain (100%), headache (62.5%), back pain (50%), pin pain and anxiety (25%), neurological disorders and pin infection (12.5%). HGT was in general well tolerated and should be considered before vertebral fusion to improve spinal flexibility and respiratory function in idiopathic or secondary scoliosis.

S168. Intraoperative neurophysiologic monitoring in spinal cord lesions: from the experimental study to the operating room

Introduction Multimodal intraoperative neurophysiologic monitoring (IONM) is considered compulsory in spine surgeries which represent a risk for the spinal cord. Nevertheless, the approach when facing an intraoperative acute spinal cord injury depends critically on the possibility of monitoring the function of the non-affected spinal cord. This is not usually possible with the standard IONM techniques if the injury is severe. In previously reported experimental studies, we have found that it is possible to monitor spinal cord segments cranial and caudal to the level of an acute spinal cord injury using epidural electrodes. Methods We present two cases of surgical correction of secondary scoliosis. Results In both cases, there was an intraoperative spinal cord injury during the instrumentation, which was detected by loss of the myogenic transcranial motor evoked potentials (TcMEPs) caudal to the intercostal thoracic muscles and loss of the lower limb somatosensory evoked potentials (SSEPs). The level of spinal cord damage was identified and confirmed by a combined use of spinal cord recorded SSEPs and D waves. Two epidural recording electrodes were placed, one cranial and one caudal to the level of the lesion. In both cases, the spinal cord SSEPs were absent above the lesion but present below. D-waves were present above the lesion and absent below. In these cases, during the remainder of the surgery, we used epidural SSEPs for monitoring of spinal cord function caudal to the lesion and D-wave for the levels cranial to the lesion. Additionally, we performed the spinal cord-to-spinal cord evoked potentials (stimulating proximally and recording distally to the lesion using the epidural electrodes), demonstrating a reproducible potential, which remained stable throughout the remainder of surgery. Conclusion Our results indicate that spinal cord monitoring using epidural electrodes in patients with acute intraoperative spinal cord lesions facilitates identification and confirmation of the level of spinal cord injury, allows the surgeon to continue with the instrumentation in those cases necessary, and can help establish a postoperative prognosis.

Positional disappearance of motor evoked potentials (MEPs) is much more likely to occur in non-idiopathic scoliosis

Introduction To evaluate intraoperative disappearance of MEPs related to patient positioning in neurologically asymptomatic patients with spinal deformity planed for posterior instrumentation with or without fusion. Material and methods This is a retrospective review of all neurologically asymptomatic children and adolescents who were planned for posterior instrumentation under MEP control during the last 3 years. A total of 189 patients were included. Age at surgery ranged between 7 and 17 years. There were 159 patients with adolescent idiopathic scoliosis (AIS), 4 neurofibromatosis, 6 connective tissue disease, 6 skeletal dysplasia, 5 metabolic disorder including muccopolysaccharidosis, and 9 early onset scoliosis or kyphoscoliosis of unknown origin. All patients underwent MEP monitoring and general anesthesia according to general guidelines with some personal variations. MEP recording is undertaken 11 times on average between induction of anesthesia and the end of surgery, and in case of abnormal findings, surgery is temporarily discontinued and necessary measures undertaken (increase temperature and blood pressure…), and if needed a wake-up test is performed. In case of permanent signal disappearance and no gross motor function during the wake-up test, surgery is definitively discontinued. Patients with permanent loss of MEP signal requiring definitive surgery discontinuation were thoroughly reviewed and represent the core of this study. Results Six patients showed permanent loss of MEP signal during the early stages of surgery, three of which even before incision. There were one AIS (in which the loss of signal was later found to be related to a simple technical problem), one early onset kyphoscoliosis, one neurofibromatosis, one muccopolysaccharidosis, one Ehlers Danlos disease, and one congenital progressive anterior bloc with multilevel thoracic and lumbar stenosis. All of them resumed normal motor function after wake-up, except for the case with progressive anterior bloc who woke-up paraplegic but has regained ambulation with crutches one year later. An extensive work-up was undertaken secondarily in all 6 cases including total spine MRI, lower limb EMG, etc., to identify any etiology that could explain the loss of signal but was negative in all. The hypothesis of positional temporary suffering of the spinal cord was therefore considered. Discussion AIS seems rarely if ever associated with intraoperative neurological risk even the one related to patient position. When MEPs disappear permanently especially at the very early stages of surgery, this may be due to position, and is much more likely to occur in patients with secondary scoliosis, suspected to have a more vulnerable spinal cord.

Adolescent idiopathic scoliosis (AIS), cerebrospinal fluid (CSF) flow and ciliopathy

AIS is a three-dimensional deformity of spine, affecting 1 to 3% of the population between 10 and 16 years. Its mechanism of occurrence is not known but polygenic initiating factors are admitted. Thus, Ptk7 mutant zebrafish have scoliosis associated with a change in CSF flow. The Ptk7 gene is an essential regulator of Wnt signaling pathway, involved in ciliary function. From this animal model, we hypothesize that some AIS are secondary to ciliopathy, with modification of CSF intramedullary flow. We present the results of a pilot feasibility study on the evaluation of CSF flow in AIS. Single-center study of 13 patients (12 girls and 1 boy, mean age 15.2 years) with AIS (mean Cobb's angle 33.7°; 6 left thoracolumbar curves, 5 right thoracic, 2 right lumbar). These patients required medullospinal MRI for various causes (rachialgia, suspicion of secondary scoliosis, preoperative assessment…). During this MRI (1.5 Tesla), an CSF flow analysis was performed (at the level of apical vertebra, and upper end vertebra and lower end vertebra). Of the 13 MRIs performed, 2 flow studies are not interpretable. The interpretable results show, at systole, a mean flow at thoracic level: 4.23 ± 0.47 cm/s. No difference was found between levels of scoliotic curvature (apical vertebra, upper and lower end vertebrae). Three patients had a pathological thoracic flow: 2 slowing down and 1 acceleration. In patient 1, the results showed a decrease of flow from 2.4 cm/s in T3 (level of T3 vertebra) to 0.8 cm/s in T7, in patient 2, a steady flow at 2.5 cm/s in thoracic and lumbar level, but physiologically there is a lumbothoracic gradient acceleration, and in patient 3 acceleration to 12.7 cm/sec in T6. This pilot study shows abnormalities of CSF flow in some patients with AIS. Our results require to be confirmed by a controlled study. Nevertheless, this result suggests that ciliary dysfunction may be an etiologic factor of AIS. Different etiologic pathways can be discussed involving the Wnt signaling pathway, the melatonin-signaling pathway or the cerebrospinal fluid-contacting neurons. Thanks to IMANORD-HPVA radiologic team.

Thoracic skeletal anomalies following surgical treatment of esophageal atresia. Lessons from a national cohort.

Thoracotomy as surgical approach for esophageal atresia treatment entails the risk of deformation of the rib cage and consequently secondary thoracogenic scoliosis. The aim of our study was to assess these thoracic wall anomalies on a large national cohort and search for factors influencing this morbidity. Pediatric surgery departments from our national network were asked to send recent thoracic X-ray and operative reports for patients born between 2008 and 2010 with esophageal atresia. The X-rays were read in a double-blind manner to detect costal and vertebral anomalies. Among 322 inclusions from 32 centers, 110 (34.2%) X-rays were normal and 25 (7.7%) displayed thoracic malformations, including 14 hemivertebrae. We found 187 (58.1%) sequelae of surgery, including 85 costal hypoplasia, 47 other types of costal anomalies, 46 intercostal space anomalies, 21 costal fusions and 12 scoliosis, with some patients suffering from several lesions. The rate of patients with these sequelae was not influenced by age at intervention, weight at birth, type of atresia, number of thoracotomy or size of the center. The rate of sequelae was higher following a classical thoracotomy (59.1%), whatever the way that thoracotomy was performed, compared to nonconverted thoracoscopy (22.2%; p=0.04). About 60 % of the patients suffered from a thoracic wall morbidity caused by the thoracotomy performed as part of surgical treatment of esophageal atresia. Minimally invasive techniques reduced thoracic wall morbidity. Further studies should be carried out to assess the potential benefit of minimally invasive approaches to patient pulmonary functions and on the occurrence of thoracogenic scoliosis in adulthood. Level III retrospective comparative treatment study.

Magnetically controlled growing rod in early onset scoliosis: a 30-case multicenter study

Preliminary results of magnetically controlled growing rods (MCGR) are encouraging. However, only short case series of MCGR for the treatment of early onset scoliosis (EOS) have been reported. Our aim was to evaluate its effectiveness and complications. We report a 30-case retrospective, consecutive, multicenter series of MCGR. Effectiveness was judged upon: deformity correction and difficulties to achieve desired distraction. Secondary endpoints included complications and revision surgeries. Median age at surgery was 9.1years (5-13). Mean follow-up was 18.4months (12-33.9). Mean Cobb angle was 66° preoperatively and 44° at latest follow-up. MCGR has avoided an average of 2.03 scheduled surgical procedures per patient compared to traditional growing rod (GR). The intended total length gain was 40.1mm per patient (5-140) and the total measured length gain was 21.9mm (45.5% discrepancy). There were 24 complications: 7 proximal pull-outs of the hooks, 3 rod breakages, 6 failures of the lengthening of which 4 complete blockages and 2 complete blockages followed by backtracking, 1 proximal junctional kyphosis, 1 wound dehiscence, 1 superficial infection, 1 deep infection requiring implant removal, 1 pulmonary embolism, 1 pulmonary insufficiency, 1 secondary lumbar scoliosis, and 1 painful outpatient distraction. Eight patients had a gradual loss of effectiveness of distractions. There were 13 revision surgeries in 9 patients. MCGR provides satisfactory deformity correction and avoids repeated surgical procedures for lengthening. However, it has substantial complication rate. Although less frequent than in GR, the law of diminishing returns also applies to MCGR.

VEPTR: Single Centre Experience of 9 Years

Introduction The operative treatment of scoliosis with vertical expandable prosthetic titanium rib (VEPTR) implants has been established in Europe since 2002. Between 2005 and 2014, we have treated 72 scoliosis patients with VEPTR implants. Methods This is a prospective uncontrolled study in a single scoliosis center. Of 72 cases; 51 were females and 21 males, with a mean age of 7.5 years (3–13 years). The underlying pathology was congenital scoliosis in 39 cases, neuromuscular scoliosis in 21 and early-onset scoliosis in 12. The grade of the deformity has been measured according to Cobb method of anteroposterior radiographs; pre- and postoperatively, and after every distraction of the rods. This took place every 6–9 months until post-pubertal end-fusion operation. The evaluation included patient (or parents') satisfaction score, complication rate and growth of the patient. Of 72 children, 10 have been already operated before. Results The primary deformity ranged from 45° to 130° with a mean of 65°. After the first correction, the mean Cobb angle was 32° (25°- 75°). No complications occurred during the instrumentation surgery. The mean operative time was: 95 minute. (65–175 minute.), with a mean blood loss of 125 ml. In all cases, intraoperative neuromonitoring with SEP and MEP has been performed. In 29 cases, a “rib-to-lumbar spine-hybrid” has been used, and combined with a “rib-to-rib” in 32 cases. In the other 11 cases, a “rib-to-pelvis” construct has been used. Delayed wound healing occurred in 4 patients, another patient had pneumonia, that was successfully treated. Proximal hook dislocation occurred in 14 cases after distraction. Skin perforation complicated 10 cases and needed partial removal of implant. No neurological complications or deep spinal infection occurred. The mean hospital stay was 18 days after first implantation (14–31). One to 12 distraction operations have been done in 52 patients. A deformity correction with a mean of 15,7° grades have been achieved (19.8%). In 20 cases, the secondary scoliosis have been later instrumented. In 12 cases, the implant has been removed and replaced by pedicular-screw growing rod system. The end-fusion operation has been already performed in 12 cases. Conclusion The early results have been considerable. Yet after 9 years of experience with the VEPTR systems, some major problems occurred with the proximal junctional kyphosis and with implant-related complications. Like other growth-sparing systems, the VEPTR implant showed a complication-rate of 29%

Characteristics of patients with more than 20° of improvement or worsening during conservative treatment of adolescent idiopathic scoliosis.

Since the beginning of history of Medicine, it has been possible to learn from the worst and best results of treatments. Our aim was to verify which patients can reach the best and worst results during conservative treatment. All AIS patients with more than 2 visits included in a prospective clinical database started in September 2003 were reviewed on August 31st 2010. A cut-off of 20 degrees (improvement or worsening) from the first observation was used to select patients. Patients were analysed for diagnosis, morphology, Cobb degrees at start, curve improved/worsened, treatment, gender, Body Mass Index, clinical parameters. Out of 1886 consecutive patients, 62 (3.3%) changed 20° or more: 26 (1.4%) improved (range 20-34°), 36 (1.9%) progressed (20-60°). Relative Risk of progression of 20° or more was increased more than 10 times in cases of thoracic curve or secondary scoliosis, 5 times for Moe scoliosis and BMI <15 kg/mq, 3 times for age <12 years, and congenital or juvenile scoliosis. Relative Risk of improvement of 20° statistically was increased more than 3 times in cases of previous exercises, female gender, thoracolumbar curve or scoliosis, ISICO treatment, and age <12 years. Not all our results correspond to the usually reported prognostic factors in ample case series, but it must be taken into account that only wide variations (20° or more) have been considered here. In this population we had 1.9% of patients who improved at least 20° with conservative treatment, and this is notable as well. Finally, since these results are not similar to what would be expected according to the known natural history, conservative treatment appears able to change it.

De la scoliose idiopathique au mal de Pott : présentation d’une observation et discussion diagnostique

Idiopathic scoliosis is the most common form of spinal deformity in adolescence. However, secondary causes of scoliosis should always be considered so as to provide appropriate treatment and avoid complications. Additional explorations, such as MRI, are required in the presence of atypical signs. We report a case of spinal tuberculosis, or Pott's disease, misdiagnosed as idiopathic scoliosis, and then present a discussion to help identify the warning signs during the evaluation of scoliosis that might indicate secondary scoliosis and suggest when to perform further radiologic exploration.

In favour of the definition “adolescents with idiopathic scoliosis”: juvenile and adolescent idiopathic scoliosis braced after ten years of age, do not show different end results

Methods Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Participants: Inclusion criteria: idiopathic scoliosis; European Risser 0-2; 25° to 45° Cobb; age 10 years or more at start of treatment. Exclusion criteria were for both groups: secondary scoliosis and pathologies known to be possible causes of scoliosis, neurological, previous treatment for scoliosis (brace or surgery).

Morbidity and radiographic outcomes of severe scoliosis of 90° or more: a comparison of hybrid with total pedicle screw instrumentation.

ObjectivesUntreated severe scoliosis is associated with increased mortality and remains a significant surgical challenge. Few studies have reported mortality after the surgical treatment of severe scoliosis beyond a 2-year follow-up. The objectives of this study were to evaluate mortality beyond standard 2-year follow-up and compare radiographic outcomes using hybrid or pedicle screw instrumentation for severe scoliosis.MethodsWe evaluated 32 consecutive patients [11 males, mean age at surgery 15.3 (range 10.7–20.7) years] operated for a scoliosis of 90° or more using either hybrid (n = 15) or pedicle screw (n = 17) instrumentation. The follow-up time averaged 2.9 (2.0–6.6) years for radiographic and quality of life measurements and 5.5 years (2.0–9.0) years for mortality data. Of these patients, one had adolescent idiopathic scoliosis, three secondary scoliosis, and 28 neuromuscular scoliosis. Twelve patients in the hybrid and two patients in the pedicle screw groups underwent anteroposterior surgery (p < 0.001), and three patients in both groups had an apical vertebral column resection.ResultsOne (3.1 %) patient died during follow-up for severe pneumonia. Preoperatively, the mean magnitude of the major curve was 109° (90°–127°) in the hybrid and 100° (90°–116°) in the pedicle screw groups (p = 0.015), and was corrected to 45° (19°–69°) in the hybrid and 27° (18°–40°) in the pedicle screw groups at the 2-year follow-up (p < 0.001), with a mean correction of the major curve of 59 % (37–81 %) in the hybrid versus 73 % (60–81 %) in the pedicle screw groups, respectively (p = 0.0023). There were six postoperative complications, including one transient spinal cord deficit necessitating reoperation in the hybrid group as compared with five complications in the pedicle screw group (p = 0.53).ConclusionsThe mid-term mortality rate after the surgical treatment of severe scoliosis was low. Severe scoliosis can be treated safely with significantly better correction of the spinal deformity using pedicle screws than hybrid instrumentation.

In favour of the definition "adolescents with idiopathic scoliosis": juvenile and adolescent idiopathic scoliosis braced after ten years of age, do not show different end results. SOSORT award winner 2014.

BackgroundThe most important factor discriminating juvenile (JIS) from adolescent idiopathic scoliosis (AIS) is the risk of deformity progression. Brace treatment can change natural history, even when risk of progression is high. The aim of this study was to compare the end of growth results of JIS subjects, treated after 10 years of age, with final results of AIS.MethodsDesign: prospective observational controlled cohort study nested in a prospective database. Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Inclusion criteria: idiopathic scoliosis; European Risser 0–2; 25 degrees to 45 degrees Cobb; start treatment age: 10 years or more, never treated before. Exclusion criteria: secondary scoliosis, neurological etiology, prior treatment for scoliosis (brace or surgery). Groups: 27 patients met the inclusion criteria for the AJIS, (Juvenile Idiopathic Scoliosis treated in adolescence), demonstrated by an x-ray before 10 year of age, and treatment start after 10 years of age. AIS group included 45 adolescents with a diagnostic x-ray made after the threshold of age 10 years. Results at the end of growth were analysed; the threshold of 5 Cobb degree to define worsened, improved and stabilized curves was considered. Statistics: Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), Chi-square and T-test of all data was calculated to find differences among the two groups. 95% Confidence Interval (CI) , and of radiographic changes have been calculated.ResultsWe did not find any Cobb angle significant differences among groups at baseline and at the end of treatment. The only difference was in the number of patients progressed above 45 degrees, found in the JIS group. The RR of progression of AJIS was, 1.35 (IC95% 0.57-3.17) versus AIS, and it wasn't statistically significant in the AJIS group, in respect to AIS group (p = 0.5338).ConclusionThere are no significant differences in the final results of AIS and JIS, treated with total respect of the SRS and SOSORT criteria, in adolescence. Brace efficacy can neutralize the risk of progression.

Orthopedic issues in vascular anomalies

Vascular malformations impact the musculoskeletal system depending on the tissue involved (skin, subcutis, muscle, cartilage, or bone), the extent of involvement, and the type of anomalous vessels (arteries, capillaries, veins, or lymphatics). These malformations can cause a multitude of musculoskeletal problems for the patient and their Orthopedic Surgeon to manage. Leg-length discrepancy, intra-articular involvement, muscular lesions, and primary or secondary scoliosis are just to name a few. All of these problems can cause pain, deformity, and a range of functional limitations. Surgical and nonsurgical treatment plans both have a role in the care of these patients. Patients with vascular malformations may also suffer from life-threatening cardiovascular and hematologic abnormalities. For those patients who undergo surgery, thromboembolic risk is elevated, wound breakdown and infection are much more common, and bleeding risk continues well into the postoperative course. Because of the complex nature of these disorders, the clinician must have a full understanding of the types of lesions, their natural history, appropriate diagnostic studies, associated medical problems, indications for treatment, and all the treatment options. For severe malformations, especially syndromes such as CLOVES and Klippel–Trenaunay syndrome, interdisciplinary team management is essential for the best outcomes.

Extraspinal ossifications after implantation of vertical expandable prosthetic titanium ribs (VEPTRs).

IntroductionThough developed for thoracic insufficiency syndrome, the spinal growth-stimulating potential and the ease of placement of vertical expandable titanium ribs (VEPTRs) has resulted in their widespread use for early-onset spine deformity. Observation of implant-related ossifications warrants further assessment, since they may be detrimental to the function-preserving non-fusion strategy.Patients and methodsRadiographs (obtained pre and post index procedure, and at 4-year follow-up) and the records of 65 VEPTR patients from four paediatric spine centres were analysed. Ossifications were classified as type I (at anchor points), type II (along the central part) or type III (re-ossification after thoracostomy).ResultsThe average age at the index procedure was 6.5 years (min 1, max 13.7). The most prevalent spine problem was congenital scoliosis (37) with rib fusions (34), followed by neuromuscular and syndromic deformities (13 and 8, respectively). Idiopathic and secondary scoliosis (e.g. after thoracotomy) were less frequent (3 and 4, respectively). Forty-two of the 65 (65 %) patients showed ossifications, half of which were around the anchors. Forty-five percent (15/33) without pre-existing rib fusions developed a type II ossification along the implant. Re-ossifications of thoracostomies were less frequent (5/34, 15 %). The occurrence of ossifications was not associated with patient-specific factors.ConclusionsImplant-related ossifications around VEPTR are common. In contrast to harmless bone formation around anchors, ossifications around the telescopic part and the rod section are troublesome in view of their possible negative impact on chest cage compliance and spinal mobility. This potential side effect needs to be considered during implant selection, particularly in patients with originally normal thoracic and spinal anatomy.