Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal. There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced. Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described. The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery. Cite this article:
There is a paucity of information on the pre-operative coronal
imbalance in patients with degenerative lumbar scoliosis (DLS) and
its influence on surgical outcomes. A total of 284 DLS patients were recruited into this study, among
whom 69 patients were treated surgically and the remaining 215 patients
conservatively Patients were classified based on the coronal balance
distance (CBD): Type A, CBD <
3 cm; Type B, CBD >
3 cm and C7
Plumb Line (C7PL) shifted to the concave side of the curve; Type
C, CBD >
3 cm and C7PL shifted to the convex side.Aims
Patients and Methods
We reviewed 34 consecutive patients (18 female-16 male) with
isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis
who underwent in situ posterolateral arthodesis between the L5 transverse
processes and the sacral ala with the use of iliac crest autograft.
Ten patients had an associated scoliosis which required surgical correction
at a later stage only in two patients with idiopathic curves unrelated
to the spondylolisthesis. No patient underwent spinal decompression or instrumentation
placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative
blood loss 200 ml (150 to 340). There was one wound infection treated
with antibiotics but no other complication. Radiological assessment
included standing posteroanterior and lateral, Ferguson and lateral flexion/extension
views, as well as CT scans. Aims
Methods
Acute angulation at the thoracolumbar junction
with segmental subluxation of the spine occurring at the level above
an anteriorly hypoplastic vertebra in otherwise normal children
is a rare condition described as infantile developmental thoracolumbar
kyphosis. Three patient series with total of 18 children have been
reported in the literature. We report five children who presented
with thoracolumbar kyphosis and discuss the treatment algorithm. We
reviewed the medical records and spinal imaging at initial clinical
presentation and at minimum two-year follow-up. The mean age at
presentation was eight months (two to 12). All five children had
L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously
in three children kept under monitoring. In contrast, the deformity
was progressive in two patients who were treated with bracing. The
kyphosis and segmental subluxation corrected at latest follow-up
(mean age 52 months; 48 to 60) in all patients with near complete
reconstitution of the anomalous vertebra. The deformity and radiological
imaging on a young child can cause anxiety to both parents and treating
physicians. Diagnostic workup and treatment algorithm in the management
of infantile developmental thoracolumbar kyphosis is proposed. Observation
is indicated for non-progressive kyphosis and bracing if there is evidence
of kyphosis and segmental subluxation deterioration beyond walking
age. Surgical stabilisation of the spine can be reserved for severe
progressive deformities unresponsive to conservative treatment. Cite this article:
There is a wide range of reports on the prevalence of neurological injuries during scoliosis surgery, however this should depend on the subtypes and severity of the deformity. Furthermore, anterior versus posterior corrections pose different stresses to the spine, further quantifications of neurological risks are presented. Neuromonitoring data was prospectively entered, and the database between 2006 and 2012 was interrogated. All deformity cases under the age of 21 were included. Tumour, fracture, infection and revision cases were excluded. All “red alerts” were identified and detailed examinations of the neuromonitoring records, clinical notes and radiographs were made. Diagnosis, deformity severity and operative details were recorded. 2290 deformity operations were performed: 2068 scoliosis (1636 idiopathic, 204 neuromuscular, 216 syndromic, and 12 others), 89 kyphosis, 54 growing rod procedures, and 80 operations for
A combined anterior and posterior surgical approach
is generally recommended in the treatment of severe congenital kyphosis,
despite the fact that the anterior vascular supply of the spine
and viscera are at risk during exposure. The aim of this study was
to determine whether the surgical treatment of severe congenital thoracolumbar
kyphosis through a single posterior approach is feasible, safe and
effective. We reviewed the records of ten patients with a mean age of 11.1
years (5.4 to 14.1) who underwent surgery either by pedicle subtraction
osteotomy or by vertebral column resection with instrumented fusion
through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°)
pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0
months (29 to 85). Spinal cord monitoring was used in all patients
and there were no complications during surgery. These promising
results indicate the possible advantages of the described technique
over the established procedures. We believe that surgery should
be performed in case of documented progression and before structural
secondary curves develop. Our current strategy after documented
progression is to recommend surgery at the age of five years and
when 90% of the diameter of the spinal canal has already developed. Cite this article:
An eight-week-old boy developed severe thoracic
spondylodiscitis following pneumonia and septicaemia. A delay in
diagnosis resulted in complete destruction of the T4 and T5 vertebral
bodies and adjacent discs, with a paraspinal abscess extending into
the mediastinum and epidural space. Antibiotic treatment controlled
the infection and the abscess was aspirated. At the age of six months,
he underwent posterior spinal fusion Spondylodiscitis should be included in the differential diagnosis
of infants who present with severe illness and atypical symptoms.
Delayed diagnosis can result in major spinal complications with
a potentially fatal outcome.
We report the results of vertebral column resection
(VCR) for paediatric patients with spinal deformity. A total of
49 VCRs in paediatric patients from four university hospitals between
2005 and 2009 with a minimum two-year follow-up were retrospectively
identified. After excluding single hemivertebral resections (n =
25) and VCRs performed for patients with myelomeningocele (n = 6),
as well as spondylectomies performed for tumour (n = 4), there were
14 patients who had undergone full VCR at a mean age of 12.3 years
(6.5 to 17.9). The aetiology was congenital scoliosis in five, neuromuscular
scoliosis in three, congenital kyphosis in two, global kyphosis
in two, adolescent idiopathic scoliosis in one and secondary scoliosis
in one. A total of seven anteroposterior and seven posterolateral approaches
were used. The mean major curve deformity was 86° (67° to 120°) pre-operatively
and 37° (17° to 80°) at the two-year follow-up; correction was a
mean of 54% (18% to 86%) in the anteroposterior and 60% (41% to
70%) in the posterolateral group at the two-year follow-up (p =
0.53). The mean Scoliosis Research Society-24 total scores were
100 (92 to 108) for the anteroposterior and 102 (95 to 105) for
the posterolateral group. There was one paraparesis in the anteroposterior
group necessitating urgent re-decompression, with a full recovery. Patients undergoing VCR are highly satisfied after a successful
procedure.
Purpose. To report the results of full vertebral column resection (VCR) for paediatric spinal deformity. Methods and Results. All VCR (n=47) for paediatric spinal deformity were retrospectively evaluated from four university hospitals performing these procedures in Finland between 2005 and 2010. After excluding single
Introduction. The potential structural effect of the sacral tilt on the development of disc wedging adjacent to lowest instrumented vertebra (LEV), and consequent postoperative coronal trunk decompensation in the surgical treatment of idiopathic scoliosis are well known. The aim of this study is firstly to establish the possible role of sacral tilt, limb length inequality, and associated pelvic girdle anomalies in the cause of idiopathic scolisosis, and secondly to determine the effect of sacral tilt on adjacent disc wedging below LEV in some idiopathic curves such as thoracolumbar/lumbar curves, and double major curves postoperatively. Methods. Between 2006 and 2008, 159 patients with idiopathic scoliosis from outpatient clinics were included in analyses. In all patients, standing posteroanterior and lateral spinal column and Ferguson radiographs were routinely taken. If direct radiographs suggested iliac bone asymmetry, hemi-pelvis volume measurements were done with CT scan. Curve type, sacral tilt, L5 tilt, iliac asymmetry, and limb-length differences were measured. As a second part of study, 87 surgically treated patients with double major curves were examined retrospectively in terms of adjacent subjacent disc wedging below LEV and sacral tilt. Results. In the first part of the study, the mean age of patients was 14·21 years (range 2–25) and all but 14 were female. The curve types were lumbar in 31 patients, thoracolumbar in 42, double major in 55, thoracic in 27, and triple in four. Sacral tilt towards the convex side of TL/L curve was present in 117 (74%) patients with an average of 8° measured from Ferguson graphs. L5 tilt towards the convex side of TL/L curve, and limb length inequality of less than 5 mm on the convex side of TL/L curve were more prevalent in patients with sacral tilt (57%) than in those without sacral tilt (p=0·021). On hemi-pelvis volume measurement, patients with no sacral tilt (n=42) had no difference in both sides whereas patients with sacral tilt (n=117) showed significant difference, with the convex side being smaller. We noted a correlation between L5 tilt and sacral tilt (p=0·048) and between sacral tilt and hemi-pelvis volume (p=0·024). There was no correlation between sacral tilt and pelvic asymmetry, age, sex, curve type, or amount of limb length inequality. In the second part of the study, disc wedging adjacent to LEV was present in 75 of 87 patients and sacral tilt was present in 72 of 75 (96%) (p=0·008). Six patients had limb length inequality of more than 1 cm, showing the postoperative trunk decompensation, which was corrected by elevating the shorter leg by shoe-lift. Conclusions. This study revealed significant association between sacral tilt and hemi-pelvis hypoplasia independent from age. This association may have a primary role in the cause of this disease. Although LEV is paralel to pelvis, intervertebral disc adjacent to LEV is often wedged and there is lumbosacral hemicurve distally below the instrumentation in patients treated by either anterior or posterior surgery. We believe that lumbosacral hemicurve due to sacral tilt behaves like
Study Design. An observational study in patients with congenital spinal deformity. Objective. To review the relationship between hemivertebrae and the posterior spinal elements in congenital spinal deformity. Summary of background data. The vertebral body anomalies of congenital scoliosis have been classified and their natural history is well known. More recently a variety of posterior element anomalies have been classified. The relationship between posterior and anterior structures is important when posterior excision of a hemivertebrae is undertaken. Methods. Patients recorded as having congenital spinal deformity were identified from a database. All available imaging was obtained and reviewed with particular reference to posterior element anatomy as visualised on CT or MRI scans. Results. In total 36 patients with congenital spinal deformity were identified and their imaging was reviewed. 29 hemivertebrae were identified in 24 patients. Clear images were obtained of the posterior elements in 18 cases. 9 isolated hemilaminae (as visualised on coronal CT or MRI) were seen in 8 patients with associated hemivertebrae. In 7 of 9 cases the hemilamina was found to be one level cranial to the hemivertebrae and in the remaining 2 cases it was at the same level. Conclusion. When planning excision of a
The purpose of this study was to ascertain whether early diagnosis through antenatal ultrasound screening and intervention lead to a reduction in morbidity associated with congenital scoliosis. Prospective cohort study. All fetuses with vertebral body anomalies detected over a thirteen years period were included. Maternal risk factors, accuracy of antenatal diagnosis, associated fetal anomalies and ultimate outcome are described. Twenty-four fetuses with congenital hemivertebrae were identified from 39,000 antenatal scans (incidence 0.061%). The mothers' median age at conception was 26 years (range 18-40 years). The median fetal gestational age at diagnosis was 20 weeks (range 18-38 weeks). The median gestational age at delivery was 38 weeks (range 27-40). Antenatal ultrasound identified eighteen fetuses with a single
Diastematomyelia is a rare congenital abnormality
of the spinal cord. This paper summarises more than 30 years’ experience
of treating this condition. Data were collected retrospectively
on 138 patients with diastematomyelia (34 males, 104 females) who
were treated at our hospital from May 1978 to April 2010. A total
of 106 patients had double dural
Purpose of the study: Neurophysiological monitoring during pedicular screw insertion has been used to verity bone integrity of instrumented pedicles. The purpose of this study was to determine, experimentally, whether the EMG thresholds after stimulation of dorsal pedicular screws depend on the distance between the nerve structures and the screw, or on the interposition of different tissues. Material and methods: EMG thresholds were recorded after stimulation of 18 VPD in fivde pigs, by varying the distance between the screws and the spinal cord (2, 6, 10 mm). The thresholds were recorded after rupture of the median pedicular cortical and after interposition of different tissues (blood, muscle, fat and bone) between the screws and the spinal cord. In four patients with a
We report five children who presented at the mean age of 1.5 years (1.1 to 1.9) with a progressive thoracolumbar kyphosis associated with segmental instability and subluxation of the spine at the level above an anteriorly-wedged hypoplastic vertebra at L1 or L2. The spinal deformity appeared to be developmental and not congenital in origin. The anterior wedging of the vertebra may have been secondary to localised segmental instability and subsequent kyphotic deformity. We suggest the term ‘infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine’ to differentiate this type of deformity from congenital displacement of the spine in which the congenital vertebral anomaly does not resolve. Infantile developmental kyphosis with segmental subluxation of the spine, if progressive, may carry the risk of neurological compromise. In all of our patients the kyphotic deformity progressed over a period of three months and all were treated by localised posterior spinal fusion. At a mean follow-up of 6.6 years (5.0 to 9.0), gradual correction of the kyphosis was seen on serial radiographs as well as reconstitution of the hypoplastic wedged vertebra to normality. Exploration of the arthrodesis was necessary at nine months in one patient who developed a pseudarthrosis.
Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) at last follow up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last followup. One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.
In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result. Early treatment minimizes the risks of surgery. Anatomical and physiological pitfalls in the treatment of congenital kyphosis are discussed. Anterior instrumented fusion of congenital kyphosis provides sagital and coronal correction in very young children with low risk of complications.
Summary of Background Data: The craniofacial malformations described by Goldenhar can be associated with congenital anomalies of the vertebrae. This non-random association of abnormalities represents unilateral errors in the morphogenesis of the spine, as well as the first and second branchial arches. Purpose of the study: The aim of the present study was to determine the prevalence of Goldenhar related conditions in patients with congenital deformities of the spine and to describe the types of vertebral abnormalities and the necessity for treatment. Material-Methods: We performed a retrospective study of 668 consecutive patients with congenital deformities of the spine. The medical records and spinal radiographs were reviewed and patients with a Goldenhar associated condition were identified. The vertebral anomalies causing the spine deformity were detected on antero-posterior and lateral spine radiographs. The type and site of the craniofacial abnormalities, as well as other musculoskeletal deformities and systemic anomalies were recorded. Results: Fourteen patients had Goldenhar associated conditions (7 males and 7 females). A thoracic scoliosis was the most common type of deformity occurring in ten patients (71.5%). Eight of these patients had an isolated
Cervico-thoracic congenital scoliosis is a difficult deformity to obtain good correction due to its anatomical characteristics and lack of proper instrumentation. Surgical treatments often end up with poor correction by convex epiphysiodesis alone, making hideous residual head tilt. This is a report of 2 cases with cervico-thoracic congenital scoliosis, which underwent total excision of
A combination of hemivertebrae and diastematomyelia is rare. We have identified 12 such patients seen during a period of 11 years in the orthopaedic, spinal and neurosurgical units in Nottingham and analysed their treatment and outcome.