Clinically significant proximal junctional kyphosis (PJK) occurs in 20% of children treated with posterior distraction-based growth friendly surgery. In an effort to identify modifiable risk factors, it has been theorized biomechanically that low radius of curvature (ROC) implants (i.e., more curved rods) may increase post-operative thoracic kyphosis, and thus may pose a higher risk of developing PJK. We sought to test the hypothesis that EOS patients treated with low ROC (more curved rods) distraction-based treatment will have a greater risk of developing PJK as compared to those treated with high ROC (straighter) implants.

This is a retrospective review of prospectively collected data obtained from a multi-centre EOS database on children treated with rib-based distraction with minimum 2-year follow-up. Variables of interest included: implant ROC at index (220 mm or 500 mm), patient age, pre-operative scoliosis, pre-operative kyphosis, and scoliosis etiology. In the literature, PJK has been defined as clinically significant if revision surgery with superior extension of the upper instrumented vertebrae was performed.

In 148 scoliosis patients, there was a higher risk of clinically significant PJK with low ROC (more curved) rods (OR: 2.6 (95%CI 1.09-5.99), χ2 (1, n=148) = 4.8, p = 0.03). Patients had a mean pre-operative age of 5.3 years (4.6y 220 mm vs 6.2y 500 mm, p = 0.002). A logistic regression model was created with age as a confounding variable, but it was determined to be not significant (p = 0.6). Scoliosis etiologies included 52 neuromuscular, 52 congenital, 27 idiopathic, 17 syndromic with no significant differences in PJK risk between etiologies (p = 0.07). Overall, patients had pre-op scoliosis of 69° (67° 220mm vs 72° 500mm, p = 0.2), and kyphosis of 48° (45° 220mm vs 51° 500mm, p = 0.1). The change in thoracic kyphosis pre-operatively to final follow up (mean 4.0 ± 0.2 years) was higher in patients treated with 220 mm implants compared to 500 mm implants (220 mm: 7.5 ± 2.6° vs 500 mm: −4.0 ± 3.0°, p = 0.004).

Use of low ROC (more curved) posterior distraction implants is associated with a significantly greater increase in thoracic kyphosis which likely led to a higher risk of developing clinically-significant PJK in EOS patients.

Abstract. Objectives. To evaluate the safety and efficacy of vertebroplasty with short segmented cement augmented pedicle screws fixation for severe osteoporotic vertebral compression fractures (OVCF) with posterior/anterior wall fractured patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ± 0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20 ± 5.90 to 5.30 ± 1.40 postoperative with 5% (3.30 ± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80 ± 11.9% to 87.6 ± 13.1% postoperative with 4.5 ± 4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because. Vertebroplasty is viable option for restoring vertebral anterior column in patients who are considered as contraindications for vertebroplasty, like DGOU-4. It provides anterior support avoiding corpectomy, minimise blood loss and also duration of surgery. Addition of short segment fixation gives adequate support with less stress risers at the junctional area

Abstract. Objectives. The principle of osteoporotic vertebral compression fracture (OVCF) is fixing instability, providing anterior support, and decompression. Contraindication for vertebroplasty is anterior or posterior wall fracture. The study objectives was to evaluate the efficacy and safety of vertebroplasty with short segmented PMMA cement augmented pedicle screws for OVCF with posterior/anterior wall fracture patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ±0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20±5.90 to 5.30±1.40 postoperative with 5% (3.30± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80±11.9% t0 87.6±13.1% postoperative with 4.5±4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because It provides anterior support with cementing that avoids corpectomy. Short segment fixation has less stress risers at the junctional area

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Proximal junctional kyphosis (PJK) is defined as adjacent segment kyphosis >10° between the upper instrumented vertebrae and the vertebrae 2 levels above following scoliosis surgery. There are few studies investigating the predictors and clinical sequelae involved with this relatively common complication. Our purpose was to determine the radiographic predictors of post-op PJK and to examine the association between PJK and pain/HRQOL following surgery for AIS.

The Post-Operative Recovery after Scoliosis Correction: Home Experience (PORSCHE) study was a prospective multicenter cohort of AIS patients undergoing spinal fusion surgery. Pre-op and minimum 2 year f/u scoliosis and sagittal spinopelvic parameters (thoracic kyphosis–TK, lordosis–LL, pelvic tilt-PT, sacral slope-SS, pelvic incidence-PI) were measured and compared to numeric rating scale for pain (NRS) score, SRS-30 HRQOL and to the presence or absence of PJK (proximal junctional angle >100). Continuous and categorical variables were assessed using logistic regression and binomial variables were compared to binomial outcomes using chi-square.

163 (137 females) patients from 8 Canadian centers met inclusion criteria. At final f/u, PJK was present in 27 patients (17%). Pre-op means for PJK vs No PJK: Age 14.1 vs 14.7yr; females 85 vs 86%; scoliosis 57±22 vs 62±15deg; TK 28±18 vs 19±16deg ∗, LL 62±11 vs 60±12deg, PT 8±12 vs 10±10deg, SS 39±8 vs 41±9deg, PI 47±14 vs 52±13deg, SVA −9±30 vs −7±31mm. Final f/u for PJK vs No PJK: Scoliosis 20±11 vs 18±8deg, final TK 26±12 vs 19±10deg∗, LL 60±11 vs 57±12deg, PT 9±12 vs 12±13deg, SS 39±9 vs 41±9deg, PI 48±17 vs 52±14deg, SVA −23±26 vs −9±32mm∗. Significant findings: Pre-op kyphosis >40deg has an odds ratio (OR) of 4.41 (1.50–12.92) for developing PJK∗. The presence of PJK was not associated with any significant differences in NRS or SRS-30. ∗denotes p<0.05.

This prospective multicenter cohort of AIS patients demonstrated a 17% risk of developing PJK. Pre-op thoracic kyphosis >40deg was associated with the development of PJK; however, the presence of PJK was not associated with increased pain or decreased HRQOL.

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To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

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This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

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Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Introduction. Hip osteoarthritis (OA) results in reduced hip range of motion and contracture, affecting sitting and standing posture. Spinal pathology such as fusion or deformity may alter the ability to compensate for reduced joint mobility in sitting and standing postures. The effects of postural spinal alignment change between sitting and standing is not well understood. Methods. A retrospective radiographic review was performed at a single academic institution of patients with sitting and standing full-body radiographs between 2012 and 2017. Patients were excluded if they had transitional lumbosacral anatomy, prior spinal fusion or hip prosthesis. Hip OA severity was graded by the Kellgren-Lawrence grades and divided into two groups: low-grade OA (LOA; grade 0–2) and severe OA (SOA; grade 3–4). Spinopelvic parameters (Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), and PI-LL), Thoracic Kyphosis (TK; T4-T12), Global spinal alignment (SVA and T1-Pelvic Angle; TPA; T10-L2) as well as proximal femoral shaft angle (PFSA: as measured from the vertical), and hip flexion (difference between change in PT and change in PFSA) were also measured. Changes in sit-stand radiographic parameters were compared between the LOA and SOA groups with unpaired t-test. Results. 548 patients were identified with sit-stand radiographs, of which there were 311 patients with LOA & 237 with SOA. After propensity score matching for Age, BMI, and PI, 183 LOA & 183 SOA patients were analyzed. Standing alignment analysis demonstrated that SOA patients had greater SVA (31.1 ± 36.68 vs 21.7 ± 38.83, p=0.02), and lower TK (−36.21 ± 11.98 vs −41.09 ± 11.47, p<0.001). SOA patients had lower PT, greater PI-LL, lower LL, lower T10-L2, and lower TPA (p>0.05). PFSA (9.09 5.19 vs 7.41 4.48, p<0.001) was significantly different compared to LOA while SOA KA was not significantly different compared to LOA. Sitting alignment analysis demonstrated that SOA patients had higher PT (29.69 ± 15.65 vs 23.32 ± 12.12, p<0.001), higher PI-LL (21.64 ±17.86 vs 12.44 ±14.84 p<0.001), lower LL (31.67 ± 16.40 vs 41.58 ± 14.73, p<0.001), lower TK (−33.22 ± 15.76 vs −38.57 ± 13.01, p=0.01), greater TPA (27.91 ± 14.7 vs 22.55 ± 11.38 p=0.01). TK, SVA, and PFSA were not significantly different compared to LOA. SOA and LOA groups demonstrated differences in standing and sitting spinopelvic alignment for all global and regional parameters except PI. When examining the postural changes from standing to sitting, there was less hip ROM in SOA than LOA (71.45 ± 18.55 vs 81.64 ± 12.57, p<0.001). As a result, SOA patients had more change in PT (15.24 ± 16.32 vs 7.28 ± 10.19, p<0.001), PI-LL (20.62 ± 17.25 vs 13.74 ± 11.16, p<0.001), LL (−21.37 ± 15.55 vs −13.09 ± 12.34, p<0.001), and T10-L2 (−4.94 ± 7.45 vs −1.08 ± 5.19, p<0.001) to compensate. SOA had a greater improvement in TPA (15.06 vs 9.59, p<0.001), and less change in PFSA (86.65 vs 88.81, p<0.001) compared to LOA. Conclusions. Spinopelvic compensatory mechanisms are adapted for reduced joint mobility associated with hip OA in standing and sitting

Aims

The aim of this study was to evaluate improvements in the quality and safety of paediatric spinal surgery following the implementation of a specialist Paediatric Spinal Surgical Team (PSST) in the operating theatre.

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The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

Aims

Posterior tilt of the pelvis with sitting provides biological acetabular opening. Our goal was to study the post-operative interaction of skeletal mobility and sagittal acetabular component position.

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We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis.

Aims

A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed.

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: Bone Joint J 2015;97-B:982–7.

Background:

Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities.

Neural axis anomalies in idiopathic scoliosis (AIS) are well documented, with prevalence of 7% in adolescents; 20% in early-onset and up to 40% in congenital, the case for pre-operative MRI of brainstem to sacrum is well made in these groups. SK is rarer than AIS and the prevalence of anomalies is not defined. The case for routine MRI scan is unclear. A recent report concluded that routine MRI was not indicated, although this was based on only 23 MRI scans in 85 patients. At our institution all patients are undergo whole spine MRI following a diagnosis of SK. We aimed to assess the incidence of significant neural anomalies in Scheuermann's Kyphosis. Using a keyword search for “Scheuermann”, we reviewed all SK patients' MRI reports over the past 6 years. 117 MRI scans were identified. 13 patients did not fulfil the radiological criteria for SK and thus 104 (73M: 31F) scans were reviewed. 14 (13%) of 104 scans showed unexpected Significant abnormal findings. There were 8 (8%) with neural axis anomalies: 4 syrinxes; 1 cord anomaly; 2 cerebellar descents and 1 cerebellar tumour. All these patients had normal neurological examination except one with examination consistent with a known diagnosis of Parkinson's. A further 6 patients had non-neural anomalies. The presence of neural axis anomalies may influence the management of a patient with SK. Neurological compromise during correction is higher in patients with neural axis anomalies and this risk can often be partially mitigated by a preceding neurosurgical procedure (such as foramen magnum decompression or shunt). Furthermore it is well described that these anomalies often occur in patients who demonstrate a normal neurological examination. This study confirms this. Given that MRI is widely available and considering the devastating life implications of neurological injury, we advise pre-operative MRI scan in all SK patents

The current trend in kyphosis correction is for “every level” instrumentation to achieve intraoperative stability, correction, fusion and implant longevity. We evaluate the medium term follow up of a low implant density (LID) construct. All patients with adolescent kyphosis (idiopathic or Scheurmann's) on our deformity database were identified. Radiographs and records were analysed for neurological complications, correction and revision. The constructs included were all pedicle screw anchors with multiple apical chevron osteotomies and a proximal and distal “box” of 6 to 8 screws. A four rod cantilever reduction manoeuvre with side to side connectors completed the construct. Kyphosis for any other cause was excluded. Follow up less than 12 months was excluded. 23 patients were identified with an average follow up 27 months (72 to 12 months) and a mean implant density of 1.1 (53.5% of “available” pedicles instrumented). There was 1 false positive neurophysiological event without sequelae (4%). There were no proximal junctional failures (0%). There were no pseudarthroses or rod breakages (0%). There was 1 loss of distal rod capture (early set screw failure) (4%). This was revised uneventfully. There were 4 infections requiring debridement (early series). Average initial correction was 44% (77.7 degrees to 43.5 degrees) with a 1% loss of correction at final follow up (43.5 to 44.0 degrees). The fulcrum bending correction index was 107% (based on fulcrum extension radiographs). 85% of curves had a fulcrum flexibility of less than 50%. The average cost saving compared to “every level “instrumentation was £5700 per case. This paper shows that a LID construct for kyphosis has technical outcomes as good as high density constructs. The obvious limitation of the study is the small number of patients in the cohort. The infection rates have improved with changes to perioperative process in the later series of patients. We do not believe these are a consequence of the construct itself