The December 2022 Children’s orthopaedics Roundup. 360. looks at: Immobilization of torus fractures of the wrist in children (FORCE): a randomized controlled equivalence trial in the UK; Minimally invasive method in treatment of idiopathic congenital vertical talus: recurrence is uncommon; “You’re O.K. Anaesthesia”: closed reduction of displaced paediatric forearm and wrist fractures in the office without anaesthesia; Trunk range of motion and patient outcomes after anterior vertebral body tethering versus posterior spinal fusion: comparison using computerized 3D motion capture technology; Selective dorsal rhizotomy for individuals with spastic cerebral palsy; Scheuermann’s kyphosis and posterior spinal fusion; All-pedicle-screw constructs in skeletally immature patients with severe idiopathic early-onset scoliosis; Proximal femoral screw hemiepiphysiodesis in children with cerebral palsy

Aims. To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management. Methods. We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire. Results. The mean follow-up was 8.4 years (2 to 14.9). There were 85 patients (96.6%) with a thoracic deformity. Posterior spinal fusion with closing-wedge osteotomies and hybrid instrumentation was used in 86 patients; two patients underwent combined anterior and posterior spinal fusion. The mean kyphosis was corrected from 94.5° to 47.5° (p < 0.001). Coronal and sagittal balance returned to normal. The rate of complications was 12.5%: there were no neurological deficits, implant failure, or revision surgery. SRS-22 scores improved from a mean 3.6 (1.3 to 4.1) to 4.6 (4.2 to 5.0) at two years (p < 0.001) with a high rate of patient satisfaction. Non-smokers and patients with lower preoperative SRS-22 scores showed greater improvement in their quality of life. Sagittal pelvic balance did not change after correction of the kyphosis and correlated with lumbar lordosis but not with thoracic or thoracolumbar kyphosis. Conclusion. Posterior spinal fusion using hybrid instrumentation, closing-wedge osteotomies, and iliac bone grafting achieves satisfactory correction of a severe kyphosis resulting in improvements in physical and mental health and a high degree of patient-reported satisfaction. Cite this article: Bone Joint J 2021;103-B(1):148–156

Aims. 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. Methods. A retrospective review of patients treated surgically for Scheuermann’s kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable. Results. There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches. Conclusion. A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368–1374

Aims. Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service. Methods. Descriptive study of prospectively collected data. Clinical data of all patients undergoing surgery for spinal deformity between 2005 and 2018 was collected, compared to the demographics of the national population, and analyzed by underlying aetiology. Results. Our cohort comprised 2,205 patients; this represents an incidence of 14 per 100,000 individuals among the national population aged between zero and 18 years. There was an increase in mean annual incidence of spinal deformity surgery across the study period from 9.6 (7.2 to 11.7) per 100,000 individuals in 2005 to 2008, to 17.9 (16.1 to 21.5) per 100,000 individuals in 2015 to 2018 (p = 0.001). The most common cause of spinal deformity was idiopathic scoliosis accounting for 56.7% of patients. There was an increase in mean incidence of surgery for adolescent idiopathic scoliosis (AIS) (from 4.4 (3.1 to 5.9) to 9.8 (9.1 to 10.8) per 100,000 individuals; p < 0.001), juvenile idiopathic scoliosis (JIS) (from 0.2 (0.1 to 0.4) to one (0.5 to 1.3) per 100,000 individuals; p = 0.009), syndromic scoliosis (from 0.7 (0.3 to 0.9) to 1.7 (1.2 to 2.4) per 100,000 individuals; p = 0.044), Scheuermann’s kyphosis (SK) (from 0.2 (0 to 0.7) to 1.2 (1.1 to 1.3) per 100,000 individuals; p = 0.001), and scoliosis with intraspinal abnormalities (from 0.04 (0 to 0.08) to 0.6 (0.5 to 0.8) per 100,000 individuals; p = 0.008) across the study period. There was an increase in mean number of posterior spinal fusions performed each year from mean 84.5 (51 to 108) in 2005 to 2008 to 182.5 (170 to 210) in 2015 to 2018 (p < 0.001) and a reduction in mean number of growing rod procedures from 45.5 (18 to 66) in 2005 to 2008 to 16.8 (11 to 24) in 2015 to 2018 (p = 0.046). Conclusion. The incidence of patients with spinal deformity undergoing surgery increased from 2005 to 2018. This was largely attributable to an increase in surgical patients with adolescent idiopathic scoliosis. Paediatric spinal deformity was increasingly treated by posterior spinal fusion, coinciding with a decrease in the number of growing rod procedures. These results can be used to plan paediatric spinal deformity services but also evaluate preventative strategies and research, including population screening

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction.

In this article, we review the current concepts in AIS surgery.

Cite this article: Bone Joint J 2018;100-B:415–24.

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity. We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation. Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image

The SRS-22 instrument was developed to assess quality of life in adolescent idiopathic scoliosis patients (AIS). The aim of our study was to evaluate the impact of surgical treatment on quality of life in neurologically normal patients with complex spinal deformity of a range of aetiologies using the SRS-22 questionnaire. We analysed prospectively collected SRS-22 data on 407 consecutive patients (315 females-92 males) treated from 2006–2012 under the care of the senior author. 97.6% of patients had a posterior (PSF), 1.3% an anterior (ASF) and 1.1% an anterior-posterior (A/PSF) spinal fusion. Questionnaires were completed at 4 stages of treatment: preoperatively, 6-months, 12-months and 24-months postoperatively. Other variables included age at surgery, gender, diagnosis and year of surgery. 9 diagnoses were included in the study: 271 patients had AIS; 39 Scheuermann's kyphosis; 31 spondylolisthesis; 16 congenital scoliosis; 13 JIS; 6 IIS; 13 scoliosis associated with intraspinal anomalies; 11 syndromic scoliosis; 7 scoliosis associated with congenital cardiac disease. Mean age at surgery was 15.14±2.07 years. Age at surgery was divided in 3 groups to compare outcomes against previous studies: 10–12, 13–15, and 15–19 years. Mean total SRS-22 scores for the whole group were: preoperative 3.62±0.66; 6-month 4.12±0.44; 12-month 4.39±0.40; and 24-month 4.52±0.37 (p<0.0001). Individual preoperative scores for the whole group were: function 3.77±0.75; pain 3.7±0.97; self-image 3.14±0.66; mental 3.86±0.77. Mean 24-month postoperative scores for the whole group were: function 4.39±0.42; pain 4.59±0.56; self-image 4.39±0.51; mental 4.43±0.56; satisfaction 4.81±0.40. All changes observed at 2-year follow-up were statistically significant (p<0.0001). Male preoperative total score (3.64±0.66) did not have a significant difference compared to female (3.62±0.66); however 24-month total score improvement was significant, with males (4.62±0.25) performing better than females (4.49±0.39) including satisfaction (p=0.004). Spondylolisthesis patients performed worse preoperatively (2.93±0.26) compared to other diagnoses (p<0.0001); AIS 3.67±0.64, congenital 3.81±0.57, syndromic 3.80±0.54, Scheuermann's 3.48±0.75, JIS 3.90±0.63, scoliosis with congenital cardiac disease 4.04±0.41 or intraspinal anomalies 3.71±0.66, and IIS 3.58±0.80. No change in total and individual scores was observed at 24-month review across diagnoses (p>0.05). There were no significant changes between each year of surgery in the study period and the total values at each stage (p>0.05). There were no significant changes between the 3 age ranges at each stage (p>0.05). Patients undergoing ASF performed significantly better at preoperative function (4.7±0.27) compared to PSF (3.76±0.74) and A/PSF (3.68±0.72), (p=0.19). All values at 2-years were not significant in comparison regarding type of operation (p>0.05). All individual domains and total SRS-22 scores improved after surgical correction of spinal deformity in our young patient cohort with an incremental change between preoperative, 6-month, 12-month and 24-month postoperative. Our 24-month postoperative outcomes in all diagnoses compare favourably to reported SRS-22 scores in healthy adolescents (function: 4.31±0.54; pain: 4.44±0.67; image: 4.41±0.64; mental health: 3.96±0.81; total 4.26±0.54). We are planning to continue this study with longer follow-up in order to allow comparison of our SRS-22 outcomes after surgical treatment to those obtained in patients treated with bracing or patients who were followed untreated (previous reports SRS-22 total scores: 4.2 for braced patients and 4.1 for observed patients)

Aim:. To present the results of multi-modal IOM in 298 patients who underwent spinal deformity correction. Method:. We reviewed the notes, surgical and IOM charts of all patients who underwent spinal surgery with the use of cortical and cervical SSEPs, as well as upper/lower limb transcranial electrical MEPs under the senior author. We recorded IOM events which we categorised as true, transient true and false (+) or (−). We correlated the IOM events with surgical or anaesthetic incidents. Results:. Diagnosis included idiopathic scoliosis in 224, congenital in 12, syndromic in 14, scoliosis with intraspinal anomaly in 5, scoliosis with congenital cardiac disease in 4, spondylolisthesis in 2, spinal tumour in one, and Scheuermann's kyphosis in 36 patients. We identified 3 true (+) monitoring events occurring in 2 patients (1%), 6 transient true (+) (2%), and 11 transient false (+) events (3.7%). True (+) events occurred during deformity correction in one patient with severe AIS and during osteotomies in another with severe Scheuermann's. Transient true (+) events occurred during posterior osteotomies in 2 patients with Scheuermann's, during scoliosis correction (apical correction with sublaminar wires) in one and placement of concave apical pedicle screw in another patient, and 2 IOM changes during positioning (one during reduction of spondylolisthesis-one during positioning on the surgical table). Transient false (+) events were mainly related to low blood pressure (10 patients). There were no false (−) IOM events and none of our patients had postoperative neurological complications. Sensitivity of our IOM technique was 100% [all patients with impending spinal cord injury will have a (+) event] and specificity 96% (patients with normal IOM had 96% chance that the cord was safe). Positive predictive value was 65.3% (65.3% chance that an IOM event reflected a surgical-related cause of cord injury); negative predictive value 100% (100% chance that normal IOM corresponded to no cord injury). We found no difference between patients with AIS and Scheuermann's in terms of risk of true or transient true (+) IOM events (Fisher's exact test, p=0.12). Discussion:. Multimodal IOM is highly sensitive and specific for spinal cord injury. This technique is reliable to assess the condition of the spinal cord during high-risk major spinal deformity surgery. Conflict of interest statement: None

Introduction:. Scheuermann's kyphosis is a fixed round back deformity characterised by wedged vertebrae seen on radiograph. It is known patients presented with a negative sagittal balance before operation. Few studies investigated the outcome after operation, especially the change in the lumbar hyperlordosis. Aim:. To investigate the change in sagittal profile after correction surgery. Method:. This is a retrospective review of cases from 2001 to 2012. Our centre uses a posterior, four rod cantilever reduction technique for all Scheuermann's Kyphosis correction. 36 cases are identified. They include 24 males and 12 females with an average age of 20 and follow up of 27 months. First 8 cases used the stainless steel hybrid implants. The remaining 28 had titanium all pedicle screw system. All had intra-operative spinal cord monitoring. Results:. The target of thoracic kyphosis correction is around the accepted upper end of normal limit (40°). The average thoracic kyphosis Cobb angle was 78.5°. The immediate post-op angle was 43.2° and at final follow up, 43.6°. The average lumbar lordosis changed from 65.7° pre-op to 48.8° post-op, which is now bigger than the thoracic kyphosis. The result is the transfer of average sagittal balance (C7 plumb line) from −2.2 cm to −3.5 cm, which remains posterior to the posterior corner of S1 after the surgery. Discussion:. Surgery can improve the roundback deformity but not the overall sagittal profile. We have no explanation to this phenomenon. This could imply the pathology of Scheuermann's Kyphosis involves the whole spine, not just the wedging thoracic segment. Conflict Of Interest Statement: No conflict of interest

Purpose of the study. Two patients with very severe thoracolumbar Scheuermann's kyphosis who developed spontaneous bony fusion across the apex of the deformity are presented and their treatment, as well as surgical outcome is discussed. Summary of Background Data. Considerable debate exists regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Surgical correction is indicated in the presence of severe kyphosis which carries the risk of neurological complications, persistent back pain and significant cosmetic deformity. Methods. We reviewed the medical notes and radiographs of 2 adolescent patients with severe thoracolumbar Scheuermann's kyphosis who developed spontaneous posterior and anteroposterior fusion across the apex of the deformity. Results. Patient 1. A male patient aged 17 years and 11 months underwent kyphosis correction when the deformity measured 115o and only corrected to 100o on supine hyperextension radiograph against the bolster; he had a small associated scoliosis. The surgery involved a combined single-stage anterior and posterior spinal arthrodesis T4-L3 with the use of posterior pedicle hook/screw/rod instrumentation and autologous rib graft. The anterior longitudinal ligament was ossified from T10 to L1 with bridging osteophytes extending circumferentially from T11 to T12 at the apex of kyphosis and displacing the major vessels anteriorly. The intervertebral discs from T9 to T12 were very stenotic and immobile. The osteophytes were excised both on the convexity and concavity of the associated thoracolumbar scoliosis. The anterior longitudinal ligament was released and complete discectomies back to the posterior longitudinal ligament were performed from T7 to L1. During the posterior exposure, the spine was found to be spontaneously fused across the apex of the kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T7 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the anterior and posterior osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 58o was achieved and maintained at follow-up. Autologous rib graft was used to enhance a solid bony fusion. Patient 2. A female patient aged 18 years and one month underwent kyphosis correction when the deformity measured 115o and only corrected to 86o on supine hyperextension radiograph against the bolster; she had a small thoracolumbar scoliosis. The surgery involved a single-stage posterior spinal arthrodesis T2-L4 with the use of posterior pedicle hook/screw/rod instrumentation and autologous iliac crest bone. The spine was spontaneously fused across the apex of kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T6 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 60o was achieved and maintained at follow-up. Autologous iliac crest graft was used to achieve a solid bony fusion. In both patients the preoperative MRI assessed the intraspinal structures but failed to diagnose the solid fusion across the posterior bony elements at the apex of kyphosis. A CT scan with 3D reconstruction would have illustrated the bony anatomy across the kyphosis giving valuable information to assist surgical planning. This is recommended in the presence of rigid thoracolumbar Scheuermann's kyphosis which does not correct in hyperextension, especially if the plain radiograph shows anterior bridging osteophytes. Conclusion. Spontaneous posterior or anteroposterior fusion can occur across the apex of severe thoracolumbar Scheuermann's kyphosis; this should be taken into account when surgical correction is anticipated. The bony ankylosis may represent the natural history of an extreme deformity as an attempt of the spine to auto-stabilise. A combination of factors including a rigid deformity, which limits significantly active movement of the spine, as well as anterior vertebral body wedging with severe adjacent disc stenosis which induces bridging osteophyte formation may result in the development of spontaneous fusion across the apex of the kyphosis either posteriorly or anteroposteriorly. In the presence of an isolated posterior fusion, segmental posterior closing wedge osteotomies with complete excision of the ossified ligamentum flavum and fused facets should mobilise the thoracolumbar spine and allow for kyphosis correction. An additional anterior spinal release including complete discectomies, resection of the anterior longitudinal ligament and osteophytes is required if the bony fusion extends anteroposteriorly. Patients with Scheuermann's kyphosis should be ideally treated at an earlier stage and with a lesser degree of deformity so that this ossification process is prevented

Purpose of the study. We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. Summary of Background Data. Body piercing has become increasingly more common due to change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following Orthopaedic or Spinal procedures associated with body piercing have not been reported. Methods. We reviewed the medical notes and radiographs of an adolescent patient with severe Scheuermann's kyphosis and multiple body piercings who underwent an uneventful posterior spinal arthrodesis with pedicle hook/screw/rod instrumentation and autologous iliac crest bone graft and developed septic shock. Results. Septic shock developed on postoperative day 2 after reinsertion of all piercings following patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteraemia (coagulase-negative Staphylococci/Streptococci warneri) and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. Conclusion. The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery. Despite the wide array of complications associated to body art there are no clear guidelines for body piercing. There is growing public awareness and several countries are laying regulations which have not yet been internationally standardized. A clear practice guideline in the perioperative management of piercings is needed as the incidence of body piercing and associated complications is rising. There is need for surgeons to be aware of the hazards of body piercing and its implications. We propose that multiple piercings should not be reinserted after major surgery and appropriate counseling should be provided to the patients as part of the consent process

Background. Improvement of Scheuermann's thoracic kyphosis in the growing spine with Milwaukee brace treatment has been reported. However, the role of brace treatment in Mb. Scheuermann is controversial. We report results of brace treatment by low profile scoliosis module with sternal shield. Indication. Thoracic kyphosis >55° or back pain and kyphosis >50°. Material. 21 consecutive patients (17 boys, 4 girls) referred to the Orton Orthopaedic Hospital between 2000-2007. One boy interrupted treatment and the follow-up of two boys was carried out at another hospital. The data of 18 patients are reported. Results. The mean age of patients at the beginning of treatment was 14 years (11-17) and the average thoracic kyphosis was 71° (50-94). On extension radiographs, the kyphosis decreased to 43°(16-66) with a mean correction of 38%. The average time of brace treatment was 2,5 (1-7) years. The final follow- up visit was at the age of 19 (15-21) years. At the final follow-up, the mean thoracic kyphosis was 59° (30-78). Permanent correction of thoracic kyphosis was achieved in 15 patients (83%) with a mean correction of 15 degrees. In two patients no correction was achieved and in one patient the kyphosis increased 9°. No patient required operative treatment. Discussion and conclusion. The efficiency of brace treatment is difficult to prove because natural history of Scheuermann's kyphosis is not fully known. Our material is too small for any final conclusions. However, treatment of the growing spine with modified low profile brace seem to decrease progression of kyphosis in most cases and operative treatment may be avoided

Objective. The use of all pedicle screw constructs for the management of spinal deformities has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges for the spinal surgeon. The purpose of this study was to evaluate the complications and radiological outcomes of surgery in 124 consecutive patients with spinal deformity. These patients underwent correction of coronal and sagittal imbalance with segmental pedicle screw fixation only. Background. All pedicle screw constructs have been associated with improved correction in all three planes. In patients with severe deformity, such constructs can obviate the need for anterior surgeries, and the higher implant cost is offset by the avoidance of dual anterior and posterior approaches. Pedicle screw fixation enables enhanced correction of spinal deformities, but the technique is still not widely applied for thoracic deformities for fear of neurological complications. This is a retrospective study that was carried out on 124 patients who underwent segmental screw fixation for coronal and sagittal spinal deformities. The purpose of this study was to evaluate the complications and outcomes of this technique and also assess the evidence of enhanced correction. Material and Methods. A total of 124 consecutive patients subjected to pedicle screw fixation for spinal deformities were analysed after a minimum period of follow-up of two years. Etiologic diagnoses were idiopathic scoliosis in 32, neuromuscular scoliosis 48, Scheuermann's kyphosis in 28 and others 16. They were reviewed using the medical records and preoperative, intraoperative and postoperative radiographs. Computed tomography was performed when screw position was questionable. Deformity correction was determined on preoperative and postoperative radiographs. The positions of the screws were evaluated using intraoperative and postoperative radiographs. There were 51 male and 73 female patients with the mean age of 17.2 years (range, 10-25 years). The average cobb angle for scoliosis and kyphosis were 55°(range 45°-85°) and 72° (range 68°-100°) respectively. Results. A total of 2784 pedicle screws were inserted and 1488 screws were inserted in the thoracic spine (18 screws/patient). Screw-related neurological complications occurred in two patients 0.4%; these comprised a transient paraparesis and dural tear. Other complications comprised six intraoperative pedicle fractures, 12 screw loosening, four postoperative infections and one haemothorax. There were no significant screw-related neurological or visceral complications. The average correction was 78% for scoliosis and 51% for kyphosis. The mean estimated blood loss was 653 ml (range, 510-850), the mean operation time was 148 minutes (range, 120-220). Conclusion. We were able to demonstrate that application of pedicle screw construct is safe and advantageous in the management of spinal deformities. Significant correction has been achieved with a single stage posterior surgery in all groups. Scoliosis and kyphotic deformity corrections were 78% and 51% respectively; this is far superior to correction achieved with one stage surgery with other constructs. This study showed that improved derotation has decreased the need for thoracoplasty, thus eliminating its risk of associated morbidity. Superior control of the deformity obviated the need for an anterior approach in severe curves. Improved correction, lower morbidity and shorter hospitalisation has compensated for higher implant cost. We believe using all pedicle screw fixation is a relatively safe procedure and offers an excellent correction. This correction was maintained throughout the follow up period. Despite our safety record in thoracic pedicle screw placement, we believe this technique can be potentially dangerous in inexperienced hands, and requires a long learning curve. Therefore, a thorough anatomical knowledge of pedicle morphology, a detailed analysis of pre-operative imaging coupled with experience is essential to avoid complications. Ethics approval None. Interest Statement None

Objective. To compare the radiological and clinical outcomes following three different techniques used in the correction of Scheuermann's kyphosis. Materials and Methods. Twenty three patients with comparable preoperative radiographic and physical variables (age, gender, height, weight, body mass index) underwent correction of thoracic kyphotic deformity using three different surgical methods. Group A (n=8) had combined anterior and posterior fusion with instrumentation using morselised rib graft. Group B (n=7) had combined anterior and posterior fusion with instrumentation using titanium interbody cages. Group C (n=8) had posterior segmental pedicle screw fixation only. All groups had posterior apical multi-level chevron osteotomy and posterior instrumentation extending from T2 to L2/3. Preoperative and postoperative curve morphometry studied on plain radiographs included Cobb angle, sagittal vertical axis (SVA), sacral inclination (SI) and lumbar lordosis (LL). Preoperative and postoperative questionnaires including ODI, VAS and SRS-22 were also analysed. Results. The average follow-up was 70 months for group A, 66 months for group B and 35 months for group C. For the whole cohort, the preoperative median cobb angle for thoracic Kyphosis was 88.4°, SVA +3.5 centimeters (cms), lumbar lordosis was 66 °, and the median sacral inclination angle was 40°. The average immediate postoperative cobb angle for thoracic kyphosis was 42°, SVA -1.5 cms, lumbar lordosis 45 ° and sacral inclination angle was 30°. At follow-up, the average cobb angle for thoracic kyphosis was 42.0°, SVA +1 cm, lumbar lordosis 42.0 ° and sacral inclination angle was 22.0 °. There was a significant difference between preoperative and postoperative measurements in all three groups, indicating that good correction and satisfaction was achieved. Three patients had distal junctional Kyphosis in early cases. There was no significant difference obtained in the final cobb angle between group A, group B and group C. All three groups retained the postoperative correction with respect to thoracic kyphosis, and changes in ODI and SRS-22 scores were similar in three groups. Conclusion. In all groups the SVA became negative following correction and at long-term follow-up it was observed to return towards normal physiological limits. The compensatory lumbar curve reduces and this was associated with a decrease in sacral inclination. This method of compensation, without causing junctional kyphosis, has not previously been reported. We were unable to demonstrate a significant difference between the three groups with regards to the clinical outcome, the degree of initial correction, loss of correction and complications. Therefore, in conclusion, we believe a single stage posterior correction and segmental instrumentation not only provides the same clinical and radiological outcomes, but also reduces blood loss, operative time and hospital stay. Ethics approval: None. Interest Statement: None

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth. The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.

Purpose: To investigate the potential value of titanium anterior interbody cages compared to morselized rib graft for anterior interbody fusion in combination with posterior instrumentation, correction and fusion for Scheuermann’s kyphosis. Methods and Materials: A Non-Randomised historic cohort study of two surgical techniques in matched subjects was carried out.15 patients with identical pre-operative radiographic and physical variables (age, gender, height, weight, BMI ) were managed with combined anterior release, interbody fusion, posterior instrumentation, correction and fusion . Group A (n=8) had morsilized rib graft inserted into each intervertebral disc space. Group B (n=7) had titanium interbody cages packed with bone graft inserted at each level. The posterior instrumentation extended from T2 to L2 in both groups. Pre- and post-operative curve morphometry was studied on plain radiographs by two independent observers. The indices studied included Cobb angle, Ferguson’s angle(FA) , Voutsinas index(VI), Sagittal Vertical Axis (SVA), Sacral Inclination (SI) and Lumbar Lordosis (LL). Interbody Fusion was assessed at final follow up. Each patient was reviewed at 3, 6, 12, 24, 48 and 60 months following surgery with standing radiographs. Wilcoxon-matched pairs test and Mann-Whit-ney test were used for statistical analysis. Results: The average follow-up for groups A was 70 and Group B,66 months. For the whole group, the pre-operative : postoperative median Cobb angle, FA, VI, SVA and SI were 86: 42degrees, 50 : 28.4degrees, 28.7 :13, −3.5 : −4.0 centimetres and 40 : 34 degrees respectively. There were significant differences for all variables [p< 0.01] indicating good correction. At four-year follow-up, fusion criteria were satisfied in 12 / 15 cases (80%). Three patients had distal junctional kyphosis. There was no significant difference with respect to the variables between the two groups and both retained the post-operative correction achieved. Conclusion: There was no significant advantage in the use of anterior titanium interbody cages over the use of morselized rib graft in the surgical management of Scheuermann’s Kyphosis

Background: To analyse the effects of surgery on sagittal alignment. 1. in patients with severe Scheuermann’s kyphosis. To assess the ability of two surgical techniques to prevent loss of correction in the thoracic kyphosis. To assess factors of patient’s Body Mass Index (BMI) and instrumentation level on the risk of adjacent level kyphosis or pullout. Methods: A retrospective study of 13 consecutive cases of rigid Scheuermann’s kyphosis. Group A: 6 patients with anterior interbody cages. GroupB: 7 patients with interbody autogenous rib graft. All patients were instrumented posteriorly from T2 to L2. Radiographs from initial presentation, pre-operatively, post-operatively and at final follow –up were assessed. The thoracic kyphosis, lumbar lordosis, sagittal balance. 2. and sacral inclination were measured. Results: There were 7 males and 6 females with a mean age of 22 years (range 15 to 38yrs). The mean follow-up was 26 months (range 7 to 53 mths). In Group A: the mean preoperative kyphosis was 87° (range 82° to 92° ) and postoperative kyphosis was 45° (range 38° to 60°). The mean loss of correction was 0.3° (range 0° to2°). In Group B: the mean preoperative kyphosis was 83° (range 70° to 100°) while the postoperative kyphosis was 43° (range 30° to 60°). The mean loss of correction was 1.1° (range 0°to 2°) at final follow-up. The mean lumbar lordosis pre-operatively for all patients was 66° (range 62° to 84°) reducing to 48° (range 34° to 82°) following surgery. The mean sacral inclination pre-operatively was 41° (range 18° to 80°) reducing to 32 °(range 14°to 40°) following surgery. The mean sagittal balance preoperatively was −1.1 cm (range +0.1 to −3.5). It reduced postoperatively to −2.2 cm (range +1.5 to −4 cm) and was −1.6cm (range +0.2 to – 3.5cm) at final follow- up. Three patients with BMI greater than 25 had an increased lumbar lordosis at final follow up, with one case of implant failure and 2 cases with lower junctional kyphosis. No patient had an upper thoracic junctional kyphosis. There was no evidence of neurological compromise. Conclusion: Patients had a mean thoracic kyphosis correction of 41° (49%). This was maintained during follow-up with no significant difference between autograft and cages. Cranially, all patients had instrumentation to T2 and there was no junctional kyphosis. Caudally, three obese patients (BMI > 25) suffered screw pullout (1 patient) or junctional kyphosis (2 patients). Instrumentation to L3 may avoid this complication in this patient group. The lumbar lordosis and sacral inclination reduced immediately postoperatively, with further correction at final follow –up

Introduction: Surgical treatment is indicated in Scheuermann’s disease with severe kyphotic deformity, and/or unremitting pain. Proximal or distal junctional kyphosis and loss of correction have been reported in the literature, due to short fusion level, overcorrection, or posterior only surgery with failure to release anterior tethering. We reviewed surgically treated Scheuermann’s kyphosis cases, to evaluate the factors affecting the sagittal balance. Methods and results: 35 cases (22 male, 13 female) of Scheuermann’s kyphosis were treated surgically in this centre during 1993–1999. Mean age at operation was 21.5 years (14–53 years). The kyphosis was high thoracic (Gennari Type I) in two cases, mid thoracic (Type II) in 11 cases, low thoracic or thoraco-lumbar (Type III) in eight cases, and whole thoracic (Type IV) in 14 cases. Mean pre-operative kyphosis (Cobb angle) was 81° (range 70° to 110°). Ten cases (mean kyphosis 77°) had one stage posterior operation only with segmental instrumentation. Twenty-five cases had combined anterior and posterior (A-P) surgery. Fifteen cases (mean kyphosis 81°) had one stage thoracoscopic release and posterior instrumentation, and 10 cases (mean kyphosis 89°) had open anterior release, followed by second stage posterior instrumentation. Minimum follow-up was 14 months (mean 45 months, range 14–140 months). The mean post-operative kyphosis was 47.2°. Kyphosis correction achieved ranged from 39% after posterior surgery only, to 42% after thoracoscopic A-P surgery, and 48% after open A-P surgery. Mean loss of correction was 12° after posterior only surgery, 9.5° after thoracoscopic A-P surgery, and 6° after open A-P surgery. Four cases of open A-P surgery had additional anterior cages to stabilise the kyphosis before posterior instrumentation; a mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 25 years (n=16) had significantly better kyphosis correction (p< 0.05). Two cases (6%) developed distal junctional kyphosis due to fusion short of the first lordotic segment, requiring extension of fusion. Four cases (12%) developed proximal junctional kyphosis requiring extension of fusion; all of them had primary posterior surgery only. Location of the curve (Gennari Type) had no significant influence on the initial curve, degree of immediate correction, or loss of correction. Complications included infection (4 cases), pneumothorax (1 case), haemothorax (1 case), instrumentation failure (3 cases); 3 cases had persistent back pain. Conclusion: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann’s kyphosis. Loss of correction, and proximal junctional kyphosis are more frequent after posterior surgery only, and short fusion. Use of cages anteriorly prevents loss of correction. Correction is better achieved in younger patients, but is not influenced by the location of the curve