Aims

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

Aims

Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution.

Aim. To investigate anterior instrumented corrective fusion for thoracolumbar or lumbar scoliosis. Methods. A retrospective review of medical records and radiographs of 38 consecutively managed patients who underwent anterior spine surgery for thoracolumbar curves by a single surgeon between 2001 and 2011. The cohort consisted of 28 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up x-rays. Results. Thoracolumbar/lumbar curves were corrected from 70 to 27 degrees. The thoracic compensatory curve spontaneously corrected from 34 to 19 degrees. Sagittal imbalance of greater than 4 centimeters was found in 40 percent of patients preoperatively and in 16 percent post operatively (85 percent negative sagittal imbalance, 15 percent positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.13 of a grade. Average operative time was 194 minutes and estimated blood loss was 450 ml. The diaphragm was taken down in 36 of the 38 patients but no post-op ventilation was required. The average high care stay was 1.2 days. Average follow-up was 18 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 29 degrees, and the mean compensatory thoracic curve measuring 21 degrees. There were no significant neurological or respiratory complications. Conclusion. Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. NO DISCLOSURES

Purpose. 1. To evaluate how radiological parameters change during the first 3 years following anterior endoscopic surgery. 2. To report complications encountered in this period. Methods. Between April 2000 and June 2006,106 patients underwent an anterior endoscopic instrumented fusion. There were 95 females and 11 males. Average age was 16.1 years (range 10-46). 103 (97%) had right-sided idiopathic curves. The majority were Lenke type 1 (79%). Patients were assessed at 3, 6, 12, 24, and 36 months. 83 patients had 1 year follow-up, 69 had 2 years or more. The following were investigated; the structural curve, instrumented curve, non-structural curves, skeletal age at operation and sagittal profile (T5-T12). Results. The mean Cobb angle of the structural curve was 52.3 degrees. 2 months following surgery, it was 21.4 degrees, with a correction rate was 59%. There was a partial loss of correction thereafter (29.3 degrees at 3 years, P=<0.001). The instrumented curve did not change significantly. The mean post-operative Cobb angles of the proximal and distal non-structural curves (when present) at 2months were 19.6 and 19.7 degrees respectively. At 3 years they were 18.8 and 24.4. The change in the distal curve was significant (p=<0.05). The pre-operative sagittal profile was 19 degrees. At 2 months it was 28 degrees and 31 degrees at 3 years. Skeletal maturity at time of surgery was not found to influence the structural curve. There were 12 fractured rods. All were 4.5mm rods and all but 2 were using rib autograft. There were 8 cases of proximal screw pullout. Conclusion. Anterior endoscopic surgery is effective in restoring both sagittal and coronal balance. However, there is small loss of coronal correction in the structural curve. 11% of rods fractured, though none occurred in the 94 patients where a larger rod (5.5mm) and femoral allograft was used

Introduction: Compared with open instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS), endoscopic surgery offers clinical benefits that include reduced pulmonary morbidity and improved cosmesis. However, quantitative data on the radiological improvement of vertebral rotation using this method is limited. The aim of this study was to measure pre-operative and postoperative axial vertebral rotational deformity at the curve apex in endoscopic anterior instrumented scoliosis surgery patients using computed tomography (CT), and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction. Methods: Between November 2002 and August 2005, twenty patients with right-sided thoracic curves underwent endoscopic single-rod anterior instrumented fusion. Pre and post surgical axial vertebral rotation was measured at the curve apex on preoperative and two-year postoperative CT using Aaro and Dahlborn’s method. Rib hump deformity correction was retrieved from a surgical database and correlated to the CT findings. Linear regression was used to investigate the correlation between apical vertebral rotation measured on CT and rib hump measured using a scoliometer. Results: The mean angle of correction achieved in axial vertebral body derotation at the apical vertebra as measured by CT was 7.9°. This equated to a 43% improvement (range 20–90%). The preoperative and postoperative clinical measurements i.e. rib hump deformity correction, correlated significantly with CT measurements using regression analysis (p=0.03) and the mean improvement in rib hump deformity was 55%. Conclusion: To our knowledge, this is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves the axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares favourably historically published figures for all-hook-rod constructs in posterior spinal fusion. In addition, the CT measurements obtained significantly correlated to the clinical outcome of rib hump deformity correction

Study Aims: This study’s objectives were to measure pre-operative and postoperative axial vertebral rotational deformity at the curve apex in endoscopically-treated anterior-instrumented scoliosis patients using CT, and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction. Introduction: Thoracoscopic instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS) has clinical benefits that include reduced pulmonary morbidity, postoperative pain, and improved cosmesis. However, quantitative data on radiological improvement of vertebral rotation using this method is lacking. Methods: Between November 2002 and August 2005, 20 AIS patients with right-sided thoracic major curves underwent endoscopic single-rod anterior fusion. Preoperative and two-year postoperative CT was performed to assess axial vertebral rotation at the curve apex. Correlation between apical vertebral rotation measured on CT and rib hump measured using a scoliometer was assessed. Results: The mean angle of correction achieved in axial vertebral body derotation at the apical vertebra measured by CT was 7.9° and equated to 43% improvement. Preoperative and postoperative rib hump deformity correction correlated significantly with CT measurements using regression analysis (p=0.03). The mean improvement in rib hump deformity was 55%. Conclusion: We believe this is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares favourably with historically published figures of 24% for patients with posterior all-hook-rod constructs. CT measurements correlated significantly to the clinical outcome of rib hump deformity correction. Ethics: local committee approval. Statement of Interest: none

Study Design: Retrospective study with clinical and radiological evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebae (HV). Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurological compromise. Summary of background data: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique. Materials and Methods: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. 13 patients had a single posterolateral HV and 2 patients a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range 8–33). Mean follow-up period was 6.8 years. 13 HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine. Results: The average operating time was procedure was 150 minutes (range, 130 to 210 minutes). The average blood loss 180 mL (range, 100 to 330 mL), equivalent to a mean external blood volume loss of 15% (range, 11 to 24%). 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. Key points:. 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

Study Design: Retrospective study with clinical and radiological evaluation of 29 patients with congenital scoliosis who underwent 31 short segment anterior instrumented fusions of lateral hemivertebrae. Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital scoliosis in children below the age of 6. Summary of background data: A variety of treatments have been described in the literature for the treatment of HV. We report the results of a novel technique. Materials and Methods: Between 1996 and 2005, 29 consecutive patients with 31 lateral HV and progressive scoliosis underwent short segment anterior instrumentation and fusion with preservation of the HV. Mean age at surgery was 2.9 years. Mean follow-up period was 6.3 years. Results: Preoperative segmental Cobb angle averaging 39°, was corrected to 150 after surgery, being 15º at the last follow up (60% of improvement). Compensatory cranial and caudal curves corrected by approximately 50% and did not change significantly on follow up. The angle of segmental kyphosis averaged 13º before surgery, 12º after surgery, and 12° at follow up. There was 2 wound infection requiring surgical debridment, 1 intraoperative fracture of the vertebral body and 1 case lost correction due to implant failure. All went on to stable bony union. There were no neurologic complications. Conclusions: Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and to prevent the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion which is of great importance in the growing spine

Introduction: Open instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS) is a proven technique for vertebral derotation that, compared with posterior spinal fusion procedures, invariably requires fewer distal fusion levels to be performed. With the advent and evolution of endoscopic anterior instrumentation, further clinical benefits are possible such as reduced pulmonary morbidity, improved cosmesis and less postoperative pain. However, quantitative data on the radiological improvement of vertebral rotation using this method is limited. The aim of this study was to measure preoperative and postoperative axial vertebral rotational deformity at the apex of the curve in endoscopic anterior instrumented scoliosis surgery patients using computed tomography (CT), and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction. Methods: Between November 2002 and August 2005, adolescent idiopathic scoliosis patients with right-sided thoracic major curves were selected for endoscopic single-rod anterior fusion by the senior authors. Low-dose pre-operative CT was performed as described previously (1) and two-year postoperative CT was also performed on consenting patients in accordance with local ethical committee approval. The pre and post surgical axial vertebral rotation was measured at the curve apex using Aaro and Dahlborn’s method (2). Intraobserver and interobserver variability was assessed. Additional clinical information such as rib hump deformity correction and change in the Cobb angle was retrieved from a surgical database and correlated to the CT findings. Least squares linear regression was used to investigate the correlation between apical vertebral rotation measured on CT and rib hump measured using a scoliometer. Results: Twenty patients were included in the study. The mean angle of correction achieved in axial vertebral body derotation at the apical vertebra measured by CT was 7.9° (median preoperative angle 17.3° [range 12.5° to 27.3°] and median postoperative angle 10.3° [range 1.8° to 18.1°]. This equated to a 43% improvement (range 20–90%). The preoperative and postoperative clinical measurements i.e. rib hump deformity correction, correlated significantly with CT measurements using regression analysis (p=0.03) and the mean improvement in rib hump deformity was 55% (median preoperative 15.0° [range 10° to 30°] and median postoperative 7.0° [range 4° to 10°]). 95% confidence intervals for intraobserver and interobserver validity were within the ranges ±4.5° to ±6.4°. Discussion: We believe this is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves the axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares more favourably than the historically published figure of 24% in a cohort of patients with all-hook-rod constructs used for posterior spinal fusion (3). Patient age and gender demographics, curve magnitude and curve types in the historical study were similar to our group, and an identical CT protocol for measuring vertebral derotation was utilised. In addition, the CT measurements obtained significantly correlated to the clinical outcome of rib hump deformity correction

Thoracoscopic spinal instrumentation and fusion has emerged as a viable alternative to open anterior and posterior techniques for the treatment of thoracic adolescent idiopathic scoliosis. Furthermore, the morbidity associated with thoracoscopy is limited, and the cosmetic result more desirable because of the minimal skin and chest wall dissection required with this method. However, the technique is technically demanding and has been perceived as having a steep learning curve. The objective of our study is to anal the initial series of 50 patients performed by a single surgeon, with respect to the coronal and sagittal alignment on radiographs, as well as a review of the peri-operative data and complications. Fifty consecutive patients who underwent thoraco-scopic instrumentation and fusion were divided into two groups for the purpose of this study: the first 25 cases (1st group) and the second 25 cases (2nd group). The minimum follow-up of these cases was 12 months (range 12 to 67 months). Data collected included the operative time, intra-operative blood loss, number of levels instrumented, length of the hospital stay, the number of days in the ICU, and the duration of analgesia. No major complications, such as neurological deficit, vascular injury, or implant failure were observed. No significant difference was encountered between the groups in terms of age and menarche at surgery, pre-operative curve magnitude and flexibility, sagittal profile, as well as the number of levels in the curve pre-operatively. The second group had significantly better coronal deformity correction at one week post-operatively (9.5 degrees versus 16.3 degrees, p < 0.001), six months post-operatively (12.1 degrees versus 18.9 degrees, p < 0.001), and at latest follow-up (15.1 degrees versus 19.5 degrees, p < 0.05). The percentage correction of scoliosis was significantly better in the second group at one week postoperatively (p < 0.001), six months post-operatively (p < 0.001), and at latest follow-up (p = 0.014). The percentage change in thoracic kyphosis and lumbar lordosis after surgery was not significantly different between both groups at various times of follow-up. There was no difference between both groups with regards to the number of levels fused, hospital stay, and duration of parenteral analgesia. Operative time was significantly less in the second group (302 minutes versus 372 minutes, p < 0.001). Estimated blood loss was also less in the second group (170 cc versus 266 cc, p = 0.04). The length of ICU stay was also shorter in the second group (1.8 days versus three days, p = 0.004). From the loess (locally-weighted regression) fit, the learning curve is estimated to be 30 cases with regards to the operative time, ICU duration, and the coronal plane deformity correction. The learning curve associated with thoracoscopic spinal instrumentation is acceptable. The complication rates remained stable throughout the surgeon’s experience. Thoracoscopic anterior instrumented fusion is a viable surgical alternative to standard posterior fusion and instrumentation for adolescent idiopathic scoliosis requiring selective thoracic fusion

Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated.

We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis.

There was only one neurological complication, which occurred in a patient with a 127° congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available.

Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels.

In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.