Aims. 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. Patients and Methods. 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. Results. A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. Conclusion. This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227–33

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.

Aims. We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique. Patients and Methods. We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15). Results. The mean post-operative follow-up was 5.8 years (2.5 to 9.5). There were no neurological complications, deep wound infection, obvious nonunion or need for revision surgery. Upper thoracic scoliosis was corrected by a mean 68.2% (38% to 48%, p < 0.001). Main thoracic scoliosis was corrected by a mean 71% (43.5% to 8.9%, p < 0.001). Lumbar scoliosis was corrected by a mean 72.3% (41% to 90%, p < 0.001). No patient lost more than 3° of correction at follow-up. The thoracic kyphosis improved by 13.1° (-21° to 49°, p < 0.001); the lumbar lordosis remained unchanged (p = 0.58). Coronal imbalance was corrected by a mean 98% (0% to 100%, p < 0.001). Sagittal imbalance was corrected by a mean 96% (20% to 100%, p < 0.001). The Scoliosis Research Society Outcomes Questionnaire score improved from a mean 3.6 to 4.6 (2.4 to 4, p < 0.001); patient satisfaction was a mean 4.9 (4.8 to 5). . Conclusions. This technique carries low neurological and vascular risks because the screws are placed in the pedicles of the convex side of the curve, away from the spinal cord, cauda equina and the aorta. A low implant density (pedicle screw density 1.2, when a density of 2 represents placement of pedicle screws bilaterally at every instrumented segment) achieved satisfactory correction of the scoliosis, an improved thoracic kyphosis and normal global sagittal balance. Both patient satisfaction and functional outcomes were excellent. Cite this article: Bone Joint J 2017;99-B:1080–7

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting thoracolumbar/lumbar idiopathic scoliosis in adolescent patients. Summary of Background Data. Thoracolumbar/lumbar scoliosis has been traditionally treated through an anterior approach and instrumented arthrodesis with the aim to include in the fusion the Cobb-to-Cobb levels and preserve distal mobile spinal segments. Posterior instrumentation has been extensively used for thoracic or thoracic and lumbar scoliosis. In the advent of all-pedicle screw constructs there is debate on whether thoracolumbar/lumbar scoliosis is best treated through an anterior or a posterior instrumented arthrodesis. Methods. We reviewed the medical notes and radiographs of 19 consecutive adolescent patients with Lenke 5C idiopathic scoliosis (17 female-2 male, prospectively collected single surgeon's series). We measured the scoliosis, thoracic kyphosis and lumbar lordosis angles, apical vertebral rotation (AVR) and translation (AVT), trunk shift (TS), as well as the lower instrumented vertebra angle (LIVA) both pre-and post-operatively and at minimum 2-year follow-up. SRS 22 data was available for all patients. Results. All patients underwent posterior spinal arthrodesis of the primary thoracolumbar/lumbar curve using all-pedicle screw constructs. Mean age at surgery was 15.1 years. We identified 3 separate groups: Group 1 (9 patients) had a fusion to include the preoperative Cobb-to-Cobb levels of the curve; in Group 2 (8 patients) the fusion extended 1-2 levels distal (all patients) +/− proximal (4 patients) to the end Cobb vertebrae; in Group 3 (2 patients) the fusion extended to one level proximal to the lower end Cobb vertebra. Eight patients had compensatory thoracic curves. Mean Cobb angle before surgery was 60.3° (range: 43-91°). This was corrected by 79% to mean 13° (p<0.001) with no patient losing >2° correction at follow-up. Mean preoperative Cobb levels of the thoracolumbar/lumbar curve were 6.3; mean levels of instrumented fusion were 7 (mean extent of fusion: preoperative Cobb angle + 0.7 levels). Mean preoperative thoracic kyphosis was 34.7° and lumbar lordosis 45.3°. Mean postoperative thoracic kyphosis was 36.6° and lumbar lordosis 43°. Mean theatre time was 3.8 hours, hospital stay 7.5 days and intraoperative blood loss 0.26 blood volumes. There were no neurological complications other than one temporary brachial plexus neuropraxia (recovered before patient discharge from hospital), no wound infections or detected non-union at follow-up. Mean preoperative SRS 22 score was 3.7; this was improved to 4.5 at 2-year follow-up (p=0.01). Pain and self-image demonstrated significant improvement (p=0.02, p=0.001 respectively) with mean satisfaction rate 4.8. Comparison between Groups 1 and 2 showed similar age at surgery but higher preoperative scoliosis in Group 2 (Group 1: 54°/Group 2: 65°, p=0.05). Preoperative AVR, TS and LIVA were similar between the 2 groups (p>0.05). Preoperative AVT was significantly higher in Group 2 (Group 1: 3.3 cm/Group 2: 5 cm, p=0.01). Conclusion. Pedicle screw instrumentation can achieve excellent correction of Lenke 5C idiopathic scoliosis which is maintained at follow-up. This is associated with high patient satisfaction and low complication rates. Greater preoperative AVT and scoliosis angle predicted the need for longer fusion both distally and proximally beyond the end vertebra of the preoperative Cobb angle

To present the results of surgical correction in patients with double or triple thoracic/lumbar AIS (Lenke types 2,3,4) with the use of a novel convex/convex unilateral segmental screw correction technique in a single surgeon's prospective series. We reviewed the medical records and spinal radiographs of 92 consecutive patients (72 female-20 male). We measured scoliosis, thoracic kyphosis, lumbar lordosis, scoliosis flexibility and correction index, coronal and sagittal balance before and after surgery, as well as at minimum 2-year follow-up. SRS-22 data was available preoperatively, 6-month, 12-month and 2-year postoperatively for all patients. Surgical technique. All patients underwent posterior spinal fusion using pedicle screw constructs. Unilateral screws were placed across the convexity of each individual thoracic or lumbar curve to allow for segmental correction. ‘Corrective rod’ was the one attached to the convexity of each curve with the correction performed across the main thoracic scoliosis always before the lumbar. Maximum correction of main thoracic curves was always performed, whereas the lumbar scoliosis was corrected to the degree required to achieve a balanced effect across the thoracic and lumbar segments and adequate global coronal spinal balance. Concave screws were not placed across any deformity levels. Bilateral screws across 2 levels caudally and 1–2 levels cephalad provided proximal/distal stability of the construct. Mean age at surgery was 14.9 years with mean Risser grade 2.8. The distribution of scoliosis was: Lenke type 2–26 patients; type 3–43 patients; type 4–23 patients. Mean preoperative Cobb angle for upper thoracic curves was 45°. This was corrected by 62% to mean 17° (p<0.001). Mean preoperative Cobb angle for main thoracic curves was 70°. This was corrected by 69% to mean 22° (p<0.001). Mean preoperative Cobb angle for lumbar curves was 56°. This was corrected by 68% to mean 18° (p<0.001). No patient lost >2° correction at follow-up. Mean preoperative thoracic kyphosis was 34° and lumbar lordosis 46°. Mean postoperative thoracic kyphosis was 45° (p<0.001) and lumbar lordosis 46.5° (p=0.69). Mean preoperative coronal imbalance was 1.2 cm. This corrected to mean 0.02 cm at follow-up (p<0.001). Mean preoperative sagittal imbalance was −2 cm. This corrected to mean −0.1 cm at follow-up (p<0.001). Mean theatre time was 187 minutes, hospital stay 6.8 days and intraoperative blood loss 0.29 blood volumes (1100 ml). Intraoperative spinal cord monitoring was performed recording cortical and cervical SSEPs and transcranial upper/lower limb MEPs and there were no problems. None of the patients developed neurological complications, infection or detected non-union and none required revision surgery to address residual or recurrent deformity. Mean preoperative SRS-22 score was 3.6; this improved to 4.6 at follow-up (p<0.001). All individual parameters also demonstrated significant improvement (p<0.001) with mean satisfaction rate at 2-year follow-up 4.9. The convex-convex unilateral pedicle screw technique can reduce the risk of neurological injury during major deformity surgery as it does not require placement of screws across the deformed apical concave pedicles which are in close proximity to the spinal cord. Despite the use of a lesser number of pedicle fixation points compared to the bilateral segmental screw techniques, in our series it has achieved satisfactory scoliosis correction and restoration of global coronal and sagittal balance with improved thoracic kyphosis and preserved lumbar lordosis. These results have been associated with excellent patient satisfaction and functional outcomes as demonstrated through the SRS-22 scores

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

Aim:. To determine radiographic variables that predict the need for distal extension of the fusion beyond Cobb-to-Cobb levels in treating thoracolumbar/lumbar (TL/L) scoliosis (Lenke 5) in adolescent patients. Method:. We reviewed the medical notes and radiographs of the senior author's consecutive series of 53 adolescent patients with TL/L scoliosis treated by posterior instrumented spinal arthrodesis using an all-pedicle screw construct. Our patients were categorised into 2 groups: patients with instrumented fusion between Cobb-to-Cobb levels of the TL/L curve (Group 1), and patients that required distal extension beyond the caudal Cobb level (Group 2). Pearson correlation and binary logistic regression analyses (significance p<0.05) were performed to identify variables that predict the need for distal extension. Results:. Groups 1 and 2 comprised 36 and 17 patients, respectively. The following preoperative parameters significantly correlated with distal extension of the fusion: TL/L scoliosis angle (TL/L), TL/L supine maximum lateral bending angle, TL/L apical vertebral translation (AVT), TL/L flexibility index (FI), lowest instrumented vertebra angle (LIVA), and compensatory thoracic scoliosis angle (TH). Binary logistic regression analysis optimised a predictive equation incorporating TL/L, AVT, FI, LIVA, and TH parameters that provides an 81% accuracy in predicting the need for Cobb-to-Cobb fusion or distal extension. There was no difference in demographic data or SRS-22 scores between the 2 groups. Discussion:. Regression analysis of preoperative radiographic variables can accurately predict the need for distal extension of the fusion beyond the preoperative Cobb-to-Cobb levels during posterior spinal arthrodesis in patients with adolescent idiopathic thoracolumbar/lumbar scoliosis. Conflict Of Interest Statement: No conflict of interest

Introduction. The Proprio-oculo-vestibular system is involved in scoliosis. In Congress ZORAB, Oxford 2006, we showed correlations between morphological semicircular canals (SCC) anomalies and vestibular dysfunctions associated with oculomotor anomalies. We will describe a set of specific anomalies in adolescent idiopathic scoliosis (AIS) in favour of an altered perception of space. Methods. The study included 95 patients with AIS: 57 had thoracolumbar scoliosis, 24 thoracic scoliosis, and 14 lumbar deformation. Patients were submitted to a set of tests: (1) three-dimensional vestibular evaluation with semicircular canal-specific horizontal and vertical stimulations; (2) measurement of the static ocular torsion; (3) ocular smooth pursuits analyses with a new automatised programme; and (4) posturographic recording (static and dynamic tests). The tests were done before and after treatment (vestibular training and oculomotor training). Results. In AIS, the vestibular and oculomotor results highlighted lateralised signs following a specific pattern: in the case of a right thoracic and right thoracic/left lombar scoliosis we found a right head tilt (head to shoulder), a left horizontal vestibular predominance associated with a posterior vertical predominance, a pronounced exocylotorsion on left eye, and specific abnormal horizontal and vertical smooth pursuits. All these signs were not found in mirror in cases of inversed deformation nor in cases of lumbar scoliosis. Conclusions. We propose that in some AIS, the proprio-oculo-vestibular system is altered and induces anomalies in space perception with consequences on the descending direct vestibulospinal output and consequences on the cognitive top-down influence. Our results suggest that the most common deformation (right thoracic/left lombar) is organised on a predeterminate brain level

Aims

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.

Aims

The aim of this study was to determine the influence of pelvic parameters on the tendency of patients with adolescent idiopathic scoliosis (AIS) to develop flatback deformity (thoracic hypokyphosis and lumbar hypolordosis) and its effect on quality-of-life outcomes.

Aims

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.

Aims

The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT.

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second ^{rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws.}

Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates.

A self-control ratio, the spine-pelvis index (SPI), was proposed for the assessment of patients with adolescent idiopathic scoliosis (AIS) in this study. The aim was to evaluate the disproportionate growth between the spine and pelvis in these patients using SPI. A total of 64 female patients with thoracic AIS were randomly enrolled between December 2010 and October 2012 (mean age 13 years, standard deviation (sd) 2.17; 9 to 18) and a further 73 healthy female patients with a mean age of 12.4 years (mean age 12.4 years, sd 2.24; 9 to 18), were randomly selected from a normal control database at our centre. The radiographic parameters measured included length of spine (LOS), height of spine (HOS), length of thoracic vertebrae (LOT), height of thoracic vertebrae (HOT), width of pelvis (WOP), height of pelvis (HOP) and width of thorax (WOT). SPI was defined as the ratio LOS/HOP. The SPI and LOT/HOP in patients with AIS showed a significant increase when compared with normal girls (p < 0.001 and p < 0.001 respectively), implying an abnormal pattern of growth of the spine relative to the pelvis in patients with AIS.

No significant difference in SPI was found in different age groups in the control group, making the SPI an age-independent parameter with a mean value of 2.219 (2.164 to 2.239). We also found that the SPI was not related to maturity in the control group.

This study, for the first time, used a self-control ratio to confirm the disproportionate patterns of growth of the spine and pelvis in patients with thoracic AIS, highlighting that the SPI is not affected by age or maturity.

Cite this article: Bone Joint J 2015;97-B:1668–74.

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities.

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108^° (80 to 150^°) and was corrected to 62^° (43^° to 85^°); the mean thoracic kyphosis from 17^° (-23^° to 35^°) to 47^° (25^° to 65^°); the mean scoliosis from 82^° (0^° to 125^°) to 22^° (0^° to 40^°); the mean pelvic obliquity from 21^° (0^° to 38^°) to 3^° (0^° to 15^°); the mean sacral slope from 79^° (54^° to 90^°) to 50^° (31^° to 66^°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.