The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation.

Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)).

We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage.

Cite this article: Bone Joint J 2014;96-B:94–9.

Purpose: To identify patients in whom anterior scoliosis correction was not possible and to determine pre-operative factors that may predict such an outcome.

Methods: From 1999–2005, 257 patients were listed for anterior correction with the Kaneda Anterior Spine System (KASS). Of these 246 were completed successfully. However in 11 cases it was not possible to complete the procedure.

We performed a retrospective review of case notes and X-rays. A control group of 22 patients, in whom anterior surgery was completed, matched to age, sex and type of curve, was used.

Results: Two reasons for abandoning anterior instrumentation were identified; loss of cord signal (7) and failure to achieve adequate correction after anterior release and reduction (4).

Of the seven patients with lost signal three were syndromic and four were associated with syrinx. In all seven, loss of signal occurred on clamping of segmental vessels. All seven had no residual neurological deficit post-operatively and had uncomplicated posterior correction the following week.

All four patients in whom inadequate correction was achieved after anterior release and repositioning had idiopathic curves. Of these two were thoracic and two were thoracolumbar. Mean pre-operative Cobb angle was 67 (range 59–85) compared to a mean of 56 (range 42–68) in the control group. Mean pre-operative stiffness index was 91% (range 85%–100%) compared to a mean stiffness index of 65% (range 53–80) in the control population.

Conclusion: Whilst a successful outcome is achieved in a majority of KASS instrumentations we have identified two reasons why anterior surgery has to be abandoned. Whilst one often cannot pre-operatively anticipate intra-operative loss of cord signal, we found that in cases with an underlying syrinx there is a particular risk of this occurrence. Our experience has shown particularly stiff curves (Stiffness index ≥ 85%) may not be suitable for stand-alone anterior surgery.

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection.

Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications.

At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus.

Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only.

Objective: To assess the validity of the Tokuhashi and Tomita scoring systems in the prediction of prognosis following spinal surgery for skeletal metastases.

Design: A retrospective cohort study of patients treated in a specialist spinal unit

Subjects: All patients undergoing definitive surgery for metastastes of the spine were considered eligible. Time to death or current length of survival was available in 147* of these which was confirmed by the Cancer Registry. Medical and nursing case notes were reviewed and prognostic scores using the methods of Tokuhashi et al, and Tomita et al. were calculated for each patient.

*

death data for further patients currently awaited from Cancer Registry.

Outcome measures: Mean survival period with 95% confidence intervals for patients grouped according to prognostic score.

Results: Thirty-two patients were still alive and 113 had confirmed death dates. Forty-three patients had Tokuhashi scores of 9 or greater with a mean survival of 20.1 months (95% confidence interval 5.8 months) compared to 9.5 months (2.9 months) for scores 6–8 and 3.5 months (1.8 months) for scores below this. Tomita scoring showed a similar trend with those with better prognostic profiles but without the same degree of statistical significance. The overall 30-day mortality was 8.2% with no significant difference between any other groups.

Conclusion: In patients presenting with metastatic disease involving the spine, published prognostic profiles offer some guidance to likely survival of the patient and so the appropriateness of surgical treatment.