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. Thoracic kyphosis >55° or back pain and kyphosis >50°.Background
Indication
The purpose was to analyze preoperative symptoms, curve characteristics, and outcome of surgery in patients operated on for isthmic spondylolisthesis with concomitant scoliosis. Overall, 151(9.1%) of 1667 scoliosis patients had spondylolisthesis treated surgically in 21 (13.9%)(19 females, 2 males; 11 low-, 10 high-grade). Patients' age at admission was 13.5(10-17)y. Preoperatively, 5/21 were pain-free (1 high-grade, 4 low-grade), 7 (2 high-grade) had LBP, 2 (both high-grade) radiating pain, and 7 (5 high-grade) had both. Hamstring tightness was present in 5/10 high-grades. Scoliosis was primary thoracic in 3/11 low-grade and secondary lumbar with oblique rotated take-off of L5 in 8/11 low-grade patients. Of the high-grades, 7/10 had sciatic curves and 3 secondary lumbar. In low-grades, the main indication for surgery was pain in 3/11 and lumbar curve progression or the intent to prevent it in 7/11. The operative technique was uninstrumented posterolateral fusion in 8/11, instrumented L4-S1 fusion with reduction of L4-tilt in 2, and direct repair in 1 patient. High-grades were fused to prevent further slipping regardless of subjective symptoms (uninstrumented anterior 5, combined 2, instrumented reduction 3). Selective thoracic fusion for scoliosis was performed in 3 patients. None of the lumbar curves needed fusion. All sciatic curves resolved. The follow-up time was 10.6(2-21)y. Of the low-grade patients, 5 were pain-free, 4 had moderate pain, and 2 had a severe chronic pain syndrome. One had broken pedicle screws without sequelae. Of the high-grade patients, 4 were pain-free, 6 had moderate pain. One had a pain-free peroneal weakness after slip reduction.
Literature review of the best available evidence on the accuracy of computer assisted pedicle screw insertion. Pedicle screw misplacement rates with the conventional insertion technique and adequate postoperative CT examination have ranged from 5 to 29 % in the cervical spine, from 3 to 58 % in the thoracic spine, and from 6 to 41% in the lumbosacral region. Despite these relatively high perforation rates, the incidence of reported screw-related complications has remained low. Interestingly, the highest rates of neurovascular injuries have been reported from the lumbosacral spine in up to 17% of the patients. Gertzbein and Robbins introduced a 4-mm “safe zone” in the thoracolumbar spine for medial encroachment, consisting of 2-mm of epidural and 2-mm of subarachnoid space. Later, several authors have found the safety margins to be significantly smaller, suggesting that the “safe zone” thresholds of Gertzbein and Robbins do not apply to the thoracic spine, and seem to be too high even for the lumbar spine. The midthoracic and midcervical spine, as well as the thoracolumbar junction set the highest demands for accuracy in pedicle screw insertion, with no room for either translational or rotational error at e.g. T5 level. Computer assisted pedicle screw insertion (navigation) was introduced in the early 90's to increase the accuracy and safety of pedicle screw insertion.Study design
Background
