Aims. Closed suction subfascial drainage is widely used after instrumented
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:
Aims. Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with
Aims. In a multicentre, randomised study of adolescents undergoing
posterior spinal fusion for idiopathic scoliosis, we investigated
the effect of adding gelatine matrix with human thrombin to the
standard surgical methods of controlling blood loss. Patients and Methods. Patients in the intervention group (n = 30) were randomised to
receive a minimum of two and a maximum of four units of gelatine
matrix with thrombin in addition to conventional surgical methods
of achieving haemostasis. Only conventional surgical methods were
used in the control group (n = 30). We measured the intra-operative
and total blood loss (intra-operative blood loss plus post-operative
drain output). Results. Each additional hour of operating time increased the intra-operative
blood loss by 356.9 ml (p <
0.001) and the total blood loss by
430.5 ml (p <
0.001). Multiple linear regression analysis showed
that the intervention significantly decreased the intra-operative
(-171 ml, p = 0.025) and total blood loss (-177 ml, p = 0.027).
The decrease in haemoglobin concentration from the day before the
operation to the second post-operative day was significantly smaller
in the intervention group (-6 g/l, p = 0.013) than in the control
group. . Conclusion. The addition of gelatine matrix with human thrombin to conventional
methods of achieving haemostasis reduces both the intra-operative
blood loss and the decrease in haemoglobin concentration post-operatively
in adolescents undergoing
1. Four out of five patients with spondylolisthesis, four-fifths of whom were seen at least five years after operation, had their symptoms relieved after
1. The results of
We studied 29 girls and one boy with adolescent idiopathic scoliosis who were at Risser grade 0 at the time of
We present the results of correcting a double or triple curve
adolescent idiopathic scoliosis using a convex segmental pedicle
screw technique. 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).Aims
Patients and Methods
Twenty-four children with infantile or juvenile idiopathic scoliosis had their spines corrected and solidly fused posteriorly before the age of eleven years. The growth of the fusion area was then accurately measured for a mean of 4.5 years during the adolescent growth spurt. During this period all longitudinal growth in the posterior elements ceased. The vertebral bodies continued to grow anteriorly, but the thick posterior fusion prevented the development of a lordosis. Initially the anterior growth was accommodated by narrowing of the intervertebral disc spaces, but eventually the vertebral bodies bulged laterally towards the convexity and pivoted on the posterior fusion, giving rise to loss of correction, increasing vertebral rotation and recurrence of the rib hump.
The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications.Aims
Methods
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°) 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:
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
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.
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
The June 2024 Spine Roundup. 360. looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following
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
An eight-week-old boy developed severe thoracic
spondylodiscitis following pneumonia and septicaemia. A delay in
diagnosis resulted in complete destruction of the T4 and T5 vertebral
bodies and adjacent discs, with a paraspinal abscess extending into
the mediastinum and epidural space. Antibiotic treatment controlled
the infection and the abscess was aspirated. At the age of six months,
he underwent
This study evaluates the long-term survival of
spinal implants after surgical site infection (SSI) and the risk
factors associated with treatment failure. . A Kaplan-Meier survival analysis was carried out on 43 patients
who had undergone a
We report five children who presented at the mean age of 1.5 years (1.1 to 1.9) with a progressive thoracolumbar kyphosis associated with segmental instability and subluxation of the spine at the level above an anteriorly-wedged hypoplastic vertebra at L1 or L2. The spinal deformity appeared to be developmental and not congenital in origin. The anterior wedging of the vertebra may have been secondary to localised segmental instability and subsequent kyphotic deformity. We suggest the term ‘infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine’ to differentiate this type of deformity from congenital displacement of the spine in which the congenital vertebral anomaly does not resolve. Infantile developmental kyphosis with segmental subluxation of the spine, if progressive, may carry the risk of neurological compromise. In all of our patients the kyphotic deformity progressed over a period of three months and all were treated by localised
The February 2024 Spine Roundup360 looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?
We investigated the incidence of anomalies in
the vertebral arteries and Circle of Willis with three-dimensional
CT angiography in 55 consecutive patients who had undergone an instrumented
posterior fusion of the cervical spine. We recorded any peri-operative and post-operative complications.
The frequency of congenital anomalies was 30.9%, abnormal vertebral
artery blood flow was 58.2% and vertebral artery dominance 40%. . The posterior communicating artery was occluded on one side in
41.8% of patients and bilaterally in 38.2%. Variations in the vertebral
arteries and Circle of Willis were not significantly related to
the presence or absence of posterior communicating arteries. Importantly,
18.2% of patients showed characteristic variations in the Circle
of Willis with unilateral vertebral artery stenosis or a dominant
vertebral artery, indicating that injury may cause lethal complications.
One patient had post-operative cerebellar symptoms due to intra-operative
injury of the vertebral artery, and one underwent a different surgical
procedure because of insufficient collateral circulation. . Pre-operative assessment of the vertebral arteries and Circle
of Willis is essential if a
The August 2024 Spine Roundup360 looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture.
The April 2023 Spine Roundup360 looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.
The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.
Five cases of syphilitic aortic aneurysm with erosion of the spinal column are reviewed. Four patients underwent operation. When erosion of the spine was mild or moderate, the aortic lesion only was treated. Aneurysm associated with extensive vertebral erosion was treated in two cases by anterior spinal fusion combined with replacement of the disc and part of the aorta. In one of these cases the spine was later reinforced by a
The operative and anaesthesic technique for 44 patients undergoing
Twenty-three patients with severe paralytic thoracolumbar scoliosis due to a myelomeningocele were treated by a two-stage procedure. Before operation the mean scoliosis was 98 degrees: after the first-stage procedure, an anterior spinal fusion and correction with Dwyer instrumentation, this was reduced to a mean of 45 degrees. Approximately two weeks later a
Spondylolysis occurring after a spinal fusion is considered to result from operative damage to the pars interarticularis on both sides. Fourteen cases are reported, and compared with the 23 cases which have previously been published. The defects are usually recognised within five years of fusion, and usually occur immediately above the fusion mass. Other contributory causes may be: fatigue fracture from concentration of stress; damage and altered function of the posterior ligament complex; and degenerative disc disease immediately above or below the fusion. Fusion technique is critical, since virtually all cases occurred after posterior interlaminar fusions. This complication is easily overlooked in patients with recurrent back pain after an originally successful
Thirteen patients with dystrophic spinal deformities from neurofibromatosis treated by anterior and posterior fusion have been reviewed. The shortest follow-up was five years, the average seven years. Combined fusion produced satisfactory results in patients with a smooth kyphoscoliosis or with scoliosis without kyphosis, but it was unsatisfactory in patients with an angular kyphoscoliosis. Of the five patients with angular kyphoscoliosis, one had a persistent pseudarthrosis after operation and all had progression of the kyphosis despite the treatment. The morbidity rate also was high in this group of patients. Many of the complications were related to soft-tissue manifestations of the disease. It is recommended that very special attention be paid to the dystrophic angular deformity in neurofibromatosis; even anterior and
Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly.
Bone-marrow transplantation has increased the survival of patients with mucopolysaccharidosis-I. We describe the spinal problems and their management in 12 patients with this disorder who have been followed up for a mean of 4.5 years since transplantation. High lumbar kyphosis was seen in ten patients which was associated with thoracic scoliosis in one. Isolated thoracic scoliosis was seen in another. One patient did not have any significant problems in the thoracic or lumbar spine but had odontoid hypoplasia, which was also seen in three other children. Four of the eight patients in whom MRI of the cervical spine had been performed had abnormal soft tissue around the tip of the odontoid. Neurological problems were seen in two patients. In one it was caused by cord compression in the lower dorsal spine 9.5 years after
The factors during and after operation which influence the development of a solid and stable
We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous
This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction? A total of 45 patients with a thoracic AIS which needed surgical correction and fusion were included in a prospective study. All patients underwent pulmonary function testing (PFT) and low-dose biplanar radiographs both preoperatively and one year after surgery. The following measurements were recorded: forced vital capacity (FVC), slow vital capacity (SVC), and total lung capacity (TLC). Rib cage volume (RCV), maximum rib hump, main thoracic curve Cobb angle (MCCA), medial-lateral and anteroposterior diameter, and T4-T12 kyphosis were calculated from 3D reconstructions of the biplanar radiographs.Aims
Methods
One hundred and sixty-seven patients with adolescent idiopathic scoliosis were allocated prospectively to one of three different groups for correction before undergoing
Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7).Aims
Methods
We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in
The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion.Aims
Methods
This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed.Aims
Methods
To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele. We reviewed 12 consecutive patients (7M:5F; mean age 12.4 years (9.2 to 16.8)) including demographic details, spinopelvic parameters, surgical correction, and perioperative data. We assessed the impact of surgery on patient outcomes using the Spina Bifida Spine Questionnaire and a qualitative questionnaire.Aims
Methods
Total hip arthroplasty (THA) patients undergoing or having a prior lumbar spine fusion (LSF) have an increased risk of mechanical complications. The aim of this registry-based, retrospective comparative cohort study is to assess the longer term survival of THA in patients who have undergone a LSF during a 17-year period (2000 to 2017). A registry-based population study was conducted on 679 patients who underwent both THA and LSF surgeries. Patients were identified from the regional arthroplasty data base and cross linked to patients with LSF from the regional hospital discharge database between 2000 and 2017. Demographic data, diagnosis leading to primary THA, primary implant survival, perioperative complications, number and causes of failure, and patients requiring revision arthroplasty were collated and compared. For comparison, data from 67,919 primary THAs performed during the same time time period were also retrieved and analyzed.Aims
Methods
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. 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 Aims
Methods
Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA.Aims
Methods
The purpose of this study was to evaluate the incidence and analyze the trends of surgeon-reported complications following surgery for adolescent idiopathic scoliosis (AIS) over a 13-year period from the Scoliosis Research Society (SRS) Morbidity and Mortality database. All patients with AIS between ten and 18 years of age, entered into the SRS Morbidity and Mortality database between 2004 and 2016, were analyzed. All perioperative complications were evaluated for correlations with associated factors. Complication trends were analyzed by comparing the cohorts between 2004 to 2007 and 2013 to 2016.Aims
Methods
We studied the effects of hyperbaric oxygen (HBO) and zoledronic acid (ZA) on posterior lumbar fusion using a validated animal model. A total of 40 New Zealand white rabbits underwent posterior lumbar fusion at L5–6 with autogenous iliac bone grafting. They were divided randomly into four groups as follows: group 1, control; group 2, HBO (2.4 atm for two hours daily); group 3, local ZA (20 μg of ZA mixed with bone graft); and group 4, combined HBO and local ZA. All the animals were killed six weeks after surgery and the fusion segments were subjected to radiological analysis, manual palpation, biomechanical testing and histological examination. Five rabbits died within two weeks of operation. Thus, 35 rabbits (eight in group 1 and nine in groups 2, 3 and 4) completed the study. The rates of fusion in groups 3 and 4 (p = 0.015) were higher than in group 1 (p <
0.001) in terms of radiological analysis and in group 4 was higher than in group 1 with regard to manual palpation (p = 0.015). We found a statistically significant difference in the biomechanical analysis between groups 1 and 4 (p = 0.024). Histological examination also showed a statistically significant difference between groups 1 and 4 (p = 0.036). Our results suggest that local ZA combined with HBO may improve the success rate in
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. A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression.Aims
Methods
Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly. This retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes.Aims
Methods
Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome.Aims
Methods
The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. The Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed.Aims
Patients and Methods
The aim of this study was to investigate the impact of maturity status at the time of surgery on final spinal height in patients with an adolescent idiopathic scoliosis (AIS) using the spine-pelvic index (SPI). The SPI is a self-control ratio that is independent of age and maturity status. The study recruited 152 female patients with a Lenke 1 AIS. The additional inclusion criteria were a thoracic Cobb angle between 45° and 70°, Risser 0 to 1 or 3 to 4 at the time of surgery, and follow-up until 18 years of age or Risser stage 5. The patients were stratified into four groups: Risser 0 to 1 and selective fusion surgery (Group 1), Risser 0 to 1 and non-selective fusion (Group 2), Risser 3 to 4 and selective fusion surgery (Group 3), and Risser 3 to 4 and non-selective fusion (Group 4). The height of spine at follow-up (HOSf) and height of pelvis at follow-up (HOPf) were measured and the predicted HOS (pHOS) was calculated as 2.22 (SPI) × HOPf. One-way analysis of variance (ANOVA) was performed for statistical analysis.Aims
Patients and Methods
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:
The December 2014 Spine Roundup360 looks at: surgeon outcomes; complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis.
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. No patient underwent spinal decompression or instrumentation
placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative
blood loss 200 ml (150 to 340). There was one wound infection treated
with antibiotics but no other complication. Radiological assessment
included standing posteroanterior and lateral, Ferguson and lateral flexion/extension
views, as well as CT scans. Aims
Methods
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:
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.
The aims of our study were to provide long-term information on
the behaviour of the thoracolumbar/lumbar (TL/L) curve after thoracic
anterior correction and fusion (ASF) and to determine the impact
of ASF on pulmonary function. A total of 41 patients (four males, 37 females) with main thoracic
(MT) adolescent idiopathic scoliosis (AIS) treated with ASF were
included. Mean age at surgery was 15.2 years (11 to 27). Mean follow-up
period was 13.5 years (10 to 18).Aims
Patients and Methods
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.
The December 2013 Spine Roundup360 looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.
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.
The purpose of this study was to determine whether
patients with a burst fracture of the thoracolumbar spine treated
by short segment pedicle screw fixation fared better clinically
and radiologically if the affected segment was fused at the same
time. A total of 50 patients were enrolled in a prospective study
and assigned to one of two groups. After the exclusion of three
patients, there were 23 patients in the fusion group and 24 in the
non-fusion group. Follow-up was at a mean of 23.9 months (18 to
30). Functional outcome was evaluated using the Greenough Low Back
Outcome Score. Neurological function was graded using the American
Spinal Injury Association Impairment Scale. Peri-operative blood transfusion requirements and duration of
surgery were significantly higher in the fusion group (p = 0.029
and p <
0.001, respectively). There were no clinical or radiological
differences in outcome between the groups (all outcomes p >
0.05).
The results of this study suggest that adjunctive fusion is unnecessary
when managing patients with a burst fracture of the thoracolumbar
spine with short segment pedicle screw fixation.
There are many causes of paraspinal muscle weakness which give rise to the dropped-head syndrome. In the upper cervical spine the central portion of the spinal cord innervates the cervical paraspinal muscles. Dropped-head syndrome resulting from injury to the central spinal cord at this level has not previously been described. We report two patients who were treated acutely for this condition. Both presented with weakness in the upper limbs and paraspinal cervical musculature after a fracture of C2. Despite improvement in the strength of the upper limbs, the paraspinal muscle weakness persisted in both patients. One ultimately underwent cervicothoracic fusion to treat her dropped-head syndrome. While the cause of the dropped-head syndrome cannot be definitively ascribed to the injuries to the spinal cord, this pattern is consistent with the known patho-anatomical mechanisms of both injury to the central spinal cord and dropped-head syndrome.
This prospective study of 136 children with progressive infantile scoliosis treated under the age of four years, and followed up for nine years, shows that the scoliosis can be reversed by harnessing the vigorous growth of the infant to early treatment by serial corrective plaster jackets. In 94 children (group 1), who were referred and treated in the early stages of progression, at a mean age of one year seven months (6 to 48 months) and with a mean Cobb angle of 32° (11° to 65°), the scoliosis resolved by a mean age of three years and six months. They needed no further treatment and went on to lead a normal life. At the last follow-up, their mean age was 11 years and two months (1 year 10 months to 25 years 2 months), 23 (24.5%) were at Risser stages 4 and 5 and 13 girls were post-menarchal. In 42 children (group 2), who were referred late at a mean age of two years and six months (11 to 48 months) and with a mean Cobb angle of 52° (23° to 92°), treatment could only reduce but not reverse the deformity. At the last follow-up, at a mean age of ten years and four months (1 year 9 months to 22 years 1 month), eight children (19%) were at Risser stages 4 and 5 and five girls were post-menarchal. Fifteen children (35.7%) had undergone spinal fusion, as may all the rest eventually.
The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.
Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use.
A combination of hemivertebrae and diastematomyelia is rare. We have identified 12 such patients seen during a period of 11 years in the orthopaedic, spinal and neurosurgical units in Nottingham and analysed their treatment and outcome.