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Sarwahi V, Hasan S, Visahan K, Rahman E, Eigo K, Galina J, Goldstein J, Dowling TJ, Fakhoury J, Lo Y, Amaral T. Congenital scoliosis presenting in teenage years outcomes without hemivertebra excision. Spine Deform 2025; 13:835-843. [PMID: 39875733 DOI: 10.1007/s43390-025-01039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 12/31/2024] [Indexed: 01/30/2025]
Abstract
PURPOSE In congenital scoliosis, the surgical strategy approach of hemivertebra excision, with or without instrumentation and fusion, is a common approach to correction of scoliosis. However, hemivertebra excisions are technically challenging, with potential complications including spinal cord injury, nerve root injury and cerebrospinal fluid leak. The purpose of this study was to determine whether correction of congenital scoliosis can be achieved using a posterior instrumentation/fusion-only approach without the need for hemivertebra excision. METHODS 35 patients with congenital scoliosis and hemivertebra operated between 2007 and 2024 were matched to 35 AIS patients by BMI, levels fused, and preoperative Cobb. Wilcoxon rank-sum tests, chi-square tests, and Fisher's Exact tests were utilized. RESULTS Age (p = 0.22), BMI (p = 0.25) and preoperative Cobb (p = 0.79) were similar between hemivertebra and AIS patients. Cobb correction (HV: 71.8% vs. AIS: 70.4%; p = 0.92) and EBL (500 cc vs. 400 cc; p = 1.0) were similar. Operative time (310.0 min vs. 242.0 min; p < 0.001) and length of stay (7.0 days vs. 5.0 days; p < 0.001) were statistically different. Patients operated on after 2018, when the Rapid Recovery Protocol was implemented, had a similar length of stay (4.5 vs. 5.0; p = 0.92). Patients in both cohorts had similar SRS-22 scores. CONCLUSION Choosing fusion levels in congenital patients, on similar principles to AIS, leads to avoidance of hemivertebra excision, including lumbosacral hemivertebrae. This approach is safer than hemivertebra excision and has similar, or better, curve correction than previously reported.
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Affiliation(s)
- Vishal Sarwahi
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA.
| | - Sayyida Hasan
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Keshin Visahan
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Effat Rahman
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Katherine Eigo
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Jesse Galina
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Jeffrey Goldstein
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Thomas J Dowling
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Jordan Fakhoury
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
| | - Yungtai Lo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Terry Amaral
- Department of Orthopaedics, Spinal Deformity and Pediatric Orthopaedics, Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, NY, 11042, USA
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Jain A, Ahuja K, Roberts SB, Tsirikos AI. Techniques of Deformity Correction in Adolescent Idiopathic Scoliosis-A Narrative Review of the Existing Literature. J Clin Med 2025; 14:2396. [PMID: 40217846 PMCID: PMC11989510 DOI: 10.3390/jcm14072396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2025] [Revised: 03/26/2025] [Accepted: 03/26/2025] [Indexed: 04/14/2025] Open
Abstract
Surgical management of adolescent idiopathic scoliosis [AIS] is a complex undertaking with the primary goals to correct the deformity, maintain sagittal balance, preserve pulmonary function, maximize postoperative function, and improve or at least not harm the function of the lumbar spine. The evolution of surgical techniques for AIS has been remarkable, transitioning from rudimentary methods of spinal correction to highly refined, biomechanically sound procedures. Modern techniques incorporate advanced three-dimensional correction strategies, often leveraging pedicle screw constructs, which provide superior rotational control of the vertebral column. A number of surgical techniques have been described in the literature, each having its own pros and cons. This narrative review provides a detailed analysis of the contemporary surgical techniques used in the treatment of patients with AIS.
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Affiliation(s)
- Aakash Jain
- All India Institute of Medical Sciences, Rishikesh 249201, India;
| | - Kaustubh Ahuja
- All India Institute of Medical Sciences, Rishikesh 249201, India;
| | - Simon B. Roberts
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK;
| | - Athanasios I. Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK;
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Hui VYT, Cheung JPY, Cheung PWH. Lateral view fulcrum bending radiographs predict postoperative hypokyphosis after selective thoracic fusion in adolescent idiopathic scoliosis. Asian Spine J 2025; 19:102-111. [PMID: 40037324 PMCID: PMC11895112 DOI: 10.31616/asj.2024.0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 12/05/2024] [Accepted: 12/16/2024] [Indexed: 03/06/2025] Open
Abstract
STUDY DESIGN A retrospective observational study. PURPOSE To identify the surgical and preoperative risk factors on fulcrum bending radiographs for postoperative hypokyphosis in patients with Lenke 1 adolescent idiopathic scoliosis (AIS). OVERVIEW OF LITERATURE AIS is associated with thoracic hypokyphosis. Persistent hypokyphosis causes reduced pulmonary function and spinopelvic malalignment. Indications for Ponte osteotomies and releases to improve postoperative kyphosis restoration in patients with hypokyphosis are still unclear. Previous studies have demonstrated that kyphosis correction was limited by sagittal flexibility based on lateral view fulcrum bending radiographs. METHODS Patients with Lenke 1 AIS undergoing posterior spinal fusion were included. Standing and fulcrum bending radiographs on the coronal and sagittal planes were analyzed at preoperative, immediate, and 2-year postoperative periods. The primary outcome was postoperative hypokyphosis (T5-12 thoracic kyphosis [TK] <20°). Risk factors for postoperative hypokyphosis were identified by multivariate logistic regression, and the optimal cutoff for significant risk factors was determined by receiver operating characteristic analysis. RESULTS In total, 156 patients were included in the analysis, of which 68 (43.6%) were hypokyphotic at 2-year follow-up. Low T5-12 TK on lateral view fulcrum bending films (immediate postoperative odds ratio [OR], 0.870; 95% confidence interval [CI], 0.826-0.917; 2-year postoperative OR, 0.916; 95% CI, 0.876-0.959; p<0.001) and high convex side implant density (2-year postoperative OR, 1.749; 95% CI, 1.056-2.897; p=0.03) were significant risk factors for postoperative hypokyphosis. Other baseline demographic and surgical factors did not affect postoperative kyphosis correction. The T5-12 TK cutoff on fulcrum bending for 2-year postoperative hypokyphosis was 12.45° (area under the curve, 0.773; 95% CI, 0.661-0.820). CONCLUSIONS Fulcrum bending radiography is useful in assessing coronal and sagittal flexibility for preoperative planning. In patients with T5-12 kyphosis <12.5° on lateral view fulcrum bending radiographs, Ponte osteotomies or releases, or a decrease in convex side implant density should be considered to improve kyphosis restoration and reduce the risk of 2-year postoperative hypokyphosis.
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Affiliation(s)
- Victoria Yuk Ting Hui
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Prudence Wing Hang Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
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Krishnan A, Chauhan V, Agarawal S, Dave B, Devanand D, Dave MB, Mayi S, Rai RR, Anil A, Panthackel M, Murkute K. The Technique of a Modified Ponte Osteotomy Using Ultrasonic Bone Scalpel in Spinal Deformity Correction: Does It Save Time and Reduce Blood Loss? Cureus 2025; 17:e77858. [PMID: 39991401 PMCID: PMC11845863 DOI: 10.7759/cureus.77858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2025] [Indexed: 02/25/2025] Open
Abstract
Background and objective Posterior column osteotomies, such as Smith-Petersen and Ponte osteotomies, are widely utilized in the surgical correction of spinal deformities to address sagittal and coronal imbalances by releasing the posterior tension band. While traditional methods using rongeurs and osteotomies are effective, these are often associated with prolonged operative time, significant blood loss, and increased risk to neural structures. These challenges have driven interest in advanced tools like the ultrasonic bone scalpel (UBS), which uses high-frequency vibrations to enable precise bone cutting with minimal damage to surrounding tissues. This innovative tool has demonstrated significant reductions in blood loss and operative time in various spinal procedures. However, its specific application in modified Ponte osteotomies remains underexplored. This study evaluates the UBS's safety, efficiency, and impact on blood loss in complex deformity corrections and presents a refined technique for optimizing outcomes in these challenging surgeries. Additionally, it outlines a refined technique for executing modified Ponte osteotomies with this advanced tool. Methods This retrospective study included all patients who underwent spinal deformity surgery involving modified Ponte osteotomy with a UBS between January 2013 and June 2022. Key metrics analyzed included the number of modified Ponte osteotomy segments performed per surgery, the total time taken for osteotomies, and the average time required per segment. Blood loss was evaluated with a focus on epidural and bony sources, and methods for controlling bleeding were documented. Safety parameters included intraoperative neurophysiological signal integrity and the incidence of dural tears. Results A total of 695 modified Ponte osteotomy segments were performed in 111 patients undergoing complex spinal deformity correction surgery. The average number of segments created per procedure was 6.26 ± 1.59 (range: three to nine). The mean operative time required for all segments per surgery was 19.16 ± 5.66 minutes, with an average time of 3.05 ± 0.29 minutes per segment (range: 2.13-4.66 minutes). Epidural bleeding was observed at an average of 1.65 ± 1.27 points per surgery (range: 0-6), equating to 0.26 ± 0.20 points per segment. Bleeding was effectively controlled with bipolar ablation and absorbable gelatin sponge packing, and no significant bony bleeding was reported. Of note, there were no instances of intraoperative neuromonitoring signal loss or dural tears, demonstrating the safety of the technique. No splinters occurred while osteotomizing in any case. Conclusions The use of UBS significantly enhances the efficiency and safety of modified Ponte osteotomy during spinal deformity correction surgeries. This technique not only reduces operative time but also minimizes blood loss, offering an advanced approach to achieving precise osteotomies without compromising patient safety. These findings underscore the benefits of incorporating UBS into complex spinal surgical procedures.
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Affiliation(s)
- Ajay Krishnan
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
- Spine Surgery, Bhavnagar Institute of Medical Science, Bhavnagar, IND
| | - Vikrant Chauhan
- Orthopaedics, Government Doon Medical College and Hospital, Dehradun, IND
| | - Sandesh Agarawal
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
- Orthopaedic Surgery, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Bharat Dave
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Degulmadi Devanand
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Mirant B Dave
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Shivanand Mayi
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Ravi R Rai
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Abhijith Anil
- Orthopaedics/Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Mikeson Panthackel
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
| | - Kishore Murkute
- Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, IND
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Kulkarni AG, Kumar P, Yeshwanth T, Gunjotikar S, Goparaju P, Adbalwad YM, Chadalavada ARSS, Umarani A, Patil S. Optimising deformity correction: a retrospective comparative analysis of two techniques in high magnitude curves in adolescent idiopathic scoliosis. Asian Spine J 2024; 18:794-802. [PMID: 39763355 PMCID: PMC11711172 DOI: 10.31616/asj.2024.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 10/14/2024] [Accepted: 10/14/2024] [Indexed: 01/11/2025] Open
Abstract
STUDY DESIGN A retrospective comparative study. PURPOSE To validate the hypothesis that a combination of multilevel Ponte osteotomy (PO) with intraoperative traction (IOT) results in a better correction than IOT alone in high-magnitude curves in adolescent idiopathic scoliosis (AIS) and does not possess an attributable risk of neurological injury. OVERVIEW OF LITERATURE On a comprehensive review of the literature, the choice of technique adopted for curves between 65° and 100° remains controversial with no major consensus favoring one technique over the other. METHODS Twenty-four patients with AIS (Cobb >65°) underwent surgery at a single center between January 2014 and December 2021. The first 10 patients underwent surgery using only IOT (T group), whereas the subsequent 14 patients underwent surgery with a combination of IOT and PO (TP group). RESULTS The mean preoperative Cobb angles in the T and TP groups were 89.35°±6.05° and 92.32°±9.28°, respectively (p=0.59). The mean flexibility index (FI) of the T and TP groups were 0.31±0.016 and 0.36±0.03, respectively (p=0.41). The mean postoperative Cobb angle in the T and TP groups were 40.25°±5.95° and 19.1°±3.20°, respectively (p=0.041). Apical vertebral rotation improved from mean grade 3.2 (2-4) to grade 2.6 (1-3) in the T group and from mean grade 3.6 (2-4) to mean grade 1.8 (1-3) in the TP group. Postoperatively, the mean thoracic kyphosis was 13.84°±2.10° and 21.02°±1.68° in T and TP groups (p=0.044). Transient signal-loss intraoperatively was noted in two patients, one in each group. No episodes of postoperative neurological deficits were reported. No incidences of pseudarthrosis/implant-related complications were reported at the end of 2 years in either group. CONCLUSIONS IOT and PO complement one another and can be safely combined without an attributable risk of neurological injury.
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Affiliation(s)
| | - Priyambada Kumar
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
| | - Thonangi Yeshwanth
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
| | - Sharvari Gunjotikar
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
| | - Praveen Goparaju
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
| | | | | | - Arvind Umarani
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
| | - Shankargouda Patil
- Department of Spine Surgery, Bombay Hospital and Medical Research Centre, Mumbai,
India
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Nasto LA, Mousavi Nasab SH, Sieczak A, Cattolico A, Ulisse P, Pola E. Ponte osteotomies for treatment of spinal deformities: they are not all made equal. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2787-2793. [PMID: 38822151 DOI: 10.1007/s00586-024-08334-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/23/2024] [Accepted: 05/23/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE To compare surgical outcomes of Ponte's osteotomies for treatment of adolescent idiopathic scoliosis (AIS), Scheuermann's kyphosis (SK), and adult scoliosis (AdS). METHODS We conducted a retrospective review of patients with AIS, SK, and AdIS who underwent posterior spinal instrumented fusion (PSIF) at our Institution from January 2019 to December 2022. Demographics, imaging, and intraoperative data (including number of osteotomies performed, blood losses, surgical timing, and complications) were extracted from patient charts. RESULTS A total of 80 patients (62 AIS, 7 SK, and 11 AdS) were enrolled in the study. All patients were treated with a PSIF and a total of 506 Ponte osteotomies were performed (5.8 ± 4.1, 9.3 ± 2.4, and 7.5 ± 2.5 average osteotomies per patient in the AIS, SK, and AdS group, respectively; p = 0.045). Average time per osteotomy was 6.3 ± 1.5 min in the AIS group, and 5.8 ± 2.1 and 8.7 ± 4.0 in the SK and AdS group, respectively (p = 0.002). Blood loss was significantly smaller in the SK group (8.6 ± 9.6 ml per osteotomy) compared to AIS group (34.9 ± 23.7 ml) and AdS group (34.9 ± 32.7 ml) (p = 0.001). A total of 4 complications were observed in the AIS group (1.1%) and 2 complications in the AdS group (2.4%), but this was not statistically significant. CONCLUSIONS Our study shows that Ponte's osteotomies are safe and effective in surgical treatment of AIS, SK, and AdS. Blood loss and execution time per osteotomy are significantly smaller in the SK group compared to AIS and AdS. No significant differences were noted in terms of complications between the three groups.
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Affiliation(s)
- Luigi Aurelio Nasto
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy.
| | - Seyed Hirbod Mousavi Nasab
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy
| | - Angelo Sieczak
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy
| | - Alessandro Cattolico
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy
| | - Paolo Ulisse
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy
| | - Enrico Pola
- Department of Orthopaedics, Azienda Ospedaliera Universitaria "Luigi Vanvitelli", Università degli Studi della Campania "Luigi Vanvitelli" School of Medicine, Piazza Luigi Miraglia 2, Padiglione 3 Est, 1° Piano, 80138, Naples, Italy
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Gorijala VK, Reddy RP, Anetakis KM, Balzer J, Crammond DJ, Shandal V, Shaw JD, Christie MR, Thirumala PD. Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1644-1656. [PMID: 38285275 DOI: 10.1007/s00586-023-08063-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Vamsi Krishna Gorijala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Rajiv P Reddy
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeffrey Balzer
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Donald J Crammond
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Varun Shandal
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michelle R Christie
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Al Rashdan A, Alessa M, Ababneh F, Al Taimeh F, Althunaibat Z. Effectiveness of Facetectomy in Correction of Adolescent Idiopathic Scoliosis. Cureus 2024; 16:e55768. [PMID: 38463404 PMCID: PMC10921130 DOI: 10.7759/cureus.55768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 03/12/2024] Open
Abstract
INTRODUCTION Surgical correction of adolescent idiopathic scoliosis (AIS) using the facetectomy technique with the utilization of segmental pedicle screws aims to achieve correction of coronal and sagittal imbalances and preserve normal neurological function. In this study, we aimed to certify the effectiveness of the facetectomy technique in the correction of AIS by analyzing technique outcomes. METHODS This is a retrospective, single-center study. From January 2018 to March 2022, a total of 51 patients with AIS who underwent inferior facetectomy with segmental pedicle screw constructs at the Royal Rehabilitation Center were reviewed. Radiological parameters including the major curve Cobb angle, and global coronal balance were evaluated preoperatively, postoperatively, and at the final follow-up. Surgical parameters and complications were also reported. RESULTS The mean major curve Cobb angle was 59.5 ± 4.9° preoperatively, 13.6 ± 2.7° postoperatively, and 14.5 ± 2.6° at the final follow-up, with correction rates of 77.2% and 75.7%, respectively. The mean global coronal balance was 2.7 ± 1.1 cm preoperatively, 1.7 ± 0.73 cm postoperatively, and 1.4 ± 0.55 cm at the final follow-up. Two cases of pleural injuries were reported intraoperatively. Postoperatively, two cases experienced superficial wound infections, one experienced pulmonary embolism, and one patient had revision surgery due to the loosening of a single screw. None of these complications lasted long. CONCLUSIONS When combined with posterior segmental pedicle screw constructs, inferior facetectomy can provide an effective rate of correction in a reasonably safe manner.
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Affiliation(s)
| | - Monther Alessa
- Department of Orthopedics, Royal Medical Services, Amman, JOR
| | - Faris Ababneh
- Department of Orthopedics, Royal Medical Services, Amman, JOR
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Tanida S, Masamoto K, Tsukanaka M, Futami T. No short-term clinical improvement and mean 6° of thoracic kyphosis correction using limited-level Ponte osteotomy near T7 for Lenke type 1 and 2 adolescent idiopathic scoliosis: a preliminary study. J Pediatr Orthop B 2023; 32:537-546. [PMID: 36943678 DOI: 10.1097/bpb.0000000000001074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
This study was a retrospective single surgeon case series approved by institutional review board and showed the efficacy of limited Ponte osteotomy at T6/7, 7/8 and 8/9 (limited-PO) in the sagittal plane for patients with Lenke type 1 and 2 adolescent idiopathic scoliosis (AIS). A total of 37 consecutive patients [7 males and 30 females; average age 16.0 ± 2.5 (range: 12-21)] over a 4-year period with posterior corrective fusion surgery were included. Initially, 18 patients were operated on without limited-PO [P(-)-group]. Midway in the series, the senior author switched to the limited-PO [P(+)-group]. The limited-PO has been performed to form the apex of thoracic kyphosis at the T7 level, together with the restoration of thoracic kyphosis. The mean amount of the correction angle of thoracic kyphosis was more in the P(+)-than in P(-)-group (13.8 ± 9.6° vs. 7.8 ± 8.0°, P = 0.046) at 1-year after surgery. Cervical lordosis was spontaneously corrected more in P(+)-than in P(-)-group. The apex of thoracic kyphosis was controlled around the T7 level postoperatively in most cases (18/19 cases). There was no significant difference between the two groups in terms of blood loss and operative time per level, or Scoliosis Research Society-22 domain scores. Limited-PO contributed to the restoration of the whole spinal sagittal alignment for Lenke type 1 and 2 AIS; however, in this preliminary study, the clinical improvement was unclear at least in the short term, because the kyphosis angle obtained by limited-PO was only approximately 6°.
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Affiliation(s)
- Shimei Tanida
- Department of Orthopaedic Surgery, Shiga General Hospital
| | | | - Masako Tsukanaka
- Department of Orthopaedic Surgery, Shiga Medical Center for Children, Shiga, Japan
| | - Toru Futami
- Department of Orthopaedic Surgery, Shiga Medical Center for Children, Shiga, Japan
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Yanik HS, Ketenci IE. Correction of severe adult idiopathic scoliosis posteriorly with skipped pedicle screw instrumentation and rod augmentation. Medicine (Baltimore) 2023; 102:e35359. [PMID: 37746973 PMCID: PMC10519490 DOI: 10.1097/md.0000000000035359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/16/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Although it is challenging to correct severe adult idiopathic scoliosis (ADIS) deformities, optimal results can be achieved by multiple asymmetric Ponte osteotomies with lower surgical risks. Skipping the apical instrumentation and using multiple rods and connectors may further facilitate the procedure. We named this method as "modular correction technique" (MCT). METHODS Sixty-two patients with severe ADIS who were treated with MCT were recruited into this study, and retrospectively evaluated. Radiographic and functional outcomes as well as pulmonary functions were examined preoperatively and at last follow-up. Main radiologic parameters were related to Cobb angles, coronal, sagittal, and shoulder balance. Scoliosis Research Society-22 questionnaire and the Oswestry Disability Index were used to evaluate clinical outcomes. RESULTS Average age of the patients was 41.3 years (range: 23-65). Thirty-nine of the patients were female and 23 of them were male. Coronal Cobb angle of the main curve, shoulder balance, coronal, and sagittal balance significantly improved after the surgery. Forced vital capacity and forced expiratory volume in the first second were mildly improved after the surgery, however the improvement was not statistically significant. Postoperative clinical outcome scores improved significantly. CONCLUSION MCT can be performed with low risk of complications and relatively low operation time and blood loss. It facilitates rod insertion and correction maneuvers. Radiologic, especially coronal balance, and functional outcomes can be improved with minimal morbidity while deterioration of pulmonary function is prevented. This technique is useful in severe but relatively flexible ADIS deformities.
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Affiliation(s)
- Hakan Serhat Yanik
- Department of Orthopedics and Traumatology, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
| | - Ismail Emre Ketenci
- Department of Orthopedics and Traumatology, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
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11
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Faldini C, Viroli G, Barile F, Manzetti M, Ialuna M, Traversari M, Vita F, Ruffilli A. One stage correction via the Hi-PoAD technique for the management of severe, stiff, adolescent idiopathic scoliosis curves > 90°. Spine Deform 2023; 11:957-967. [PMID: 36811705 PMCID: PMC10260697 DOI: 10.1007/s43390-023-00663-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 02/04/2023] [Indexed: 02/24/2023]
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE to assess the efficacy and safety of Hi-PoAD technique in patients with a major thoracic curve > 90°, < 25% of flexibility and deformity spread over more than five vertebral levels. METHODS retrospective review of AIS patients with a major thoracic curve (Lenke 1-2-3) > 90°, with < 25% of flexibility and deformity spread over more than five vertebral levels. All were treated via the Hi-PoAD technique. Radiographic and clinical score data were collected pre-operatively, operatively, at 1 year, 2 years and at last follow-up (2 years minimum). RESULTS 19 patients were enrolled. A 65.0% correction rate of the main curve was achieved, from 101.9° to 35.7° (p < 0.001). The AVR reduced from 3.3 to 1.3. The C7PL/CSVL reduced from 1.5 to 0.9 cm (p = 0.013). Trunk Height increased from 31.1 to 37.0 cm (p < 0.001). At the final follow-up no significant changes, except from an improvement in C7PL/CSVL (from 0.9 cm to 0.6 cm; p = 0.017). SRS-22 increased in all patients, from 2.1 to 3.9 at 1 year of follow-up (p < 0.001). 3 patients had a transient drop of MEP and SEP during maneuver and were managed with temporary rods and a second surgery after 5 days. 2 of these 3 cases (66.7%) had a Total-Deformity Angular Ratio (T-DAR) > 25; conversely, among patients who had a one-stage procedure, only 1 (6.2%) had a T-DAR > 25 (p = 0.008). CONCLUSIONS The Hi-PoAD technique proved to be a valid alternative for the treatment of severe, rigid AIS involving more than 5 vertebral bodies. STUDY DESIGN Retrospective comparative cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cesare Faldini
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Giovanni Viroli
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
| | - Francesca Barile
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Marco Manzetti
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Marco Ialuna
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Matteo Traversari
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Fabio Vita
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Alberto Ruffilli
- Department of Biomedical and Neuromotor Science-DIBINEM, 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, University of Bologna, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
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12
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Wan SHT, Wong DLL, To SCH, Meng N, Zhang T, Cheung JPY. Patient and surgical predictors of 3D correction in posterior spinal fusion: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1927-1946. [PMID: 37079078 DOI: 10.1007/s00586-023-07708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/18/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Restoration of three-dimensional (3D) alignment is critical in correcting patients with adolescent idiopathic scoliosis using posterior spinal fusion (PSF). However, current studies mostly rely on 2D radiographs, resulting in inaccurate assessment of surgical correction and underlying predictive factors. While 3D reconstruction of biplanar radiographs is a reliable and accurate tool for quantifying spinal deformity, no study has reviewed the current literature on its use in evaluating surgical prognosis. PURPOSE To summarize the current evidence on patient and surgical factors affecting sagittal alignment and curve correction after PSF based on 3D parameters derived from reconstruction of biplanar radiographs. METHODS A comprehensive search was conducted by three independent investigators on Medline, PubMed, Web of Science, and Cochrane Library to obtain all published information on predictors of postoperative alignment and correction after PSF. Search items included "adolescent idiopathic scoliosis," "stereoradiography," "three-dimensional," "surgical," and "correction." The inclusion and exclusion criteria were carefully defined to include clinical studies. Risk of bias was assessed with the Quality in Prognostic Studies tool, and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development, and Evaluations approach. 989 publications were identified, with 444 unique articles subjected to full-text screening. Ultimately, 41 articles were included. RESULTS Strong predictors of better curve correction included preoperative normokyphosis (TK > 15°), a corresponding rod contour, intraoperative vertebral rotation and translation, and upper and lower instrumented vertebrae selected based on sagittal and axial inflection points. For example, for Lenke 1 patients with junctional vertebrae above L1, fusion to NV-1 (1 level above the neutral vertebra) achieved optimal curve correction while preserving motion segments. Pre-op coronal Cobb angle and axial rotation, distal junctional kyphosis, pelvic incidence, sacral slope, and type of instrument were identified as predictors with moderate evidence. For Lenke 1C patients, > 50% LIV rotation was found to increase spontaneous lumbar curve correction. Pre-op thoracolumbar apical translation and lumbar lordosis, Ponte osteotomies, and rod material were found to be predictors with low evidence. CONCLUSIONS Rod contouring and UIV/LIV selection should be based on preoperative 3D TK in order to achieve normal postoperative alignment. Specifically, Lenke 1 patients with high-lying rotations should be fused distally at NV-1, while hypokyphotic patients with large lumbar curves and truncal shift should be fused at NV to improve lumbar alignment. Lenke 1C curves should be corrected using > 50% LIV rotation counterclockwise to the lumbar rotation. Further investigation should compare surgical correction between pedicle-screw and hybrid constructs using matched cohorts. DJK and overbending rods are potential predictors of postoperative alignment.
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Affiliation(s)
- Sandra Hiu-Tung Wan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Darren Li-Liang Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Samuel Ching-Hang To
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Nan Meng
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Teng Zhang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jason Pui-Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
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13
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Zhu F, Zhang Y, Wang G, Ning Y, Leng X, Huang B. Posterior Multisegment Apical Convex plus Concave Intervertebral Release Combined with Posterior Column Osteotomy for the Treatment of Rigid Thoracic/Thoracolumbar Scoliosis. World Neurosurg 2023; 170:43-53. [PMID: 36442784 DOI: 10.1016/j.wneu.2022.11.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intervertebral release (IVR) in the apical region is critical for full release of a rigid spine. Previous studies have mainly reported IVR techniques using an anterior approach or posterior apical convex IVR. We first report the surgical procedure of posterior multisegment apical convex plus concave IVR combined with posterior column osteotomy (PCO) for treating rigid thoracic/thoracolumbar scoliosis. METHODS This study retrospectively analyzed clinical, radiologic outcomes and technique notes of 18 patients with rigid scoliosis treated with posterior multisegment convex plus concave IVR combined with PCO. RESULTS The preoperative, postoperative, and final follow-up mean sagittal Cobb angles of the main curve were 75.2° (58.7°-110.2°), 18.4° (9°-35.1°), and 19.0° (8.2°-36.3°), respectively. The mean correction rate was 75.3% (66.7%-86.7%). In cases of thoracolumbar kyphosis, the preoperative, postoperative, and final follow-up mean sagittal Cobb angles were 45.7° (40.5°-52.6°), 18.8° (10.2°-27.5°), and 19.8° (11.1°-29°), respectively. The mean correction rate was 57% (42.1%-72.6%). The mean axial vertebral rotation (AVR) in the IVR region was 24.4° (14.3°-46.3°) preoperatively and was corrected to 10.9° (10.9°-26.6°) postoperatively. The mean correction rate for AVR was 55.9% (41.1%-78.6%). The coronal and sagittal Cobb angles and AVR postoperatively were significantly lower than those preoperatively (P < 0.001). This case series reported 2 cases of pleural effusion and 1 case of wound infection. CONCLUSIONS Single posterior multilevel apical convex plus concave IVR combined with PCO is a safe and effective surgical method for treating rigid thoracic/thoracolumbar scoliosis that does not need 3-column osteotomy.
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Affiliation(s)
- Fengzhao Zhu
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Yaqing Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Guanzhong Wang
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Ya Ning
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Xue Leng
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Bo Huang
- Department of Orthopedics, Xinqiao Hospital, Army Military Medical University, Chongqing, China.
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Wang F, Chen K, Ji T, Ma Y, Huang H, Zhou P, Wei X, Chen Z, Bai Y. Do hypokyphotic adolescent idiopathic scoliosis patients treated with Ponte osteotomy obtain a better clinical efficacy? A preliminary retrospective study. J Orthop Surg Res 2022; 17:491. [PMID: 36384684 PMCID: PMC9670489 DOI: 10.1186/s13018-022-03390-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022] Open
Abstract
Study design A retrospective case–control study. Objective To evaluate whether Ponte osteotomy improves thoracic kyphosis and to determine its clinical efficacy in hypokyphotic adolescent idiopathic scoliosis (AIS).
Methods Eighty consecutive Lenke type 1 AIS patients with hypokyphotic curves who underwent posterior spinal fusion by one spine surgeon at a single institution were recruited. According to whether Ponte osteotomy was performed, the patients were divided into two groups. The preoperative, immediate, one-year postoperative, and two-year postoperative radiographs were analyzed. The demographic characteristics, surgical information, radiographic parameters, Scoliosis Research Societye-22 (SRS-22) questionnaire, and complications were compared. Results The sagittal alignment and coronal alignment were both improved in the Ponte group and the control group postoperatively. There was no significant difference in the preoperative parameters between the two groups, except the TL/L, CB, and LL. Significant differences were found in the MT (15.18° ± 2.84° vs. 20.33° ± 3.75°, P < 0.001) and TK (24.23° ± 2.71° vs. 19.93° ± 2.38°, P < 0.001) at the two-year follow-up. The Ponte group had a longer operation time and more intraoperative blood loss. No significant difference was observed between the groups in the SRS-22 scores at the final follow-up. Conclusions Ponte osteotomy could obtain better coronal correction and sagittal contour restoration in AIS patients with hypokyphosis. However, Ponte osteotomies might lead to more intraoperative blood loss and longer operation time. Moreover, no discrepancy was found in the postoperative health-related quality of life of the included patients. Therefore, we considered that the Ponte osteotomy may be an alternative method to restore the desired thoracic kyphosis, which needs further study.
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Shaheen M, Koltsov JCB, Cohen SA, Langner JL, Kaur J, Segovia NA, Vorhies JS. Complication risks and costs associated with Ponte osteotomies in surgical treatment of adolescent idiopathic scoliosis: insights from a national database. Spine Deform 2022; 10:1339-1348. [PMID: 35810408 DOI: 10.1007/s43390-022-00534-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/23/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Risks of Ponte osteotomies (POs) used for posterior spinal fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) are challenging to assess because of the rarity of complications. Using a national administrative claims database, we evaluated trends, costs and complications associated with PO used in PSF for AIS patients. METHODS Using ICD-9/CPT codes, we identified patients (ages 10-18) with AIS who underwent PSF (± PO) between 2007 and 2015 in the IBM® MarketScan® Commercial Databases. Costs and trends of POs were evaluated. Odds of neurological complications and readmissions within 90 days and reoperations within 90 days and 2 years were assessed. RESULTS We identified 8881 AIS patients who had undergone PSF, of which 8193 had 90-day follow-up and 4248 had 2-year follow-up. Overall, 28.8% had PO. Annual rate of POs increased from 17.3 to 35.2% from 2007 to 2015 (p < 0.001). Risk-adjusted multivariable logistic regression demonstrated no relationship between POs and neurologic complications (p = 0.543). POs were associated with higher odds for readmission (1.52 [1.21-1.91]; p < 0.001) and reoperation (2.03 [1.13-3.59]; p = 0.015) within 90 days, but there were no differences in the odds of reoperation within 2 years (p = 0.836). Median hospital costs were $15,854 (17.4%) higher for patients with POs (p < 0.001) and multivariable modeling demonstrated POs to be an independent predictor of increased costs (p < 0.001). CONCLUSION Annual rate of POs increased steadily from 2007 to 2015. POs were not associated with increased odds of neurological complications but had higher costs and higher rates of readmissions and reoperations within 90 days. By 2 years, differences in reoperation rate were not significant. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mohammed Shaheen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - Jayme C B Koltsov
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - Samuel A Cohen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - Joanna L Langner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - Japsimran Kaur
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - Nicole A Segovia
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA
| | - John S Vorhies
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, 94304, USA.
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Harfouch EB, Bunyan RF, Al Faraidy M, Dajim NB, Al Mulhim FA, Alnemari HH, Bashir S. The Effect of Ponte Osteotomies on the Sagittal Shape of Rods and Spine Derotation in Adolescent Idiopathic Scoliosis: A Single-Center, Retrospective Cohort Study. World Neurosurg X 2022; 15:100125. [PMID: 35620483 PMCID: PMC9126986 DOI: 10.1016/j.wnsx.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background Adding a Ponte osteotomy (PO) to other surgical techniques for correcting adolescent idiopathic scoliosis (AIS) profoundly affects the entire sagittal shape of the rod. POs are an effective procedure for correcting thoracic hypokyphosis in patients with AIS. Methods A retrospective review of 40 patients with AIS was conducted. The sample was divided into 2 groups: PO and non-PO. On a lateral radiograph, the rod end angle (A) was calculated using the intersections of the tangents with the rod end points. The maximal deflection (D) was obtained for each rod. In addition, the rod apex angle (B) was calculated using the intersection of the tangents at 2 points, each 1 cm to 1 side of the rod apex; the distance between the rods at the apex was then measured. Results Concave rods tended to be straight or even lordotic at the apex in the non-PO group (−0.9° vs. +5.9° in the PO group; P = 0.000). The rod end angle and deflection were significantly lower in the non-PO group (15.2° and 7.1 mm vs. 26.3° and 17.8 mm in the PO group; P = 0.000 and P = 0.000). The convex rods were less kyphotic in the non-PO group; for the non-PO group, the end angle and deflection were 27.6° and 16 mm versus 33.4° and 23.8 mm in the PO group (P = 0.03 and P = 0.000). No significant difference between the groups was observed for the convex rod apex angle (P = 0.8). The rod apices were more superimposed in the PO group (2.9 mm vs. 9.3 mm in the non-PO group; P = 0.000). Conclusions POs increase the overall sagittal kyphosis and improve the three-dimensional derotation of the apex in patients with AIS.
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Affiliation(s)
| | - Reem Fahd Bunyan
- Department of Neurology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mona Al Faraidy
- Department of Anesthesia, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Nayef Bin Dajim
- Department of Spine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | | | - Haitham H Alnemari
- Department of Spine, King Faisal Medical City, Abha, Saudi Arabia.,Department of Spine, McMaster University, Hamilton, Ontario, Canada
| | - Shahid Bashir
- Neuroscience Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Surgical Releasing for Severe and Rigid Scoliosis: Posterior Approach is Better than Anterior Approach. Clin Spine Surg 2022; 35:190-195. [PMID: 33044268 DOI: 10.1097/bsd.0000000000001086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/28/2020] [Indexed: 11/25/2022]
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Harfouch EB, Bunyan RF, Faraidy MA, Alnemari HH, Bashir S. Ponte osteotomies increase risk of intraoperative neuromonitoring alerts in adolescent idiopathic scoliosis surgery. Surg Neurol Int 2022; 13:154. [PMID: 35509562 PMCID: PMC9062905 DOI: 10.25259/sni_67_2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/07/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Ponte osteotomies (PO) are commonly used in adolescent idiopathic scoliosis (AIS) surgeries to improve the coronal and sagittal deformity correction. Here, we compared the incidence of perioperative neurologic complications for patients undergoing AIS with versus without PO.
Methods:
In a retrospective cohort study of 80 consecutive AIS patients undergoing scoliosis correction, 40 underwent PO, while 40 did not. All operations were performed by one surgeon at one tertiary care center. Patients’ demographics, Lenke classifications, surgical data, and deformity characteristics were comparable in both groups. Perioperative neurologic complications, defined as spinal cord or nerve root injuries identified by the surgeon, were tracked for those undergoing AIS surgery with or without PO being performed.
Results:
The risk of IOM alerts was significantly higher in the PO patients (12.5%: 5 patients) versus those in the No-PO group (0%, P = 0.021). Despite these changes, no patient incurred an increased postoperative deficit. Nevertheless, PO group patients demonstrated a higher coronal deformity correction rate (PO: 71% ± 10.9 vs. NoPO: 64.2% ± 11.5, P = 0.008) and a greater kyphosis Cobb angle (PO: 25.2 ± 6 vs. No-PO: 17.5 ± 9.4, P = 0.0001) on postoperative follow-up.
Conclusion:
While PO improved 3D correction of AIS, it increased the risk of IOM alerts in 12.5% of cases.
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Affiliation(s)
| | - Reem Fahd Bunyan
- Neurology, Neuroscience Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia,
| | - Mona Al Faraidy
- Department of Anesthesia, King Fahad Specialist Hospital, Dammam, Saudi Arabia,
| | - Haitham H. Alnemari
- King Faisal Medical City, Abha, Saudi Arabia,
- McMaster University, Hamilton, Canada
| | - Shahid Bashir
- Neurology, Neuroscience Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia,
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Burke CA, Speirs JN, Nelson SC. Maximizing mechanical advantage: surgical technique increases stiffness in spinal instrumentation. Spine Deform 2022; 10:295-299. [PMID: 34748141 DOI: 10.1007/s43390-021-00425-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE While there has been a great improvement in the treatment of adolescent idiopathic scoliosis, sagittal deformity correction has remained challenging. Increased rod stiffness has been shown to reduce thoracic flattening. We propose that the surgical technique can increase rod stiffness. A mechanical study was created to quantify the effect this has on construct stiffness. METHODS The sagittal bending stiffness of a constrained over contoured rod was measured using four different commonly used instrumentation systems. Pedicle screws were secured into custom printed blocks. One block was completely immobilized, while the other block was subject to four levels of constraint. This includes no constraint, mild constraint, moderate constraint, and maximal constraint with both blocks immobilized. The rod apex was loaded until 1 cm of displacement occurred. The stiffness was then calculated and compared between groups. RESULTS All four rod types showed increased bending stiffness as the construct became more constrained. The moderately constrained and the maximally constrained groups had a significantly higher stiffness compared to the unconstrained groups in all rod types (p < 0.05). The 6.0 mm titanium circular rods showed the highest increase in stiffness between maximal and no constraint, which became 3.02 × stiffer. CONCLUSIONS Rod stiffness is not only determined by size, shape, and metal alloy, but also by surgical technique. Constraining the spinal instrumentation by first locking the rod to the proximal and distal anchors significantly increases the sagittal bending stiffness. In a mechanical model this technique increases rod bending stiffness regardless of the material or shape.
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Affiliation(s)
- Corey A Burke
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA
| | - Joshua N Speirs
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA.
| | - Scott C Nelson
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA, 02354, USA
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Uehara M, Ikegami S, Kuraishi S, Oba H, Takizawa T, Munakata R, Hatakenaka T, Koseki M, Takahashi J. Pre-operative angle of trunk rotation in prone position estimates postoperative correction results. Medicine (Baltimore) 2021; 100:e28445. [PMID: 34941198 PMCID: PMC8702033 DOI: 10.1097/md.0000000000028445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 12/08/2021] [Indexed: 01/05/2023] Open
Abstract
This study investigated whether postoperative rotational deformity in adolescent idiopathic scoliosis patients could be predicted by prone-position pre-operative angle of trunk rotation (ATR).Surgical rib hump correction is performed with the patient in a prone position. However, the association between pre-operative ATR in the prone position and postoperative ATR results is unknown.Thirty-four consecutive patients who underwent skip pedicle screw fixation for Lenke type 1 or 2 adolescent idiopathic scoliosis were retrospectively reviewed. All subjects were followed for a minimum of 1 year. ATR measurements were taken for the standing-flexion position with a scoliometer before surgery and at 1 year afterward. Pre-operative measurements were also taken for the prone position. Correlations between pre- and postoperative ATR were calculated by means of Pearson correlation coefficient. Associations between the correction angle from the standing-flexion position to prone position and postoperative standing-flexion correction angle were determined by linear regression analysis.Pre- and postoperative ATR for the standing-flexion position showed a moderate association (r = 0.64, P < .01). A similar correlation was seen for pre-operative prone-position ATR and postoperative standing-flexion ATR (r = 0.56, P < .01). In linear regression analysis, there was significant proportional error between the correction angle from the standing-flexion position to prone position and postoperative standing-flexion correction angle (β = 0.40, P < .01).In conclusion, pre-operative ATR in either standing-flexion or prone position and postoperative standing-flexion ATR displayed moderate associations. Linear regression analysis revealed that ATR correction angle could be estimated by calculating the correction gains of 0.4° per 1° of correction angle in the prone position.
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Affiliation(s)
- Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Shugo Kuraishi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Takashi Takizawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Ryo Munakata
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Terue Hatakenaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Michihiko Koseki
- Faculty of Textile Science and Technology, Shinshu University, 3-15-1 Tokida, Ueda, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
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Rushton PRP, Aldebeyan S, Ghag R, Sponseller P, Yaszay B, Samdani AF, Lonner B, Shah SA, Newton PO, Miyanji F. What is the effect of intraoperative traction on correction of adolescent idiopathic scoliosis (AIS)? Spine Deform 2021; 9:1549-1557. [PMID: 34133013 DOI: 10.1007/s43390-021-00369-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Determine the efficacy of intraoperative traction (IOT) on curve correction in AIS. METHODS A prospective, multicenter, longitudinal database identified patients with major thoracic AIS (Lenke 1-4) treated with surgery using IOT and follow-up of 2 years. These cases were matched to comparable cases treated without traction (non-IOT). All patients were treated with single-stage posterior only surgery with pedicle screw constructs. Perioperative, radiographic and clinical outcome data at 2 years post-op were compared between the groups. RESULTS 104 cases treated with IOT were matched to 104 treated without IOT. Operating room time was significantly greater in the IOT group (339 vs. 306 min, p = < 0.001). Neuromonitoring alerts were more frequent in the IOT group (23% vs. 5%, p < 0.001). There were no postoperative neurological deficits in either group. The IOT group showed significantly greater MT curve correction (IOT 71% vs. non-IOT 66.7%, p < 0.003), with the effect most pronounced in curves > 70° (IOT 72% vs. non-IOT 64%, p = 0.04). IOT was associated with a significant reduction in 2D T5-T12 kyphosis measurements (IOT - 6.5° vs non-IOT + 0.48°, p < 0.001), yet significant improvements in estimated 3D thoracic kyphosis were made in both groups, with the non-IOT group making greater improvement when compared to the IOT group (IOT + 18.1° vs. non-IOT + 22.3° vs., p = 0.008). CONCLUSIONS IOT is associated with modestly enhanced coronal deformity correction. Surgeons should be aware of the increased rates of neuromonitoring alerts when using this technique and its affect on the sagittal profile. Given this IOT may be best suited to larger curves. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | | | - Ravi Ghag
- British Columbia Children's Hospital, Vancouver, BC, Canada
| | | | - Burt Yaszay
- Rady Children's Hospital and Health Center, San Diego, CA, USA
| | | | | | - Suken A Shah
- Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Peter O Newton
- Rady Children's Hospital and Health Center, San Diego, CA, USA
| | - Firoz Miyanji
- British Columbia Children's Hospital, Vancouver, BC, Canada
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Floccari LV, Poppino K, Greenhill DA, Sucato DJ. Ponte osteotomies in a matched series of large AIS curves increase surgical risk without improving outcomes. Spine Deform 2021; 9:1411-1418. [PMID: 33861426 DOI: 10.1007/s43390-021-00339-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/24/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE The routine use of Ponte osteotomies in adolescent idiopathic scoliosis (AIS) surgery is controversial with conflicting data for coronal plane correction and little analysis in the sagittal plane. The objective of this study was to analyze the efficacy of Ponte osteotomies in large curve AIS. METHODS A single institution, prospectively-collected series of consecutive AIS patients who had Ponte osteotomies (P cohort) was directly matched to patients with no Pontes (NP cohort) by age, gender, Lenke classification, surgeon, coronal, and sagittal Cobb angles. The radiographic review included adjusted values using a 3D-derived published formula for preoperative T5-T12 kyphosis. Patient-reported outcomes (PROs) were assessed with the SRS-30 and Spinal Appearance Questionnaire (SAQ). RESULTS There were 68 patients (34/cohort) with minimum 2-year follow-up with no differences between P and NP cohorts in age, preoperative coronal Cobb (74.5° vs 70.8°), flexibility index, measured or 3D-adjusted T5-T12 kyphosis. Rod material/diameter, fusion levels, blood loss, and operative time did not differ, but implant density was higher in the P group (1.53 vs 1.31, p < 0.001). The P group had 7.9% greater coronal Cobb correction (66.6% vs 58.7%, p < 0.003) without difference in final Cobb angles (24.7° vs. 29.1°, p = 0.052). There were no differences in measured or adjusted T5-T12 kyphosis in the sagittal plane. The P group had a 15% rate of critical intraoperative neuromonitoring changes versus 0% in the NP group (p = 0.053). At follow-up, there were no differences in scoliometer measurements or any domain of SRS-30 or SAQ scores. CONCLUSION In this first reported matched series of AIS patients, Ponte osteotomies provide small radiographic gains in the coronal plane with no improvement in the sagittal plane and no change in truncal rotation. There was a higher risk of critical intraoperative neuromonitoring changes, and no benefits in patient-reported outcomes. This calls into question the routine use of Ponte osteotomies in AIS, even for curves averaging 70 degrees. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Lorena V Floccari
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH, USA
| | - Kiley Poppino
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX, 75219, USA
| | - Dustin A Greenhill
- Department of Orthopedic Surgery, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Daniel J Sucato
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX, 75219, USA.
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Hi-PoAD technique for Adolescent Idiopathic Scoliosis in Adult: Personal case series. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3509-3516. [PMID: 34142248 DOI: 10.1007/s00586-021-06897-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 04/13/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this article is to present an original surgical technique for the treatment of rigid Adult Idiopathic Scoliosis (AdIS) and the results at minimum 2 years follow-up in a cohort of 40 patients. METHODS We retrospectively reviewed 40 patients affected by rigid AdIS, older than 40 years and operated with a posterior one stage surgical technique summarized with the acronym Hi-PoAD, (high-density pedicle screws, Ponte osteotomies, asymmetric rods contouring, direct vertebral rotation). The demographic and surgical data were collected, and the improvement of clinical scores and radiologic parameters was obtained after surgery, at 1 and 2 years and at final follow-up, to assess deformity correction, coronal and sagittal balance and clinical outcome. RESULTS The average follow-up was 2.9 years (range 2-3.5). Average coronal Cobb angle decreased from 65.0° ± 8.4 to 18.9° ± 3.9 (p < 0.01). Rotation sagittal angle decreased from 26.2° ± 4.4° to 12.4° ± 2.8° (p < 0.01). Mean thoracic kyphosis improved from 23.1° ± 3.6° to 36.0° ± 3.9°. SRS-22 improved form 2.9 ± 0.4 to 3.7 ± 0.6 (p < 0.01). Four early post-operative deep wound infections were observed, all healed after debridement and implant retention. No mechanical complication, junctional kyphosis, deformity progression or non-union were recorded at the last follow-up. CONCLUSIONS Hi-PoAD technique proved to be safe and effective in the treatment of rigid Adult Idiopathic Scoliosis. The reason for the success is related to the combined strategies adopted, that dissipates corrective forces over several levels, reducing mechanical stress at the screw-bone interface and optimizing corrective potential.
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Impact of multilevel facetectomy on segmental spinal flexibility in patients with thoracic adolescent idiopathic scoliosis. Clin Biomech (Bristol, Avon) 2021; 83:105296. [PMID: 33639367 DOI: 10.1016/j.clinbiomech.2021.105296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 02/05/2021] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to intraoperatively assess the effects of multilevel facetectomy on segmental spinal flexibility in patients with thoracic adolescent idiopathic scoliosis. METHODS Twenty patients who underwent posterior thoracic adolescent idiopathic scoliosis curve correction were evaluated. Compressive or distractive loaded force of 50N was applied on the handle of a compressor or distractor connected to the necks of pedicle screws inserted at T7 to T11. Segmental spinal flexibility rates were calculated based on the distance between screw heads under the loaded and unloaded conditions. In addition, the flexibility rates were obtained before and after multilevel facetectomy. FINDINGS Absolute flexibility rates of all segments significantly increased after multilevel facetectomy under both compressive and distractive forces (P < 0.01). The absolute change in the flexibility rate was significantly higher at the concave side than at the convex side under both compressive (P < 0.01) and distractive loaded forces (P = 0.046). No significant correlation was found between change in the flexibility rates and preoperative Cobb angle or preoperative curve flexibility. INTERPRETATION From a biomechanical point of view, multilevel facetectomy provides proper spinal flexibility to improve the correction rate of posterior adolescent idiopathic scoliosis surgery. The effects are higher at the concave side than at the convex side.
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Severe persistent coronal imbalance following instrumented posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:1295-1304. [PMID: 32500442 DOI: 10.1007/s43390-020-00153-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/28/2020] [Indexed: 12/09/2022]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE The aim of this study was to identify the risk factors and health-related quality of life (HRQoL) impact of severe (> 4 cm) post-operative coronal imbalance at 2 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Coronal imbalance is an unfavorable outcome following PSF for AIS, though the degree of imbalance in such patients is typically mild. We hypothesize that a small number of patients become and remain severely imbalanced post-operatively, though this phenomenon has not been well studied. METHODS Prospectively collected data from a large multicenter registry were reviewed. Patients with severe coronal imbalance (SCIB; > 4 cm) 2 years after PSF were included. Matched controls without SCIB at 2 years were included at a 3:1 ratio. Comparisons were made between demographics, pre-operative radiographic measures, surgical factors, residual post-operative radiographic measures, and 2-year SRS-22 scores. RESULTS Nine of 954 (0.9%) patients (88.9% females; mean age 14.8 ± 2.3 years) were found to be severely imbalanced at 2 years. These patients had significantly greater pre-operative bending thoracic curve magnitude (45° vs. 33°; p = 0.013), curve flexibility (22.9% vs. 63.3%; p = 0.004), and kyphosis (41° vs. 26.5°; p = 0.034) compared to matched controls. Pre-operative curve flexibility of < 20% was associated with a 23.8 times greater odds of SCIB (95% CI 2.1-250; p = 0.008). With respect to HRQoL, median SRS-22 pain (4.1 vs. 4.8; p = 0.041), self-image (3.9 vs. 4.6; p = 0.013), general function (4.5 vs. 5; p = 0.022), and total (4.1 vs. 4.7; p = 0.012) scores at 2 years were significantly lower in cases compared to controls. CONCLUSIONS In the present study, thoracic curve stiffness was a strong risk factor for severe post-operative coronal imbalance, which was associated with poor HRQoL measures. Increased pre-operative thoracic curve stiffness (< 20% flexibility) should raise surgeon awareness for altering surgical approach to minimize the risk of severe post-operative coronal imbalance. LEVEL OF EVIDENCE Level III.
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Restoration of Thoracic Kyphosis in Adolescent Idiopathic Scoliosis Over a Twenty-year Period: Are We Getting Better? Spine (Phila Pa 1976) 2020; 45:1625-1633. [PMID: 32890296 DOI: 10.1097/brs.0000000000003659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A multicenter, prospectively collected database of 20 years of operatively treated adolescent idiopathic scoliosis (AIS) was utilized to retrospectively examine pre- and postoperative thoracic kyphosis at 2-year follow-up. OBJECTIVE To determine if the adoption of advanced three-dimensional correction techniques has led to improved thoracic kyphosis correction in AIS. SUMMARY OF BACKGROUND DATA Over the past 20 years, there has been an evolution of operative treatment for AIS, with more emphasis on sagittal and axial planes. Thoracic hypokyphosis was well treated with an anterior approach, but this was not addressed sufficiently in early posterior approaches. We hypothesized that patients with preoperative thoracic hypokyphosis prior to 2000 would have superior thoracic kyphosis restoration, but the learning curve with pedicle screws would reflect initially inferior restoration and eventual improvement. METHODS From 1995 to 2015, 1063 patients with preoperative thoracic hypokyphosis (<10°) were identified. A validated formula for assessing three-dimensional sagittal alignment using two-dimensional kyphosis and thoracic Cobb angle was applied. Patients were divided into 1995-2000 (Period 1, primarily anterior), 2001-2009 (Period 2, early thoracic pedicle screws), and 2010-2015 (Period 3, modern posterior) cohorts. Two-way repeated measures analysis of variance and post-hoc Bonferroni corrections were utilized with P < 0.05 considered significant. RESULTS Significant differences were demonstrated. Period 1 had excellent restoration of thoracic kyphosis, which worsened in Period 2 and improved to near Period 1 levels during Period 3. Period 3 had superior thoracic kyphosis restoration compared with Period 2. CONCLUSION Although the shift from anterior to posterior approaches in AIS was initially associated with worse thoracic kyphosis restoration, this improved with time. The proportion of patients restored to >20° kyphosis with a contemporary posterior approach has steadily improved to that of the era when anterior approaches were more common. LEVEL OF EVIDENCE 3.
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Shi Y, Li YH, Guan ZP, Huang YC, Yu BS. Modified surgical treatment for a patient with neurofibromatosis scoliosis: A case report. World J Orthop 2020; 11:523-527. [PMID: 33269219 PMCID: PMC7672799 DOI: 10.5312/wjo.v11.i11.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 09/07/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The correction surgery for severely multidimensional spinal deformity in neurofibromatosis type I is very difficult and it is still a very big challenge for spine surgeons. CASE SUMMARY A 44-year-old woman presented with progressive kyphosis for more than 10 years and low back pain for 2 years. She had been diagnosed with neurofibromatosis at a local hospital many years ago. Conservative treatments had been applied, but the symptoms got worse rather than alleviated. Therefore, surgery was required. CONCLUSION For this patient with severe deformity, the correction treatment of Ponte osteotomy followed by satellite rod technique in the region of the apical vertebra and the technique of pedicle screws and dual iliac screws had been applied, and successful clinical outcomes were achieved.
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Affiliation(s)
- Yan Shi
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Yun-He Li
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Zhi-Ping Guan
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Yong-Can Huang
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Bin-Sheng Yu
- Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
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Ha AS, Cerpa M, Lenke LG. State of the art review: Vertebral Osteotomies for the management of Spinal Deformity. Spine Deform 2020; 8:829-843. [PMID: 32468384 DOI: 10.1007/s43390-020-00144-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
Spinal deformity is a complex condition caused by various etiologies (degenerative, neuromuscular, congenital, developmental, traumatic, neoplastic, idiopathic) leading to clinical deformity, axial back pain, and neurologic deficits. Patients presenting with severe deformities require vertebral osteotomies to achieve the necessary curve correction for radiographic and clinical improvement. The three major vertebral osteotomy techniques commonly used at this time are the posterior column osteotomy (PCO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR). The different vertebral osteotomies have unique merits and pitfalls that need to be addressed during preoperative planning to achieve maximum benefit while limiting or avoiding possible complications. The more difficult vertebral osteotomies have a steeper learning curve and requires extensive pre, intra and postoperative management of the patient. This review will aim to discuss the indications, surgical techniques, and clinical outcomes for each of these different vertebral osteotomy techniques with illustrative cases.
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Affiliation(s)
- Alex S Ha
- The Och Spine Hospital, NewYork-Presbyterian/Columbia University Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA
| | - Meghan Cerpa
- The Och Spine Hospital, NewYork-Presbyterian/Columbia University Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA.
| | - Lawrence G Lenke
- The Och Spine Hospital, NewYork-Presbyterian/Columbia University Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA
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Grabala P, Helenius IJ. Clinical and Radiological Outcomes of Less Invasive Temporary Internal Distraction Followed by Staged Pedicle Screw Instrumentation in Adolescents with Severe Idiopathic Scoliosis at 2-Year Minimum Follow-Up. World Neurosurg 2020; 143:e464-e473. [PMID: 32750520 DOI: 10.1016/j.wneu.2020.07.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Temporary placement of an internal distraction rod is one of the surgical options in the treatment of severe scoliosis to avoid preoperative halo traction or vertebral column resection. This technique can be applied in a single session or staged. The aim of our study was to report the outcomes of less-invasive temporary internal distraction (LI-TID) in the surgical treatment of adolescents with severe idiopathic scoliosis (IS). METHODS We performed a single-center, retrospective study of 22 adolescents (19 girls; mean age, 14.8 ± 2.0 years) with severe IS (major curve, ≥90°) who had undergone LI-TID, followed by staged pedicle screw instrumentation, with a minimum of 2 years of follow-up available. The demographic data, radiographic outcomes, pulmonary function test results, perioperative data, revised 22-item Scoliosis Research Society Outcomes questionnaire results, complications, and neuromonitoring data were collected. RESULTS The average major curve was 120° (range, 90°-160°) preoperatively and 59° (range, 29°-69°) at the final follow-up examination. Thoracic kyphosis (T5-T12) had improved from an average of 80° preoperatively to 33° postoperatively (range, 22°-69°), and the spinal height (T1-S1) had increased from 332 mm (range, 198-432 mm) preoperatively to 405 mm (range, 258-495 mm) at the final follow-up visit. Of the 22 patients, 5 (22.7%) had experienced an intraoperative neuromonitoring change without postoperative neurologic deficits, and 2 had developed superior mesenteric artery syndrome, with resolution after conservative treatment. The mean percentage of the predicted forced vital capacity had improved from 44.5% ± 11.3% to 66.5 ± 10.8 at final follow-up (P < 0.05). The total questionnaire score had improved significantly from 2.9 ± 0.61 to 4.1 ± 0.44 (P < 0.05). CONCLUSION The results from the present study have shown that staged LI-TID, followed by pedicle screw instrumentation, is safe and effective in adolescents with severe IS, with improvements in spinal deformity, pulmonary function, and health-related quality of life.
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Affiliation(s)
- Pawel Grabala
- Department of Paediatric Orthopaedics and Traumatology, Medical University of Bialystok, The Faculty of Medicine, Bialystok, Poland.
| | - Ilkka J Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Abstract
Adolescent idiopathic scoliosis represents a complex, three-dimensional deformity of the spine. Posterior spinal fusion is commonly performed in severe cases to avoid the long-term adverse sequelae associated with progressive spinal deformity. The goals of spinal fusion include halting the progression of deformity, optimizing spinal balance, and minimizing complications. Recent advances in short-segment spinal fixation have allowed for improved three-dimensional deformity correction. Preoperative planning and assessment of spinal flexibility is essential for successful deformity correction and optimization of long-term outcomes. Judicious use of releases and/or spinal osteotomies may allow for increased mobility of the spine but are associated with increased surgical time, blood loss, and risk of complications. Appreciation of implant design and material properties is critical for safe application of correction techniques. Although multiple reduction techniques have been described, no single technique is optimal for every patient.
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Yoshihara H, Penny GS, Kaur H, Shah NV, Paulino CB. Are inferior facetectomies adequate and suitable for surgical treatment of adolescent idiopathic scoliosis? Medicine (Baltimore) 2019; 98:e18048. [PMID: 31764829 PMCID: PMC6882642 DOI: 10.1097/md.0000000000018048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
STUDY DESIGN Retrospective review. BACKGROUND Inferior facetectomies, with the utilization of segmental pedicle screw constructs for corrective fixation, can provide adequate flexibility and post less risk of neural tissue and blood loss. We analyzed outcomes of surgical treatment for adolescent idiopathic scoliosis (AIS) using inferior facetectomies and segmental pedicle screw constructs. We hypothesized that adequate main curve correction and suitable surgical outcomes would be observed using this technique. METHODS We reviewed 38 AIS patients who underwent inferior facetectomies and segmental pedicle screw constructs by 2 surgeons at a single institution between May 2014 and December 2016. Coronal and sagittal radiographic measurements were evaluated over 1-year follow-up by 2 trained observers not associated with the surgeries. Surgical details, complications, and hospital length of stay (LOS) were also recorded. RESULTS Mean fusion levels were 11.0 ± 1.7. The mean Cobb angle of main AIS curves improved from 48.6± 10.1 degree preoperatively to 11.8± 6.2 degree postoperatively and 12.4± 6.2 degree at 1-year follow-up, which percentage correction was 75.9% and 74.6%, respectively. The mean thoracic kyphosis (T5-12) angle was 20.7± 11.6 degree preoperatively, 17.4± 8.0 degree postoperatively, and 16.8± 8.4 degree at 1-year follow-up. The mean surgical time, estimated blood loss, and LOS were 232.4 ± 35.7 minutes, 475.0 ± 169.6 mL, and 3.5 ± 1.3 days. Twelve patients received blood transfusion. There were no neurological or wound complications. CONCLUSIONS This case series demonstrated adequate correction of main AIS curves, acceptable thoracic kyphosis and blood loss, and short surgical time and LOS in AIS patients treated with inferior facetectomies and segmental pedicle screw constructs, potentially indicating that inferior facetectomies are adequate and suitable for AIS surgery when segmental pedicle screw constructs are utilized.
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Bastrom TP, Bartley CE, Newton PO. Patient-Reported SRS-24 Outcomes Scores After Surgery for Adolescent Idiopathic Scoliosis Have Improved Since the New Millennium. Spine Deform 2019; 7:917-922. [PMID: 31732002 DOI: 10.1016/j.jspd.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/05/2018] [Accepted: 01/08/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Observational. OBJECTIVE To examine changes in patient-reported two-year postoperative outcomes via the Scoliosis Research Society (SRS)-24 Outcomes Instrument from 2001 through 2015. SUMMARY OF BACKGROUND DATA Techniques for correction of adolescent idiopathic scoliosis (AIS) have evolved over the years, but it is unclear how these changes have impacted patient-reported outcomes. METHODS AIS patients with two-year postoperative follow-up from a prospective multicenter registry were divided into three-year groups based on trends in surgical approach and construct type (2010-2014: 52% anterior, 43% posterior hybrids; 2005-2011: 3% anterior, 5% posterior hybrids; 2012-2015: 0% anterior, 0.2% posterior hybrids). Because of the ordinal scale (1-5) and bipolar nature of the response sets for the SRS-24, domain/total scores were categorized as ≤3 (predominantly negative) or 4-5 (predominantly positive). Variables were compared across the three groups. RESULTS A total of 1,695 patients were analyzed; 172 (2010-2014), 926 (2005-2011), and 597 (2012-2015). Average age was 14.7 ± 2 years, the average primary curve was 55° ± 13°, and the group was primarily female (82%). There was a decline in the rate of positive scores for preoperative pain and self-image across the three groups (p < .05). There was an increase in the rate of positive scores for two-year postoperative self-image after surgery, function after surgery, and satisfaction (p < .05). Decreases in length of hospital stay, blood loss, surgical time, preoperative kyphosis, and postoperative trunk shift were observed (p < .05). Increases were observed in levels fused, preoperative major coronal curve, preoperative rib prominence, preoperative trunk shift, percentage correction of major curve, kyphosis restoration, and the rate of double/triple curves (p < .05). CONCLUSION The percentage of patients with positive postoperative SRS scores has increased in the modern era, providing evidence that newer surgical techniques are resulting in improved outcomes based on the patients' perspectives. Interestingly, recent patients were more afflicted with negative pain and self-image before surgery.
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Affiliation(s)
- Tracey P Bastrom
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Carrie E Bartley
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Peter O Newton
- Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA.
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- Setting Scoliosis Straight Foundation, 2535 Camino Del Rio S. Suite 325, San Diego, CA, 92108, USA
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One-Stage Posterior Multiple-Level Asymmetrical Ponte Osteotomies Versus Single-Level Posterior Vertebral Column Resection for Severe and Rigid Adult Idiopathic Scoliosis: A Minimum 2-Year Follow-up Comparative Study. Spine (Phila Pa 1976) 2019; 44:E1196-E1205. [PMID: 31415466 DOI: 10.1097/brs.0000000000003101] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To compare the efficacy and safety of one-stage posterior multiple-level asymmetrical Ponte osteotomies (MAPOs) and single-level posterior vertebral column resection (VCR) for severe and rigid adult idiopathic scoliosis (ADIS). SUMMARY OF BACKGROUND DATA The surgical treatment of severe and rigid ADIS is a demanding and difficult challenge due to its complicated characteristics. Spine surgeons have often pursued advanced correction techniques such as VCR for such patients, which reported to present excellent correction outcomes. But this attractive procedure brought the greatest risk to both surgeons and patients. METHODS A total of 48 patients who underwent MAPO or VCR and fusion surgery with minimum 2-year follow-up between February 2009 and November 2015 were enrolled. Twenty-six patients were included in MAPO group and 12 patients in VCR group with an average age of 26.65 ± 8.40 and 27.92 ± 7.50 years, respectively. The average follow-up was 30.24 ± 10.55 months. The surgical details and complications were recorded. The radiological parameters and clinical outcome including Oswestry Disability Index and Scoliosis Research Society-22 questionnaire scores were collected and analyzed. RESULTS The main curve in MAPO and VCR group were corrected from an average of 98.52° ± 16.50° to 44.11° ± 17.72° and 108.91° ± 16.56° to 56.49° ± 18.82° with no significant difference. The postoperative coronal and sagittal parameters of the two groups were all improved and it showed no significant differences between the two groups. The mean operative time and blood loss of VCR group were significantly greater than those of MAPO group. All the clinical scores were significantly improved at final follow-up, with no significant difference. The incidence of complications in MAPO group was 3.85%, which was significantly lower than that of VCR group. CONCLUSION The surgical procedure of multiple asymmetrical Ponte osteotomy is a safe, easy-to-operate, and effective technique that can correct scoliosis and restore the sagittal alignment. It can gain similar correction outcome to VCR, offering the advantages of reduced operation time, blood loss, and greatly reduced the complication. LEVEL OF EVIDENCE 3.
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Newton PO, Wu KW, Bastrom TP, Bartley CE, Upasani VV, Yaszay B. What Factors Are Associated With Kyphosis Restoration in Lordotic Adolescent Idiopathic Scoliosis Patients? Spine Deform 2019; 7:596-601. [PMID: 31202377 DOI: 10.1016/j.jspd.2018.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Review of a prospective adolescent idiopathic scoliosis (AIS) multicenter registry. OBJECTIVE To evaluate predictors of surgical thoracic kyphosis restoration in AIS patients with lordotic preoperative thoracic sagittal profiles. SUMMARY OF BACKGROUND DATA Prior work on kyphosis-producing techniques has yielded mixed findings and has focused on the sagittal plane in 2D. METHODS A validated formula to predict 3D T5-T12 sagittal alignment using standard 2D measures was applied in a cohort of 1614 Lenke 1-4 patients treated with posterior instrumentation using 5.5-mm-diameter rods. Patients with 3D kyphosis 1 standard deviation (12.2°) below the mean (5.3°) were identified as the study cohort. Predictors of 3D T5-T12 kyphosis at two years were evaluated using univariate analysis followed by Classification and Regression Tree (CART). RESULTS There were 134 patients identified. All had preoperative 3D T5-T12 kyphosis of <-7°. The average 3D kyphosis was -13° ± 5° preoperatively and 20° ± 7° at two years (p < .001). The thoracic coronal curve improved from 62° ± 12° to 21° ± 8° at two years (p < .001). Of 15 variables analyzed, multivariate CART analysis identified only surgeon as a predictor of 2-year kyphosis. Two surgeon groups were identified by CART which included those who restored more kyphosis versus those who restored less. Subsequent analysis demonstrated significant differences between groups in the rate of Ponte osteotomies used (p < .023), stainless steel versus cobalt chromium rods (p < .001), and segmental screw fixation (p < .001). CONCLUSION Kyphosis restoration in patients with preoperative lordosis in the thoracic sagittal plane is possible. In this analysis, there was not one single technique identified as being solely responsible for the ability to restore kyphosis. The most predictive factor identified was the surgeon performing the correction, which is likely a reflection of focus on deformity correction in three planes, as well as a combination of methods used to restore kyphosis. LEVEL OF EVIDENCE Level III, therapeutic.
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Affiliation(s)
- Peter O Newton
- Department of Orthopedics, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA; Department of Orthopedics, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Kuan Wen Wu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, No. 7, Zhongshan South Road, Zhongzheng District, Taipei City, Taiwan 100
| | - Tracey P Bastrom
- Department of Orthopedics, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA
| | - Carrie E Bartley
- Department of Orthopedics, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA
| | - Vidyadhar V Upasani
- Department of Orthopedics, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA; Department of Orthopedics, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital-San Diego, 3020 Children's Way, San Diego, CA 92123, USA; Department of Orthopedics, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
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- Setting Scoliosis Straight Foundation, 2535 Camino del Rio S, San Diego, CA 92108, USA
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Zhang Y, Hai Y, Tao L, Yang J, Zhou L, Yin P, Pan A, Zhang Y, Liu C. Posterior Multiple-Level Asymmetrical Ponte Osteotomies for Rigid Adult Idiopathic Scoliosis. World Neurosurg 2019; 127:e467-e473. [PMID: 30922897 DOI: 10.1016/j.wneu.2019.03.173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/15/2019] [Accepted: 03/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of posterior multiple-level asymmetrical Ponte osteotomies for rigid adult idiopathic scoliosis. METHODS A retrospective study was conducted for adult patients with rigid idiopathic scoliosis (flexibility of main curve <25%) who underwent one-stage multiple-level asymmetrical Ponte osteotomies with a minimum of 2-year follow-up between February 2009 and November 2015. The demographic data and surgical issues were collected, and the improvement of clinical function scores and radiologic parameters were obtained after surgery and during the follow-up to assess deformity correction, spinal balance, and clinical outcome. RESULTS A total of 49 patients were included (10 male and 39 female) in this study, with an average age of 26.53 years old. The average follow-up was 28.37 ± 6.98 months. All the cases presented a significant improvement of the main curve and focal kyphosis from 85.62 ± 19.80° to 36.19 ± 16.74° and 53.98 ± 26.80° to 30.88 ± 18.69°, with a mean correction rate of 57.73% and 41.23%. The postoperative coronal and sagittal parameters were all significantly improved, except coronal balance. The mean operative time and blood loss were 267.86 ± 54.49 minutes and 838.78 ± 538.93 mL. All the clinical function scores of patients were significantly improved at the final follow-up. Only one patient had a complication related to surgical incision, with no neurologic complications occurring. CONCLUSIONS The surgical procedure of multiple-level asymmetrical Ponte osteotomy is a safe and effective technique, with reduced operation time, blood loss, and complications, and may offer an appropriate option to address the problems of rigid adult idiopathic scoliosis.
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Affiliation(s)
- Yangpu Zhang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China.
| | - Luming Tao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Jincai Yang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Lijin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Peng Yin
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Aixing Pan
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Yaoshen Zhang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Chang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, China
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Ponte Osteotomies Increase the Risk of Neuromonitoring Alerts in Adolescent Idiopathic Scoliosis Correction Surgery. Spine (Phila Pa 1976) 2019; 44:E175-E180. [PMID: 30005041 DOI: 10.1097/brs.0000000000002784] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational cohort study of prospective database registry. OBJECTIVE To determine the incidence of neurological complications in AIS patients undergoing surgical treatment with PO. SUMMARY OF BACKGROUND DATA Despite the widespread use of Ponte Osteotomies (PO) in adolescent idiopathic scoliosis (AIS) correction, outcomes and complications in patients treated with this technique have not been well characterized. METHODS A multicenter prospective registry of patients undergoing surgical correction of AIS was queried at 2-year follow-up for patient demographics, surgical data, deformity characteristics, and peri-operative complications. A neurological complication was defined as perioperative nerve root or spinal cord injury as identified by the surgeon. Patients were divided into those who underwent peri-apical PO and those without, and further stratified by Lenke curve classification into 3 groups (I-types 1 and 2, II-types 3, 4, 6, and III-type 5). Patients with- and without neurological complications were compared with respect to baseline demographics, surgical variables, curve types, fusion construct types (screws vs. hybrid), curve magnitude (coronal and sagittal Cobb), apical vertebral translation, and coronal-deformity angular ratios (C-DAR). RESULTS Of 2210 patients included in the study, 1611 underwent PO. Peri-operative neurological complications occurred in 7 patients, with 6 in the PO group (0.37%) and 1 in non-PO group (0.17%) though this was not a statistically significant risk factor for peri-operative neurological injury (P = 0.45). Neuromonitoring alerts were recorded in 168 patients (7.6%: 9.3% PO group; 4.2% no-PO group (P < 0.001)). Multivariate logistic regression analysis found PO and curve magnitude to be independent risk factors for intraoperative neuromonitoring alerts (P < 0.01). CONCLUSION PO and curve magnitude were independent risk factors for intraoperative neuromonitoring alerts in surgical AIS correction. The effect of Ponte osteotomy on neurological complications remains unknown due to the low incidence of these complications. LEVEL OF EVIDENCE 3.
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Yahara Y, Seki S, Makino H, Watanabe K, Uehara M, Takahashi J, Kimura T. Three-Dimensional Computed Tomography Analysis of Spinal Canal Length Increase After Surgery for Adolescent Idiopathic Scoliosis: A Multicenter Study. J Bone Joint Surg Am 2019; 101:48-55. [PMID: 30601415 PMCID: PMC6319593 DOI: 10.2106/jbjs.18.00531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The most severe complication after surgery for adolescent idiopathic scoliosis is spinal cord injury. There is a relationship between corrective surgery and subsequent elongation of the spinal canal. We sought to investigate which factors are involved in this phenomenon. METHODS Seventy-seven patients with adolescent idiopathic scoliosis (49 with Lenke type 1 and 28 with type 2) who underwent spinal correction surgery were included. The mean patient age at surgery was 14.2 years (range, 11 to 20 years). The spines of all patients were fused within the range of T2 to L2, and computed tomography (CT) data were retrospectively collected. We measured the preoperative and postoperative lengths of the spinal canal from T2 to L2 using 3-dimensional (3D) CT-based imaging software. We also examined the association between the change in T2-L2 spinal canal length and the radiographic parameters. RESULTS The length of the spinal canal from T2 to L2 was increased by a mean of 8.5 mm in the patients with Lenke type 1, 12.7 mm in those with type 2, and 10.1 mm overall. Elongation was positively associated with the preoperative main thoracic Cobb angle in both the type-1 group (R = 0.43, p < 0.005) and the type-2 group (R = 0.77, p < 0.000001). The greatest elongation was observed in the periapical vertebral levels of the main thoracic curves. CONCLUSIONS Corrective surgery for adolescent idiopathic scoliosis elongated the spinal canal. The preoperative proximal, main thoracic, and thoracolumbar/lumbar Cobb angles are moderate predictors of postoperative spinal canal length after scoliosis surgery. CLINICAL RELEVANCE It is important to understand how much the spinal canal is elongated after surgery to lessen the risk of intraoperative and postoperative neurological complications.
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Affiliation(s)
- Yasuhito Yahara
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Hiroto Makino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University Medicine and Dental General Hospital, Niigata, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoatsu Kimura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
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Feng J, Zhou J, Huang M, Xia P, Liu W. Clinical and radiological outcomes of the multilevel Ponte osteotomy with posterior selective segmental pedicle screw constructs to treat adolescent thoracic idiopathic scoliosis. J Orthop Surg Res 2018; 13:305. [PMID: 30497489 PMCID: PMC6267836 DOI: 10.1186/s13018-018-1001-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/12/2018] [Indexed: 11/10/2022] Open
Abstract
Background To compare the clinical and radiological outcomes of the surgical correction of Lenke type 1 to 4 scoliosis by using a multilevel Ponte osteotomy procedure with posterior selective segmental pedicle screw constructs or posterior release and selective segmental pedicle screw constructs only in patients with adolescent thoracic idiopathic scoliosis. Methods Retrospective analysis of 65 patients, 32 treated with the multilevel Ponte procedure (Group A) and 33 with posterior soft tissue release only (Group B). The groups were compared with regard to the change in spinal alignment from preoperative to postoperative assessment and over the follow-up period. Results A correction rate of the main thoracic curve of 63.9 ± 4.5% was obtained for group A and 65.2 ± 2.4% for group B (P = 0.17). However, the Cincinnati correction index was greater for group A (1.8 ± 0.3) than that for group B (1.4 ± 0.2, P < 0.001), with a smaller change in angle over the period from 1 week postoperatively to the 2-year follow-up (P < 0.05). The operative time, volume of blood loss, and volume of transfusion were greater for group A than for group B (P < 0.05). Conclusion The multilevel Ponte osteotomy procedure, with posterior selective segmental pedicle screw constructs, improves the Cincinnati correction index and restores the thoracic kyphosis in patients with adolescent thoracic idiopathic scoliosis.
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Affiliation(s)
- Jing Feng
- Department of Orthopaedics, First Hospital of Wuhan, No. 215 Zhongshan Road, Wuhan, 430022, China
| | - Juan Zhou
- Department of Orthopaedics, First Hospital of Wuhan, No. 215 Zhongshan Road, Wuhan, 430022, China
| | - Mi Huang
- Department of Orthopaedics, First Hospital of Wuhan, No. 215 Zhongshan Road, Wuhan, 430022, China
| | - Ping Xia
- Department of Orthopaedics, First Hospital of Wuhan, No. 215 Zhongshan Road, Wuhan, 430022, China.
| | - Wei Liu
- Department of Orthopaedics, First Hospital of Wuhan, No. 215 Zhongshan Road, Wuhan, 430022, China.
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Akbar M, Almansour H, Lafage R, Diebo BG, Wiedenhöfer B, Schwab F, Lafage V, Pepke W. Sagittal alignment of the cervical spine in the setting of adolescent idiopathic scoliosis. J Neurosurg Spine 2018; 29:506-514. [PMID: 30141764 DOI: 10.3171/2018.3.spine171263] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to investigate the impact of thoracic and lumbar alignment on cervical alignment in patients with adolescent idiopathic scoliosis (AIS).METHODSEighty-one patients with AIS who had a Cobb angle > 40° and full-length spine radiographs were included. Radiographs were analyzed using dedicated software to measure pelvic parameters (sacral slope [SS], pelvic incidence [PI], pelvic tilt [PT]); regional parameters (C1 slope, C0-C2 angle, chin-brow vertical angle [CBVA], slope of line of sight [SLS], McRae slope, McGregor slope [MGS], C2-7 [cervical lordosis; CL], C2-7 sagittal vertical axis [SVA], C2-T3, C2-T3 SVA, C2-T1 Harrison measurement [C2-T1 Ha], T1 slope, thoracic kyphosis [TK], lumbar lordosis [LL], and PI-LL mismatch); and global parameters (SVA). Patients were stratified by their lumbar alignment into hyperlordotic (LL > 59.7°) and normolordotic (LL 39.3° to 59.7°) groups and also, based on their thoracic alignment, into hypokyphotic (TK < -33.1°) and normokyphotic (TK -33.1° to -54.9°) groups. Finally, they were grouped based on their global alignment into either an anterior-aligned group or a posterior-aligned group.RESULTSThe lumbar hyperlordotic group, in comparison to the normolordotic group, had a significantly larger LL, SS, PI (all p < 0.001), and TK (p = 0.014) and a significantly smaller PI-LL mismatch (p = 0.001). Lumbar lordosis had no influence on local cervical parameters.The thoracic hypokyphotic group had a significantly larger PI-LL mismatch (p < 0.002) and smaller T1 slope (p < 0.001), and was significantly more posteriorly aligned than the normokyphotic group (-15.02 ± 8.04 vs 13.54 ± 6.17 [mean ± SEM], p = 0.006). The patients with hypokyphotic AIS had a kyphotic cervical spine (cervical kyphosis [CK]) (p < 0.001). Furthermore, a posterior-aligned cervical spine in terms of C2-7 SVA (p < 0.006) and C2-T3 SVA (p < 0.001) was observed in the thoracic hypokyphotic group.Comparing patients in terms of global alignment, the posterior-aligned group had a significantly smaller T1 slope (p < 0.001), without any difference in terms of pelvic, lumbar, and thoracic parameters when compared to the anterior-aligned group. The posterior-aligned group also had a CK (-9.20 ± 1.91 vs 5.21 ± 2.95 [mean ± SEM], p < 0.001) and a more posterior-aligned cervical spine, as measured by C2-7 SVA (p = 0.003) and C2-T3 SVA (p < 0.001).CONCLUSIONSAlignment of the cervical spine is closely related to thoracic curvature and global alignment. In patients with AIS, a hypokyphotic thoracic alignment or posterior global alignment was associated with a global cervical kyphosis. Interestingly, upper cervical and cranial parameters were not statistically different in all investigated groups, meaning that the upper cervical spine was not recruited for compensation in order to maintain a horizontal gaze.
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Affiliation(s)
- Michael Akbar
- 1Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Haidara Almansour
- 1Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Bassel G Diebo
- 3Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York; and
| | | | - Frank Schwab
- 2Hospital for Special Surgery, New York, New York
| | | | - Wojciech Pepke
- 1Clinic for Orthopaedics and Trauma Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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Seki S, Yahara Y, Makino H, Kawaguchi Y, Kimura T. Selection of posterior spinal osteotomies for more effective periapical segmental vertebral derotation in adolescent idiopathic scoliosis-An in vivo comparative analysis between Ponte osteotomy and inferior facetectomy alone. J Orthop Sci 2018; 23:488-494. [PMID: 29478623 DOI: 10.1016/j.jos.2018.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Ponte osteotomy is a useful method in posterior spinal release. However, it is unclear whether Ponte osteotomy itself contributes to vertebral derotation in surgery for adolescent idiopathic scoliosis (AIS) patients compared to inferior facetectomy alone. This study aimed to assess the effect of Ponte osteotomy on the magnitude of periapical vertebral body rotation compared to inferior facetectomy alone. This study was a prospective collected data. METHODS The study included 63 patients with AIS (Thoracic curve type, 35; thoracolumbar/lumbar curve type, 27), who underwent surgery between August 2011 and January 2015. All AIS patients underwent posterior spinal fusion with uniplanar screws and Ponte osteotomies on three periapical intervertebral segments. We measured and analyzed the flexibility of periapical intervertebral rotation pre- and post-bilateral inferior facetectomy, and post-Ponte osteotomy with our device (three times). The difference in intervertebral rotation between pre- and post-Ponte osteotomy was analyzed. RESULTS The mean increase in angle was 5.6° for thoracic curves and 6.4° for thoracolumbar curves. The increase in angle for thoracolumbar curves was significantly larger than that for thoracic curves (P < 0.05). The more an apical region of the scoliosis was located at caudal side of spine, the more the flexibility due to Ponte osteotomy increased (P < 0.05). The significant differences of the increase in intervertebral flexibility between inferior facetectomies and Ponte osteotomies were recognized at middle thoracic and thoracolumbar regions (P < 0.005). CONCLUSIONS Our data suggest that Ponte osteotomy has a loosening effect on periapical scoliotic curvature compared to inferior facetectomy alone. Ponte osteotomy is likely to be associated with an increase in loosening of the middle thoracic and thoracolumbar regions.
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Affiliation(s)
- Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Yasuhito Yahara
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Hiroto Makino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Tomoatsu Kimura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
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Ponte A, Orlando G, Siccardi GL. The True Ponte Osteotomy: By the One Who Developed It. Spine Deform 2018; 6:2-11. [PMID: 29287812 DOI: 10.1016/j.jspd.2017.06.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/23/2017] [Indexed: 10/18/2022]
Abstract
STUDY DESIGN Technique and applications. OBJECTIVES To define the anatomy, biomechanics, indications, and surgical technique of the true Ponte osteotomy. SUMMARY OF BACKGROUND DATA The Ponte osteotomy, originally developed for thoracic kyphosis, was the first one to obtain posterior shortening of the thoracic spine, maintaining the anterior column load-sharing capacity. It has become a widely applied technique in various types of spine deformities and a frequent topic of presentations at meetings and in scientific articles. Several of them offer unquestionable evidence of an incorrect execution, with consequently distorted outcomes and erroneous conclusions. A clearing up became essential. METHODS Our original experience is based on a series of 240 patients with thoracic hyperkyphosis operated in the years 1969-2015, at first with a standard posterior Harrington technique and then by using the Ponte osteotomy with different instrumentations. A series of 78 of them, operated in the years 1987-1997, who had Ponte osteotomies at every level, is presented. RESULTS The average preoperative kyphosis has been corrected from 80° (range 61°-102°) to 31° (range 15°-50°) by a substantial posterior shortening. CONCLUSIONS A number of publications use the term Ponte osteotomy loosely for by far incomplete resections and mixing it up with Smith-Petersen's osteotomy. The true Ponte osteotomy is capable of producing marked flexibility in extension, flexion and rotation, justifying its wide use in thoracic deformities, mainly in scoliosis. An exact performance of the osteotomy with adequate bony resections, including the laminae, is an absolute condition to take full advantage of its properties. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Alberto Ponte
- Stuart Clinic, 5952 Via Trionfale, Rome 00136, Italy.
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Luo M, Jiang H, Wang W, Li N, Shen M, Li P, Xu G, Xia L. Influence of screw density on thoracic kyphosis restoration in hypokyphotic adolescent idiopathic scoliosis. BMC Musculoskelet Disord 2017; 18:526. [PMID: 29237433 PMCID: PMC5729421 DOI: 10.1186/s12891-017-1877-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 11/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies have reported that rod composition and diameter, as well as the correction technique are key factors associated with thoracic kyphosis (TK) restoration. However, few study has analyzed the correlation between screw density and TK restoration in hypokyphotic adolescent idiopathic scoliosis (AIS). Methods Fifty-seven thoracic AIS patients with preoperative TK < 10° treated with all pedicle screw fixation with a minimum 2-year follow-up were recruited. Preoperative and postoperative radiographic measurements, and information of posterior instrumentation were reviewed. Pearson and Spearman correlation coefficient analysis were used to assess relationships between change in TK and number of variables. Then, the included patients were classified into two groups (Group 1: postoperative TK ≥ 20°; Group 2: postoperative TK < 20°) to evaluate the influence factors of TK restoration. Results The average preoperative TK was 4.75°, which was significantly restored to 17.30° (P < 0.001). Significant correlations were found between change in TK and flexibility of major thoracic curve (r = 0.357, P = 0.006), preoperative TK (r = −0.408, P = 0.002), and screw density of concave side (r = 0.306, P = 0.021), respectively. In the subgroup comparison, 17 patients (29.8%) maintain the postoperative TK ≥ 20°, increased flexibility of major thoracic curve (P < 0.001), screw number of concave side (P = 0. 029), and cobalt chromium rods (P = 0.041) were found in the group of postoperative TK ≥ 20°. Conclusions TK restoration remains a challenge for AIS patients with hypokyphosis, especially for the poor flexibility ones. Except for thicker and cobalt chromium rods, screw density of concave side might be another positive predictor of restoring normal kyphosis, which provides a stronger corrective force on the sagittal plane with more pedicle screws.
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Affiliation(s)
- Ming Luo
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Honghui Jiang
- Department of Orthopaedic Surgery, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, People's Republic of China
| | - Wengang Wang
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Ning Li
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Mingkui Shen
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Peng Li
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Genzhong Xu
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China
| | - Lei Xia
- Institute of Spinal Deformity, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, People's Republic of China.
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Chan A, Parent E, Narvacan K, San C, Lou E. Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal surgery: a systematic review on screw-related complications and breach rates. Spine J 2017; 17:1215-1229. [PMID: 28428081 DOI: 10.1016/j.spinee.2017.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Severe adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity requiring surgery to stop curve progression. Posterior spinal instrumentation and fusion with pedicle screws is the standard surgery for AIS curve correction. Vascular and neurologic complications related to screw malpositioning are concerns in surgeries for AIS. Breach rates are reported at 15.7%, implant-related complications at 1.1%, and neurologic deficit at 0.8%. Free-hand screw insertion remains the prevailing method of screw placement, whereas image guidance has been suggested to improve placement accuracy. PURPOSE This study aimed to systematically review the screw-related complication and breach rates from posterior spinal instrumentation and fusion with pedicle screws for patients with AIS when using free-hand methods for screw insertion compared with image guidance methods. STUDY DESIGN This is a systematic review of prognosis, comparing image guidance with no image guidance in surgery. PATIENT SAMPLE One randomized controlled trial and multiple prospective cohort studies that reported complication or breach rates in posterior spinal instrumentation and fusion with pedicle screws for AIS. OUTCOME MEASURES Number of complications and breaches reported in databases or recorded from postoperative imaging. METHODS Databases searched included MEDLINE, Embase, CINAHL, CENTRAL, and Web of Science. Studies of Level 3 evidence or greater as defined by the Centre for Evidence-Based Medicine were included. Articles were screened to focus on patients with AIS undergoing posterior fusion with pedicle screws or hybrid systems. Two independent reviewers screened abstracts, full texts, and extracted data. The Quality in Prognostic Studies (QUIPS) appraisal tool was used to determine studyrisk of bias (ROB). Level of evidence summary statements were formulated based on consistency and quality of reporting. RESULTS Seventy-nine cohort studies were identified, including four comparing computed tomography (CT) guidance with free-hand methods head-to-head, eight on image guidance, and 671. on free-hand methods alone. Moderate evidence from individual head-to-head studies show CT guidance has lower breach rates than free-hand methods. No complications were found in these studies. From individual cohort studies, moderate evidence shows CT guidance has lower point estimates of breach rates than free-hand methods at 7.9% compared with 9.7%-17.1%. Screw-related complication rates are conflicting at 0% in CT navigation compared with 0%-1.7% in 13 low- and moderate-quality studies. CONCLUSIONS Although point estimates on breach rates are decreased with CT navigation compared with free-hand methods, complication rates remain conflicting between the two methods. Current evidence is limited by small sample sizes, lack of comparison groups, and poorly predefined complications. Randomized controlled trials with larger samples with standardized definitions and recording of predefined breach and complication occurrences are recommended.
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Affiliation(s)
- Andrew Chan
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, 1098 Research Transition Facility 8308-114 St, Edmonton, Alberta T6G 2V2, Canada
| | - Eric Parent
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 8205 114 St 2-50 Corbett Hall, Edmonton, Alberta T6G 2G4, Canada.
| | - Karl Narvacan
- Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 Walter C Mackenzie Health Sciences Centre 8440 112 St NW, Edmonton, Alberta T6G 2R7, Canada
| | - Cindy San
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Edmond Lou
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, 2D, Walter C Mackenzie Health Sciences Centre - 8440 - 112 St, Edmonton, Alberta T6G 2B7, Canada
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Han S, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Lee BH, Choi HY. Multilevel Posterior Column Osteotomies Are Not Inferior For the Correction of Rigid Adult Spinal Deformity Compared with Pedicle Subtraction Osteotomy. World Neurosurg 2017; 107:839-845. [PMID: 28847551 DOI: 10.1016/j.wneu.2017.08.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Posterior column osteotomy (PCO) has been used for the correction of various spinal deformities. However, little evidence is available regarding the effects of multilevel PCO in adult spinal deformity (ASD) surgery. This study aimed to show the usefulness of PCO in rigid ASD surgery by assessing radiographic and clinical outcomes. We also aimed to assess the corrective potential of multilevel PCOs compared with a single-level pedicle subtraction osteotomy (PSO). METHODS Between 2012 and 2016, the medical records of 70 consecutive patients who underwent a multilevel PCO (35 patients) or a single-level PSO (35 patients) for ASD in a single institute were reviewed. Baseline data, radiographic measurements, and clinical outcomes using the Scoliosis Research Society-22 (SRS-22) questionnaire were compared between groups. RESULTS The following variables were no different between the groups: age at surgery, sex, level fused, preoperative and postoperative radiologic parameters, and bone mineral density T score. However, operation time (380.0 vs. 483.6 minutes), estimated blood loss (1175.7 vs. 1362.6 mL), and the number of complications (8 vs. 20) were significantly reduced in the PCO group compared with the PSO group. A significant improvement in the SRS-22 score was seen in both groups after surgery, although no difference was observed between the groups postoperatively. CONCLUSIONS Multilevel PCOs for the correction of rigid ASD were slightly superior to PSO, regarding clinical outcomes. Radiographic outcomes were similar between groups. Thus, multilevel PCOs may be a viable option for the treatment of rigid ASD with a mobile segment.
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Affiliation(s)
- Sanghyun Han
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Byoung Hun Lee
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Ho Yong Choi
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
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Abstract
Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.
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Lonner BS, Toombs CS, Paul JC, Shah SA, Shufflebarger HL, Flynn JM, Newton PO. Resource Utilization in Adolescent Idiopathic Scoliosis Surgery: Is There Opportunity for Standardization? Spine Deform 2017; 5:166-171. [PMID: 28449959 DOI: 10.1016/j.jspd.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 11/23/2016] [Accepted: 01/03/2017] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Recent healthcare reforms have raised the importance of cost and value in the management of disease. Value is a function of benefit and cost. Understanding variability in resources utilized by individual surgeons to achieve similar outcomes may provide an opportunity for cutting costs though greater standardization. The purpose of this study is to evaluate differences in use of implants and hospital resources among surgeons performing adolescent idiopathic scoliosis (AIS) surgery. METHODS A multicenter prospective AIS operative database was queried. Patients were matched for Lenke curve type and curve magnitude, resulting in 5 surgeons and 35 matched groups (N = 175). Mean patient age was 14.9 years and curve magnitude 50°. Parameters of interest were compared between surgeons via ANOVA and Bonferroni pairwise comparison. RESULTS There was no significant difference in percentage curve correction or levels fused between surgeons. Significant differences between surgeons were found for percentage posterior approach, operative time, length of stay (LOS), estimated blood loss (EBL), cell saver transfused, rod material, screw density, number of screws, use of antifibrinolytics, and cessation of intravenous analgesics. Despite differences in EBL and cell saver transfused, there were no differences in allogenic blood (blood bank) use. CONCLUSION Significant variability in resource utilization was noted between surgeons performing AIS operations, although radiographic results were uniform. Standardization of resource utilization and cost containment opportunities include implant usage, rod material, LOS, and transition to oral analgesics, as these factors are the largest contributors to cost in AIS surgery.
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Affiliation(s)
- Baron S Lonner
- Department of Orthopaedic Surgery, Mount Sinai-Beth Israel Medical Center, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA.
| | - Courtney S Toombs
- New York University School of Medicine, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA
| | - Justin C Paul
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, Scoliosis and Spine Associates, 820 Second Avenue, New York, NY 10017, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, AI Du Pont Hospital, Nemours Children's Clinic - Wilmington of the Nemours Foundation, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Harry L Shufflebarger
- Department of Orthopaedic Surgery, Miami Children's Hospital, Nicklaus Children's Orthopedic Spine Center, 3100 SW 62 Avenue NE Wing #108, Miami, FL 33155, USA
| | - John M Flynn
- Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Division of Orthopedic Surgery, 2nd Floor Wood Building, 34th St. & Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady Children's Hospital, Pediatric Orthopedic & Scoliosis Ctr, 3030 Children's Way #410, San Diego, CA 92123, USA
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The effect of sublaminar wires on the rib hump deformity during scoliosis correction manoeuvres. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:771-7. [PMID: 27549661 DOI: 10.1007/s00590-016-1841-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION During thoracic curve correction, the tightening of the sublaminar wires through concavity creates a medial and a dorsal translation of the spine. However, little is known about the effect of the sublaminar wires on the axial plane. METHODS This is prospective case series analysis of 30 consecutive surgical patients with main thoracic adolescent idiopathic scoliosis. All of the patients were fused with hybrid instrumentation (apical concavity-sublaminar wires) and differential rod contouring (over-kyphosis concavity/under-kyphosis convexity). The degrees of the rib hump were measured with a scoliometer placed at the apex of the deformity at five different times: (1) preoperatively through the Adam's test, and during surgery (sterilised scoliometer), (2) with the patient lying prone, (3) after the Ponte osteotomies, (4) after the apical sublaminar tightening, and (5) after convexity apical derotation and compression manoeuvres. RESULTS (1) Preoperatively, the Adam's test was 16.3° ± 4.6. (2) Lying prone and under general anaesthesia, it decreased to 11.4° ± 3.9. (3) After exposure and Ponte osteotomies, it was 7.1° ± 4. (4) After the wire tightening, it was 10.8° ± 4.7. (5) After the convexity manoeuvres, it was 4.8° ± 3.7. The degrees of the rib hump final correction were 11.6° ± 4 (70 % correction). The tightening of the sublaminar wires increased the rib hump by 3.5°. CONCLUSIONS The sublaminar wire tightening towards the concave rod seemed to create an effect opposite of the desired effect, increasing the apical rotation and the thoracic rib hump deformity. Convexity manoeuvres (apical screw derotation and compression) are necessary and must be coupled with an under-bending of the convex rod to neutralise this effect.
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Holewijn RM, Schlösser TPC, Bisschop A, van der Veen AJ, Stadhouder A, van Royen BJ, Castelein RM, de Kleuver M. How Does Spinal Release and Ponte Osteotomy Improve Spinal Flexibility? The Law of Diminishing Returns. Spine Deform 2015; 3:489-495. [PMID: 27927536 DOI: 10.1016/j.jspd.2015.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 02/12/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Experimental study. OBJECTIVES To evaluate the effect of stepwise resection of posterior spinal ligaments, facet joints, and ribs on thoracic spinal flexibility. SUMMARY OF BACKGROUND DATA Posterior spinal ligaments, facet joints and ribs are removed to increase spinal flexibility in corrective spinal surgery for deformities such as adolescent idiopathic scoliosis (AIS). Reported clinical results vary and biomechanical substantiation is lacking. METHODS Ten fresh-frozen human cadaveric thoracic spinal specimens (T6-T11) were studied. A spinal motion simulator applied a pure moment of ±2.5 Nm in flexion, extension, lateral bending (LB) and axial rotation (AR). Range of motion (ROM) was measured for the intact spine and measured again after stepwise resection of the supra/interspinous ligament (SIL), inferior facet, flaval ligament, superior facet, and rib heads. RESULTS SIL resection increased ROM in flexion (10.2%) and AR (3.1%). Successive inferior facetectomy increased ROM in flexion (4.1%), LB (3.8%) and AR (7.7%), and flavectomy in flexion (9.1%) and AR (2.5%). Sequential superior facetectomy only increased ROM in flexion (6.3%). Rib removal provided an additional increase in flexion (6.3%), LB (4.5%) and AR (13.0%). Extension ROM increased by 10.5% after the combined removal of the SIL, inferior facet and flaval ligament. CONCLUSIONS Posterior spinal releases in these non-scoliotic spines led to an incremental increase in spinal flexibility, but each sequential step had less effect. As compared to SIL resection with inferior facetectomy, additional superior facetectomy did not improve flexibility in AR and LB and only 6.3% in flexion. The data presented from this in vitro study should be interpreted with care, as no representative cadaveric spine model for AIS was available, However, the results presented here at least question the benefits of performing routine complete facetectomies (i.e. Ponte osteotomies) to increase spinal flexibility in scoliosis surgery.
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Affiliation(s)
- Roderick M Holewijn
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Tom P C Schlösser
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Arno Bisschop
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Albert J van der Veen
- Department of Physics and Medical Technology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Agnita Stadhouder
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Barend J van Royen
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - René M Castelein
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Marinus de Kleuver
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Do Ponte Osteotomies Enhance Correction in Adolescent Idiopathic Scoliosis? An Analysis of 191 Lenke 1A and 1B Curves. Spine Deform 2015; 3:483-488. [PMID: 27927535 DOI: 10.1016/j.jspd.2015.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 02/19/2015] [Accepted: 03/02/2015] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN Retrospective review of a prospectively collected multicenter database of patients with adolescent idiopathic scoliosis (AIS). OBJECTIVE To determine if Ponte osteotomies improve correction in Lenke 1A and 1B AIS curves treated with pedicle screws. SUMMARY OF BACKGROUND DATA There is little data studying the risks and benefits of Ponte osteotomies in AIS. METHODS We identified patients with Lenke 1A and 1B curve types treated with pedicle screw constructs and a 2-year follow-up. They were grouped based on whether they did (PO) or did not (NoPO) have Ponte osteotomies. Demographic, surgical, and radiographic data collected preoperatively and at 2 years were statistically analyzed using unpaired Student t test and Fisher exact test. RESULTS One hundred ninety-one patients met the inclusion criteria (mean age of 14.7 ± 2.2 years), and among those, 125 patients (65.4%) had Ponte osteotomies (average of 4.3 ± 1.5 Pontes per patient). The patients treated with Ponte osteotomies had similar clinical and radiographic parameters (major Cobb: PO = 51.5°, NoPO = 50.8°, p = .6) to the patients who did not have Ponte osteotomies except that they had stiffer and more lordotic curves (Flexibility Index: PO = 47.3%, NoPO = 54.5%, p = .04; T5-T12 kyphosis: PO = 18.7°, NoPO = 23.2°, p = .02). At 2 years, the patients treated with Ponte osteotomies had significantly better thoracic Cobb angle correction (Correction Index: PO = 67.1%, NoPO = 61.8%, p = .01) and an increase in T5-T12 kyphosis (PO = +3.0°, NoPO = -0.4°, p = .045). The Ponte group demonstrated greater rib prominence correction (PO = 53.2%, NoPO = 38.4%, p = .02). There were no neurologic events in this cohort. CONCLUSIONS Although the use of Ponte osteotomies was not randomized, these data suggest that greater deformity correction in all 3 planes may be possible when Ponte osteotomies are performed for the stiffer and more lordotic Lenke 1A and 1B curves. The clinical significance of these overall small statistical differences remains to be determined. LEVEL OF EVIDENCE III.
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Abstract
The management of severe pediatric spinal deformities continues to evolve as advances in spinal instrumentation, surgical techniques, and neuromonitoring occur. The techniques of spinal osteotomies have been refined to allow surgeons to perform better corrections with less operative time, more safely, and through a posterior approach alone, making multiple patient positioning changes during surgery a less common occurrence. With these techniques comes a learning curve for the entire surgical team, wherein communication and planning can help minimize major complications and morbidity. This overview will review various techniques used in the correction of severe spinal deformities. Topics reviewed include the role of anterior release, traction, posterior releases, and osteotomies. Indications, techniques, and pitfalls will be reviewed. A clear understanding of the patient's deformity, normal sagittal parameters, spinal anatomy, and the principles of neuromonitoring will help improve surgical planning and patient outcome.
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