Pre-operative Halo-Pelvic Traction for Neurofibromatosis Patients with Severe Proximal Thoracic Spinal Deformity: Indications and Early Treatment Outcome

@#Introduction: To report the indications and early treatment outcomes of pre-operative halo-pelvic traction in patients with neurofibromatosis associated with severe proximal thoracic (PT) spinal deformity. Materials and methods: We reviewed four patients with neurofibromatosis with severe PT spinal deformity. Case 1, a 16-year-old male presented with severe PT kyphoscoliosis (scoliosis: 89°, kyphosis: 124°) and thoracic myelopathy. Case 2 was a 14-year-old, skeletally immature male who presented with a PT lordoscoliosis (scoliosis: 85°). Case 3, a 13-year-old male, presented with severe PT kyphoscoliosis (scoliosis: 100°, kyphosis: 95°). Case 4, a 35-year-old gentleman, presented with severe PT kyphoscoliosis (scoliosis: 113°, kyphosis: 103°) and thoracic myelopathy. All patients underwent pre-operative halo-pelvic traction. After a period of traction, all patients underwent posterior spinal fusion (PSF) with autologous bone grafts (local and fibula bone grafts) and recombinant human bone morphogenetic protein-2 (rhBMP-2). Results: Both patients with thoracic myelopathy regained near normal neurological status after halo-pelvic traction. Following traction, the scoliosis correction rate (CR) ranged from 18.0% to 38.9%, while the kyphosis CR ranged from 14.6% to 37.1%. Following PSF, the scoliosis CR ranged from 24.0% to 58.8%, while the kyphosis CR ranged from 29.1% to 47.4%. The total distraction ranged from 50-70mm. Duration of distraction ranged from 26-95 days. The most common complication encountered during halo-pelvic traction was pin-related e.g. pin tract infection, pin loosening and migration, osteomyelitis, and halo-pelvic strut breakage. No patients had cranial nerve palsies or neurological worsening. Conclusion: Pre-operative correction of severe PT spinal deformities could be performed safely and effectively with the halo-pelvic device prior to definitive surgery.

Delayed Post-operative Spinal Epidural Haematoma after Posterior Spinal Surgery: Report of Two Cases

@#Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.

Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine

@#Introduction: This was a retrospective study aimed to investigate the perioperative outcomes of long construct minimally invasive spinal stabilisation (MISt) using percutaneous pedicle screws (PPS) versus conventional open spinal surgery in the treatment of spinal fracture in ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). Material and Methods: Twenty-one patients with AS and DISH who were surgically treated between 2009 and 2017 were recruited. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union rate. Results: Mean age was 69.2 ± 9.9 years. Seven patients had AS and 14 patients had DISH. 17 patients sustained AO type B3 fracture and 4 patients had type B1 fracture. Spinal trauma among these patients mostly involved thoracic spine (61.9%), followed by lumbar (28.6%) and cervical spine (9.5%). MISt using PPS was performed in 14 patients (66.7%) whereas open surgery in 7 patients (33.3%). Mean number of instrumentation level was 7.9 ± 1.6. Mean operative time in MISt and open group was 179.3 ± 42.3 minutes and 253.6 ± 98.7 minutes, respectively (p=0.028). Mean intra-operative blood loss in MISt and open group was 185.7 ± 86.4ml and 885.7 ± 338.8ml, respectively (p<0.001). Complications and union rate were comparable between both groups. Conclusion: MISt using PPS lowers the operative time and reduces intra-operative blood loss in vertebral fractures in ankylosed disorders. However, it does not reduce the perioperative complication rate due to the premorbid status of the patients. There was no significant difference in the union rate between MISt and open surgery.

The Clinical Effectiveness of School Screening Programme for Idiopathic Scoliosis in Malaysia

Introduction: There is no large population size study on school screening for scoliosis in Malaysia. This study is aimed to determine the prevalence rate and positive predictive value (PPV) of screening programme for adolescent idiopathic scoliosis. Materials and Methods: A total of 8966 voluntary school students aged 13-15 years old were recruited for scoliosis screening. Screening was done by measuring the angle of trunk rotation (ATR) on forward bending test (FBT) using a scoliometer. ATR of 5 degrees or more was considered positive. Positively screened students had standard radiographs done for measurement of the Cobb angle. Cobb angle of >10° was used to diagnose scoliosis. The percentage of radiological assessment referral, prevalence rate and PPV of scoliosis were then calculated. Results: Percentage of radiological assessment referral (ATR >5°) was 4.2% (182/4381) for male and 5.0% (228/4585) for female. Only 38.0% of those with ATR >5° presented for further radiological assessment. The adjusted prevalence rate was 2.55% for Cobb angle >10°, 0.59% for >20° and 0.12% for >40°. The PPV is 55.8% for Cobb angle >10°, 12.8% for >20° and 2.6% for > 40°. Conclusions: This is the largest study of school scoliosis screening in Malaysia. The prevalence rate of scoliosis was 2.55%. The positive predictive value was 55.8%, which is adequate to suggest that the school scoliosis screening programme did play a role in early detection of scoliosis. However, a cost effectiveness analysis will be needed to firmly determine its efficacy.