The Thoracic Lordosis Correction Improves Sacral Slope and Walking Ability in Neuromuscular Scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report on neuromuscular patients with preserved walking ability, but forward bending of the body due to thoracic lordosis, and to suggest thoracic lordosis correction as the surgical treatment. SUMMARY OF BACKGROUND DATA: It is an established fact that lumbar lordosis or pelvic parameter is directly related to thoracic sagittal balance. However, the reverse relationship has not been fully defined yet. Loss of thoracic kyphosis results in positive sagittal balance, which causes walking difficulty. Neuromuscular patients with thoracic lordosis have not been reported yet, and there have been no reports on their surgical treatments. METHODS: This study analyzed 8 patients treated with thoracic lordosis correction surgery. Every patient was diagnosed with muscular dystrophy. In thoracic lordosis correction surgery, anterior release was performed in the first stage and posterior segmental instrumentation was performed in the second stage. Radiographic parameters were compared and walking ability was evaluated with gait analysis. All patients were classified according to the modified Rancho Los Amigos Hospital system preoperatively and 2 years postoperatively to evaluate functional ability. The average follow-up period was 2.9 years. RESULTS: Before surgery, the mean thoracic sagittal alignment was -2.1-degree lordosis, the mean Cobb angle and sacral slope increased to 36.3 and 56.6 degrees, respectively. The anterior pelvic tilt in gait analysis was 29.3 degrees. At last follow-up after surgery, the mean thoracic sagittal alignment changed to 12.6-degree kyphosis, and the Cobb angle and sacral slope decreased to 18.9 and 39.5 degrees, respectively. Lumbar lordosis and the sacral slope showed significant positive correlation (P<0.001). The improvement in thoracic lordosis showed a significant correlation to the preoperative flexibility of the major curve (P=0.028). The anterior pelvic tilt in gait analysis improved to 15.4 degrees. The functional ability improved in 2 (50%) of 4 patients in class 2 and maintained in remaining 6 patients 2 years after surgery. CONCLUSIONS: Thoracic lordosis correction surgery in neuromuscular scoliosis patients with thoracic lordosis improved the sacral slope in the standing position and the anterior pelvic tilt in gait. Sagittal imbalance was compensated by the spinopelvic mechanism, and back and hip extensor muscles seem to play a major role in this compensation.

A case of intraductal tubulopapillary neoplasm of pancreas with severe calcification, a potential pitfall in diagnostic imaging.

We experienced a case of intraductal tubulopapillary neoplasms (ITPN) of the pancreas with severe calcification, which complicated image diagnosis. A pancreas head tumor was detected in a Japanese female in her 50s. Early enhancement by contrast-enhanced CT and coarse calcification suggested a neuroendocrine tumor, although the obstruction and dilation of the main pancreatic duct appeared to be an intraductal tumor. An endoscopic ultrasound-guided fine needle aspiration biopsy specimen revealed adenocarcinoma tissue. Pancreaticoduodenectomy was performed, and the patient has been well without evidence of recurrence for over 10 months. Pathological examination on the resected specimen revealed that the tumor showed papillary and tubulo-cribriform growth patterns. Together with typical immunohistochemical results, the final diagnosis of ITPN was made. Characteristically, this case showed extensive calcification of both psammoma body-type and non psammoma body-type with foamy macrophage aggregation. This is the first report of ITPN with two types of calcification and macrophage. Since calcification might be one of the characteristic histological findings in ITPN as shown in our case, the possibility of ITPN should be also considered when calcification is detected in pancreatic lesions by various imaging modalities.

Usefulness of Noninvasive Positive-pressure Ventilation During Surgery of Flaccid Neuromuscular Scoliosis.

STUDY DESIGN: This is a retrospective study. OBJECTIVE: To assess the effects of noninvasive positive-pressure ventilation (NIPPV) through evaluations of outcomes and incidences of postoperative pulmonary complications among patients with flaccid neuromuscular scoliosis for pulmonary support in the perioperative periods. BACKGROUND DATA: There is no report on the effects of NIPPV on neuromuscular scoliosis patient during the perioperative periods. METHODS: We retrospectively reviewed 73 patients diagnosed with neuromuscular scoliosis who underwent staged anterior and posterior spinal surgery and instrumentations for deformity correction from 2003 to 2010. A total of 73 patients were divided depending on whether they had received NIPPV treatment or not during the perioperative period. Twenty-eight patients who received NIPPV for respiratory support and 45 patients with no mechanical ventilation were compared according to age, sex, body mass index, number of fusion levels, and end-tidal pressure of CO(2) and forced vital capacity values. The incidence of pulmonary complications associated with either group (pneumonia, atelectasis, pneumothorax, prolonged ventilator support, and postoperative tracheostomy) was then evaluated. RESULTS: In between the 2 groups, the forced vital capacity (41% vs. 64%, P<0.0001) were observed to be significantly decreased with the use of NIPPV. End-tidal pressure of CO(2) was not statistically different between the 2 groups. Although statistically not significant, patients in the non-NIPPV group had a higher incidence of pulmonary complications (38% vs. 21%, P=0.1584). None of the aforementioned patients required tracheostomy. In addition, no other mortality or neurological complications were noted postoperatively. CONCLUSIONS: There is a definite advantage of using NIPPV, because the incidence of postoperative pulmonary complications and the need for tracheostomy in patients with severely decreased pulmonary function are not increased from the use of NIPPV.

Analysis of single nucleotide polymorphism in adolescent idiopathic scoliosis in Korea: for personalized treatment.

PURPOSE: The incidence of adolescent idiopathic scoliosis (AIS) has rapidly increased, and with it, physician consultations and expenditures (about one and a half times) in the last 5 years. Recent etiological studies reveal that AIS is a complex genetic disorder that results from the interaction of multiple gene loci and the environment. For personalized treatment of AIS, a tool that can accurately measure the progression of Cobb's angle would be of great use. Gene analysis utilizing single nucleotide polymorphism (SNP) has been developed as a diagnostic tool for use in Caucasians but not Koreans. Therefore, we attempted to reveal AIS-related genes and their relevance in Koreans, exploring the potential use of gene analysis as a diagnostic tool for personalized treatment of AIS therein. MATERIALS AND METHODS: A total of 68 Korean AIS and 35 age- and sex-matched, healthy adolescents were enrolled in this study and were examined for 10 candidate scoliosis gene SNPs. RESULTS: This study revealed that the SNPs of rs2449539 in lysosomal-associated transmembrane protein 4 beta (LAPTM4B) and rs5742612 in upstream and insulin-like growth factor 1 (IGF1) were associated with both susceptibility to and curve severity in AIS. The results suggested that both LAPTM4B and IGF1 genes were important in AIS predisposition and progression. CONCLUSION: Thus, on the basis of this study, if more SNPs or candidate genes are studied in a larger population in Korea, personalized treatment of Korean AIS patients might become a possibility.

Surgical outcome of lumbar fusion surgery in patients with Parkinson disease.

STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the overall surgical outcome of lumbar fusion surgery in patients with Parkinson disease (PD). SUMMARY OF BACK GROUND DATA: Poor bone quality and muscular dysfunction are important clinical manifestations connected with musculoskeletal diseases in PD patients. These secondary changes caused by PD often result in spinal pathology, indicating spine operations for some patients with scoliosis, kyphosis, osteoporotic fracture, or degenerative spondylosis. However, little is known about the surgical outcome or prognosis of spine surgery in PD patients. METHODS: Lumbar fusion surgery was performed on 20 patients who had PD and degenerative spinal diseases. At the time of lumbar fusion surgery, the mean duration of PD, age, sex, the preoperative visual analog pain scale (VAS, 0 to 100 mm) for low back pain, Hoehn and Yahr staging, and other comorbidities were evaluated. Patients' postoperative clinical outcome was measured using the criteria of Kim and Kim and VAS for back pain. Radiographic assessment was made using plain films and a dynamogram. RESULTS: At the time of the spine surgery, Hoehn and Yahr staging of PD was from 1 to 2 in all patients. Only 1 patient had a satisfactory outcome; a good result according to Kim and Kim's criteria. The average postoperative VAS (mm) was 55.2, whereas the mean preoperative VAS (mm) was 53.9. Radiological assessment showed fusion status in 15 patients and probably no solid fusion mass in 5 patients. CONCLUSIONS: A poor surgical outcome would be inevitable because of the worsening of symptoms owing to the natural history of PD. Therefore, our current study suggested surgical indication should be exercised cautiously in the patients with PD and spinal stenosis.

Value of preoperative pulmonary function test in flaccid neuromuscular scoliosis surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the prognostic value of preoperative pulmonary function test (PFT) for postoperative pulmonary complications and to identify the operability associated with severely decreased forced vital capacity (FVC) (<30%) status in flaccid neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA: The preoperative PFT, especially more than 30% FVC, is known as a critical factor for the operability of flaccid neuromuscular scoliosis. But only one study reported that patients with pre-existing respiratory failure on nocturnal noninvasive ventilation can undergo an operation for deformity correction without mortality and severe complications. METHODS: A total of 74 patients (45 male and 29 female) presented with flaccid neuromuscular scoliosis. For all patients, preoperative PFTs were evaluated and subdivided into three groups (<30% FVC, 30%-50% FVC, and >50% FVC). Then postoperative pulmonary complications, pneumothorax, pneumonia, atelectasis, prolonged ventilator care in the intensive care unit (more than 72 hours), and postoperative tracheostomy were evaluated. RESULTS: Among these patients, 59 had muscular dystrophy; 5, spinal muscular atrophy; 2, cerebral palsy; and 8, others. The mean age at surgery was 16.8 years (range, 5-32 years). The mean preoperative Cobb angle was 54.6° (16°-135°). The overall postoperative pulmonary complication rate was 31% (23 complications in 74 patients). The less than 30% FVC group had 6 complications among 18 patients; the 30% to 50% FVC group had 7 complications among 18 patients; and the more than 50% FVC group had 10 complications among 38 patients. There were no deaths during the perioperative period. There is no statistical difference between the three groups (P = 0.6195). CONCLUSION: Patients with flaccid neuromuscular scoliosis can undergo an operation for deformity correction regardless of the severely decreased pulmonary function.

Video-assisted thoracoscopic surgery plus lumbar mini-open surgery for adolescent idiopathic scoliosis.

PURPOSE: The objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion. MATERIALS AND METHODS: This is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year. RESULTS: The average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05). CONCLUSION: Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.

Comparison between Operated Muscular Dystrophy and Spinal Muscular Atrophy Patients in terms of Radiological, Pulmonary and Functional Outcomes.

STUDY DESIGN: Retrospective comparative study. PURPOSE: To study and compare the surgical outcomes of muscular dystrophy (MD) and spinal muscle atrophy (SMA). OVERVIEW OF LITERATURE: There are few reports that have evaluated and compared the surgical outcomes of MD and SMA patients. METHODS: The patients (n = 35) were divided into two groups: a MD group with 24 patients and a SMA group with 11 patients. The average follow-up period was 21 months. All patients were operated for scoliosis correction using posterior instrumentation and fusion. In the immediate postoperative period, all efforts were made to reduce the pulmonary complications using non-invasive positive pressure ventilation and a coughing assist devices. The patients were evaluated by radiograph in terms of the Cobb's angle, pelvic obliquity, T1 translation, thoracic kyphosis and lumbar lordosis. The pulmonary function and self-image satisfaction were also assessed. RESULTS: There was a lower correction rate in the MD group (41.5%) than in the SMA group (48.3%), even though the curves were smaller in the MD group. The correction in the pelvic obliquity was significantly better in the SMA group (p = 0.03). The predicted vital capacity showed a 4% reduction in the MD group 1 year after surgery, while the SMA group showed a 10% reduction. The peak cough flow and end tidal PCO(2) did not deteriorate and were well maintained. The average score for the improvement in self-image satisfaction postoperatively was 3.96 and 4.64 for the MD and SMA groups, respectively. The total complication rate was 45.7%; 14.3% of which were respiratory-related. CONCLUSIONS: Surgical intervention for MD and SMA may be performed safely in patients with a very low forced vital capacity (< 30%) through aggressive preoperative and postoperative rehabilitation efforts.

Vascular injury in thoracolumbar spinal surgeries and role of angiography in early diagnosis and management.

STUDY DESIGN: A retrospective outcomes study. OBJECTIVE: To stress on the importance of early diagnosis with the help of angiography and proper treatment of vascular injuries occurring during thoracolumbar surgeries and to report our results. SUMMARY OF BACKGROUND DATA: Vascular injury is a rare but dangerous complication that can develop during thoracolumbar surgeries and if not treated properly then it can lead to severe complications including the death of the patient. METHODS: The patients included in this study were the ones who were suspected to have a possible vascular injury after a thoracolumbar surgery. Contrast enhanced computed tomography was performed for patients having clinical signs suggesting vascular injury. Among these patients, who were suspected to have active bleeding and major vessel injury on computed tomography were further subjected to angiography. RESULTS: Of the 10 cases included in the study, vascular injury was identified to be arterial in origin in 8 cases and venous in 3 cases. Among the 8 cases of identified arterial injury, angiography was performed in 4 cases, of which 3 were found to have active bleeding and were subjected to immediate intervention. Of the 4 cases in which angiography was not performed, 3 of them expired at variable postoperative periods. Complications developed in total 5 cases including 3 cases of mortality, 1 case of infection, and 1 case of cauda equina syndrome. CONCLUSIONS: The vascular injuries during thoracolumbar spinal surgeries need immediate and aggressive treatment. In arterial injuries, we can prevent serious consequences by subjecting the patient to an angiography as early as possible followed by a therapeutic embolization. In contrast, for venous injuries if hemostasis has been confirmed, then an immediate intervention may not be always required.