Crecimiento guiado con barras magnéticas en pacientes con escoliosis de inicio temprano. Reporte preliminar / Guided growth with magnetic rods in early onset scoliosis. Preliminary report

Introducción: El tratamiento de las escoliosis de inicio temprano guiado con barras magnéticas permite realizar distracciones no invasivas y ambulatorias. El objetivo de este estudio fue evaluar nuestra primera serie de casos con escoliosis de inicio temprano tratados con el sistema de barras magnéticas. Materiales y Métodos: Se realizó una revisión de casos tratados con el sistema de barras magnéticas entre 2014 y 2018. Se formaron dos grupos: grupo I (procedimientos primarios con barras magnéticas) y grupo II (conversiones de sistema tradicional a barras magnéticas). Resultados: Se evaluó a 19 pacientes. La edad promedio en el momento de la cirugía era de 7 años y 4 meses, con un seguimiento promedio de 2 años y 7 meses. El grupo I tenía 12 pacientes y el grupo II, 7 pacientes. Los valores angulares promedio preoperatorio y posoperatorio inmediato de la escoliosis fueron 62° y 42°, respectivamente; los de cifosis, 49° y 34°, respectivamente. La distancia T1-T12 fue de 160 a 176 mm. La distancia T1-S1 fue de 285 a 317 mm. Hubo una complicación: protrusión del implante e infección, y fue necesario retirar el material (grupo II). Conclusiones: Los resultados preliminares sugieren que es un método seguro y eficaz. Si bien los resultados a corto y mediano plazo son alentadores, persisten algunos desafíos importantes e incógnitas en relación con el comportamiento mecánico del implante en un seguimiento prolongado. Nivel de Evidencia: IV

Introduction: Early onset scoliosis (EOS) treatment with the magnetically controlled growing rod (MCGR) system allows for the use of non-invasive outpatient distractions. The purpose of this study was to assess our first series of EOS patients treated with MCGRs. Materials and methods: We conducted a review of EOS cases treated with MCGRs between 2014 and 2018. The study population was divided into two groups: Group I, patients undergoing primary MCGR insertion; Group II, patients undergoing conversion from conventional growth system to MCGR. Results: The study population consisted of 19 patients. The average age at the time of surgery was 7 years and 4 months, with an average post-operative follow-up of 2 years and 7 months. Group I consisted of 12 patients and Group II of 7 patients. The mean preoperative scoliosis angle was 62° and immediate postoperatively was 42°. The mean preoperative kyphosis angle was 49°and immediate postoperatively was 34°. The average preoperative T1-T12 length was 160mm and immediate postoperatively was 176mm. The average preoperative T1-S1 length was 285mm and immediate postop-eratively was 317mm. There was 1 late complication, an implant protrusion with an associated infection, in a neuropathic scoliosis patient (Group II) who required implant removal. Conclusion: Our preliminary results suggest that the MCGR system is a safe and effective method. Although the short- and medium-term results are encouraging, further studies are warranted to overcome important and unknown challenges regarding the mechanical behavior of the implant in the long term. Nivel de Evidencia: IV

Aneurysmal Bone Cysts of the Spine in Children: A Review of 18 Cases.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to evaluate the clinical presentation, treatments, outcome, complications, and recurrence rate in the surgical and nonsurgical management of spinal aneurysmal bone cyst (ABC) in a series of 18 pediatric patients. METHODS: Between 1988 and 2014, we evaluated 18 pediatric patients diagnosed with ABC confirmed by pathology studies. We analyzed clinical and radiological features, non-surgical and surgical treatment, outcome, and complications. RESULTS: The series included 12 male and 6 female patients with a mean age of 10 years and 4 months, with a mean follow-up of 5 years. Location of the ABC was lumbar in 8, cervical in 7, thoracic in 2, and sacral in 1 case. Axial pain was the most common symptom followed by radicular involvement. Surgery was performed in the presence of spine instability or neurological involvement (tumor resection) and in the remaining, nonsurgical treatment (percutaneous intralesional injection of methylprednisolone and calcitonin). Recurrence was observed in 4 patients requiring reintervention. There were no procedure-related complications. CONCLUSION: In patients without neurological involvement or spinal instability, nonsurgical treatment is the treatment of choice. Total or subtotal removal combined with posterior instrumented spinal fusion is recommended in cases with a neurological deficit. Both procedures have shown good long-term results.

Quality of life and patient satisfaction in bracing treatment of adolescent idiopathic scoliosis.

BACKGROUND: Bracing is used as a valid non-surgical treatment for adolescent idiopathic scoliosis (AIS) to avoid progression of the deformity and thereby surgery. The effect of bracing treatment on quality of life of patients with AIS has been a topic of interest in the international literature. The aim of this study was to evaluate the quality of life and patient satisfaction during bracing treatment for AIS of a pediatric hospital. MATERIAL AND METHOD: We assessed a total of 43 non-consecutive female patients (mean age at questionnaire, 13 years and 1 month and 10 years and 8 months to 14 years and 5 months; mean period of usage of brace, 1 year and 7 months), with adolescent idiopathic scoliosis (AIS), older than 10 years of age until skeletal maturity, with a Risser sign less than 3 and scoliosis between 20 and 45°, treated with thoracolumbosacral orthosis (TLSO) for a period longer than 6 months, and without other comorbidities or previous surgeries, were evaluated. The patients were administered a previously validated to Spanish questionnaire on quality of life (Brace Questionnaire (BrQ); Grivas TB et al.). BrQ is a validated tool and is considered a disease-specific instrument; its score ranges from 20 to 100 points, and higher BrQ scores are associated with better quality of life. RESULTS: The patients reported using the brace for a mean of 17.6 h daily and for a mean period of 1 year and 7 months at the time of the study. Overall, 72% of the study population reported to be in some way psychologically affected by the brace wearing, 56% felt their basic motor activities were affected, 54% felt socialization with their environment was affected, 46% considered their quality of life deteriorated due to pain, and 40% reported conflicts in the school environment. CONCLUSION: Patients with AIS treated with bracing reported a negative impact (53.5% overall) on quality of life and treatment satisfaction in terms of psychological, motor, social, and school environment aspects. An interdisciplinary approach would be important for the integrated psychosocial care of these patients.

When and how to discontinue bracing treatment in adolescent idiopathic scoliosis: results of a survey.

BACKGROUND: Currently, there is little consensus on how or when to discontinue bracing in adolescent idiopathic scoliosis (AIS). An expert spine surgeon national survey could aid in elucidate discontinuation of the brace.Few data have been published on when and how to discontinue bracing treatment in patients with AIS resulting in differences in the management of the condition. The aim of this study was to characterize decision-making of surgeons in the management of bracing discontinuation in AIS. METHODS: An original electronic survey consisting of 12 multiple choice questions was sent to all the members of the National Spine Surgery Society (497 surveyed). Participants were asked about their type of medical practice, years of experience in the field, society memberships, type of brace they usually prescribed, average hours of daily brace wearing they recommended, and how and when they indicated bracing discontinuation as well as the clinical and/or imaging findings this decision was based on. Exclusion criteria include brace discontinued because of having developed a curve that warranted surgical treatment. RESULTS: Of a total of 497 surgeons, 114 responded the survey (22.9%). 71.9% had more than 5 years of experience in the specialty, and 51% mainly treated pediatric patients. Overall, 95.5% of the surgeons prescribed the thoracolumbosacral orthosis (TLSO), indicated brace wearing for a mean of 20.6 h daily. Regarding bracing discontinuation, indicated gradual brace weaning, a decision 93.9% based on anterior-posterior (AP) and lateral radiographs of the spine and physical examination, considered a Risser ≥ IV and ≥ 24 months post menarche. CONCLUSIONS: The results of this study provide insight in the daily practice of spine surgeons regarding how and when they discontinue bracing in AIS. The decision of bracing discontinuation is based on AP/lateral spinal radiographs and physical examination, Risser ≥ IV, regardless of Tanner stage, and ≥ 24 months post menarche. Gradual weaning is recommended.

Neurophysiological Monitoring in Radiofrequency Ablation of Spinal Osteoid Osteoma With a Progressive Time and Temperature Protocol in Children.

STUDY DESIGN: Retrospective. Level IV Evidence. OBJECTIVE: To assess the utility of intraoperative neurophysiological monitoring (IONM) to detect and eventually prevent impending neurovascular damage during computed tomography (CT)-guided radiofrequency ablation (RFA) of spinal osteoid osteoma (OO) in children. SUMMARY AND BACKGROUND DATA: To our knowledge, this is the first case series of spinal OO in pediatric patients treated at a single center employing IONM during RFA. METHODS: This is a retrospective study of seven consecutive patients (3 girls and 4 boys, mean age: 9 years 4 months) with imaging and clinical signs compatible with spinal OO who underwent CT-guided RFA, under general anesthesia, and IONM in a single center between 2011 and 2015. Before the RFA procedure, a CT-guided percutaneous biopsy of the nidus was performed in the same setting. RFA was divided into four cycles of increasing time and temperature and performed under IONM in every patient. RESULTS: Two patients had lesions located in the thoracic spine and five patients had lumbar involvement. The RFA technical and clinical success was 85.7%. Six patients presented with reversible neurophysiological changes either during biopsy needle positioning or RFA cycles. In the remaining case, as IONM changes did not improve after several minutes of neuroprotective hypertension, the procedure was interrupted. Neither neurologic nor vascular complications were observed after RFA treatment. In only one biopsy sample, OO was confirmed by histopathologic studies. CONCLUSION: CT-guided RFA is an accepted minimally invasive technique for the treatment of spinal OO in children. IONM may be a helpful tool that requires minimal additional time and provides feedback on the state of the spinal cord and nerves at risk during the procedure. We promote the use of IONM during these procedures to detect and possibly prevent impending neurologic damage. LEVEL OF EVIDENCE: Level IV.

Surgical Treatment With Pedicle Screws of Scoliosis Associated With Osteogenesis Imperfecta in Children.

STUDY DESIGN: Retrospective study. OBJECTIVE: To assess results of posterior instrumented fusion using pedicle screws in 12 children with osteogenesis imperfecta (OI) with spinal deformity at a single institution from 2001 to 2012. SUMMARY OF BACKGROUND DATA: This is the first case series of OI patients who underwent non-cement augmented screw-rod instrumented fusion published in the literature. METHODS: Of a total of 54 children with spinal deformity associated with OI, 12 (22.2%) were submitted to posterior spinal fusion with pedicle screws (80% density) because of severe spinal deformity. Here we reported the results in seven females and five males. RESULTS: Five thoracic (41.7%), five double (thoracic and lumbar 41.7%), and two lumbar (16.7%) curves were considered. The mean number of fused levels was 11.8 (range: 5 to 16). Mean age at surgery was 13 years 8 months. Mean follow-up was 7 years 11 months (range: 3 years 7 months to 16 years 1 month). The mean preoperative scoliosis angle was 75.6°, whereas the postoperative angle was 31.4° (58.5% correction rate). The mean preoperative kyphosis angle was 57.4° and the postoperative angle was 42.3°. We observed one superficial infection, one dural tear, and three cases of proximal junctional kyphosis; two patients required one revision surgery each (2 years and 4 months postoperatively on average). CONCLUSIONS: To our knowledge, this is the first case series published in the literature regarding OI with instrumented fusion with non-cement augmented pedicle screws exclusively in children with spinal deformity. We found that posterior spinal fusion with the screw-rod system in OI deformity in children is feasible and reliable, and has acceptable clinical and imaging results in the long-term follow-up. LEVEL OF EVIDENCE: Level IV.

Hemivertebra Resection With Instrumented Fusion by Posterior Approach in Children.

STUDY DESIGN: We conducted a retrospective study of patients with congenital scoliosis due to hemivertebra (HV) and performed resection with instrumentation through posterior approach-only with long term follow-up. OBJECTIVES: The objective of this study was to assess results of HV resection by posterior approach-only with instrumentation between 2002 and 2011. SUMMARY AND BACKGROUND DATA: Hemiepiphysiodesis, arthrodesis in situ and resection without instrumentation had been performed in the past with different results. Hemivertebra resection with spinal instrumentation through anterior and posterior approach has been advocated as the treatment of choice. METHODS: A total of 67 patients with 78 HV and 70 surgical procedures were evaluated. Thirty-five of the patients were females and 32 were males. The mean age of the patients was 5.5 years (from 0.8 to 16 yr), and the mean follow-up period was 6.55 years (from 2.1 to 10.8 yr). Eighteen patients presented additional pathologies: specific syndromes, cardiopathies, thoracic, abdominal, and bone malformations. Sixteen patients had partial HV while 51 had full mobility HV. Twenty-eight of the HV were thoracic, 16 thoracolumbar, 28 lumbar, and six lumbosacral. RESULTS: The scoliosis mean preoperative angular value was 38.55°, and the mean postoperative angular value was 19.89°. The kyphosis mean preoperative angular value was 29.98° and the mean postoperative angular value was 15.41°. One rod was used in 38 surgical procedures (54.28%) and 2 rods in 32 procedures (45.72%). We used monoaxial screws in 45 patients, poliaxial screws in 17 patients, and both monoaxial screws and poliaxial screws in one patient. Screws and hooks were used in one patient and hooks in three patients. Arthrodesis was performed in 64 patients, and no complications were registered in those without arthrodesis. Postoperative orthesis was used in 57 opportunities. Several complications during or after HV resection by posterior approach-only were reported. Two patients suffered from intraoperative neurophysiological complications, which were resolved during surgery with minimum gestures and presented no sequelae. Two patients developed superficial infections and needed toilette and IV antibiotic therapy. Two patients needed an additional surgery due to secondary curves, 4.9 yr after primary surgery on average. One patient developed crankshaft. CONCLUSIONS: We concluded that HV resection by posterior approach-only with instrumentation is a simple, secure, reliable, less invasive and well tolerated technique that can successfully resolve this kind of congenital scoliosis in children.