Evaluation of outpatient halo-gravity traction in patients with severe scoliosis: development of a monitoring device.

INTRODUCTION: Patients with severe spinal deformities represent a major clinical and surgical challenge. Halo-gravity traction (HGT) is a traditional method to correct the deformity prior to surgery. Typically, children undergoing HGT remain in the hospital until surgery. Therefore, it has been suggested to treat these children at lower level healthcare centers or even at home. The aim of this study was to develop a tool to assess patient adherence to HGT together with a program to analyze traction results. MATERIALS AND METHODS: An original recording system was designed with an Arduino Nano®. The data extracted from the memory card were compiled into a text file and then analyzed with the MatLab R2018a MathWorks®. RESULTS: Five patients receiving HGT for severe scoliosis were asked to use the device both in the wheelchair and in bed to evaluate its usefulness. CONCLUSIONS: A device was developed to monitor the use of HGT at home. The device provides information on the time of HGT use and the traction weight placed throughout the day, as well as on the correct functioning of the system in bed and in the wheelchair.

Hemivertebra Resection in Small Children. A Literature Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To evaluate the lowest possible age to resect an HV in very young patients with a congenital deformity. METHODS: We sought to retrieve all studies reporting age at HV excision in patients with congenital scoliosis. Studies written in English were included. No publication date restrictions were imposed. A search of the PubMed and LiLacs databases was conducted. Additionally, a hand search was performed to supplement the database search. RESULTS: We found 140 articles. Twenty two studies were included into the final assessment. There was considerable heterogeneity in the included studies, both regarding age and the surgical techniques used. There was also a broad spectrum of recommendations regarding suggested age for treatment. The youngest patient undergoing resection and fusion was 3 months of life at the time of surgery. CONCLUSION: How young a patient could and should be submitted to HV resection surgery is still a matter of debate in the literature. Prophylactic surgery might be a proper treatment for young children with congenital scoliosis before malformation becomes a deformity, adding no additional neurological, vascular, or anesthesia-related complications. The defect can be treated early while the deformity is treated late.

Infection Recurrence in Instrumented Spinal Fusion in Children.

STUDY DESIGN: Level 4 retrospective case series. OBJECTIVES: Surgical site infection (SSI) is one of the main complications of instrumented spinal fusion. The aim of our study was to evaluate infection recurrence (same bacteria) or reinfection (different bacteria) in posterior spinal fusion in children. METHODS: A retrospective study was conducted to evaluate patients who were successfully treated for SSI after instrumented spinal fusion due to deformity, with irrigation and debridement (I&D) procedures, followed by antibiotic therapy, with a follow-up of at least 2 years. RESULTS: Overall, 29 patients with a mean age of 14 + 3 years were evaluated. Preoperative diagnosis was nonidiopathic scoliosis in 23, idiopathic scoliosis in 5, and Scheuermann's disease in 1 patient. The etiology was Gram-positive cocci (40.9%), Gram-negative bacilli (27.2%), and polymicrobial infection (31.8%). A mean of 1.5 (1-3) I&D procedures were performed. Intravenous antibiotic treatment was given for a mean of 15.8 (4-86) days, followed by oral treatment for a mean of 335.1 (0-1095) days. Mean follow-up was 5 + 2 years (2 to 14 + 7 years) during which 28 patients were cured (96.6%) and 1 patient developed reinfection (3.4%). This reinfection was treated with oral clindamycin for 6 months. After the infection persisted, the decision was to remove the implants. CONCLUSIONS: In this series of 29 pediatric patients who underwent instrumented spinal fusion due to deformity, we reported one case of reinfection (3.4%). Given that 96.6% of infections were resolved, we suggest treatment with I&D procedures with retention of implants to treat acute SSI.

Surgical treatment of segmental spinal dysgenesis: a report of 19 cases.

STUDY DESIGN: Retrospective review. OBJECTIVE: To describe clinical presentation, surgical management, long-term results, and complications in patients with segmental spinal dysgenesis (SSD). In addition, we sought to emphasize early surgery for this complex congenital abnormality. SSD is a rare congenital malformation characterized by focal stenosis, spinal subluxation, kyphosis, and absence of the nerve roots. Neurologic function ranges from normal to complete paraplegia. Progression of the deformity and neurologic deterioration is the rule. METHODS: An independent spinal surgeon reviewed the complete records of 19 patients with SSD, between 1998 and 2015 at a single institution. Mean follow-up was 10 years and 6 months (2-14 years). RESULTS: We evaluated 11 males and 8 females, with a mean age of 2 years and 9 months (5 months-15 years). The dysgenetic segment involved an average of 2.9 vertebrae (1-5); the upper thoracic region was most commonly involved in ten cases. Fifteen patients had severe spinal stenosis. 14 patients presented neurological deficits and 15 patients had associated organ and musculoskeletal anomalies.Twenty-seven surgeries were performed, a mean of 1.76 procedures (1-5) to obtain solid fusion. Neurologic function improved in four, deteriorated in three, and remained unchanged in 12 patients Seven complications were recorded. CONCLUSION: We strongly recommend decompression and fusion as soon as possible to preserve or prevent neurologic deterioration. Although challenging, it was possible to achieve a solid instrumented fusion in all cases; however, a high rate of patients may deteriorate or not recover neurological status after surgery. LEVEL OF EVIDENCE: Level IV evidence.

Long-term results of hemivertebra excision: How does the spine behave after the peak of puberty?

INTRODUCTION: Early hemivertebra (HV) excision and posterior spinal fusion (PSF) is advocated as the treatment of choice in congenital kyphoscoliosis. We assessed global spinal balance and spinal deformity status once the pubertal peak has taken place, in children with a history of HV excision and PSF at age younger than 5 years. METHODS: Twenty-seven children with congenital kyphoscoliosis without co-existing proximal/distal congenital spinal abnormalities who underwent HV excision and PSF of ≤ 5 levels at age younger than 5 years and who had reached the peak of puberty at the last follow-up visit were evaluated. RESULTS: Twenty-seven HV excision were performed. Mean age at surgery was 3 years and 2 months. A mean of 3.2 segments were fused. Imbalance of the trunk was observed in 80% of thoracic and 75% of thoracolumbar HV excision. No arthrodesis technique (4 cases) presented 100% of spine decompensation. All children younger than 2 years at the time of surgery developed spinal imbalance. Eighteen patients (67%) had global spine imbalance; 81% male population and 63% of the female population. Mean age at surgery was 3 years + 2 months. Mean age of the patients at the time of the study was 15 years + 5 months. Mean follow-up was 12 years + 3 months. CONCLUSION: Many of these patients developed spinal imbalance and scoliosis worsened at the final follow-up. Early age at surgery, preoperative scoliosis severity, HV location, no arthrodesis technique, and the adding-on phenomenon may be involved.

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.

Antibiotic prophylaxis in high-risk pediatric spine surgery: Is cefazolin enough?

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe pathogens found in SSI during pediatric-instrumented spine surgery, and to assess the relationship between pathogens and the etiology of the spinal deformity. Surgical site infection (SSI) after pediatric spine fusion is a well-known complication with incidence rates between 0.5 and 42%, associated with the patient underlying disorder. Pathogens involved in SSI seem to be related to patient characteristics, such as the etiology of the spinal deformity. GNB (gram-negative bacilli) are more frequent in neuropathic, muscular, and syndromic conditions. High-risk pediatric patients with a spine deformity undergoing instrumented surgery might benefit from receiving perioperative intravenous prophylaxis for GNB. METHODS: We conducted a retrospective study at our tertiary-care pediatric hospital from January 2010 to January 2017. We reviewed records of all episodes of SSI that occurred in the first 12 months postoperatively. All patients who underwent instrumented spine surgery were included in this study. RESULTS: We assessed 1410 pediatric-instrumented spine surgeries; we identified 68 patients with deep SSIs, overall rate of 4.8%. Mean age at instrumented spine surgery was 12 years and 9 months. Time elapsed between instrumented surgery and debridement surgery was 28.8 days. Cultures were positive in 48 and negative in 20. Of the 48 positive culture results, 41 (72%) were GNB, 12 (21%) gram-positive cocci (GPC), three (5%) gram-positive anaerobic cocci (GPAC), and one (2%) coagulase-negative staphylococci (CoNS). Of the 68 patients with primary SSIs, 46 were considered to have a high risk of infection, which reported GNB in 81%, GPC in 15%, GPAC in 2%, and CoNS in 2%. CONCLUSION: Cefazolin prophylaxis covers GPC and CoNS, but GNB with unreliable effectiveness. Gram-negative pathogens are increasingly reported in SSIs in high-risk patients. Adding prophylaxis for GNB in high-risk patients should be taken into account when considering spine surgery. LEVEL OF EVIDENCE: IV.

Proximal junction kyphosis after posterior spinal fusion for early-onset scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to assess the presence of proximal junctional kyphosis (PJK) in our population of children with early-onset scoliosis (EOS) and to identify the predisposing factors for the development of PJK in the postoperative period after posterior spinal fusion (PSF). Few studies have been conducted to evaluate the incidence of proximal junction kyphosis (PJK) in children after early-onset scoliosis (EOS) after posterior spinal fusion (PSF). MATERIALS AND METHODS: Overall, 114 pediatric patients aged < 10 years who underwent surgery for scoliosis or kyphoscoliosis at a single center between 2013 and 2015 were evaluated. Forty-five patients submitted to PSF of five or more levels met the inclusion criteria. The sample included 12 female and 10 male patients. Mean age at surgery was 7 years and 8 months. RESULTS: PJK was observed in 22 patients (48.9%). Overall, the mean proximal junctional angle at 12 and 36 months was 17.1° and 22°, respectively. The uppermost instrumented vertebra (UIV) with the highest PJK rate was T6-T7. The lowest instrumented vertebra (LIV) with the highest PJK rate was L2. Etiology was idiopathic in 4, neuromuscular in 11, congenital in 14, and syndromic in 16. According to underlying disorder, prevalence of PJK was 78% in those with a congenital, 50% in those with a syndromic, 12% in those with idiopathic, and 9% in those with a neuromuscular EOS. Surgical revision rate was 4% (one patient). Mean postoperative follow-up was of 3 years and 4 months (range 3-4 years and 1 month). CONCLUSION: Congenital and syndromic etiology, but not age at PJK onset or sex of the patient, significantly affected the incidence rate of PJK. The UIV with the highest PJK rate was T6-T7 and the LIV with the highest PJK rate was L2. The patients had a low surgical revision rate. LEVEL OF EVIDENCE: Level IV.

Manejo del dolor posoperatorio por cirugía de columna en la población pediátrica: Resultados preliminares / Pain management following spinal surgeries in pediatric patients. Preliminary results

Introducción: Aproximadamente el 80% de los pacientes pediátricos sometidos a cirugía de columna refiere dolor moderado o severo en el posoperatorio inmediato. Objetivos: Describir la presencia de dolor y su intensidad durante el posoperatorio de una cirugía de columna en pacientes pediátricos y evaluar la eficacia del tratamiento analgésico actual. Materiales y Métodos: Se evaluaron pacientes sometidos a cirugía de columna, de entre 10 y 18 años, con capacidad mental para entender el propósito del estudio. Se utilizó el esquema de medicación estándar actual posoperatorio del hospital. Se constataron la presencia del dolor, la hora de comienzo, la localización y la intensidad (escala de valoración numérica), entre otras variables. Resultados: Se evaluó a 84 pacientes pediátricos, con una edad promedio de 12 años y 9 meses, al momento de la cirugía. Las etiología fueron: idiopática (41 casos), neuropática (14 casos), sindrómica (10 casos), muscular (7 casos) y misceláneas (12 casos). El puntaje promedio en la escala de valoración numérica fue de 2,1 antes de la cirugía; de 7,3 el día 1 posoperatorio y de 3,3 el día 6 posoperatorio/alta. El tiempo promedio de internación fue de 6.3 días, el costo económico global de la internación fue de USD1090 por paciente. Conclusiones: Un importante porcentaje de pacientes pediátricos refiere dolor moderado o severo en el posoperatorio de una cirugía de columna, tan solo la mitad recibe un esquema de manejo de dolor estandarizado y adecuado. El objetivo ulterior de este estudio será protocolizar el manejo del dolor con un enfoque multimodal. Nivel de Evidencia: III

Introduction: Around 80% of pediatric patients who undergo spine surgery report moderate to severe pain in the immediate postoperative (POP) period, and only half of them are treated according to an adequate and standardized pain management scheme. Objectives: To describe the type and intensity of POP pain in children who underwent spinal surgery and evaluate the effectiveness of the current pain management protocol. Materials and Methods: We assessed children between 10 and 18 years of age who were able to understand the purpose of the study. We recorded presence of pain, time of POP pain onset, location, and referred intensity of the pain using a numeric rating scale (NRS), among other variables. Results: Overall, 84 pediatric patients were evaluated. Mean age at surgery: 12 years and 9 months. Etiology: idiopathic (41 patients), neuropathic (14 patients), syndromic (10 patients), muscular (7 patients), and miscellaneous (12 patients). Mean preoperative NRS was 2.1 and 7.3 on POP day 1, 6.6 on POP day 2, 6.2 on POP day 3, 5.1 on POP day 4, 3.7 on POP day 5, and 3.3 on POP day 6/at discharge. Mean hospital stay was 6.3 days. The mean cost of hospital stay was USD 1090 per patient. Conclusions: A high percentage of pediatric patients who underwent spinal surgery reported moderate to severe pain in the POP period, and just half of them received a standardized pain management protocol. A pain management protocol with a multimodal focus should be considered in a near future. Level of Evidence: III

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.

A Multiparametric Alarm Criterion for Motor Evoked Potential Monitoring During Spine Deformity Surgery.

PURPOSE: This is a pilot study to compare changes in the amplitude, area below the curve, number of phases, duration, and latency of the intraoperative transcranial motor evoked potentials (TcMEP) for early detection of impending spinal cord injury. An empirical ratio calculated by a combination of the above-mentioned parameters was also assessed. METHODS: Intraoperative TcMEP recordings from five patients presenting with neuromuscular kyphoscoliosis, idiopathic scoliosis, achondroplasia and lumbar kyphosis, congenital kyphosis, and achondroplasia with cervical instability were reviewed. Anesthesia was sustained with propofol or sevoflurane plus remifentanil, no muscle relaxants were used after intubation. The TcMEPs to multipulse electrical stimulation were recorded from upper-limb and lower-limb muscles. To be worthy of analyses, changes should include TcMEP disappearance or amplitude decrease >-65% during surgical/force maneuverings. RESULTS: Transient TcMEP changes related to surgical/force maneuvering were observed in all five patients consisting of a decrease in the empirical ratio value (>-95%), followed in magnitude by a drop in the area below the curve, amplitude (>-80%), duration, and number of phases, whereas latency increased. Changes returned to baseline when maneuverings were reverted. No hemodynamic/anesthetic factors were present during these events. After surgeries, no new neurological deficits were detected. CONCLUSIONS: An empirical ratio accounting for all TcMEP parameters seems to drop more than the amplitude during an intraoperative event. As few cases were analyzed, further studies in larger series of patients will be necessary to assess empirical ratio sensitivity/specificity and to determine whether this may be a useful monitoring warning criterion not leading to unnecessary interference with surgical treatment.

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.

Estudio comparativo entre la toracoscopía videoasistida y la toracotomía convencional, para la artrodesis vertebral anterior en el tratamiento de la escoliosis en niños y adolescentes / Comparative study between videoassisted thoracoscopy and conventional thoracotomy, for anterior vertebral arthrodesis in the treatment of the scoliosis in child and adolescents

Introducción: la escoliosis es la deformidad que más frecuentemente requiere tratamiento en niños y adolescentes. El tratamiento con corsets mantiene vigencia en curvas de más de 20º con pacientes esqueléticamente inmaduros. Para curvas torácicas superiores a 40-45º y de acuerdo al patrón de distribución de la misma se considera la indicación quirúrgica. El estado actual del tratamiento quirúrgico contempla la corrección, estabilización y artrodesis con implante por vía posterior o anterior en forma aislada y la realización de procedimientos combinados de artrodesis anterior simple seguida de corrección, estabilización y artrodesis por vía posterior. Para esta alternativa combinada se ha introducido en la última década la posibilidad de realizar el tiempo vertebral anterior por abordaje mínimamente invasivo toracoscópico manteniendo la estabilización convencional y colocación de implante por vía posterior y muy recientemente se comenzo a aplicar todo el proceso de artrodesis, corrección y estabilización por vía anterior con abordaje toracoscópico videoasistido. Objetivo: el objetivo de este trabajo es demostrar que el abordaje toracoscopico videoasistido para realizar artrodesis vertebrales a nivel torácico, en deformidades vertebrales de niños y adolescentes, tiene comparativamente con la técnica de abordaje convencional por toracotomía similares indicaciones y resultados finales con menor tasa de complicaciones postoperatorias... (TRUNCADO)

Estudio comparativo entre la toracoscopía videoasistida y la toracotomía convencional, para la artrodesis vertebral anterior en el tratamiento de la escoliosis en niños y adolescentes / Comparative study between videoassisted thoracoscopy and conventional thoracotomy, for anterior vertebral arthrodesis in the treatment of the scoliosis in child and adolescents

Introducción: la escoliosis es la deformidad que más frecuentemente requiere tratamiento en niños y adolescentes. El tratamiento con corsets mantiene vigencia en curvas de más de 20º con pacientes esqueléticamente inmaduros. Para curvas torácicas superiores a 40-45º y de acuerdo al patrón de distribución de la misma se considera la indicación quirúrgica. El estado actual del tratamiento quirúrgico contempla la corrección, estabilización y artrodesis con implante por vía posterior o anterior en forma aislada y la realización de procedimientos combinados de artrodesis anterior simple seguida de corrección, estabilización y artrodesis por vía posterior. Para esta alternativa combinada se ha introducido en la última década la posibilidad de realizar el tiempo vertebral anterior por abordaje mínimamente invasivo toracoscópico manteniendo la estabilización convencional y colocación de implante por vía posterior y muy recientemente se comenzo a aplicar todo el proceso de artrodesis, corrección y estabilización por vía anterior con abordaje toracoscópico videoasistido. Objetivo: el objetivo de este trabajo es demostrar que el abordaje toracoscopico videoasistido para realizar artrodesis vertebrales a nivel torácico, en deformidades vertebrales de niños y adolescentes, tiene comparativamente con la técnica de abordaje convencional por toracotomía similares indicaciones y resultados finales con menor tasa de complicaciones postoperatorias... (TRUNCADO)(AU)

Liberación bulbomedular y artrodesis occipitocervical instrumentada en niños y adolescentes

Material y método: se presentan 3 niños entre 10 y 14 años. En cada caso, los diagnósticos originales fueron: síndrome del trígono cervical o C. de Opitz, secuela de sepsis neonatal con compromiso multiarticular y síndrome de Klippel Feil. Todos presentaron inestabilidad atloaxoidea y, en un caso, occipitocervical. Todos tenían compromiso neurológico grave a nivel bulbo medular. En los 3 casos se observó una importante limitación de la movilidad cervical media e inferior como consecuencia de artrodesis previa, anquilosis o defecto de segmentación, respectivamente. Un paciente tenía, como antecedente, 3 intentos fallidos de artrodesis occipitocervical sin osteosíntesis ; por su parte, otro paciente tuvo un intento de artrodesis occipitocervical simple no instrumentada sin éxito. En los 3 casos se efectuó algún procedimiento de descompresión bulbomedular: una resección transoral de apófisis odontoides, una resección del arco posterior del atlas y una resección del arco posterior del atlas más escamotomía del occipital y plástica de ampliación de la vaina dural. La inestabilidad fue tratada con artrodesis occipitocervical instrumentada, simultáneamente con la descompresión en un caso y en forma diferida en 2 casos, mantenida en halo-chaleco por un período aproximado de 5 meses. Resultados: en los 3 casos se obtuvo una adecuada artrodesis, la recuperación neurológica fue total en un caso y parcial en los otros dos. Conclusión: Es conveniente asegurar el éxito de una artrodesis occipitocervical, incorporando una estabilización interna, cuando la movilidad cervical por debajo se encuentre previamente restringida, ya que esta condición incrementa la demanda mecánica en la charnela occipitocervical

Liberación bulbomedular y artrodesis occipitocervical instrumentada en niños y adolescentes

Material y método: se presentan 3 niños entre 10 y 14 años. En cada caso, los diagnósticos originales fueron: síndrome del trígono cervical o C. de Opitz, secuela de sepsis neonatal con compromiso multiarticular y síndrome de Klippel Feil. Todos presentaron inestabilidad atloaxoidea y, en un caso, occipitocervical. Todos tenían compromiso neurológico grave a nivel bulbo medular. En los 3 casos se observó una importante limitación de la movilidad cervical media e inferior como consecuencia de artrodesis previa, anquilosis o defecto de segmentación, respectivamente. Un paciente tenía, como antecedente, 3 intentos fallidos de artrodesis occipitocervical sin osteosíntesis ; por su parte, otro paciente tuvo un intento de artrodesis occipitocervical simple no instrumentada sin éxito. En los 3 casos se efectuó algún procedimiento de descompresión bulbomedular: una resección transoral de apófisis odontoides, una resección del arco posterior del atlas y una resección del arco posterior del atlas más escamotomía del occipital y plástica de ampliación de la vaina dural. La inestabilidad fue tratada con artrodesis occipitocervical instrumentada, simultáneamente con la descompresión en un caso y en forma diferida en 2 casos, mantenida en halo-chaleco por un período aproximado de 5 meses. Resultados: en los 3 casos se obtuvo una adecuada artrodesis, la recuperación neurológica fue total en un caso y parcial en los otros dos. Conclusión: Es conveniente asegurar el éxito de una artrodesis occipitocervical, incorporando una estabilización interna, cuando la movilidad cervical por debajo se encuentre previamente restringida, ya que esta condición incrementa la demanda mecánica en la charnela occipitocervical

Artrodesis anterior: toracoscopía en escoliosis

En el segundo semestre de 1996 realizamos los primeros 4 procedimientos toracoscópicos en columna torácica anterior en la Unidad de Patología Espinal del Hospital Dr. Juan P. Garrahan, incorporando técnicas de incipiente aplicación en otros lugares del mundo. Se realizaron en 4 pacientes un total de 20 niveles de remoción discal y artrodesis anterior a nivel torácico. Tres fueron escoliosis idiopáticas y una escoliosis neuropática asociada con siringomielia. El objetivo fue, en 3 casos, aumentar el área transversal de artrodesis y la flexibilidad de la curva, y en un caso evitar el fenómeno "cigüeñal", debido a la inmadurez esquelética. Los procedimientos fueron siempre complementados por un tiempo posterior instrumentado en fecha distinta. Los valores angulares de escoliosis oscilaron entre 45 y 115 grados. El objetivo quirúrgico fue alcanzado en los 4 casos sin necesidad de conversión a toracotomía abierta. Demandó más tiempo quirúrgico y mayores requerimientos técnicos y anestésicos que una toracotomía convencional. Tuvimos un neumotórax como única complicación postoperatoria. La evolución postoperatoria inmediata, la rápida recuperación funcional, la buena cosmesis de la herida y el excelente resultado final motivan nuestro actual uso de la técnica como rutina, con frecuencia creciente y en variadas etiologías que requieran procedimientos vertebrales anteriores a nivel torácico