The feasibility and safety of using sublaminar polyester bands in hybrid spinal constructs in children and transitional adults for neuromuscular scoliosis.

OBJECT: The authors have previously reported on their early experience with sublaminar polyester bands in spine surgery. In this paper, the authors describe the use of sublaminar polyester bands in long-segment posterior instrumented spinal fusions from the upper thoracic spine to the ilium in 21 children and transitional adults with progressive neuromuscular scoliosis. Transitional adults were patients older than 18 years of age with a spinal disorder of pediatric onset, such as spina bifida. This dedicated study represents the first reported use of polyester bands in spine surgery for neuromuscular scoliosis in this patient population in the US. METHODS: The authors retrospectively reviewed the demographics and procedural data of patients who underwent posterior instrumented fusion using sublaminar polyester bands for neuromuscular scoliosis. RESULTS: Twenty-one pediatric and adult transitional patients, ranging in age from 10 to 20 years (mean 14 years), underwent posterior instrumented fusion for progressive neuromuscular scoliosis. The average coronal Cobb angle measured 66° before surgery (range 37°-125°). Immediately after surgery, the mean coronal Cobb angle was 40° (range 13°-85°). At last follow-up, the average coronal Cobb angle was maintained at 42° (range 5°-112°). Regarding sagittal parameters, thoracic kyphosis was restored by 8%, and lumbar lordosis improved by 20% after surgery. Mean follow-up duration was 17 months (range 2-54 months). One patient with an aborted procedure due to loss of intraoperative evoked potentials was excluded from the analysis of radiographic outcomes. Mean surgical time was 7 hours 43 minutes (range 3 hours 59 minutes to 10 hours 23 minutes). All patients received either a 12- or 24-mg dose of recombinant human bone morphogenetic protein-2. Average estimated blood loss was 976 ml (range 300-2700 ml). Complications directly related to the use of sublaminar instrumentation included transient proprioceptive deficit (1 patient) and prolonged paraparesis (1 patient). Other complications noted in this series included disengagement of the rod from an iliac screw (1 patient), proximal junctional kyphosis (1 patient), noninfected wound drainage (2 patients), and perioperative death (1 patient). The lessons learned from these complications are discussed. CONCLUSIONS: Pedicle screws, laminar/pedicle/transverse process hooks, and sublaminar metal wires have been incorporated into posterior spinal constructs and widely reported and used in the thoracic and lumbar spines and sacrum with varying success. This report demonstrates the satisfactory radiological outcomes of hybrid posterior spinal constructs in pediatric and adult neuromuscular scoliosis that include sublaminar polyester bands that promise the technical ease of passing sublaminar instrumentation with the immediate biomechanical rigidity of pedicle screws and hooks. However, the high neurological complication rate associated with this technique (2/21, or 10%) tempers the acceptable radiographic outcomes.

The Blalock-Taussig shunt revisited: a contemporary experience.

BACKGROUND: The Blalock-Taussig shunt (BTS) was introduced 68 years ago before open repair of cyanotic congenital heart disease (CHD) was possible. The originally described technique has undergone many modifications but remains an integral component of the management of cyanotic CHD. We report our contemporary, single institution experience with the BTS. STUDY DESIGN: We performed a retrospective review of all patients treated with a BTS from June 1995 to December 2011. RESULTS: There were 730 BTS performed in 712 patients; 727 (99.6%) by interposition graft (modified). The BTS was predominantly right-sided (n = 657, 90%). Median age and weight at palliation were 8 days (range 0 days to 18.5 years) and 3.2 kg (1.5 to 51 kg). Median hospital length of stay was 16 days (range 0 to 347 days). There were 241 (33%) BTS performed as initial palliation for ultimate 2-ventricle (2V) circulation, 471 (65%) as part of staged palliation for patients with functionally univentricular lesions (1V), 6 (1%) as a part of 1.5-ventricle palliation, and 12 (1%) for Ebstein's anomaly. There were 473 (65%) BTS placed via sternotomy and the most common site of BTS was the right subclavian to right pulmonary artery (PA; n = 452, 62%). Hospital mortality was higher for BTS in 1V patients (1V 15% vs 2V 3%, p < 0.0001). Overall, 536 (73%) patients were bridged to complete repair or the second stage of 1V palliation after a median duration of 6.5 months (0 days to 15.3 years). Multivariable regression showed that sternotomy approach, use of cardiopulmonary bypass, innominate artery-PA shunt, and diagnosis of Ebstein's were risk factors for in-hospital mortality (p < 0.05). CONCLUSIONS: Although the BTS remains an important component of the surgical treatment of cyanotic congenital heart disease, patients with single ventricle circulation still face significant ongoing risk of mortality.