Cryo-Compression Therapy After Elective Spinal Surgery for Pain Management: A Cross-Sectional Study With Historical Control.

OBJECTIVE: Postoperative dynamic cryo-compression (DC) therapy has been proposed as a method of reducing pain and the inflammatory response in the early postoperative period after orthopedic joint reconstruction surgery. Our aim was to analyze the analgesic efficacy of DC therapy after adult lumbar spinal surgery. METHODS: DC was applied for 30 minutes every 6 hours after surgery. Pain was measured by a visual analogue scale (VAS) in the preoperative period, immediately after surgery, and every 6 hours postoperatively for the first 72 hours of the hospital stay. Patients' pain medication requirements were monitored using the patient-controlled analgesia system and patient charts. Twenty patients who received DC therapy were compared to 20 historical controls who were matched for demographic and surgical variables. RESULTS: In the postanesthesia care unit, the mean VAS back pain score was 5.87 ± 0.9 in the DC group and 6.95±1.0 (p=0.001) in the control group. The corresponding mean VAS scores for the DC vs. control groups were 3.8±1.1 vs. 5.4±0.7 (p < 0.001) at 6 hours postoperatively, and 2.7±0.7 vs. 6.25±0.9 (p<0.001) at discharge, respectively. The cumulative mean analgesic consumption of paracetamol, tenoxicam, and tramadol in the DC group vs. control group was 3,733.3±562.7 mg vs. 4,633.3±693.5 mg (p<0.005), 53.3±19.5 mg vs. 85.3±33.4 mg (p<0.005), and 63.3±83.4 mg vs. 393.3±79.9 mg (p<0.0001), respectively. CONCLUSION: The results of this study demonstrated a positive association between the use of DC therapy and accelerated improvement in patients during early rehabilitation after adult spine surgery compared to patients who were treated with painkillers only.

Is it necessary to operate all split cord malformations before corrective surgery for patients with congenital spinal deformities?

STUDY DESIGN: Retrospective case series. OBJECTIVES: To evaluate the necessity of neurosurgical interventions for split cord malformations (SCMs) before correction and instrumentation for patients with congenital spinal deformity(CSD)s. SUMMARY OF BACKGROUND DATA: SCMs are commonly associated with CSD. As pathology of SCMs understood well, the common belief of all SCM must be operated before any orthopedic intervention is needed to be revised. MATERIALS AND METHODS: Sixty-one consecutive patients with CSD and spinal dysraphism treated by correction and posterior instrumentation between 1994 and 2005 were retrospectively evaluated. Inclusion criteria were patients with CSD and SCM, who were treated with long segment instrumentation (more than 6 functional units) with at least 2 years of follow-up. Thirty-two patients (8 male and 24 female) with an age average of 11 years +8 months (4-18 years) fulfilled the criteria. While all patients with Type I SCM were managed with neurosurgical intervention (spur excision and dural reconstruction) before corrective surgery, Type II SCM cases were treated by instrumented fusion without neurologic intervention. RESULTS: There were 18 patients with Type I and 14 patients with Type II SCM. The average follow-up was 52 (24-144) months. The correction rate of deformity was 44% in type I and 47% in Type II SCM. Two patients with Type II SCM had transient neurologic deterioration while there were no neurologic events in patients with Type II SCM. CONCLUSION: Due to high incidence of SCMs, all patients with CSDs must be evaluated with MRI, before surgery. Neurosurgical interventions are recommended even for neurologically asymptomatic Type I SCM before spinal deformity surgery; however, patients with Type II SCM can be treated safely without a need of neurosurgical intervention.

Reliability and validity of adapted Turkish Version of Scoliosis Research Society-22 (SRS-22) questionnaire.

STUDY DESIGN: Outcome study to determine the internal consistency, and validity of adapted Turkish version of Scoliosis Research Society-22 (SRS-22) Instrument. OBJECTIVES: To evaluate the validity and reliability of adapted Turkish Version of SRS-22 questionnaire. SUMMARY OF BACKGROUND DATA: The SRS-22 questionnaire is a widely accepted questionnaire to assess the health-related quality of life for scoliotic patients in the United States. However, its adaptation in languages other than the source language is necessary for its multinational use. METHODS: Translation/retranslation of the English version of the SRS-22 was done, and all steps for cross-cultural adaptation process were performed properly by an expert committee. Later, SRS-22 questionnaires and previously validated Short Form-36 (SF-36) outcome instruments were mailed to 82 patients who had been surgically treated for idiopathic scoliosis. All patients had a minimum of 2 years follow-up. Fifty-four patients (66%) responded to the first set of questionnaires. Forty-seven of the first time respondents returned their second survey. The average age of the 47 patients (12 male, 35 female) was 19.8 years (range, 14-31 years). The two measures of reliability as internal consistency and reproducibility were determined by Cronbach alpha statistics and intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing with an already validated questionnaire (SF-36). Measurement was made using the Pearson correlation coefficient (r). RESULTS: The study demonstrated satisfactory internal consistency with high Cronbach alpha values for the four of the corresponding domains (pain, 0.72; self-image, 0.80; mental health, 0.72; and satisfaction, 0.83). However, the Cronbach alpha value for function/activity domain (0.48) was considerably lower than the original questionnaire. The intraclass correlation coefficient for the same domains was 0.80, 0.82, 0.78, 0.81, and 0.76, respectively, demonstrating a satisfactory test/retest reproducibility. Considering concurrent validity, two domains had excellent correlation (r = 0.75-1), while 9 had good correlation (r = 0.50 to 0.75), and 6 had moderate correlation (r =0.25-0.50). Based on these results, question 18 in the function/activity domain with lower Cronbach alpha value was revised while question 15 was excluded. The revised SRS-22 was given to 30 adolescent idiopathic scoliosis patients not included in the index study. The revision could improve the Cronbach alpha value for function/activity domain from 0.48 to 0.81. CONCLUSION: This study demonstrated that, if measures are to be used across cultures, the items must not only be translated well linguistically but also must be culturally adapted to maintain the content validity of the instrument at a conceptual level across different cultures. This may necessitate several validation studies to ensure and improve consistency in the content and face validity between source and target versions of a questionnaire due to difficulty in detecting subtle differences in the living habits of different cultures.

The validity of Lenke criteria for defining structural proximal thoracic curves in patients with adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective series. OBJECTIVE: To delineate the efficiency of using Lenke criteria during the decision of whether to include the proximal thoracic curve into instrumented fusion or not in patients with adolescent idiopathic scoliosis (AIS) treated with posterior translational instrumentation. SUMMARY OF BACKGROUND DATA: Lenke and colleagues classified the curves of patients with AIS and assigned the term "structural" or "nonstructural" to each curve. However, there is still not much consensus on the definition of structural proximal thoracic curve, and structurality criteria for proximal thoracic curve have not been validated yet. METHODS: Inclusion criteria were: (1) patients with AIS treated with a posterior translational instrumentation system and older than 10 years; (2) nonstructural upper thoracic curves (side bending Cobb <25 degrees and T2-T5 kyphosis <+20 degrees); and (3) a minimum of 2 years of follow-up. A total of 37 consecutive patients, including 6 males and 31 females, with AIS that was treated, with an average age of 15 years (range 11-24) and average follow-up of 55 months (range 24-90) were studied. For radiologic evaluation of the patients, preoperative, postoperative, and latest follow-up radiographs were used. There were 2 groups constructed according to the involvement of proximal thoracic curve into instrumented fusion. Group 1 included those patients who underwent uppermost extent of the instrumentation, either T2 or T3, indicating inclusion of proximal thoracic curve into instrumentation. Group 2 included individuals who underwent uppermost extent of the instrumentation at T4 or lower, indicating partial or no inclusion of the proximal thoracic curve into instrumented fusion. Radiographic evaluation included the measurement of proximal thoracic, main thoracic, and thoracolumbar-lumbar curves. On the lateral radiographs, sagittal Cobb angles of T2-T5, T5-T12, and T10-L2 were measured. Difference between right and left coracoid process heights, clavicle angle, and T1 tilt were determined for assessment of shoulder balance. RESULTS: The 2 groups were statistically equivalent in terms of age at surgery, follow-up time, preoperative proximal thoracic and main thoracic, and their corresponding side bending curve magnitudes, as well as the parameters related to shoulder balance before surgery (P > 0.05). The 2 groups were also statistically equivalent regarding immediate postoperative and latest follow-up proximal thoracic and main thoracic, and parameters related to shoulder balance (P > 0.05). CONCLUSION: It was observed that the Lenke description for structurality of proximal thoracic curves can effectively determine which curves need fusion and which curves do not. Because there was no difference among inclusion of a nonstructural proximal thoracic curve into fusion or solely fusing the main thoracic curve in terms of outcomes, extension of fusion to T2 or T3 is unnecessary. In this patient population, the question of what the upper extent of instrumentation should be could not be answered.

The effect of pedicle screw placement with or without application of compression across the neurocentral cartilage on the morphology of the spinal canal and pedicle in immature pigs.

STUDY DESIGN: Experimental study. OBJECTIVES: To investigate the effects of pedicle screw insertion on spinal canal and pedicle morphology in immature pigs, and, if transpedicular fixation has an effect, to document whether this occurs because of the inhabitance of the screw inside the growth plate (neurocentral cartilage [NCC]) or because of compression applied across the NCC. SUMMARY OF BACKGROUND DATA: Transpedicular fixation has been less commonly applied to the pediatric population, especially because of the risk of damage to the NCC. METHODS: Twelve newborn pigs (4-6 weeks of age) were operated on. Left sided pedicles from L1-L5 were studied, while right sides served as controls. Pigs were randomly assigned into 3 groups: (1) pedicles were probed only; (2) screws were inserted; and (3) after screw insertion, a washer and a nut were engaged at the pedicle entry point so that gradual compression across the NCC was achieved. After 4 months, spiral computerized tomography was used to measure the pedicle lengths and size of the halves of the spinal canal. RESULTS: In group 1, the operated hemi-canal area was not statistically different from the nonoperated side (P = 0.159). Pedicle screw insertion either with (P = 0.007) or without (P = 0.005) compression resulted in smaller hemi-canal area and shorter pedicles at the operated side, respectively (P = 0.008, P = 0.021). Approximately 4% to 9% shortening of the pedicle lengths and 20% to 26% narrowing of the hemi-canal areas on the instrumented side occurred with transpedicular instrumentation (groups 2, 3). CONCLUSION: Even without compression, pedicle screws passing through the NCC in immature pigs disturb spinal canal growth significantly. Clinical relevance for young children should be studied further.

The evolution of sagittal segmental alignment of the spine during childhood.

STUDY DESIGN: Cross-sectional. OBJECTIVES: The purpose of this study is to describe the normative data of the sagittal plane on pediatric age population, and to document the evolution of sagittal alignment with growth. SUMMARY OF BACKGROUND DATA: Having normative data about the sagittal plane is an integral part in the planning of the three-dimensional reconstruction of the spine. Segmental sagittal plane analysis on adults has been studied thoroughly; however, there are inadequate data on children. METHODS: A total of 151 children (72 girls, 79 boys) without musculoskeletal abnormality between the ages of 3 to 15 years were studied with the 36-inch standing lateral radiograph with the arms flexed at 30 degrees . There were a minimum of 10 children, at least 4 of them from one sex, in each age group. Variables measured on the radiograms were as follows: segmental angulations from T1-T2 to L5-S1, angles of global kyphosis (T1-T12) and lordosis (L1-S1), segmental angulations of T2-T5, T10-T12, T10-L2, and L4-S1 levels, T1 and L1 offsets in millimeters, location of thoracic and lumbar apexes, and spinopelvic alignment measurements (angles of alpha and beta, sagittal vertebral axis, and sacropelvic translation). For statistical analysis, the children were grouped in terms of ages: Group I (3-6 years of age), Group II (7-9 years of age), Group III (10-12 years of age), and Group IV (13-15 years of age). RESULTS: One-way analysis of variance showed significant differences between the following parameters among groups: segmental angulations of T1-T2 (P = 0.015), T10-L2 (P = 0.014), L4-S1 (P = 0.001), global kyphosis angle (P = 0.005), global lordosis angle (P = 0.000), thoracic apex (P = 0.007), T1 offset (P = 0.000), sagittal vertebral axis (P = 0.004), and beta angle (P = 0.000). As sagittal vertebral axis increases, there is found to be a higher L1 offset and lower thoracic apex, both of which result in leaning forward. With growing, total thoracic kyphosis and total lumbar lordosis particularly due to lower 2 motion segments were found to be increased, while thoracic apex moved upwards, T1 offset increased, and L1 offset decreased. Older children stood with a more negative SVA, and sacral inclination increased. CONCLUSION: Sagittal spinal alignment is found to be changing as a child grows. There is a statistically significant difference among different age groups, especially at cervicothoracic, thoracolumbar, and lumbosacral junctions. The position of the sacrum (inclination and translation), and spatial orientation, as well as the global magnitude of thoracic kyphosis, and lumbar lordosis changes with growth. These findings should be taken into consideration for the young patients who require spinal instrumentation. The question "whether sagittal alignment should be restored according to the normative data for the child's age or to the normative data for the adulthood" remains to be answered.

The course of sagittal plane abnormality in the patients with congenital scoliosis managed with convex growth arrest.

SUMMARY OF BACKGROUND DATA: Patient age; localization, length, and magnitude of the curve; and sagittal plane alignment are reported to be the major determinants in the selection of patients for convex growth arrest. Although the existence of sagittal plane abnormality (kyphosis or lordosis) is accepted as a contraindication for convex growth arrest, this issue has not been discussed in detail. OBJECTIVES: The purposes of this study are to investigate the effect of sagittal plane abnormality on the control of coronal plane deformity and to evaluate the course of sagittal plane abnormality of the patients with congenital scoliosis who were satisfactorily managed with convex growth arrest. STUDY DESIGN: Retrospective analysis. METHODS: Inclusion criteria are: 1) a diagnosis of congenital scoliosis in a patient younger than 6 years of age, 2) treatment with convex growth arrest, 3) follow up for more than 2 years, 4) stabilized or improved coronal plane deformity, and 5) abnormal sagittal plane alignment within the scoliotic segment before surgery. The patients were evaluated with anteroposterior and lateral radiographs, and segmental measurements were compared according to the normal of their corresponding age. RESULTS: A total of 38 patients with congenital scoliosis treated with convex growth arrest were reviewed. Among 13 patients with segmental sagittal plane deformity, 2 were excluded because of insufficient control of the scoliosis. Eleven patients (8 girls, 3 boys) with a mean age of 35 months (range 6-72 months) and mean follow-up of 40 months (range 24-76 months) fulfilled these criteria. The coronal plane deformities were 58 degrees (range 36 degrees-105 degrees) before surgery and 52 degrees (13 degrees-107 degrees) at the final follow-up. While six of the curves improved, the remaining ones stabilized. Sagittal segmental alignments within the scoliotic segments were hyperkyphotic in 9 patients and hypokyphotic in 1 and lordotic in 1. At the end of the follow-up, sagittal Cobb angle of the abnormal segments remained stable in 7 patients and deteriorated in 4. None of the 4 patients required any reconstructive spine procedure for kyphosis during follow-up. CONCLUSION: Sagittal segmental abnormality does not have a negative effect on the control of scoliosis in the majority of the patients (11 of 13). If the coronal curve stabilizes or improves, then sagittal segmental abnormality could also be stabilized (in 7 of 11 patients).

Lumbar pedicle morphology in the immature spine: a three-dimensional study using spiral computed tomography.

STUDY DESIGN: A cross-sectional study was conducted. OBJECTIVE: To investigate the pediatric pedicle morphology with the help of modern computed tomography technology. SUMMARY OF BACKGROUND DATA: The use of pedicular screws recently has gained popularity because of their ability to provide three-dimensional correction of spinal deformity. Extensive work has been published on the pedicle morphology of the adult and adolescent thoracolumbar spine. Less is known about the pedicle morphology of children. METHODS: A total of 21 patients ages 5 to 10 years underwent standard spiral computed tomography of the abdomen. The patients were grouped according to age: Group 1 (5 to 8 years of age) and Group 2 (9 to 10 years of age). Images were reformatted, and multiplanar reconstructions were used to attain images of lumbar pedicles on sagittal, coronal, and transverse planes. The measurements included the inner and outer pedicle diameters on the transverse plane, the pedicle angle on both the transverse and sagittal planes, and pedicle length. RESULTS: The smallest pedicle lengths were 24 mm for Group 1 and 25 mm for Group 2. When the average values were considered, the smallest lengths were at L5 and the longest at L3. The smallest diameter was at L1 (2.3 mm for Group 1 and 3 mm for Group 2), whereas L5 had the largest diameter (6.17 mm for Group 1 and 8.72 mm for Group 2). In the transverse plane, the pedicle angle increased from L1 to L5 in both groups. In the sagittal plane, the angulations followed an opposite trend. CONCLUSIONS: The inner transverse diameter of the lumbar pedicle, particularly in young children, is smaller than previously reported. Insertion of screws currently available commercially screws seems to be safe in the L4-L5 pedicles of children ages 5 to 8 years, and in the L3-L5 pedicles of older children. Custom-made screws might be considered for upper levels for safe application.