Magnetically controlled growing rods in early onset scoliosis : Indications, timing and treatment.

Early onset scoliosis (EOS) remains one of the most challenging aspects of pediatric spine deformity care. The management is often complex, and options are non-operative care with casting or bracing and operative interventions. Surgical treatment includes distraction-based, compression-based and growth-guided techniques. The decision making should focus on preservation of growth, control of curve progression, minimizing complications, but most importantly improvement of the quality of life. Distraction-based techniques are the most commonly used growth-friendly surgery and the magnetically controlled growing rods (MCGR) technique is being utilized increasingly more in the USA over the past 10 years. The MCGR technique was cleared by the Food and Drug Administration (FDA) and available in the USA since 2014. It is indicated for the treatment of progressive EOS in immature patients and those at risk for thoracic insufficiency syndrome (TIS) with the goal of reducing the number of planned open surgical procedures for lengthening and minimizing the complications of more conventional techniques, such as traditional growing rods (TGR). The advent of MCGR has been a game changer for patients with EOS where the distractions are non-invasive and can be performed in outpatient clinics. Long-term follow-up is essential in understanding the outcome of any new treatment method especially in a very young and growing child. Multicenter registries with prospective data collection of pediatric spine deformity patients is imperative for understanding the outcomes of different methods of treatment, minimizing the complications and improving the quality of life of these children.

Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis: a matched comparative study.

Aims: The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS). Patients and Methods: A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified. Results: The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47). Conclusion: Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.

Case report: 122° kyphosis secondary to C5-L3 laminectomy and quadriplegia, surgical correction and 30-year follow-up.

STUDY DESIGN: The study design was a case report with 30-year follow-up. OBJECTIVES: In 1980, there were no pedicle screws available, so it was a great challenge to achieve correction and fusion in a patient with no laminae, and who was quadriplegic. Such a case with such a long follow-up has not been previously reported. METHODS: This is a single case report with an ultra-long follow-up. The patient underwent an anterior fusion from T3 to L4 via two incisions, and at a second stage, a posterior fusion from T3 to S1 using Luque rods and wires passed through the foramenae. After 2 years he underwent repair of two pseudarthroses with both anterior and posterior procedures. RESULTS: He achieved solid fusion following the pseudarthrosis repair. Although being a C7 quadriplegic all his life, he is totally independent in his activities of daily living, and is fully employed. CONCLUSION: Correction and fusion can be achieved even in the absence of laminae and pedicle screws.

Pediatric spine fractures.

Children have more elastic soft tissue and more potential for remodeling than adults. Certain injuries are unique to children, including posterior limbus injuries, most cases of spinal cord injury without radiographic abnormalities, and spinal trauma in child abuse. This article discusses the pathomechanics, clinical presentation, treatment, and some of the complications of injuries of the thoracolumbar spine in children.

Back pain in childhood and adolescence.

A variety of disorders can account for back pain in the child or adolescent (Outline 1). Some of these can result in significant morbidity if not properly diagnosed and treated. Fortunately, nearly all can be correctly diagnosed by taking a thorough medical history, performing a complete physical examination, and obtaining appropriate imaging and laboratory studies. Although back pain in children and adolescents may result from overuse or minor trauma and will respond to rest and anti-inflammatories, this review should enable the orthopaedist to systematically recognize those back disorders in need of more aggressive medical intervention.

An unusual cause of low back pain. Osteomyelitis of the spinous process.

STUDY DESIGN: A case report of osteomyelitis of the spinous process. OBJECTIVE: To describe the diagnosis and successful treatment of a patient with spinous process osteomyelitis. SUMMARY OF BACKGROUND DATA: Spinous process osteomyelitis is exceedingly rare and may be misdiagnosed as paraspinal muscle strain, discitis, or vertebral body osteomyelitis. The clinical presentation of spinous process osteomyelitis is subtle, laboratory findings are nonspecific, and radiographs are often normal. METHODS: The diagnosis, treatment, and outcome of two patients with spinous process osteomyelitis (an adult and a child) with insidious, nonspecific lumbar pain and fever are reviewed. RESULTS: Magnetic resonance imaging with and without gadolinium enhancement demonstrated increased signal of the spinous process with paraspinous musculature enhancement, a finding consistent with spinous process osteomyelitis. Biopsy results demonstrated the presence of staphylococcus aureus in the child and no organisms in the adult. Treatment with intravenous antibiotics led to resolution in both cases. CONCLUSIONS: The use of magnetic resonance imaging technology permitted the early and accurate diagnosis of spinous process osteomyelitis.

Use of long rods and a short arthrodesis for burst fractures of the thoracolumbar spine. A long-term follow-up study.

Thirteen patients who had a burst fracture of the thoracolumbar spine (the twelfth thoracic to the fifth lumbar vertebra) were managed with the use of long rods and a short arthrodesis (the so-called rod-long, fuse-short technique). The patients were followed for an average of seventy-four months (range, thirty-four to 118 months). Six months after the operation, the rods were removed and the fusion mass was explored. At that time, twelve patients had a solid fusion at all levels of the arthrodesis. Of the eighty-eight facet joints that had been spanned by the rods but had not been included in the arthrodesis, two had nevertheless progressed to fusion, as determined radiographically. Physiological motion was present in forty-three of the forty-four segments for which a fusion had not been intended. Before the operation, the average anterior height of the fractured vertebrae was 61 per cent of the estimated height before the injury; this improved after the operation to an average of 83 per cent (median, 87 per cent) of the height before the injury. At the latest follow-up examination, the anterior height was an average of 78 per cent of the estimated height before the injury (median, 82 per cent; range, 51 to 93 per cent), a slight decrease compared with the value immediately after the operation. Kyphosis of the injured segment before the operation, measured for twelve of the thirteen patients, averaged 15 degrees (median, 12 degrees; range, 0 to 33 degrees); as a result of the operation, this improved an average of 15 degrees, to 0 degrees of kyphosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of scoliosis in neurofibromatosis.

Experience in a comprehensive, multispecialty neurofibromatosis clinic leads the authors to suggest that the association of spinal deformity with neurofibromatosis is less frequent than usually assumed. Previously reported statistics may be partly attributed to preselection of patients seen by spinal surgeons, and to the predominant referral of patients having severe manifestations of neurofibromatosis. A diagnosis of neurofibromatosis 1, based on National Institutes of Health criteria, is confirmed for two hundred twenty patients at the clinic. Twenty-three of these patients have structural scoliosis. Nine patients have idiopathic type curves, eight have dystrophic scoliosis, four have dystrophic kyphoscoliosis, and two have dystrophic lordoscoliosis. The authors believe that 10% is representative of the true prevalence of spinal deformity in an otherwise unselected cross section of neurofibromatosis patients.

Neurologic recovery associated with anterior decompression of spine fractures at the thoracolumbar junction (T12-L1).

Between 1981 and 1990, twenty-two patients with incomplete neurologic deficits after thoracolumbar junction fractures were treated by anterior decompression and stabilization. Two patients were unavailable for follow-up examination, eleven underwent spinal canal decompression within 48 hours of injury (Group A); and nine patients underwent surgical decompression in an average of 61 days after injury (Group B). Neurologic recovery was analyzed by a modified Frankel grading system, the ASIA motor point scale and conus medullaris function. Patients were followed for an average of 3.5 years (range, 6-92 months). No patients had any deterioration in neurologic function after surgery. Patients in Group A had a modified Frankel grade improvement with a median of two grades and a mean American Spine Injury Association motor point improvement of 21.1 +/- 4.1. Four of nine patients with conus medullaris deficits demonstrated complete functional bladder and bowel return postoperatively. Those patients in Group B had a modified Frankel grade improvement with a median of one grade and a mean ASIA motor point improvement of 7.6 +/- 1.7. None of the six patients with conus medullaris injuries showed complete improvement in bladder or bowel function postoperatively. The modified Frankel grade and ASIA motor point score improvements were significant when the two groups were compared (P less than 0.04 and P less than 0.01, respectively). In this series of patients, early anterior decompression for traumatic injuries at the thoracolumbar junction was associated with improved rates of neurologic recovery when compared to late decompression.

Second operation for slipped capital femoral epiphysis: pin removal.

Pin removal procedures were retrospectively reviewed for 43 hips in 31 patients. Original treatment had included use of Knowles, Steinmann, Hagie, and cannulated steel pins. Time to pin extraction ranged from 5 to 70 months. Average operative time was slightly more than 1 h and average blood loss was 127 ml. Bone overgrowth and difficult extraction was encountered with all pin types. Pin breakage during extraction was recorded with Steinmann and Knowles pins. Delay in return to full activity postoperatively was a common complaint. This study shows that pin removal is not without certain costs and risks.

Acute cholecystitis after spinal fusion and instrumentation in children.

Three children developed noncalculus cholecystitis after spinal fusion and instrumentation for their spinal deformity. Two children responded to conservative therapy, and one required cholecystectomy. If diagnosed early, this complication may be successfully treated by conservative means.

Hypertension after operative correction of club-foot deformity.

Severe hypertension occurred as a postoperative complication after correction of a club-foot deformity in four children (seven feet) who were between the ages of two and three years and had no history of hypertension. The hypertension subsided slowly after administration of antihypertensive medications or more rapidly after release of the correction that had been obtained operatively.

Free tissue transfer in children.

We reviewed 11 cases of free tissue transfer used to salvage limbs in young patients (age range 4-16 years, mean 8.9 years). The defects were the result of acute trauma in eight cases, osteomyelitis in one, unstable scar over bony prominence in one, and correction of a previously infected talipes equinovarus repair in another patient. Donor tissues used were the latissimus dorsi muscle, scapular skin, lateral arm skin, and vascularized fibular graft. Defect sizes included 3 x 3 to 10 x 40 cm and 11 cm of humeral diaphysis. Microvascular success rate was 100%. In each case, the successful transfer provided the viable tissue required and resulted in salvage of the limb. Our results suggest that free tissue transfer is a viable solution to limb salvage in pediatric patients.

Selection of methodology in surgical treatment of adolescent idiopathic scoliosis.

Before contemplating any surgical procedure, one has to define the goals of the operative procedure. The patient should be evaluated thoroughly by physical examination and by adequate radiographs, including bending films. The surgeon should be familiar with different types of techniques and their qualities. The goals of surgery should be outlined clearly and understood between the physician and the patient. The patient should be provided with sufficient and easy-to-understand information (Table 1), and be encouraged to have an input in the decision-making process. For instance, is the goal of surgery to stop progression? To achieve cosmetic correction? To preserve maximal spinal mobility or to help improve pulmonary function? Is it important for the patient to be cast free postoperatively? Once the goal is defined, and we are aware of the abilities of each technique, then we can arrive at a realistic expectation. Again, it is of utmost importance that the surgeon select the procedure that he or she has adequate experience in performing.

The Cardinal Glennon Children's Hospital Neurofibromatosis Clinic model.

As subspecialty neurofibromatosis clinics and centers begin to appear in many parts of the United States and elsewhere in the world, it would be worthwhile for some of the earlier clinics to share their experiences in order to facilitate the more efficient establishment of similar clinics in as many locations as possible. In this report, emphasis is placed on the multidisciplinary nature of such a clinic, as well as on the primary roles of geneticists, neurologists, orthopedists, ophthalmologists, pediatricians, nurses and other consultants.

Exposure of the anterior spine. Technique, complications, and results in 85 patients.

The anterior approach to the spine is necessary for correction of some congenital spinal deformities and other conditions, including spinal trauma, infection, and tumor. The morbidity associated with this procedure has not been extensively reviewed in the literature. Between 1981 and 1986, 85 patients (41 male and 44 female) aged 1 to 77 years underwent anterior spinal fusion by an orthopedic or general surgery team (33 pediatric patients and 52 adult patients). Thirty-four patients had scoliosis, 8 had kyphosis, 24 had spinal trauma, 9 had tumor, and 10 had infection. Fifteen patients had restrictive lung disease diagnosed by pulmonary function testing (10 children and 5 adults). The thoracoabdominal approach was used in 50 patients, thoracotomy in 22 patients, and the lumbar approach in 10 patients. Two incisions were used in three patients. Correction was accomplished by interbody fusion in 36 patients (17 with instrumentation) and strut graft in 49 patients (6 with instrumentation). Twelve strut grafts were vascularized ribs and 37 were free ribs. Eighty-two patients survived (96 percent). Seventy-four complications occurring in 50 patients all resolved prior to discharge. These included 28 pulmonary complications, 27 urinary complications, and 5 gastrointestinal complications. Three patients required prolonged mechanical ventilation. Solid fusion was seen in 78 of 85 patients, whereas pseudoarthrosis developed in 7.

Neurological complications resulting from supracondylar fractures of the humerus in children.

One hundred thirty-eight children with supracondylar fractures of the humerus were reviewed. Seventeen (12%) exhibited neurological deficits. Nine median, four ulnar, and four radial neuropathies were encountered. The neurological deficit was treated expectantly. The osseous injury was treated by a variety of methods. All patients except two recovered spontaneously in an average of 9 weeks. One patient was still improving at 9 months' follow-up. Another patient with radial neuropathy underwent exploration 6 months after injury and was found to have a transected radial nerve. This study demonstrates that neurological deficits from supracondylar humeral fractures remain common, involve all three major nerves of forearm, and, with rare exception, recover with conservative therapy.