Expert's comment concerning Grand Rounds case entitled "L5-S1 disc replacement after two previous fusion surgeries for scoliosis" (by S. Jehan, S. Elsayed, J. Webb and B. Boszczyk).

The attempt to preserve motion below a long fusion is certainly praiseworthy even if it is clearly understood with the patient that the result might be only temporary, buying some good years in the most active part of life. The analysis of the case presented here suggests that such an approach could be recommended in the right patient, with the right team. More experience and reports are necessary to evolve from an anecdotal report to a new path in the treatment of adult scoliosis.

Efficacy of aprotinin as a blood conservation technique for adult deformity spinal surgery: a retrospective study.

STUDY DESIGN: A retrospective study that involved a total of 82 adult deformity patients who underwent spinal fusion surgery with instrumentation of 6 or more levels. OBJECTIVE: The purpose of this study is to assess the efficacy and safety of aprotinin in reducing blood loss in adult spinal deformity patients. SUMMARY OF BACKGROUND DATA: Aprotinin is an antifibrinolytic agent, which has been proven to be effective as a blood-conserving agent in cardiac surgery. This study focused specifically on adult spine deformity patients. METHODS: This retrospective study analyzed a total of 82 adult deformity patients (patients with diagnosis of adult scoliosis and kyphosis) who underwent spinal fusion surgery with instrumentation of 6 or more levels. Forty-one patients who received aprotinin were compared with a control group of 41 patients who did not receive aprotinin. Specific surgical outcome parameters and postoperative complications were assessed. RESULTS: The average age of the patients was 47 years and 41 years for the aprotinin group and the control group respectively. Thirty-nine percent of cases and 44% of controls had staged anterior/posterior fusion surgery, 39% of cases and 41% of controls underwent single stage posterior fusion surgery and the remaining 27% of cases and 15% of controls had same day anterior and posterior fusion surgery. The average number of levels fused and instrumented was 11.2 for the aprotinin group and 10.7 for the control group. The differences in mean blood loss and blood returned by cell-saver were statistically significantly lower in the aprotinin group (1324 mL vs. 2113 mL; P = 0.005 and 390 mL vs. 657 mL; P = 0.003). The amount of drainage after surgery was similar (1421 mL vs. 1388 mL; P = 0.982). The aprotinin group received an average of 2.73 units of blood. This was significantly lower than the average 5.02 units that the controls received (P = 0.003). The rate of complications was comparable and no allergic reaction to aprotinin was noted. One case exhibited a transitory elevation of blood urea nitrogen/creatinine which resolved before discharge. CONCLUSION: The results of our study suggest that the administration of aprotinin is a safe and effective method to reduce blood loss and to decrease the need for transfusions without increasing risk of complication in the younger patients in relatively good general health undergoing spinal deformity surgery requiring 6 or more levels of fusion.

The eggshell technique for prevention of cement leakage during kyphoplasty.

Cement extravasation during kyphoplasty occurs between 4% and 9%, a much lower incidence than with vertebroplasty. However, because of the potential complications of cement in and around the spinal canal, any egress of cement outside the vertebral body is extremely concerning. Aborting the procedure will cease the extraosseous leakage and minimize potential immediate complications. However, the cavity will remain unfilled and the fracture unstable. Rather than aborting, we have devised a technique, called the eggshell technique, to manage the patient's fracture once extravasation is noted so that the procedure can be safely completed.

Differences in the Risser grading systems in the United States and France.

UNLABELLED: A grading system for ossification of the iliac apophysis (Risser sign) came into use in the mid 1950s in the United States and was adopted sometime later with modifications in France and other European countries. Although called by the same name, these systems have important differences that could lead to different choices of how and when to treat patients with spinal deformity. In a retrospective study, two experienced examiners (FDB and KPV) independently reviewed 301 randomly selected spine radiographs from 167 patients with adolescent idiopathic scoliosis and graded them for bilateral iliac crest apophyseal excursion each using a different system. The two grading systems were compared using percent agreements and kappa statistics. There was good to excellent agreement between the two Risser systems in only 50.8% of the patients. In disagreements regarding 147 of 148 patients, the US Risser grade was higher than the French Risser grade. In 130 of these patients (88.5%) the disagreement was one grade, and in 17 patients (11.5%), it was two grades. Therefore, the French Risser grading system uniformly undervalued the ossification excursion compared with the US Risser grading system. We think that the observed discordance is a source of miscommunication and descriptive confusion in the literature and in patient treatment. LEVEL OF EVIDENCE: Diagnostic study, Level III-1 (study of nonconsecutive patients--no consistently applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

The use of short and rigid anterior instrumentation in the treatment of idiopathic thoracolumbar scoliosis: a retrospective review of 24 cases.

STUDY DESIGN: The results of short anterior rigid rod instrumentation used to treat thoracolumbar scoliosis in 24 patients were reviewed retrospectively. OBJECTIVE: To assess the safety and efficiency of anterior correction of thoracolumbar scoliosis using a single rigid rod with segmental fixation. SUMMARY OF BACKGROUND DATA: This method of treatment results from the historical difficulties noted in obtaining adequate correction in both planes for this particular type of curve while saving as many segments as possible. This approach seems to combine the advantages and avoid the limitations of posterior segmental and previous anterior segmental techniques. METHODS: For this study, 24 patients with thoracolumbar scoliosis underwent anterior spinal correction and fusion using a single rigid rod and segmental fixation. Additionally, in five patients, this construct was supplemented by interbody titanium cages. The patients were assessed for the amount of correction obtained in the main curve, and for the spontaneous correction of the compensatory curves above and below. Trunk balance was measured on standing radiographs. The average age of the patients was 17.3 years (range, 10-43 years), and the average follow-up period was 3.6 years (range, 2-4.5 years). RESULTS: Correction of the major curve at follow-up assessment was 54%, with a 73% correction of the instrumented area. The upper compensatory curve showed a 21% correction, and the lower curve a 59% correction. Over the duration of the follow-up period, the instrumented area showed kyphosis progression of 6.5 degrees. The five patients who had insertion of Harms cages tended to have a lower rate of correction. The average number of intervertebral mobile segments fused was 2.9 (range, 2-5 segments). No intraoperative complication occurred in relation to the anterior approach. A temporary sympathectomy effect on the side of the approach was noted in most patients. Two radiologic pseudarthrosis and one loss of fixation at the top of the construct were observed. CONCLUSIONS: Anterior correction and fusion using solid rod instrumentation constitute effective and safe treatment of thoracolumbar scoliosis. As compared with posterior systems, it provides correction and rebalance of the trunk through a shorter fusion segment.

Quality of life in osteogenesis imperfecta.

The purpose of this study was to quantify the physical and mental health of a diverse adult cohort of patients with osteogenesis imperfecta (OI) utilizing a validated health self-assessment questionnaire (SF-36). In addition, a specific demographic questionnaire and a functional questionnaire were utilized to assess more specifically the physical limitations imposed by osteogenesis imperfecta in adulthood. The results of the SF-36 revealed significantly lower physical function scores compared to the U.S. adult norms. However, the SF-36 mental component scores were equal to the U.S. adult norms. The demographic questionnaire revealed high levels of educational achievement, as well as employment, despite significant physical impairments. The functional questionnaire clearly demonstrated limitations mostly related to ambulation.