Morphometric analysis of the proximal thoracic pedicles in Lenke II and IV adolescent idiopathic scoliosis: an evaluation of the feasibility for pedicle screw insertion.

PURPOSE: Pedicles on the concave side of the proximal thoracic (PT) curve in adolescent idiopathic scoliosis (AIS) patients with Lenke II and IV deformities tend to be narrow and dysplastic, making pedicle screw (PS) insertion challenging. The aim of this study was to evaluate the feasibility for PS placement in these patients using pedicle chord length, diameter, and channel morphology. METHODS: In this retrospective study, 56 consecutive AIS patients with Lenke II or IV curves who underwent instrumented posterior spinal fusion (PSF) were studied. The mean age at surgery was 14.8 years and the mean PT curve measured 45°. Two independent investigators evaluated all visible pedicles from T1 to T6 vertebral levels using axial images from intraoperative computed tomography-guided navigation recording the pedicle: (1) maximum transverse diameter 'd' at the isthmus, (2) maximum chord length 'l', and (3) qualitative assessment of the channel morphology (types A-D). RESULTS: Two hundred and sixty-eight concave and 264 convex pedicles were measured. The mean 'd' of the concave pedicles at T3 and T4 was < 3.0 mm, compared to > 5.0 mm for the convex counterparts (p < 0.001). Of all concave pedicle channels, 48% had morphology characteristics that were riskier for PS cannulation (type C or D) compared to 2% of all convex pedicle channels (type A or B) (p < 0.001). CONCLUSION: Almost half of all concave pedicles have morphologic characteristics that make them too small to accommodate a PS. Though PSs could be inserted using an in-out-in technique in these patients, alternative fixation anchors may improve strength and safety.

Cost Analysis of Magnet-driven Growing Rods for Early-onset Scoliosis at 5 Years.

STUDY DESIGN: Prospective case series of nine children with early-onset scoliosis (EOS) treated by a single surgeon with a novel implant, the magnet-driven growing rod (MdGR) in a publicly funded health care service accounting for "payer costs" (PC) incurred. OBJECTIVE: The aim of this study was to compare the cost-effectiveness of MdGR versus conventional growing rods (CGRs) with respect to the PC incurred for treating EOS at 5 years. SUMMARY OF BACKGROUND DATA: Cost estimate and mathematical modeling study projections of MdGR have shown despite high insertional costs, it breaks even with CGR by 3 to 4 years. However, no clinical study to date exists either supporting or refuting this hypothesis. METHODS: Nine patients with EOS secondary to idiopathic (two), congenital (one), syndromic (three), and neuromuscular (three) etiologies treated by submuscular insertion of MdGR against stringent inclusion criteria formed the study cohort. We collected costs incurred with all aspects of care over the lifetime of device (or at least 5 years) from payers' perspective to compute and report average PC incurred per patient. We performed this cost analysis by comparing the MdGR PC against literature reported PC for CGR at 5 years. RESULTS: There were five single rod (SR) and two dual rod (DR) de novo MdGR insertions, while two patients had conversion of CGR to MdGR. MdGR alone accounted for at least 50% of overall budget. The MdGR was at least 40% more cost-effective in comparison to the CGR (£34,741 vs. £52,293) and there were seven MdGR graduates. CONCLUSION: The first study reporting direct PC incurred in EOS treated by MdGR that is devoid of any mathematical modeling and deterministic sensitivity analysis is presented. The true societal/human cost savings taking into consideration indirect costs are likely to be significantly higher. MdGR is a promising novel implant that may eventually become the "standard of care" for certain EOS etiologies. LEVEL OF EVIDENCE: 4.

Quality assurance in segmental neck of femur fractures.

Purpose The purpose of this paper is to report a rare case of segmental neck of femur fracture (SNoFF) and highlight its quality assurance and governance implications with respect to national guidelines, care pathways and best practice tariff. Design/methodology/approach Case report of an SNoFF in a 67-year-old woman treated at a district general hospital (DGH) was used in this study. Findings SNoFF required additional implants that delayed the surgery by five days. The authors were unable to adhere to the British Orthopaedic Association standards for trauma and Scottish Inter-Collegiate Guidelines Network recommendations which indicate that all neck of femur fractures (NoFFs) be fixed within 48 h. Though the patient was discharged without any untoward event and had an uneventful recovery, this case led us to introspect and learn how best to avoid such an incident from repeating again. Research limitations/implications This case led to an overhaul of NoFF and trauma services. The local logistics was restructured to procure "Trochanteric grip plates" within 24 h to provide mandated quality of care in an effort towards improving patient experience/outcomes. Originality/value SNoFF are rare injuries and its diagnosis is either delayed or missed in at least 20 per cent of the cases on initial evaluation. The non-availability of additional implants readily on the shelf coupled with lack of a trauma bed at the tertiary centre resulted in an unacceptable delay from admission to definitive surgery. The authors recommend that all DGHs have a mechanism/emergency procurement procedure system in place to obtain the required instrumentation kits rapidly through a sharing scheme with regional hospitals or through implant vendor to avoid unacceptable delays to surgery.

Results of Bracing for Juvenile Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative therapeutic clinical study evaluating the results of bracing for juvenile idiopathic scoliosis (JIS). OBJECTIVES: To evaluate if bracing has a role in treatment of JIS and, if so, to report its success rate and factors associated with successful bracing. SUMMARY OF BACKGROUND DATA: Patients with JIS have higher mortality and morbidity in comparison to those with adolescent idiopathic scoliosis (AIS) or general population. Untreated JIS may cause severe cardiorespiratory compromise. METHODS: All children treated at our institute and followed up until either skeletal maturity or surgeries between 1956 and 1999 with JIS were included. Those who had an incomplete set of radiographs or those treated by mere observation were excluded. RESULTS: One hundred twenty-five patients, comprising of 93 who were braced as juveniles and 32 who were braced in adolescence, met the inclusion criteria. Fifty-six of them were successfully treated by bracing (32 juveniles and 24 adolescents) and 69 patients needed surgery despite bracing. When final curves greater than 45° were regarded as failure of bracing, the success rate was 41%. The braces used were Milwaukee brace (MB) and thoraco-lumbo-sacral orthosis (TLSO) and no statistically significant difference was found between the two. None of the patients had surgery of any kind during the juvenile phase (ie, at age <10 years). DISCUSSION: The overall success rate with bracing was 41%. A third of them (ie, 18/56) could be safely weaned prior to skeletal maturity without risking curve progression. The odds of needing a surgery when braced as a juvenile was 2-in-3 (34% success), which fell to almost 1-in-4 for an adolescent (75% success) and was statistically significant (p = .001). Curves with Cobb angle ≤29° when braced progressed to a degree warranting surgery at a lower rate as compared to those ≥30°, this difference was not statistically significant (p = .22). CONCLUSION: Bracing obviated the need for surgery during juvenile years in all patients and was a successful delaying strategy.

A New Fixation Technique for French-Door Cervical Laminoplasty: Surgical Results With a Minimum Follow-up of 6 Years.

DESIGN: A case series of 5 patients with multilevel cervical myelopathy treated by French-door cervical laminoplasty (FDCL) and use of unicortical iliac crest graft as spacer fixed with titanium miniplates and screws is described. OBJECTIVE: To report a minimum of 6-year follow-up results of our new plate-screw fixation technique for FDCL. SUMMARY OF BACKGROUND DATA: Hardware-assisted laminoplasty has the potential advantage of preventing restenosis by holding the laminar door "open" while healing progresses and also prevents spacer dislodgement. The use of titanium miniplates as internal fixation device for FDCL by our novel technique has not been reported. METHODS: Five patients suffering from multilevel cervical myelopathy harboring constitutionally narrow cervical canal (3) and multilevel cervical spondylotic myelopathy (2) who underwent 2-3 level FDCL and followed up prospectively for 6 years is presented. Modified Kurokawa and colleague's technique of FDCL was performed and autologous iliac crest bone graft was interposed between the sagittaly split spinous processes. A 12- to 15-hole titanium miniplate was contoured into a trapezoidal shape to sit flush with the posterior elements. The plate was anchored to bone graft and posterior elements with screws and patients mobilized without any external orthosis. RESULTS: The mean follow-up was 90.5 months. The mean improvement in Neck disability index at final follow-up was 35% and mean improvement in Visual analog scale was 4 points. Japanese orthopaedic association score improved from a mean of 10 to a mean of 14.8 postoperatively. The final outcome was good (3) and excellent (2) by Odom's criteria. All patients improved to Nurick's grade 0 or I and reported significant relief from their myelopathic symptoms and axial neck pain. There were no postoperative hardware-related complications or pseudoarthrosis. CONCLUSIONS: Titanium miniplates are excellent devices for stabilizing the interspinous spacers used in FDCL. They prevent cervical canal deformation, restenosis, spacer dislodgement and are durable, cost-effective in facilitating early mobilization at intermediate-term follow-up of 6 years.

Observational Analysis of Changing Trends in Level of Evidence of Scoliosis Research Society Annual Meeting Podium Presentations in the New Millennium (2001-2013).

STUDY DESIGN: Observational quantitative evaluation of all Scoliosis Research Society annual meeting (SRS-AM) podium presentations over a 6-year period in the new millennium for changing trends in Level of Evidence (LoE). OBJECTIVES: To report the LoE of SRS-AM podium presentations over a 13-year period in the new millennium and to compare the trends in LoE over a 3-year period between the two decades, that is, 2001-2003 versus 2011-2013. SUMMARY OF BACKGROUND DATA: LoE is a rating system introduced by the American Academy of Orthopaedic Surgeons (AAOS) in 2003 to reflect the quality of clinical studies. No study has looked into any of AAOS-affiliated spinal specialist societies' LoE, hence this study. METHODS: The SRS-AM proceedings books from two 3-year periods, 2001-2003 and 2011-2013, were retrieved. Two orthopedic surgeons independently graded each abstract on two occasions, 1 month apart, assigning them LoE from I to V, in accordance with the stringent guidelines published by AAOS. They also categorized all studies into types (ie, therapeutic, prognostic, diagnostic, economic or decision-modeling analysis, or LoE not applicable). Any disagreement between the two assessors over the LoE or the nature of study was discussed, and agreed upon by consensus. Thus, analyzed abstracts of the two groups were subsequently compared and subjected to statistical tests to determine significance. RESULTS: 637 free-papers from six annual meeting proceedings (264 in Group I and 373 in Group II) were analyzed in total. LoE I and II studies have more than doubled (p<.0001), and LoE IV studies have fallen by half in 2011-2013 as compared to 2001-2003. CONCLUSION: The SRS-AM podium presentation has shown an increase in LoE I and II studies in the new millennium. SRS is the first AAOS-affiliated subspecialty society to have undertaken an in-depth analysis of its AM podium presentations, setting a standard for other societies to emulate. LEVEL OF EVIDENCE: Not applicable.

Surgical results with the use of Silicated Calcium Phosphate (SiCaP) as bone graft substitute in Posterior Spinal Fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS).

BACKGROUND: The gold standard iliac crest bone graft (ICBG) used to achieve arthrodesis in spinal fusions is not without complications (donor-site morbidity, iliac wing fractures etc.…). Our objectives were to evaluate the role of silicated calcium phosphate (SiCaP), an osteoconductive synthetic bone graft substitute in conjunction with locally harvested autologous bone in achieving arthrodesis following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and report clinic-radiological results / adverse events with its use in a prospective single surgeon case series (Level of evidence [LoE] IV) treated by low implant density index (IDI) constructs (i.e., IDI ≤1.5). METHODS: Thirty-five patients (8♂ & 2727♀) who underwent PSF and followed-up for a minimum of 2 years formed the study cohort. The mean age at surgery was 15 years (range: 11-21y) and pre-op Cobb angle was 60° (range: 40°-90°). SiCaP mixed with locally harvested bone during exposure and instrumentation was laid over instrumented segments. The average SiCaP used per patient was 32mls (range: 10-60mls). Radiographs were assessed for fusion at serial six monthly follow-ups. All clinical adverse events and complications were recorded. RESULTS: The mean follow-up was 2.94 years (range: 2-4y). The post-op Cobb angle improved to 23° (range: 2°- 55°) and the mean in-patient stay was 7.72 days (range: 5-13d). The mean number of instrumented segments was 9.4 (range: 4-13) and implant density index (IDI) averaged 1.23 (range: 1.15-1.5). Radiographic new bone formation was seen within 3 months in all cases. All patients (except two) were highly satisfied at minimum follow-up of 8 years. There were two complications warranting revision surgery (deep infection, and implant failure without any evidence of pseudarthrosis). There were no SiCaP specific adverse events in any of the 35 patients. CONCLUSION: SiCaP facilitated early bony consolidation in operated cohort of AIS patients treated by PSF. There were no inflammatory reaction or other adverse effects associated with its use. SiCaP is a safe alternative to autologous iliac crest bone graft with reduced complications, morbidity, faster recovery and similar infection/fusion rates reported in the literature.

The furcal nerve revisited.

Atypical sciatica and discrepancy between clinical presentation and imaging findings is a dilemma for treating surgeon in management of lumbar disc herniation. It also constitutes ground for failed back surgery and potential litigations thereof. Furcal nerve (Furcal = forked) is an independent nerve with its own ventral and dorsal branches (rootlets) and forms a link nerve that connects lumbar and sacral plexus. Its fibers branch out to be part of femoral and obturator nerves in-addition to the lumbosacral trunk. It is most commonly found at L4 level and is the most common cause of atypical presentation of radiculopathy/sciatica. Very little is published about the furcal nerve and many are unaware of its existence. This article summarizes all the existing evidence about furcal nerve in English literature in an attempt to create awareness and offer insight about this unique entity to fellow colleagues/professionals involved in spine care.

Risk factors for vertebral artery injuries in cervical spine trauma.

Blunt cerebrovascular injuries (i.e. involvement of carotid and vertebral arteries) are increasingly being recognized in setting of cervical spine trauma/fractures and are associated with high incidence of stroke/morbidity and mortality. The incidence of vertebral artery injuries (VAI) is more common than previously thought and regular screening is seldom performed. However there exists no screening criteria and conflicting reports exists between spine and trauma literature. Many clinicians do not routinely screen/evaluate patients presenting with cervical spine trauma for potential VAI. This article provides a brief summary of existing evidence regarding the incidence of VAI in the background of cervical trauma/fractures. The type and fracture pattern that is associated with a high risk of VAI warranting mandatory screening/further work-up is discussed. A brief overview of diagnostic modalities and their respective sensitivity/specificity along with available treatment options is also summarized.