Outcomes of early hemivertebrectomy in children with congenital scoliosis: A prospective follow-up study.

BACKGROUND AND OBJECTIVE: Posterolateral hemivertebrectomy with monosegmental instrumentation at an early age is an established method to correct congenital scoliosis but is associated with a relatively high risk of instrumentation failure and health-related quality of life outcomes are not available. We aimed to investigate the effects hemivertebrectomy with postoperative hip spica cast on complications and health-related quality of life in small children with congenital scoliosis. METHODS: A follow-up study of 30 children (at mean age = 3.4 years, range = 1.0-8.5 years) undergoing posterolateral hemivertebrectomy and short pedicle instrumentation. Children were immobilized postoperative with hip spica cast for 6 weeks and immobilization for 4 months using a rigid thoracolumbosacral orthosis. The Caregivers filled out Scoliosis Research Society 24 outcome questionnaire preoperatively, at 6 months, and at final follow-up visit on behalf of their child. Standing radiographs were obtained preoperatively, postoperatively in the cast, and standing at final follow-up. RESULTS: Mean major curve was 41° (range = 26°-87°) preoperatively and was corrected to 14° (4.0°-35°) at final follow-up. Eight (27%) children had postoperative complications, including three (10%) deep surgical site infections. The Scoliosis Research Society 24 back domain showed an improvement from a mean of 3.8 preoperatively to 4.4 at final follow-up (p < 0.001). Function from back condition domain showed a significant deterioration from 4.2 preoperatively to 3.7 at 6 months (p = 0.020) but improved back to baseline at final follow-up (4.2, p = 0.0022 6 months vs final follow-up). CONCLUSIONS: Hemivertebrectomy with short instrumentation resulted into 64% correction of scoliosis and improved health-related quality of life in back pain and function domains.

Correction to: Genomic Subtyping in Bladder Cancer.

The original version of this article contained a mistake. The included Conflict of Interest statement was incorrect.

Genomic Subtyping in Bladder Cancer.

PURPOSE OF REVIEW: Molecular characterization of cancer allows us to understand oncogenesis and clinical prognosis as well as facilitates development of biomarkers and treatment. Our aim was to review the current literature on genomic characterization of bladder cancer, and how far we are in implementing genomics into clinical practice. RECENT FINDINGS: Bladder cancers are molecularly diverse tumors with a high mutational rate. On molecular level, bladder cancer can be categorized into at least six subtypes called luminal-papillary, luminal-unstable, luminal non-specified, basal-squamous, neuroendocrine-like, and stroma-rich. These subtypes have characteristic genomic and transcriptomic profiles and appear to have different prognoses. Several molecular subtypes have been identified in bladder cancer. Prospective trials are underway to validate the applicability of genomic subtypes for clinical decision making. Further integrative analyses of genomic alterations, gene expression, epigenetics, and proteomics need to be performed before genomic subtyping can be attained in clinical practice.

The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21 years: the role of spinal deformity surgery.

BACKGROUND: Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS). METHODS: The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8-9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses. RESULTS: The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3-176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2-32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8-70.7, p = 0.01). CONCLUSIONS: Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Morbidity and radiographic outcomes of severe scoliosis of 90° or more: a comparison of hybrid with total pedicle screw instrumentation.

OBJECTIVES: Untreated severe scoliosis is associated with increased mortality and remains a significant surgical challenge. Few studies have reported mortality after the surgical treatment of severe scoliosis beyond a 2-year follow-up. The objectives of this study were to evaluate mortality beyond standard 2-year follow-up and compare radiographic outcomes using hybrid or pedicle screw instrumentation for severe scoliosis. METHODS: We evaluated 32 consecutive patients [11 males, mean age at surgery 15.3 (range 10.7-20.7) years] operated for a scoliosis of 90° or more using either hybrid (n = 15) or pedicle screw (n = 17) instrumentation. The follow-up time averaged 2.9 (2.0-6.6) years for radiographic and quality of life measurements and 5.5 years (2.0-9.0) years for mortality data. Of these patients, one had adolescent idiopathic scoliosis, three secondary scoliosis, and 28 neuromuscular scoliosis. Twelve patients in the hybrid and two patients in the pedicle screw groups underwent anteroposterior surgery (p < 0.001), and three patients in both groups had an apical vertebral column resection. RESULTS: One (3.1 %) patient died during follow-up for severe pneumonia. Preoperatively, the mean magnitude of the major curve was 109° (90°-127°) in the hybrid and 100° (90°-116°) in the pedicle screw groups (p = 0.015), and was corrected to 45° (19°-69°) in the hybrid and 27° (18°-40°) in the pedicle screw groups at the 2-year follow-up (p < 0.001), with a mean correction of the major curve of 59 % (37-81 %) in the hybrid versus 73 % (60-81 %) in the pedicle screw groups, respectively (p = 0.0023). There were six postoperative complications, including one transient spinal cord deficit necessitating reoperation in the hybrid group as compared with five complications in the pedicle screw group (p = 0.53). CONCLUSIONS: The mid-term mortality rate after the surgical treatment of severe scoliosis was low. Severe scoliosis can be treated safely with significantly better correction of the spinal deformity using pedicle screws than hybrid instrumentation.

Effects of surgical correction of neuromuscular scoliosis on gastric myoelectrical activity, emptying, and upper gastrointestinal symptoms.

OBJECTIVES: Gastrointestinal complications are frequent after surgical correction of neuromuscular scoliosis, but the effects of scoliosis surgery on gastric function and upper gastrointestinal symptoms over the long term are unknown. METHODS: Thirty-one children (16 spastic, 15 flaccid patients) who underwent surgical correction of neuromuscular scoliosis were included in a prospective follow-up study. Median (range) age at surgery was 14.9 (5-20) years and follow-up time 4.3 (2-8) years. Electrogastrography (n=28), gastric emptying scintigraphy (n=17), and structured upper gastrointestinal symptoms questionnaire (n=26) were evaluated before and after surgery. The results were related to patients' clinical state, type and extent of corrective spinal surgery, and gastrointestinal complications. RESULTS: The median main scoliosis curve of 81 degrees (51-129 degrees) was corrected to 25 degrees (1.0-85 degrees) after surgery. In electrogastrogram, power ratio increased from preoperative 1.4 (0.30-11) to postoperative 6.2 (1.2-26) in the spastic group (P=0.008), whereas in the flaccid group, power ratio remained unchanged at 2.2 (0.1-17). Patients with prolonged postoperative paralytic ileus had the most substantial increase in gastric power ratio (P=0.038). Correction of sagittal spinal balance correlated with increased postprandial normogastric activity after surgery (R=0.459; P=0.004). The gastric emptying results, upper gastrointestinal symptoms, and body mass index were not significantly altered after scoliosis surgery. CONCLUSIONS: Gastric myoelectrical power increased after surgical correction of spastic neuromuscular scoliosis and was associated with prolonged postoperative paralytic ileus. Correction of poor, stooped spinal balance improved gastric myoelectrical activity. The net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional state was minimal.

En bloc vertebral column derotation provides spinal derotation but no additional effect on thoracic rib hump correction as compared with no derotation in adolescents undergoing surgery for idiopathic scoliosis with total pedicle screw instrumentation.

STUDY DESIGN: A comparative review of 2 cohorts with prospective data collection. OBJECTIVE: To compare clinical and radiographical parameters in patients with adolescent idiopathic scoliosis undergoing surgery, using total pedicle screw instrumentation with and without en bloc vertebral column derotation (DVR). SUMMARY OF BACKGROUND DATA: All pedicle screw instrumentations with or without DVR are an effective surgical method for adolescent idiopathic scoliosis correction. However, there are limited data comparing pedicle screw instrumentation alone with pedicle screws with DVR on clinical and radiographical outcomes. METHODS: We followed 72 consecutive children and adolescents (14 males, mean age at surgery: 14.7 [range, 9.0-18.0] years; 6 juveniles, 66 adolescents) operated for a structural thoracic idiopathic scoliosis (Lenke 1-4, or 6) using all pedicle screw construct in a prospective manner for a minimum of 2 years. Of them, 24 had pedicle screw instrumentation with apical monoaxial screws without derotation (N-DVR) and 48 with en bloc DVR. RESULTS: Preoperatively, the mean (SD) main thoracic curve was 56° ± 9° and 57° ± 11° and was corrected to 16° ± 6° in both groups at 2-year follow-up (not significant). Thoracic rib hump averaged 12.3° ± 3.6° versus 14.2° ± 5.0° (P = 0.075) preoperatively and 7.2° ± 3.8° versus 8.3° ± 3.7° at 2-year follow-up in the N-DVR and in the DVR both groups, respectively (P = 0.30). Correction of spinal rotation in the main thoracic curve as assessed by the Upsani score was significantly better in the DVR group than in the N-DVR group at 6 months (P = 0.038) and 2-year follow-up (P = 0.039). Thoracic kyphosis reduced from a mean of 23° ± 18° to 20° ± 9° in the N-DVR group but remained unchanged in the DVR group (P = 0.11 between groups at 2-year follow-up). CONCLUSION: En bloc DVR has a significant effect on radiographical spinal column derotation and may help prevent flattening of thoracic kyphosis, but this derotation is not reflected by better thoracic rib hump correction at 2-year follow-up. LEVEL OF EVIDENCE: 2.

Vertebral fracture and cause-specific mortality: a prospective population study of 3,210 men and 3,730 women with 30 years of follow-up.

INTRODUCTION: Vertebral fractures predict mortality, but little is known about their associations with the causes of death. We studied vertebral fractures for prediction of cause-specific mortality. MATERIAL AND METHODS: A nationally representative sample of 3,210 men and 3,730 women participated Mini-Finland health survey in 1978-1980. Vertebral fractures at the Th1-Th12 levels were identified from chest radiographs at baseline. Cox's proportional hazard model was used to estimate the strength of association between vertebral fracture and mortality. RESULTS: The relative risk (95% confidence interval) of death from natural causes was 1.49 (0.89-2.48) in men and 0.89 (0.60-1.31) in women with vertebral fractures (adjusted for age, body mass index, serum 25-hydroxyvitamin D, educational level, smoking, alcohol intake, physical activity and self-rated general health). Among women the adjusted relative risk of an injury death was 8.51 (3.48-20.77), whereas none of the men with vertebral fracture died due to an injury. CONCLUSION: The patterns of mortality predicted by fracture in the thoracic spine differ between men and women.

Operative treatment of isthmic spondylolisthesis in children: a long-term, retrospective comparative study with matched cohorts.

The purpose of the present study was to compare the long-term clinical, functional and radiographic outcomes of young patients operated on before or at the onset of puberty (Children) and those operated on after that (Adolescents). The study group consisted of 298 patients operated on under the age of 20 years; 55 of them were operated on before or at the onset of growth spurt (29 females<12.5 years, 26 males<14.5 years). Preoperative data were retrieved from patients' records. After mean follow-up of 17 years (10.7-26.3), physical examination, radiographic measurements and functional testing were performed by independent observers. SRS-24, Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS) were utilised to evaluate health-related quality of life. The data were compared between the two age groups in the whole study population and in 41 pairs of patients matched by gender, operative method, severity of preoperative slip, and age at follow-up. Preoperatively, one-third of children did not have significant pain symptoms. They were operated upon for resistant postural anomalies in combination with high risk of slip progression. All of the adolescents had low-back pain as the main clinical symptom. The outcomes were satisfactory in both groups in the whole population (children vs. adolescents; low-grade slip: SRS-24: 95.9 vs. 92.0, ODI: 5.2 vs. 7.5, VAS low-back pain: 18.9 vs. 21.2; high-grade slip: SRS-24: 95.6 vs. 90.6, ODI: 3.4 vs. 6.9, VAS low-back pain: 10.5 vs. 22.1). The differences were statistically significant for ODI and VAS in high-grade patients in favor of the children. The clinical relevance of these differences seems to be minimal. The results of the comparison of the matched cohorts were comparably good. One-fifth of the whole study group had a non-union which did not affect the final outcome. In the children with high-grade slips, there was a mean slip improvement of 14 percentage points due to remodelling. The overall complication rate in the whole population was 7.7%. In conclusion, spinal fusion can be carried out at an early age for low- and high-grade spondylolisthesis with good long-term clinical, functional, radiographic and health-related quality-of-life outcomes when the indications are met.

Hemivertebra resection for congenital scoliosis in young children: comparison of clinical, radiographic, and health-related quality of life outcomes between the anteroposterior and posterolateral approaches.

STUDY DESIGN: A retrospective comparative study of prospectively collected data. OBJECTIVE: To compare clinical, radiographic, and health-related quality of life (Scoliosis Research Society [SRS]-24) outcomes in patients undergoing hemivertebra excision by simultaneous anteroposterior (AP) or posterolateral only approach (PL). SUMMARY OF BACKGROUND DATA: AP hemivertebra resection for congenital scoliosis has provided reliable and safe long-term outcomes with respect to clinical and radiographic findings. Recently, PL excision has been described with rather high implant failure and revision rates. There are no studies comparing outcomes of AP and PL hemivertebra excision in 1 center. In addition, studies reporting health-related quality of life after surgery for congenital scoliosis are few. METHODS: Between 2001 and 2008, 12 AP and 11 PL hemivertebra excisions were conducted in 21 patients (16 males) with congenital scoliosis or kyphoscoliosis due to unbalanced hemivertebrae in our hospital. The average age at surgery was 4.0 years (range, 1.2-11.4) and the mean follow-up time 2.5 years (range, 1-7 years). RESULTS: Before surgery, the mean Cobb angle of the main curve was 33° (range, 25°-45°) in the AP group and 43° (range, 26°-87°) in the PL group. At the final follow-up visit, the main curve had been corrected to a mean of 12° (range, 2°-27°) and 15° (range, 6°-28°), respectively (P = NS). The Scoliosis Research Society-24 total scores were similar, 101 (range, 89-109) for the AP and 100 (range, 85-106) for the PL group at the final follow-up visit. Any complication was observed in 8% (1/12) of patients in the AP group and, whereas the PL group had 40% (4/10) complication rate with 2 temporary neurologic deficits, no implant failures were observed. All patients underwent spinal fusion during follow-up. CONCLUSION: PL resection is technically more demanding and slightly faster method for hemivertebral resection. It has nearly as good correction rate as the AP-method but more minor complications. Hemivertebrectomy seems to provide a controllable untethering effect in patients with a symptomatic tethered cord.

Incidence of spinal and spinal cord injuries and their surgical treatment in children and adolescents: a population-based study.

STUDY DESIGN: A population based, epidemiological study. OBJECTIVE: To investigate incidence of spinal and spinal cord injuries and their surgical treatment in children and adolescents in Finland. SUMMARY OF BACKGROUND DATA: Epidemiological data on spinal injuries and their treatment in children is sparse. METHODS: All spinal and spinal cord injuries in children under 18 years of age treated in hospital between 1997 and 2006 in Finland were included. The data on injuries, hospitalizations, and surgical treatment were collected from the National Hospital Discharge Register which includes all in-patient treatment episodes. Fatal spinal injuries were derived from the Official Cause-of-Death Statistics of Finland. RESULTS: The overall incidence of spinal injuries remained stable during the follow-up period, averaging 66 per 10 of the reference population aged below 18 years. The proportions of cervical, thoracic, and lumbar spine injuries altered with age: 64% of spinal injuries in children below 8 years of age were cervical, while in the older children lumbar (42%) and thoracic spine injuries (33%) were more common than cervical. The incidence of spinal cord injuries averaged 1.9 per 10 children. Thirty percent of the children with spinal injury underwent surgery. The annual incidence of fatal spinal injury averaged 2.4 per 10 children. CONCLUSION: Pediatric spinal and spinal cord injuries are rare. In contrast to previous literature, the most commonly affected area is lumbar spine. One-third of the children with spinal injury underwent surgery.

Treatment of spinal deformities in patients with diastrophic dysplasia: a long-term, population based, retrospective outcome study.

STUDY DESIGN: A long-term, population based, retrospective follow-up study. OBJECTIVE: To evaluate long-term outcomes of brace and surgical treatment for spinal deformities in patients with diastrophic dysplasia (DD). SUMMARY OF BACKGROUND DATA: Literature on the brace treatment and surgery of spinal deformities in patients with DD is limited. METHODS: All patients with DD undergoing either brace treatment or surgery for spinal deformity with a minimum of 2 years follow-up were identified in our country. Eight patients had undergone brace treatment and 12 had been treated operatively. Two patients had early progressive and the rest idiopathic-like scoliosis. Five patients underwent posterior only, 1 anterior only, and 6 anteroposterior surgery. Patients' mean age at the beginning of brace treatment was 6.9 (range, 0.9-12.7) years and at the time of surgery 13.4 (range, 6.5-20.1) years. The follow-up time averaged 17 (range, 6.6-44.3) years for the brace and 14.0 (range, 2.1-37.2) years for the surgical treatment group. The radiographic follow-up rate was 100%. RESULTS: Both thoracic and lumbar curves progressed during brace treatment (mean major curve progression 12%, range, -43%-53%). Before surgery, the mean Cobb angle of the thoracic curve was 68 degrees (range, 42 degrees-100 degrees) and 46 degrees (25 degrees-68 degrees) in the lumbar spine. At final follow-up visit, the mean correction was 23% (-6%-76%) for the thoracic curve and 25% (-68%-82%) for the lumbar curve. The correction of the major curve was higher in patients undergoing anteroposterior versus posterior only (40% vs. 13%, P = 0.017). Five (42%) operated patients had significant complications. The SRS-24 yielded 92 (79-103) points for the brace treatment and 93 (73-114) points for the surgical group, respectively. CONCLUSION: Brace treatment does not prevent progression of the spinal deformity in patients with DD. Anteroposterior surgery is indicated in patients with severe spinal deformities. The risk for major complications is high especially in patients with marked kyphosis.