Development of a mapping function ("crosswalk") for the conversion of scores between the Oswestry Disability Index (ODI) and the Core Outcome Measures Index (COMI).

INTRODUCTION: The Oswestry Disability Index (ODI) and the Core Outcome Measures Index (COMI) are two commonly used self-rating outcome instruments in patients with lumbar spinal disorders. No formal crosswalk between them exists that would otherwise allow the scores of one to be interpreted in terms of the other. We aimed to create such a mapping function. METHODS: We performed a secondary analysis of ODI and COMI data previously collected from 3324 patients (57 ± 17y; 60.3% female) at baseline and 1y after surgical or conservative treatment. Correlations between scores and Cohen's kappa for agreement (κ) regarding achievement of the minimal clinically important change (MCIC) score on each instrument (ODI, 12.8 points; COMI, 2.2 points) were calculated, and regression models were built. The latter were tested for accuracy in an independent set of registry data from 634 patients (60 ± 15y; 56.8% female). RESULTS: All pairs of measures were significantly positively correlated (baseline, 0.73; 1y follow-up (FU), 0.84; change-scores, 0.73). MCIC for COMI was achieved in 53.9% patients and for ODI, in 52.4%, with 78% agreement on an individual basis (κ = 0.56). Standard errors for the regression slopes and intercepts were low, indicating excellent prediction at the group level, but root mean square residuals (reflecting individual error) were relatively high. ODI was predicted as COMI × 7.13-4.20 (at baseline), COMI × 6.34 + 2.67 (at FU) and COMI × 5.18 + 1.92 (for change-score); COMI was predicted as ODI × 0.075 + 3.64 (baseline), ODI × 0.113 + 0.96 (FU), and ODI × 0.102 + 1.10 (change-score). ICCs were 0.63-0.87 for derived versus actual scores. CONCLUSION: Predictions at the group level were very good and met standards justifying the pooling of data. However, we caution against using individual values for treatment decisions, e.g. attempting to monitor patients over time, first with one instrument and then with the other, due to the lower statistical precision at the individual level. The ability to convert scores via the developed mapping function should open up more centres/registries for collaboration and facilitate the combining of data in meta-analyses.

Shorter and sweeter: the 16-item version of the SRS questionnaire shows better structural validity than the 20-item version in young patients with spinal deformity.

PURPOSE: In patients with adult spinal deformity, it was previously shown that 16 of the non-management items of the SRS-instrument showed a better fit to the theoretical four-factor model (pain, function, self-image, mental health) than did all 20 items. Whether the same phenomenon is observed in data from younger (< 20y) patients, for whom the questionnaire was originally designed, is not currently known. METHODS: Confirmatory factor analysis was used to evaluate the factor structure of the 20 non-management items of the SRS-instrument completed by 3618 young patients with spinal deformity (75.5% female; mean age, 15.0 ± 2.0 years) and of its equivalence across language versions (2713 English-speaking, 270 Spanish, 264 German, 223 Italian, and 148 French). The root mean square error of approximation (RMSEA) and comparative fit index (CFI) indicated model fit. RESULTS: Compared with the 20-item version, the 16-item solution significantly increased the fit (p < 0.001) across all language versions, to achieve good model fit (CFI = 0.96, RMSEA = 0.06). For both 16-item and 20-item models, equivalence across languages was not reached, with some items showing weaker item-loading for some languages, in particular German and French. CONCLUSION: In patients with adolescent idiopathic scoliosis, the shorter 16-item version showed a better fit to the intended 4-factor structure of the SRS-instrument. The wording of some of the items, and/or their equivalence across language versions, may need to be addressed. Questionnaire completion can be a burden for patients; if a shorter, more structurally valid version is available, its use should be encouraged.

Impact of radiologic variables on item responses of ODI, SRS22 and SF-36. in adult spinal deformity patients: differential item functioning (DIF) analysis results from a multi-center database.

PURPOSE: To determine if responses given to each question of the Scoliosis Research Society-22 (SRS22), Oswestry disability index (ODI) and Short Form-36 (SF-36) questionnaires are influenced by the radiological parameters. METHODS: Patients enrolled in a multi-centre prospectively collected adult spinal deformity database who had complete SRS22, ODI and SF-36 data at baseline and at one-year follow-up were analysed. The presence of a differential item function of each question within each score in relation to radiological parameters was analysed using a mixed Rasch model with the radiological threshold value(s) determined. RESULTS: Of those patients analysed (n = 1745; 1406 female, average age 51.0 ± 19.8 years), 944 were surgically and 801 were non-surgically treated. For the SRS22, questions (Q) 3, 5 and 18 were sensitive to almost all radiological parameters and the overall score was found sensitive to the Cobb angle. For the ODI, Q3, 6, 9 and 10 were not sensitive to any radiologic parameters whereas Q4 and 5 were sensitive to most. In contrast, only 3 of the SF-36 items were sensitive to radiological parameters. CONCLUSIONS: 78% of the SRS-22, 60% of the ODI and 8% of the questions in the SF-36 are sensitive to radiological parameters. Sagittal imbalance is independently associated with a poor overall outcome, but affects mental status and function more than pain and self-image. The assembly of questions responsive to radiological parameters may be useful in establishing a connection between changes in radiologic parameters and HRQL.

The Impact of Corrective Surgery on Health-Related Quality of Life Subclasses in Adult Scoliosis: Will Degree of Correction Prognosticate Degree of Improvement?

PURPOSE: Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. METHODS: This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. RESULTS: A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. CONCLUSION: Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

What level of symptoms are patients with adult spinal deformity prepared to live with? A cross-sectional analysis of the 12-month follow-up data from 1043 patients.

INTRODUCTION: Previous studies suggest that a meaningful and easily understood measure of treatment outcome may be the proportion of patients who are in a "patient acceptable symptom state" (PASS). We sought to quantify the score equivalent to PASS for different outcome instruments, in patients with adult spinal deformity (ASD). METHODS: We analysed the following 12-month questionnaire data from the European Spine Study Group (ESSG): Oswestry Disability Index (ODI; 0-100); Numeric Rating Scales (NRS; 0-10) for back/leg pain; Scoliosis Research Society (SRS) questionnaire; and an item "if you had to spend the rest of your life with the symptoms you have now, how would you feel about it?" (5-point scale, dichotomised with top 2 responses "somewhat satisfied/very satisfied" being considered PASS+, everything else PASS-). Receiver operating characteristics (ROC) analyses indicated the cut-off scores equivalent to PASS+. RESULTS: Out of 1043 patients (599 operative, 444 non-operative; 51 ± 19 years; 84% women), 42% reported being PASS+ at 12 months' follow-up. The ROC areas under the curve were 0.71-0.84 (highest for SRS subscore), suggesting the questionnaire scores discriminated well between PASS+ and PASS-. The scores corresponding to PASS+ were > 3.5 for the SRS subscore (> 3.3-3.8 for SRS subdomains); ≤ 18 for ODI; and ≤ 3 for NRS pain. There were slight differences in cut-offs for subgroups of age, treatment type, aetiology, baseline symptoms, and sex. CONCLUSION: Most interventions for ASD improve patients' complaints but do not totally eliminate them. Reporting the percentage achieving a score equivalent to an "acceptable state" may represent a more stringent and discerning target for denoting treatment success in ASD. These slides can be retrieved under Electronic Supplementary Material.

Validation of a Simplified SRS-Schwab Classification Using a Sagittal Modifier.

STUDY DESIGN: Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE: To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. SUMMARY OF BACKGROUND DATA: The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence-lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. METHODS: Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability <.05 was considered significant. RESULTS: Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. CONCLUSIONS: Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. LEVEL OF EVIDENCE: Level II.

Factors associated with having an indication for surgery in adult spinal deformity: an international european multicentre study.

PURPOSE: The aim of this study was to evaluate factors that distinguish between patients with adult spinal deformity (ASD) with and without an indication for surgery, irrespective of their final treatment. METHODS: Baseline variables (demographics, medical history, outcome measures, coronal, sagittal and neurologic parameters) were evaluated in a multicentre, prospective cohort of patients with ASD. Multivariable analyses were carried out for idiopathic and degenerative patients separately with the dependent variable being "indication for surgery" and baseline parameters as independent variables. RESULTS: In total, 342 patients with degenerative ASD and 624 patients with idiopathic ASD were included in the multivariable models. In patients with degenerative ASD, the parameters associated with having an indication for surgery were greater self-rated disability on the Oswestry Disability Index [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.07] and a lower thoracic kyphosis (OR 0.97 95% CI 0.95-0.99), whereas in patients with idiopathic ASD, it was lower (worse) SRS self-image scores (OR 0.45 95% CI 0.32-0.64), a higher value for the major Cobb angle (OR 1.03 95% CI 1.01-1.05), lower age (OR 0.96 95% CI 0.95-0.98), prior decompression (OR 3.76 95% CI 1.00-14.08), prior infiltration (OR 2.23 95% CI 1.12-4.43), and the presence of rotatory subluxation (OR 1.98 95% CI 1.11-3.54) and sagittal subluxation (OR 4.38 95% CI 1.61-11.95). CONCLUSION: Specific sets of variables were found to be associated with an indication for surgery in patients with ASD. These should be investigated in relation to patient outcomes for their potential to guide the future development of decision aids in the treatment of ASD. These slides can be retrieved under Electronic Supplementary Material.

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.

Factor analysis of the SRS-22 outcome assessment instrument in patients with adult spinal deformity.

PURPOSE: Designed for patients with adolescent idiopathic scoliosis, the SRS-22 is now widely used as an outcome instrument in patients with adult spinal deformity (ASD). No studies have confirmed the four-factor structure (pain, function, self-image, mental health) of the SRS-22 in ASD and under different contexts. Factorial invariance of an instrument over time and in different languages is essential to allow for precise interpretations of treatment success and comparisons across studies. This study sought to evaluate the invariance of the SRS-22 structure across different languages and sub-groups of ASD patients. METHODS: Confirmatory factor analysis was performed on the 20 non-management items of the SRS-22 with data from 245 American English-, 428 Spanish-, 229 Turkish-, 95 French-, and 195 German-speaking patients. Item loading invariance was compared across languages, age groups, etiologies, treatment groups, and assessment times. A separate sample of SRS-22 data from 772 American surgical patients with ASD was used for cross-validation. RESULTS: The factor structure fitted significantly better to the proposed four-factor solution than to a unifactorial solution. However, items 14 (personal relationships), 15 (financial difficulties), and 17 (days off work) consistently showed weak item loading within their factors across all language versions and in both baseline and follow-up datasets. A trimmed SRS (16 non-management items) that used the four least problematic items in each of the four domains yielded better-fitting models across all languages, but equivalence was still not reached. With this shorter version there was equivalence of item loading with respect to treatment (surgery vs conservative), time of assessment (baseline vs 12 months follow-up), and etiology (degenerative vs idiopathic), but not age (< vs ≥50 years). All findings were confirmed in the cross-validation sample. CONCLUSION: We recommend removal of the worst-fitting items from each of the four domains of the SRS-instrument (items 3, 14, 15, 17), together with adaptation and standardization of other items across language versions, to provide an improved version of the instrument with just 16 non-management items.

Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning.

PURPOSE: Regarding the close interaction between the spinal alignment and the pelvis orientation, no parameter is routinely used to describe and to evaluate the global spinopelvic balance, taking into account simultaneously the spinal part and the pelvic part of the global alignment. We described the global tilt (GT) that could analyze malalignment considering the spine and the pelvis simultaneously. From a geometrical point of view, the global tilt is the sum of the pelvic tilt (PT) and the C7 vertical tilt (angular value of sagittal vertical axis). The aim of this study is to evaluate the global tilt with comparison to PT and sagittal vertical axis (SVA), with the hypothesis that GT would be the least sensitive to positional changes. METHODS: A cohort of 22 patients with sagittal malalignment was identified from a multicentric database of adult spinal deformities (ASD). Inclusion criteria were age >30 years, SVA > 40 mm and/or PT > 20°. All patients had full spine EOS radiographs in positions 1 and 2 (P1 and P2), in which the patient was asked to stand and put his hands on his shoulders without any effort (P1), or to make an effort to be as straight as possible (P2). PT, SVA and GT were measured in both positions and changes between P1 and P2 were calculated and compared using Student's t test with significance level at p < 0.05. RESULTS: No significant changes were observed for GT; SVA and PT were significantly influenced by patient positioning. SVA decreased and PT increased for all cases in P2 whereas the changes in GT were in either direction. The average increase in PT was 7.1° (±5.4) or 30.8 % (±24.9); decrease in SVA was 45.1 mm (±25.6) or 60.0 % (±44.2) while the change in GT was 4.4° (±3.3) or 12.6 % (±9.3). DISCUSSION: GT appears to be less affected by the patient's position compared to SVA and PT. This seems logical because GT contains both spinal alignment and pelvic compensation; it is not affected by their changes in opposing directions. CONCLUSION: GT appears to be the most reliable single sagittal plane parameter in ASD. It is the least affected by patient position and incorporates both the pelvic and the spinal alignment within one measure.

Implementación de un programa de alternativas a la transfusión sanguínea en cirugía de escoliosis en pediatría / Implementation of a patient blood management program in pediatric scoliosis surgery

Objetivos. Determinar si la puesta en marcha de un programa de ahorro de sangre y la adopción y asociación progresiva de diferentes métodos reducen las necesidades transfusionales en pacientes pediátricos intervenidos de escoliosis de múltiples etiologías. Material y método. Estudio cuasiexperimental, no aleatorizado y descriptivo, aprobado por el Comité de Ética para la Investigación de nuestra institución. Se incluyeron 50 pacientes pediátricos (ASA I-III) de edades comprendidas entre los 5 y los 18 años, intervenidos de cirugía de escoliosis de cualquier etiología mediante un único tiempo posterior o doble abordaje, anterior y posterior. Se compararon un grupo histórico (recogida retrospectiva de datos), sin alternativas a la transfusión (Grupo No ahorro = 15 pacientes), y otros 3 grupos prospectivamente: Grupo HNA (hemodilución normovolémica aguda) = 9 pacientes, Grupo HNA + Rec (recuperación intraoperatoria) = 14 pacientes, Grupo EPO (HNA + Rec + eritropoyetina ± donación preoperatoria) = 12 pacientes, conforme se implementaron las diferentes alternativas a la transfusión en nuestra institución. Resultados. La tasa de transfusión en los diferentes grupos (No ahorro, HNA, HNA + Rec, EPO) fue del 100, 66, 57 y 0% de los pacientes, con una media ± DE de 3,40 ± 1,59; 1,33 ± 1,41; 1,43 ± 1,50; 0 ± 0 unidades de CH transfundidas por paciente, respectivamente, con diferencias estadísticamente significativas (p < 0,001) tanto en la tasa de transfusión como en el número de unidades. Conclusiones. La aplicación de un programa multimodal de alternativas a la transfusión sanguínea en cirugía de escoliosis pediátrica, individualizado para cada paciente, puede evitar la transfusión en la práctica totalidad de los casos (AU)

Objectives. To determine whether the implementation of a blood conservation program, and the adoption and progressive association of different methods, reduces transfusion requirements in pediatric patients undergoing scoliosis surgery of different origins. Material and method. Quasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 pediatric patients (ASA I-III) aged 5 to 18 years, undergoing scoliosis surgery of any etiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro = 15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution) = 9 patients; Group HNA + Rec (intraoperative blood salvage) = 14 patients, and Group EPO (HNA + Rec + erythropoietin ± preoperative donation) = 12 patients; according with the implementation schedule of the transfusion alternatives in our institution. Results. The rate of transfusion in different groups (No ahorro, HNA, HNA + Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean ± SD of 3.40 ± 1.59; 1.33 ± 1.41; 1.43 ± 1.50; 0 ± 0 RBC units transfused per patient, respectively. Statistically significant differences (P < .001) were found in both the transfusion rate and number of RBC units. Conclusions. The application of a multimodal blood transfusion alternatives program, individualized for each pediatric patient undergoing scoliosis surgery can avoid transfusion in all cases (AU)

The Core Outcome Measures Index (COMI) is a responsive instrument for assessing the outcome of treatment for adult spinal deformity.

INTRODUCTION: The Core Outcome Measures Index for the back (COMI-back) is a very brief instrument for assessing the main outcomes of importance to patients with back problems (pain, function, symptom-specific well-being, quality of life, disability). However, it might be expected to be less responsive than a disease-specific instrument when evaluating specific pathologies. In patients with adult spinal deformity, we compared the performance of COMI-back with the widely accepted SRS-22 questionnaire. METHODS: At baseline and 12 months after non-operative (N = 121) and surgical (N = 83) treatment, patients (175 F, 29 M) completed the following: COMI-back, SRS-22, Oswestry Disability Index (ODI) and SF-36 PCS. At 12 months' follow-up, patients also indicated on a 15-point Global Rating of Change Scale (GRCS) how their back problem had changed relative to 1 year ago. Construct validity for the COMI-back was assessed by the correlation between its scores and those of the comparator instruments; responsiveness was assessed with receiver operating characteristics (ROC) analysis of COMI-back change scores versus the criterion 'treatment success' (dichotomized GRCS). RESULTS: Baseline values for the COMI-back showed significant (p < 0.0001) correlations with SRS-22 (r = -0.85), ODI (r = 0.83), and SF-36 PCS (r = -0.82) scores; significantly worse scores for all measures were recorded in the surgical group. The correlation between the change scores (baseline to 12 months) for COMI and SRS-22 was 0.74, and between each of these change scores and the external criterion of treatment success were: COMI-back, r = 0.58; SRS-22, r = -0.58 (each p < 0.0001). The ROC areas under the curve for the COMI-back and SRS-22 change scores were 0.79 and 0.82, respectively. CONCLUSION: Both baseline and change scores for the COMI-back correlated strongly with those of the SRS-22, and differed significantly in surgical and non-operative patients, suggesting good construct validity. With the "change in the back problem" serving as external criterion, COMI-back showed similar external responsiveness to SRS-22. The COMI-back was well able to detect important change. Coupled with its brevity, which minimizes patient burden, these favourable psychometric properties suggest the COMI-back is a suitable instrument for use in registries and can serve as a valid instrument in clinical studies emerging from such data pools.

Implementation of a patient blood management program in pediatric scoliosis surgery.

OBJECTIVES: To determine whether the implementation of a blood conservation program, and the adoption and progressive association of different methods, reduces transfusion requirements in pediatric patients undergoing scoliosis surgery of different origins. MATERIAL AND METHOD: Quasi-experimental, nonrandomized, descriptive study, approved by the Ethics Committee for Research of our institution. 50 pediatric patients (ASA I-III) aged 5 to 18 years, undergoing scoliosis surgery of any etiology by a single posterior or double approach (anterior and posterior) were included. A historical group with no alternatives to transfusion: Group No ahorro=15 patients (retrospective data collection) was compared with another 3 prospective study groups: Group HNA (acute normovolemic hemodilution)=9 patients; Group HNA+Rec (intraoperative blood salvage)=14 patients, and Group EPO (HNA+Rec+erythropoietin±preoperative donation)=12 patients; according with the implementation schedule of the transfusion alternatives in our institution. RESULTS: The rate of transfusion in different groups (No ahorro, HNA, HNA+Rec, EPO) was 100, 66, 57, and 0% of the patients, respectively, with a mean±SD of 3.40±1.59; 1.33±1.41; 1.43±1.50; 0±0 RBC units transfused per patient, respectively. Statistically significant differences (P<.001) were found in both the transfusion rate and number of RBC units. CONCLUSIONS: The application of a multimodal blood transfusion alternatives program, individualized for each pediatric patient undergoing scoliosis surgery can avoid transfusion in all cases.

Ponte osteotomies in thoracic deformities.

Thoracic hyperkyphosis is a sagittal deformity that can cause back pain and neurological impairment, leading to difficulties in maintaining a straight gaze. Sagittal thoracic malalignment has different etiologies and different corrective strategies. An adequate preoperative planning is mandatory to address correctly the surgical treatment, using an appropriate sagittal deformities classification and the rules that relate pelvic parameters to spine curvatures to determine the correction needed to restore a good sagittal alignment. Ponte osteotomies are performed in long non-angular hyperkyphotic thoracic deformities, even if idiopathic scoliosis, rigid deformities or proximal junctional kyphosis after instrumented fusions can benefit from the application of this technique that requires a mobile anterior column for the correction of the deformity. Ponte's is, together with Smith-Petersen osteotomy, a posterior column osteotomy. The magnitude of correction can reach 10° per level if intervertebral discs are still mobile.

La cérvico-esternotomía como abordaje de patología tumoral u ortopédica tóraco-cervical / Cervico-sternotomy for thoracic inlet conditions in children

Introducción. La cervicotomía y la toracotomía lateral no permiten un acceso adecuado a la columna cervical inferior ni al mediastino ostero-superior con control vascular y nervioso seguros. Comunicamos nuestra experiencia con cérvico-esternotomía para estos casos. Pacientes y métodos. Operamos por esta vía 6 pacientes entre1998 y 2011 para extirpación de tumores neurales (n=2), y realización de artrodesis cervical anterior en escoliosis congénita (n=2), neuropática(n=1) y osteolítica (n=1). La cérvico-esternotomía fue seguida de timectomía, separación de la vena innominada y disección de las yugulares, carótidas y vagos. Resultados. Las medidas tumorales eran 10,9 x 3,9 x 8,7 cm y 8 x6 x 5 cm, englobando la cadena simpática paravertebral desde el arco aórtico hasta la base del cráneo, y extendiéndose desde el hilio pulmonar izquierdo hasta la región tiroidea, respectivamente. En los pacientes con escoliosis cervical, fue posible por esta vía la fijación anterior entreC5 y D5. Las complicaciones fueron síndrome de Horner y linfedemabraquial transitorio. La mediana de tiempo operatorio fue 210 minutos(rango 180-240), la pérdida sanguínea estimada fue 2,7 cc/kg (0-13,8),y la estancia hospitalaria 7 días (5-18).Conclusión. La cérvico-esternotomía es un abordaje óptimo para esta región anatómica en niños. Permite una mejor exposición del mediastinopostero superior que la cervicotomía y la toracotomía, con un adecuado control de las estructuras vasculares y nerviosas, presentando un postoperatorio sorprendentemente confortable

Background/Aim. Neither cervicotomy nor postero-lateral thoracotomy allow safe surgical access to the lower cervical spine and highposterior mediastinum with full control of the vascular and neural structures involved. We report our favorable experience with cervicosternotomy for accessing this region. Patients and methods. Six patients were operated upon between1998 and 2011 for either removal of huge cervico-thoracic neural ganglioneuromas(n=2) or anterior arthrodes is for congenital (n=2), neuropathic(n=1) or osteolytic scoliosis (n=1). In all cases, cervicotomy was followed by sternotomy, thymectomy, division of the innominateve n and dissection of jugular veins, carotid arteries and vagus nerves. esults. The tumors measured 10.9 x 3.9 x 8.7 cm and 8 x 6 x 5 cm, and involved the paravertebral chain from the aortic arch to the base of the skull and from the left lung hilus to the thyroid region respectively. In the scoliosis patients, anterior vertebral fixation between C5 and T5 was readily feasible. Blood transfusion was avoided. Horner's syndrome and transient lymphedema were the only complications. Median operative time was 210 minutes (range 180-240 minutes) and median estimated blood loss was 2.7 cc/kg (0-13.8 cc/kg). Median hospital stay was 7days (range 5-18 days).Conclusions. Cervico-sternotomy is an optimal approach for this anatomical region in children. It offers better exposure of the anteriorcervico-thoracic spine and the thoracic inlet than cervicotomy orthoracotomy. Control of the nervous and vascular structures was safely achieved in all cases and postoperative discomfort was surprisingly limited

Escoliosis idiopáticas graves. ¿El abordaje y la instrumentación modifican los resultados? / Severe idiopathic scoliosis. Does the approach and the instruments used modify the results?

Objetivo: El objetivo de este trabajo es evaluar y comparar los resultados radiográficos y las complicaciones del tratamiento quirúrgico de escoliosis idiopáticas del adolescente mayores de 75◦ mediante doble abordaje (DA) o vía posterior aislada con instrumentación híbrida (PH) o «todo-tornillos» (PT). Material y método: Se realiza una revisión retrospectiva de 69 pacientes con escoliosis idiopática del adolescente mayor de 75◦ y seguimiento superior a los 2 años para analizar la flexibilidad de las curvas, la corrección obtenida y las complicaciones en función del tipo de cirugía. El análisis estadístico se realizó mediante el test de Kruskal-Wallis para variables no paramétricas. Resultados: No existen diferencias estadísticamente significativas entre los 3 grupos en los valores del ángulo de Cobb preoperatorio (DA = 89◦, PH = 83◦, PT = 83◦), en el postoperatorio inmediato (DA = 34◦, PH = 33◦, PT = 30◦) ni al final del seguimiento (DA = 36◦, PH = 36◦, PT = 33◦) (p > 0,05). El porcentaje de corrección (DA = 60%, PH = 57%, PT = 60%) fue similar entre grupos (p > 0,05). El porcentaje de complicaciones relacionadas con el procedimiento fue del 20,8% en DA, del 10% en PH y del 20% en PT. Dos pacientes en el grupo PT experimentaron cambios en la monitorización medular sin lesión neurológica y un paciente del mismo grupo experimentó una lesión incompleta diferida y temporal. Discusión y conclusiones: No se aprecian diferencias significativas en la corrección de las escoliosis idiopáticas graves entre los pacientes intervenidos mediante doble abordaje o por vía posterior aislada, independientemente del tipo de instrumentación utilizada (AU)

Objective: The aim of this work is to evaluate and compare the radiographic results and complications of the surgical treatment of adolescents with idiopathic scoliosis greater than 75 degrees, using a double approach (DA) or an isolated posterior approach with hybrid instruments (posterior hybrid [PH]), or with «all-pedicle screws» (posterior screws [PS]). Material and method: A retrospective review was performed on 69 patients with idiopathic scoliosis greater than 75◦, with a follow-up of more than 2 years, to analyze the flexibility of the curves, the correction obtained, and the complications depending on the type of surgery. The Kruskal-Wallis test for non-parametric variables was used for the statistical analysis. Results: There were no statistically significant differences between the 3 patient groups in the pre-surgical Cobb angle values (DA = 89◦, PH = 83◦, PS = 83◦), in the immediate post-surgical (DA = 34◦, PH = 33◦, PS = 30◦), nor at the end of follow-up (DA = 36◦, PH = 36◦, PS = 33◦) (P > .05). The percentage correction (DA = 60%, PH = 57%, PS = 60%) was similar between groups (P > .05). The percentage of complications associated with the procedure was 20.8% in DA, 10% in PH and 20% in PS. Two patients in the PS group showed changes, with no neurological lesions, in the spinal cord monitoring, and one patient in the same group suffered a delayed and transient incomplete lesion. Discussion and conclusions: No significant differences were observed in the correction of severe idiopathic scoliosis between patients operated using the double or isolated posterior approach, regardless of the type of instrumentation used (AU)

[Severe idiopathic scoliosis. Does the approach and the instruments used modify the results?]. / Escoliosis idiopáticas graves. ¿El abordaje y la instrumentación modifican los resultados?

OBJECTIVE: The aim of this work is to evaluate and compare the radiographic results and complications of the surgical treatment of adolescents with idiopathic scoliosis greater than 75 degrees, using a double approach (DA) or an isolated posterior approach with hybrid instruments (posterior hybrid [PH]), or with «all-pedicle screws¼ (posterior screws [PS]). MATERIAL AND METHOD: A retrospective review was performed on 69 patients with idiopathic scoliosis greater than 75°, with a follow-up of more than 2 years, to analyze the flexibility of the curves, the correction obtained, and the complications depending on the type of surgery. The Kruskal-Wallis test for non-parametric variables was used for the statistical analysis. RESULTS: There were no statistically significant differences between the 3 patient groups in the pre-surgical Cobb angle values (DA=89°, PH=83°, PS=83°), in the immediate post-surgical (DA=34°, PH=33°, PS=30°), nor at the end of follow-up (DA=36°, PH=36°, PS=33°) (P>.05). The percentage correction (DA=60%, PH=57%, PS=60%) was similar between groups (P>.05). The percentage of complications associated with the procedure was 20.8% in DA, 10% in PH and 20% in PS. Two patients in the PS group showed changes, with no neurological lesions, in the spinal cord monitoring, and one patient in the same group suffered a delayed and transient incomplete lesion. DISCUSSION AND CONCLUSIONS: No significant differences were observed in the correction of severe idiopathic scoliosis between patients operated using the double or isolated posterior approach, regardless of the type of instrumentation used.

[Cervico-sternotomy for thoracic inlet conditions in children]. / La cérvico-esternotomía como abordaje de patología tumoral u ortopédica tóraco-cervical.

BACKGROUND/AIM: Neither cervicotomy nor postero-lateral thoracotomy allow safe surgical access to the lower cervical spine and high posterior mediastinum with full control of the vascular and neural structures involved. We report our favorable experience with cervico-sternotomy for accessing this region. PATIENTS AND METHODS: Six patients were operated upon between 1998 and 2011 for either removal of huge cervico-thoracic neural ganglioneuromas (n = 2) or anterior arthrodesis for congenital (n = 2), neuropathic (n = 1) or osteolytic scoliosis (n = 1). In all cases, cervicotomy was followed by sternotomy, thymectomy, division of the innominate vein and dissection of jugular veins, carotid arteries and vagus nerves. RESULTS: The tumors measured 10.9 x 3.9 x 8.7 cm and 8 x 6 x 5 cm, and involved the paravertebral chain from the aortic arch to the base of the skull and from the left lung hilus to the thyroid region respectively. In the scoliosis patients, anterior vertebral fixation between C5 and T5 was readily feasible. Blood transfusion was avoided. Horner's syndrome and transient lymphedema were the only complications. Median operative time was 210 minutes (range 180-240 minutes) and median estimated blood loss was 2.7 cc/kg (0-13.8 cc/kg). Median hospital stay was 7 days (range 5-18 days). CONCLUSIONS: Cervico-sternotomy is an optimal approach for this anatomical region in children. It offers better exposure of the anterior cervico-thoracic spine and the thoracic inlet than cervicotomy or thoracotomy. Control of the nervous and vascular structures was safely achieved in all cases and postoperative discomfort was surprisingly limited.

Modulación del crecimiento de columnas escolióticas en animales de experimentación mediante el uso de barras de metal inteligente / Modulation of scoliotic spine growth in experimental animals using intelligent metal bars

Objetivo. Creación de un modelo experimental de escoliosis estructurada en ratas para evaluar la eficacia de los metales con memoria de forma para corregir gradualmente la deformidad a lo largo del tiempo. Material y método. Se generó una escoliosis experimental en ratas de 3 semanas mediante una sutura entre escápula y pelvis izquierdas durante 8 semanas, tras lo cual fueron aleatorizadas en 2 grupos: control, en los que se cortó la sutura, y nitinol, en los que además se implantó un alambre recto con memoria de forma anclado a la columna. Se realizaron radiografías seriadas para determinar la eficacia del nitinol en la corrección de la escoliosis. En un segundo tiempo, evaluamos los cambios histológicos a nivel del cuerpo vertebral apical y discos adyacentes pre y poscorrección. Resultados. Se indujo una cifoescoliosis progresiva media de 81,5°. En el grupo control, tras cortar la sutura, se produjo una reducción inicial de la deformidad pero luego permaneció estable a lo largo del tiempo (54° a las 2 semanas). En el grupo nitinol se observó una reducción progresiva del valor angular de la escoliosis, hasta 8,7° de media a las 2 semanas. El acuñamiento del cuerpo vertebral apical y de los discos adyacentes se corregía parcialmente tras 2 semanas de corrección de la deformidad. Conclusión. En este modelo de escoliosis, un alambre recto de nitinol anclado a la columna ha demostrado eficacia para la corrección gradual de la cifoescoliosis, y de los cambios estructurales asociados a la misma (AU)

Objective: To create an experimental structural scoliosis model in mice to evaluate the efficacy of shape-memory metals to gradually correct the deformity over time. Material and method: Experimental scoliosis was generated in 3 week-old mice by means of a suture between the left scapula and pelvis for 8 weeks. They were then randomised into two groups: a control group, in which the suture was cut, and another, in those that also had a Nitinol straight memory-wire implant fixed to the column. Serial X-rays were performed to determine the efficacy of the Nitinol in the correction of the scoliosis. In a second time, the histological changes at apical vertical body level and the adjacent discs were evaluated preand post-correction. Results: A mean 81.5◦ kyphoscoliosis was gradually induced. In the control group, after cutting the suture, an initial reduction in the deformity was observed, but later it remained stable throughout the time (54◦ at two weeks). In the Nitinol group, a gradual reduction was observed in the scoliosis angle value, to a mean of 8.7◦ at two weeks. The curvature of the apical vertebral body and adjacent discs were partially corrected after two weeks of correcting the deformity. Conclusion: This scoliosis model has demonstrated the efficacy of a straight Nitinol wire fixed to the spinal column in the gradual correction of kyphoscoliosis and in the changes in its adjacent structures (AU)