Surgical treatment of atlantoaxial dysplasia and scoliosis in spondyloepiphyseal dysplasia congenita: A case report.

BACKGROUND: Spondyloepiphyseal dysplasia congenita (SEDC) is a rare autosomal dominant hereditary disease caused by COL2A1 mutations. SEDC primarily involves the skeletal system, with typical clinical manifestations, including short stature, hip dysplasia, and spinal deformity. Due to the low incidence of SEDC, there are only a few case reports regarding the surgical treatment of SEDC complicated with spinal deformities. CASE SUMMARY: We report a case of a 16-year-old male patient with SEDC. He presented with typical short stature, atlantoaxial dysplasia, scoliosis, and hip dysplasia. Cervical magnetic resonance imaging showed spinal canal stenosis at the atlas level and cervical spinal cord compression with myelopathy. The scoliosis was a right thoracic curve with a Cobb angle of 65°. He underwent atlantoaxial reduction, decompression, and internal fixation from C1-C2 to relieve cervical myelopathy. Three months after cervical surgery, posterior correction surgery for scoliosis was performed from T3 to L4. Scoliosis was corrected from 66° to 8° and remained stable at 2-year follow-up. CONCLUSION: This is the first case report of a patient with SEDC who successfully underwent surgery for atlantoaxial dysplasia and scoliosis. The study provides an important reference for the surgical treatment of SEDC complicated with spinal deformities.

Magnetically Controlled Growing Rod for Early-Onset Scoliosis: Systematic Review and Meta-Analysis.

BACKGROUND: The goal of the current systematic review and meta-analysis was to explore the utilization of a magnetically controlled growing rod (MCGR) for the treatment of early-onset scoliosis based on eligible studies demonstrating efficacy. METHODS: Online electronic databases were searched to identify the eligible studies updated to April 2018 according to index words. Several studies in the literature that were relevant to the present analysis were also included. Mean difference or relative risk along with 95% confidence interval was used to analyze the main outcomes. RESULTS: Eleven studies were included in the meta-analysis with 186 patients in the MCGR group and 64 patients in the conventionally growing rod (CGR) group; 3 studies were case control studies, and 8 studies were self-control studies. The results indicated that MCGR had significantly decreased the Cobb angle and thoracic kyphosis and increased T1-T12 and T1-S1 distances. In addition, the incidence of complications after MCGR therapy was 0.37%. However, there was no significant difference in the change of Cobb angle and incidence of complications between the MCGR and CGR groups. CONCLUSIONS: We demonstrated that MCGR significantly reduced the Cobb angle and thoracic kyphosis while markedly increasing T1-T12 and T1-S1 distances. However, a close comparison of MCGR with CGR reveals more high-quality randomized control trials with a larger sample size and long-term follow-ups are necessary to gather more robust evidence on the efficacy of MCGR for early-onset scoliosis.

Expert consensus for PVCR in severe, rigid and angular spinal deformity treatment: The Kunming consensus.

In the past decades, an increasing number of surgeons started using posterior vertebral column resection (PVCR) to treat severe, rigid and angular spinal deformities. Little high-level evidence is available to guide surgical treatment. The aims of our study were to identify important surgical strategies and key technical points of Chinese experts who have extensive experience in the management of severe, rigid and angular spinal deformities using PVCR, and to standardize and unify the current core concepts. Workgroups of consensus were formed by selecting nationwide representing experts and comprehensive consultations. Eight task forces for major issues were established, then retrieval of literature, collection of expert opinions and writing of review articles were carried out. A modified Delphi process was chosen in round-table forum with three face-to-face meetings. Consensus was reached with items graded more than seven points including: indications and contraindications of PVCR; review PVCR in the evolution of spinal osteotomies; The corrective mechanism and safety of spinal cord; monitoring and responses of spinal cord crisis; characteristics and therapeutic outcome of pulmonary function; management of bleeding during PVCR; relationship of pedicle screw insertion and spinal cord safety; and analysis of non-neurologic complications and prevention strategies. In conclusion, The essential properties regarding PVCR procedure are tightly linked with various factors such as medical and surgical indication, range and level of vertebral column resection, strategies of correction, corrective efficiency and control of neurological risk. PVCR is used mainly for severe, rigid spinal deformity that is not manageable by other osteotomy techniques.

Five known tagging DLL3 SNPs are not associated with congenital scoliosis: A case-control association study in a Chinese Han population.

Genetic etiology hypothesis is widely accepted in the development of congenital scoliosis (CS). The delta-like 3 (DLL3) gene, a member of the Notch signaling pathway, was implicated to contribute to human CS. In this study, a case-control association study was conducted to determine the association of single nucleotide polymorphism (SNP) in the DLL3 gene with CS in a Chinese Han Population. Five known tagging SNPs of the DLL3 gene were genotyped among 270 Chinese Han subjects (128 nonsyndromic CS patients and 142 matched controls). CS patients were divided into 3 types: type I-failure of formation (29 cases), type II-failure of segmentation (50 cases), and type III-mixed defects (49 cases). The 5 SNPs were analyzed by the allelic and genotypic association analysis, genotype-phenotype association analysis, and haplotype analysis. Allele frequencies of 5 tagging SNPs (SNP1: rs1110627, SNP2: rs3212276, SNP3: rs2304223, SNP4: rs2304222, and SNP5: rs2304214) in CS cases and controls were comparable and there were no available inheritance models. The SNPs were not associated with clinical phenotypes. Moreover, the 5 makers in the DLL3 gene were found to be in strong linkage disequilibrium (LD). Both global haplotype and individual haplotype analyses showed that the haplotypes of SNP1/SNP2/SNP3/SNP4/SNP5 did not correlate with the disease (P >0.05). Together, these data suggest that genetic variants of the DLL3 gene are not associated with CS in the Chinese Han population.

The effect of growing Rod treatment on coronal balance during serial lengthening surgeries in early onset scoliosis.

BACKGROUND: Gaining and maintaining spinal balance after surgery is of great importance for early onset scoliosis (EOS). However, tendency of balance on the coronal plane after growing rod surgery has not been studied before. This study evaluated the effect of growing rod treatment on coronal balance (CB) during serial lengthening surgeries in EOS. METHODS: All EOS patients treated with growing rod technique in our hospital from August 2002 to June 2014 were retrospectively reviewed. Radiographic data before the sixth lengthening surgery were measured on the posteroanterior X-ray images, including global CB (C7 plumbline-central sacral vertical line, C7PL-CSVL), regional CB (apical vertebrae-CSVL), Cobb angle of the main curve and pelvic inlet width (PIW). Global CB index and regional CB index were calculated as dividing global CB and regional CB by PIW, respectively. The changes of these parameters during repeated lengthening surgeries were analyzed. RESULTS: Five hundred seventy Radiographs of 67 patients, including 134 images before and after growing rod insertion surgeries and 436 images pre- and post-lengthening surgeries were measured. Global CB and global CB index did not show significant differences between every two set points during lengthening procedures (P > 0.05). The percentage of patients with C7PL-CSVL distance more than 20 mm roughly ranged from 30 to 45 % during the lengthening process. With regards to regional CB and main curve Cobb angles, there were significant differences between every two adjacent set points during the first five lengthening surgeries (P < 0.05). CONCLUSIONS: Global CB did not significantly change during serial lengthening surgeries and C7PL-CSVL distances of greater than 20 mm comprised of over one third of patients during growing rod treatment. However, worsening regional CB and Cobb angles of the main curve during lengthening intervals were corrected by lengthening manipulation and maintained at a stable level.

Correlation between severity of adolescent idiopathic scoliosis and pulmonary artery systolic pressure: a study of 338 patients.

PURPOSE: Study of patients with adolescent idiopathic scoliosis. OBJECTIVE: To examine the correlation between pulmonary arterial pressure and coronal Cobb angle of idiopathic scoliosis. METHODS: A total of 338 patients (82.8 % female) with idiopathic scoliosis (average age 15.6 years; range 14-20 years) were included. Preoperatively, the coronal Cobb angle of curvature and the apex location and direction were determined from radiographic records. Tricuspid regurgitation velocity (TRV) and inferior vena cava diameter were also measured using Doppler echocardiography. Pulmonary arterial systolic pressure (sPAP) was calculated from the TRV according to the modified Bernoulli equation and correlations between sPAP and the features of scoliosis were identified by statistical analysis. RESULTS: Among the 338 patients, there were 305 thoracic curves, 276 (90.5 %) of which were right curves, and 265 thoracolumbar/lumbar curves. sPAP varied from 5.0 to 37.6 mmHg. Pulmonary hypertension could not be excluded in the case of one patient. A mild correlation (Spearman test, correlation coefficient = 0.187, P = 0.001) between sPAP and coronal Cobb angle of the main thoracic (MT) curves was identified. Correlations between sPAP and the degree of other curves were not significant. Patients with sPAP >20 mmHg also had larger thoracic curve angles (mean MT 42.16° vs. 52.45°; U test, P = 0.002). There were no differences in sPAP levels between patients with right and left thoracic curves. CONCLUSIONS: A mild positive correlation was identified between sPAP and the coronal Cobb angle of the MT curves. There was no relationship between sPAP and the direction of the curvature.

Identification of candidate diagnostic biomarkers for adolescent idiopathic scoliosis using UPLC/QTOF-MS analysis: a first report of lipid metabolism profiles.

Adolescent idiopathic scoliosis (AIS) is a complex spine deformity, affecting approximately 1-3% adolescents. Earlier diagnosis could increase the likelihood of successful conservative treatment and hence reduce the need for surgical intervention. We conducted a serum metabonomic study to explore the potential biomarkers of AIS for early diagnosis. Serum metabolic profiles were firstly explored between 30 AIS patients and 31 healthy controls by ultra high-performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry. Then, the candidate metabolites were validated in an independent cohort including 31 AIS patients and 44 controls. The results showed that metabolic profiles of AIS patients generally deviated from healthy controls in both the discovery set and replication set. Seven differential metabolites were identified as candidate diagnostic biomarkers, including PC(20:4), 2-hexenoylcarnitine, beta-D-glucopyranuronicacid, DG(38:9), MG(20:3), LysoPC(18:2) and LysoPC(16:0). These candidate metabolites indicated disrupted lipid metabolism in AIS, including glycerophospholipid, glycerolipid and fatty acid metabolism. Elevated expressions of adipose triglyceride lipase and hormone sensitive lipase in adipose tissue further corroborated our findings of increased lipid metabolism in AIS. Our findings suggest that differential metabolites discovered in AIS could be used as potential diagnostic biomarkers and that lipid metabolism plays a role in the pathogenesis of AIS.

Dual growing rod treatment in early onset scoliosis: the effect of repeated lengthening surgeries on thoracic growth and dimensions.

PURPOSE: To investigate changes in thoracic dimensions (TDs) following repeated lengthening surgeries after dual growing rod treatment of early onset scoliosis and thereby its effect on thoracic growth. METHODS: All EOS patients treated with dual growing rod technique in Peking Union Medical College Hospital from June 2004 to June 2014 were retrospectively reviewed. Thoracic spine height (T1-T12), total spine height (T1-S1), maximal coronal chest width and pelvic inlet width (PIW) were measured on the posteroanterior X-ray images after initial growing rod insertion surgery and after each lengthening surgery. Absolute TDs measurements were normalized by PIW. Changes of absolute and normalized TDs measurements with age and number of lengthening surgeries were analyzed. RESULTS: Radiographs of 229 surgeries of 53 EOS patients were measured, including 49 images after initial growing rod insertion surgery and 180 images of lengthening surgeries. Significant positive correlations between age and all three absolute TDs were found (P < 0.01) whereas significant negative correlations between age and all three normalized TDs (P < 0.01) were identified. Similarly, negative correlations were also identified between number of lengthening surgeries and the three normalized TDs (P < 0.01). Significant differences of normalized TDs were identified between initial surgery and the first lengthening through covariance analysis (P < 0.01). Yet, such differences were seldom seen between every two adjacent lengthening surgeries. CONCLUSIONS: Growing rod technique could maintain TDs growth through repeated lengthening procedures but the growth rate was compromised as the number of lengthening procedures increased.

[Analysis of clinical results and complications of growing rod technique for congenital scoliosis].

OBJECTIVE: To evaluate clinical outcomes of growing rod technique in treating young children with congenital scoliosis. METHODS: From August 2002 to October 2009, 34 patients with congenital scoliosis underwent growing rod procedures including 12 male and 22 female patients. Four patients underwent posterior correction surgeries with single growing rod (single growing rod group), 30 patients underwent posterior correction surgeries with dual growing rod(dual growing rod group). The average age at initial surgery was 6.9(2-13) years. Five patients with severe rigid deformity or kyphosis had an osteotomy at apex vertebra with short segmental fusion followed by dual growing rod technique. The analysis included age at initial surgery and final fusion (if applicable), number and frequency of lengthenings, and complications. Radiographic evaluation including scoliosis, trunk translation, length of T1-S1, thoracic kyphosis and lumbar lordosis was conducted. RESULTS: The follow-up was 40.5 (24-110) months. In single growing rod group, the mean scoliosis Cobb angle improved from 80.9°to 59.5°after initial surgery and was 65.3°at the latest follow-up. T1-S1 length increased from average 24.3 cm to 26.0 cm after initial surgery, and to 31.1 cm at latest follow-up with an increase of 1.05 cm per year. The space available for lung ratio(SAL) in patients with thoracic curves improved from 0.81 to 0.92 at the latest follow-up. Three patients reached final fusion. Four complications occurred in 3 of the 4 patients. In dual growing rod group, the mean scoliosis Cobb angle improved from 72° ± 22°to 35 ± 14° after initial surgery and was 35 ± 17°at the last follow-up or post-final fusion. T1-S1 length increased from (25 ± 5) cm to (29 ± 5)cm after initial surgery and to (33 ± 5)cm at latest follow-up with an average T1-S1 length increase of 1.49 cm per year. The SAL in patients with thoracic curves improved from 0.84 ± 0.08 to 0.96 ± 0.06 at the latest follow-up. Three patients reached final fusion. Complications occurred in 7 of the 30 patients, and they had a total of 13 complications. CONCLUSIONS: Growing rod technique is a safe and effective choice for young children of long, complex congenital scoliosis. It maintains correction achieved at initial surgery while allowing spinal growth to continue. Implants-related complications remain the biggest challenge.

[Analysis of ribs and intraspinal anomalies in congenital scoliosis].

OBJECTIVE: To investigate the incidences and characteristics of the ribs and intraspinal abnormalities in surgical patients with congenital scoliosis. METHODS: We conducted a retrospective study of the medical records and spine radiographs of 118 patients underwent surgical treatment between January 2010 and March 2011 with congenital scoliosis. The average age was 14 years (3-50 years).Fifty-two were male and 66 were female patients. The rib and intraspinal abnormalities were compared in different vertebral anomalies. Pearson's χ(2) test were used to analyze the incidence of anomalies of the ribs and vertebrae, as well as intraspinal anomalies. RESULTS: A total of 57 (48.3%) patients were found to have intraspinal abnormalities.Split cord deformities were identified to be the most common intraspinal anomaly (32.2%), followed by syringomyelia (21.2%).Sixty-nine patients (58.5%) had rib anomalies, which occurring on the concavity of the scoliosis was most frequent. The patients with mixed deformity and failure of segment were found to have a higher incidence of rib anomaly than those with failure formation (χ(2) = 14.05, P < 0.01). The patients with multiple level malformations were found to have significantly higher incidence of rib anomaly than those with single level malformation (χ(2) = 27.50, P < 0.01).Intraspinal anomalies occurred in 42 of 69 patients (60.9%) with rib anomalies and 15 of 49 patients (30.6%) without rib anomalies in congenital scoliosis. The occurrence of intraspinal malformation has significant difference with or without rib anomalies in congenital scoliosis (χ(2) = 10.5, P < 0.01). CONCLUSIONS: The intraspinal malformation is common in patients with mixed defects and failures of segmentation. The rib anomalies occurring on the concavity of the scoliosis is most frequent. The incidence of intraspinal anomaly is significant higher in the patients with rib anomalies than those without rib anomalies. Both the occurrence and type of rib anomaly, combined with vertebral deformity are helpful in forecasting the occurrence of intraspinal abnormalis.

Whole-spine magnetic resonance imaging study in healthy Chinese adolescents.

OBJECTIVE: To establish a preliminary magnetic resonance imaging (MRI) database of whole spine of healthy Chinese adolescents. METHODS: MRI examination of whole spine and hindbrain was performed in 41 enrolled students aged 11-17 years (mean age 13.95; 18 males, 23 females) using a 1.5-T MR Scanner. Measurements of the ratio of anteroposterior (AP) and transverse (TS) diameters of the cord, cerebellar tonsillar level related to the basion-opsithion (BO) line, location of conus medullaris, total cord length, total vertebral length, cord/vertebral length ratio, thoracic cord area, thoracic vertebral area, thoracic cord/vertebral area ratio were obtained. RESULTS: Mean values of cervical AP and TS were 6.63 mm and 12.21 mm, respectively. The mean level of cerebellar tonsillar related to BO line was 3.97 mm. Mean level of conus medullaris located in L1 lower 1/3. Total cord length was 399.34 mm, total vertebral length was 529.49 mm, Cord/vertebral length ratio was 0.75 and thoracic cord/vertebral area ratio was 0.17 on average. Vertebral length was correlated with age (r = 0.352, P = 0.024) whereas cord length and their ratio were not (P > 0.05). Compared with female, male had significantly larger cervical AP and TS, longer cervical cord (P < 0.01), higher position of conus medullaris (P < 0.05). CONCLUSION: MRI is a useful tool for assessment of the whole spine. The longitudinal and cross-sectional morphology of spinal cord in healthy Chinese adolescents may benefit further study of spine cord in adolescent idiopathic scoliosis as well as in other spine diseases.

[Features of pelvic parameters in adolescent idiopathic scoliosis and their relationships with spinal sagittal parameters].

OBJECTIVE: To explore the features of pelvic parameters in patients with adolescent idiopathic scoliosis (AIS) and the relationships with spinal sagittal parameters and evaluate their roles in sagittal balance. METHODS: A total of 112 AIS patients from March 2007 to February 2011 were recruited. Six parameters were evaluated from lateral standing radiographs:pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK) and sagittal vertical axis (SVA). Pearson's correlation was used to determine the relationship between the above parameters and t-test applied to compare the differences between the subgroups: (1) by the major curve types in coronal plane (primary thoracic curve vs. primary lumbar curve); (2) by the value of SVA (positive vs. negative). RESULTS: The values of PI and SS in our cohort were 47.2° and 39.4° and they were lower than those in Caucasians as previously reported. PI was correlated with SS, PT and LL (r = 0.562, 0.773 and 0.278 respectively); TK not correlated with pelvic parameters (PI, PT and SS). SVA correlated with both spinal (TK, LL) and pelvic parameters (PI, PT). In the subgroup analyses, the values of PI and SS were significantly higher in the primary thoracic curve subgroup than those in the primary lumbar curve subgroup (49.4° vs 45.1°, 41.0° vs 38.0°). The values of PI and PT were distinctively higher in the positive SVA subgroup than those in the negative SVA subgroup (54.6° vs 45.6°, 14.3° vs 6.2°). CONCLUSION: Ethnic differences exist in the main pelvic parameters and their values are lower in Chinese than in Caucasians. There are also differences among different types of AIS. The values of main pelvic parameters are higher in AIS patients with a primary thoracic curve than in those with a primary lumbar curve. Pelvic parameters play an important role in maintaining a sagittal balance. The main pelvic parameters have influences on sagittal lumbar configuration but little on thoracic segment. A high PI value leads to a forward lean in torso with an increased PT as a result of compensation and vice versa. The alteration of PT is a major compensatory pattern of pelvis. The features of pelvic parameters should be considered during surgical planning.

[The efficacy of one-stage posterior correction surgery for scoliotic patients with little symptomatic syringomyelia].

OBJECTIVE: To investigate the safety and effectiveness of one-stage posterior correction of scoliosis associated with little symptomatic syringomyelia. METHODS: A total of 19 cases diagnosed as scoliosis with little symptomatic syringomyelia between January 2003 and November 2010 were included in this study (study group), the patients underwent one-stage posterior correction and instrumentation without neurosurgery for the syringomyelia. At the same time, 9 cases with severe symptomatic syringomyelia were included as the control group, the patients underwent neurosurgery before scoliosis correction, including suboccipital decompression and syrinx shunting. All patients underwent posterior pedicle screw or screw-hook hybrid instrumentation. The preoperative, postoperative and the last follow-up of the Cobb angle of the coronal main curve and thoracic kyphosis were measured. Also, the preoperative and postoperative of the apical vertebra translation, apical vertebra rotation and trunk shift were measured by the same person. The perioperative and the last follow-up complications of neurological injury were recorded. The surgical outcome and postoperative complications between the 2 groups were compared with the t student and chi-square statistics methods. RESULTS: There were no significant differences in gender, age, the location, length and diameter of the syringomyelia of the 2 groups (P > 0.05). The follow-up period ranged from 6 to 45 months, with a mean of 28.6 months. The average preoperative Cobb angles of coronal main curves of the 2 groups were 71° ± 23° and 68° ± 19°, the postoperative Cobb angles were 27° ± 20° and 25° ± 16°, and the last follow-up Cobb angles were 29° ± 17° and 32° ± 20°. The coronal correction rate was 66% ± 19% in the study group and 65% ± 21% in the control group (t = 0.136, P = 0.893). There was no significant difference at the last follow-up(t = 0.210, P = 0.837). The average preoperative Cobb angles of thoracic kyphosis of the 2 groups were 35° ± 18° and 32° ± 19°, the postoperative Cobb angles were 25° ± 10° and 23° ± 9°, and the last follow-up Cobb angles were 24° ± 4° and 28° ± 8°. The mean sagittal correction rate of the 2 groups were 50% ± 58% and 57% ± 53% (t = -0.303, P = 0.764). There was also no significant difference at the last follow-up time (t = 0.769, P = 0.490). There were no significant difference, in terms of the postoperative of the apical vertebra translation, apical vertebra rotation and trunk shift between the 2 groups (P > 0.05). One case in the study group complicated with a pedicle screw breaking the anterior cortex of the vertebra and one in the control group complicated with a hook loosening, postoperatively. At the last follow-up time, the neurological symptoms of the 2 groups got no aggravating. CONCLUSION: One-stage posterior correction of scoliosis associated with little symptomatic syringomyelia may be effective and safe.

Comparison of initial efficacy between single and dual growing rods in treatment of early onset scoliosis.

BACKGROUND: Initial results for the use of single and dual growing rod techniques in the treatment of early onset scoliosis (EOS) has been seldom documented. The aim of this research was to investigate the initial efficacy of single and dual growing rods in treatment of EOS. METHODS: A retrospective study of 25 early onset scoliosis cases treated with growing rod technique between November 2002 and May 2010 was performed, including six cases in the single growing rod group and 19 cases in the dual growing rod group. Operation time, intra-operative bleeding, correction rate, changes in C7-S1 distance, and incidence of complications of the first operation were compared for the two techniques. RESULTS: The average post-operative follow-up duration was 31.9 months. There was no statistical difference observed between operation time, intra-operative bleeding, and complication incidence between the single and dual growing rod groups. In addition, no statistical difference was observed in the pre-operative coronal Cobb's angle (P > 0.05), or in the pre-operative sagittal Cobb's angle between both groups (P > 0.05). The correction rate of the dual growing rod group was significantly superior to that of the single growing rod group in the coronal plane (P < 0.01), but not in the sagittal plane (P > 0.05). The C7-S1 distance in the dual growing rod group was significantly larger than that in the single growing rod group (P < 0.05). CONCLUSIONS: The growing rod technique is an effective option for surgical treatment of EOS. The dual growing rod technique shows relative superiority in the correction outcome as compared to the single growing rod technique.

[The surgery treatment of scoliosis associated with tethered cord].

OBJECTIVE: To evaluate the safety and effectiveness of correction of scoliosis associated with tethered cord without releasing it. METHODS: Twenty-two cases diagnosed as scoliosis with tethered cord between December 2005 and January 2011 were investigated retrospectively in the study. There were 8 males and 14 females. The age was from 6 to 51 years, averaged 17.7 years. There were 7 patients with clinical symptoms before surgery. All the patients underwent posterior deformity correction and instrumentation by pedicle screws directly without releasing the tethered cord. Spinal cord monitoring was conducted in all the cases. The preoperative and postoperative Cobb angle of the coronal main curve and thoracic kyphosis were measured. Also, the preoperative and postoperative values of the apical vertebra translation, apical vertebra rotation and trunk shift were measured by the same person. The incidence of perioperative complications were recorded. RESULTS: A total of 20 patients were followed up. The follow-up time was from 6 to 52 months, mean 23.5 months. The average Cobb angle of the coronal main curve were 68° ± 20° before surgery and 38° ± 21° after surgery with a mean correction of 48.1%. The difference was significant (t = 13.9, P < 0.05). The mean kyphosis was 65° ± 18° preoperatively and 28° ± 11° postoperatively, with a correction of 56.7%. The difference was also significant (t = 8.81, P < 0.05). The preoperative values of the apical vertebra translation, apical vertebra rotation and trunk shift were (5.4 ± 2.5) cm, 2.3° ± 0.6° and (2.0 ± 1.8) cm, respectively, which were corrected to (3.2 ± 1.8) cm, 1.2° ± 0.5° and (1.5 ± 1.1) cm after the surgery. Compared to the preoperative values, the difference were significant in the apical vertebra translation (t = 5.69, P < 0.05) and apical vertebra rotation (t = 10.07, P < 0.05). However, there was no difference in trunk shift. Postoperative complications occurred in 3 patients, including transient numbness of the lower extremity in 1 patient and hydrothorax in 2 patients. No neurological and instrumentation complications occurred during the follow-ups. Patients with clinical symptoms before surgery got no serious during the surgery and follow-ups. CONCLUSIONS: If there are no symptoms of tethering in scoliosis patients with tethered cord, the corrective surgeries may be safe and effective when spinal cord monitoring conducted without spinal cord untethering. But more cases are needed to confirm it.

[Surgical treatment of scoliosis associated with syringomyelia].

OBJECTIVE: To explore the clinical manifestations and surgical strategies of scoliosis associated with syringomyelia. METHODS: A total of 50 cases diagnosed as scoliosis with syringomyelia between January 2003 and November 2010 were recruited. They were divided into 2 groups: Group A, neurosurgery before scoliosis correction, including suboccipital decompression and syrinx shunting; Group B, one-staged posterior correction and instrumentation without previous neurosurgery. The preoperative, postoperative and last follow-ups of Cobb angle of coronal main curve and thoracic kyphosis were measured. Also the preoperative and postoperative apical vertebra translation, apical vertebra rotation and trunk shift were measured by the same person. The surgical efficacies and complications of correction were compared between 2 groups. RESULTS: All patients underwent posterior pedicle screw instrumentation and had a mean follow-up period of 32.1 months. Among them, 42 patients had clinical symptoms or signs preoperatively and 3 patients improved postoperatively. The mean correction of coronal curve was 65.7% and a mean loss of correction 6.4% during the follow-up. The mean correction of apical vertebra translation and apical vertebra rotation were 63.0% and 60.0% respectively. However, the trunk shift increased 0.4 cm. There were no statistically significant differences for the correction efficacies and complications between 2 groups (P > 0.05). CONCLUSION: Scoliosis associated with syringomyelia may be effectively managed if a surgeon manipulates carefully intraoperatively and perioperative spinal monitoring is practiced. Furthermore syrinx will not increase the incidence of postoperative complications without prophylactic neurosurgery.

Roles of preoperative arterial blood gas tests in the surgical treatment of scoliosis with moderate or severe pulmonary dysfunction.

BACKGROUND: It has been stated that preoperative pulmonary function tests are essential to assess the surgical risk in patients with scoliosis. Arterial blood gas tests have also been used to evaluate pulmonary function before scoliotic surgery. However, few studies have been reported. The aim of this study was to investigate the roles of preoperative arterial blood gas tests in the surgical treatment of scoliosis with moderate or severe pulmonary dysfunction. METHODS: This study involved scoliotic patients with moderate or severe pulmonary dysfunction (forced vital capacity < 60%) who underwent surgical treatment between January 2002 and April 2010. A total of 73 scoliotic patients (23 males and 50 females) with moderate or severe pulmonary dysfunction were included. The average age of the patients was 16.53 years (ranged 10 - 44). The demographic distribution, medical records, and radiographs of all patients were collected. All patients received arterial blood gas tests and pulmonary function tests before surgery. The arterial blood gas tests included five parameters: partial pressure of arterial oxygen, partial pressure of arterial carbon dioxide, alveolar-arterial oxygen tension gradient, pH, and standard bases excess. The pulmonary function tests included three parameters: forced expiratory volume in 1 second ratio, forced vital capacity ratio, and peak expiratory flow ratio. All five parameters of the arterial blood gas tests were compared between the two groups with or without postoperative pulmonary complications by variance analysis. Similarly, all three parameters of the pulmonary function tests were compared. RESULTS: The average coronal Cobb angle before surgery was 97.42° (range, 50° - 180°). A total of 15 (20.5%) patients had postoperative pulmonary complications, including hypoxemia in 5 cases (33.3%), increased requirement for postoperative ventilatory support in 4 (26.7%), pneumonia in 2 (13.3%), atelectasis in 2 (13.3%), pneumothorax in 1 (6.7%), and hydrothorax in 1 (6.7%). No significant differences in demographic characteristics or perioperative factors (P > 0.05) existed between the two groups with or without postoperative pulmonary complications. According to the variance analysis, there were no statistically significant differences in any parameter of the arterial blood gas tests between the two groups. CONCLUSIONS: No significant correlation between the results of the preoperative arterial blood gas tests and postoperative pulmonary complications existed in scoliotic patients with moderate or severe pulmonary dysfunction. However, the postoperative complications tended to increase with the decrease of partial pressure of arterial oxygen in the arterial blood gas tests.

Evaluation of vertical traction radiography for predicting the outcome of moderate to severe rigid scoliosis correction.

OBJECTIVE: To determine the efficacy of imaging patients in a state of traction ("traction imaging") for selection of upper and lower vertebrae to undergo instrumentation (UIV and LIV, respectively) to correct moderate to severe, rigid scoliosis. METHODS: Twenty-seven patients aged 11-21 years (average, 15.5 years) who had been treated at our institution for scoliosis of the thoracic spine between 2004 and 2008 were retrospectively analyzed. All patients were treated with the third multiple hook-screw and rod instrumentation system. Standardized radiographic measurements (anteroposterior, sagittal, bending, fulcrum, traction) were taken and Cobb's angles, apical vertebra translation (AVT), and traction-stable vertebrae determined. RESULTS: All patients were followed for 6-36 months (average, 14.7 months). The Cobb's angles under preoperative vertical traction correlated positively with those measured postoperatively in standing anteroposterior film (P < 0.01). Preoperative AVT under vertical traction was significantly different from that measured postoperatively in standing anteroposterior film (P < 0.01). The traction radiography-determined UIV slant angles were significantly different from those preoperatively without traction and the postoperative values, whereas traction radiography-determined LIV values were not significantly different from those found preoperatively without traction (P > 0.05). CONCLUSIONS: Traction radiographic imaging is an effective, feasible preoperative assessment for determining which vertebrae are stable, designing the surgical strategy and choosing the UIV and LIV for correcting moderate to severe, rigid scoliosis.