Lowest Instrumented Vertebrae Selection for Posterior Fusion of Lenke 5C Adolescent Idiopathic Scoliosis: Can We Stop the Fusion One Level Proximal to Lower-end Vertebra?

BACKGROUND: The most appropriate fusion levels remains challenging, especially in Lenke type 5 curves. In Lenke 5 adolescent idiopathic scoliosis (AIS) generally fusion includes the lower end vertebra (LEV). This study determines whether it is appropriate to fuse mild to moderate Lenke 5 curves to LEV-1, if possible. MATERIALS AND METHODS: Forty-two patients with mild to moderate Lenke 5 AIS that underwent posterior fusion were retrospectively evaluated. The preoperative goal was to stop the instrumentation at LEV-1 in all patients if possible. However, the final decision was made intraoperatively according to the alignment of the disc below lowest instrumented vertebra (LIV). In 19 patients, this goal was achieved and LIV was LEV-1, whereas 23 patients were fused to LEV. Hence, two groups occurred and they were compared in terms of coronal, sagittal, and LIV related parameters at 1 year and 3 years postoperatively. Surgical times were also noted. Clinical outcomes were assessed using scoliosis research society (SRS-22) and Short Form-36 questionnaires. RESULTS: Two groups were well matched according to preoperative values. Postoperative radiographic results were also similar, except LIV disc angle and LIV translation, which were significantly higher in LEV-1 group at 1 and 3 years followup (P < 0.05). Surgical times were significantly longer in LEV group (P = 0.036). No significant correction loss was observed between 1 and 3 years followup. There were no significant differences regarding postoperative clinical outcomes except the activity domain of SRS-22, which was significantly higher in LEV-1 group, but the significance was weak (P = 0.045). CONCLUSIONS: Fusion to LEV-1was associated with the higher amount of LIV disc angle and LIV translation, which did not cause coronal and sagittal imbalance and decreased the quality of life scores. Hence, if intraoperatively a level disc below LIV can be achieved, fusion to LEV-1 may be an option in mild to moderate Lenke 5 curves, to save one more mobile segment.

How accurate is visual estimation of perioperative blood loss in adolescent idiopathic scoliosis surgery?

OBJECTIVE: The aim of this study was to assess whether the visual estimation method for perioperative blood loss is accurate in adolescent idiopathic scoliosis surgery. METHODS: Sixty-five consecutive patients, who were operated on from 2012 to 2015 and had a diagnosis of AIS, were included into the study. Gender, age, preoperative weight and height, preoperative major curve magnitude and T5‒T12 kyphosis angles, the fusion level, and the time of surgery were recorded. Perioperative blood loss was estimated by the same anesthesiologist for all patients. Then, an experienced surgeon estimated the perioperative blood loss by a gravimetric method, and the results were compared. RESULTS: Seventeen (26.2%) of the patients were male and 48 (73.8%) were female. The mean age was 15.8 ± 1.9. The mean height of the patients was 162.1 ± 8.9 cm and the mean weight was 52.6 ± 8.9 kg. The mean preoperative major curve magnitude and kyphosis angles were 49.5 ± 9.2 and 47.1 ± 12.7 respectively. The mean estimate of the surgeon was 1009 ± 404.5 ml and the mean estimate of the anesthesiologist was 434 ± 217.6 ml and the difference was statistically significant (p < 0.05). Moreover, if blood loss was high during the operation, the difference between the estimates of the surgeon and anesthesiologist was also higher. CONCLUSIONS: Even in operations where most of the blood goes into a suction canister, such as for AIS, a visual estimation method is not accurate. A short training regarding optimizing the amount of blood contained in sponges that are not fully soaked may be sufficient to improve this method.

Three-Dimensional Correction in Patients With Lenke 1 Adolescent Idiopathic Scoliosis: Comparison of Consecutive Versus Interval Pedicle Screw Instrumentation.

STUDY DESIGN: A retrospective-matched cohort study. OBJECTIVE: To assess the correction of the adolescent idiopathic scoliosis (AIS) deformity in three dimensions, comparing consecutive and interval pedicle screw (PS) instrumentation techniques. SUMMARY OF BACKGROUND DATA: The number of the sites that should be implanted with pedicle screws in AIS surgery is controversial. Coronal and sagittal planes have been investigated thoroughly but there are very little data about transverse plane correction according to PS density. METHODS: A total of 76 AIS patients who underwent posterior fusion with PS instrumentation were recruited in this study. Patients were divided into two groups according to PS density with 38 patients in each group. In group 1, consecutive PS instrumentation was used (CPS group), and in group 2 interval pedicle screw instrumentation (IPS group). Two groups were matched according to similar patient age, fusion levels, curve magnitude and flexibility, identical Lenke curve type, and identical operative methods. Patients were compared at 1-year follow-up according to radiographic changes in coronal, sagittal, and transverse planes. Clinical outcomes were assessed using Scoliosis Research Society-22 and spinal appearance questionnaires. RESULTS: The two cohorts were well matched. At 1-year follow-up, major coronal Cobb angle changes were 45.4° in CPS group and 38.9° in IPS group (P = 0.049). T5-T12 sagittal Cobb angle changes were 5.1° and 5.9° in CPS and IPS groups, respectively (P = 0.897). Apical vertebral rotation changes were measured as 12.0° in CPS group and as 3.6° in IPS group, which demonstrated a significant difference (P = 0.001). Scoliosis Research Society-22 scores were similar in both groups, whereas spinal appearance questionnaire appearance domain was significantly better in CPS group at 1-year follow-up (P = 0.035). CONCLUSION: CPS provides better deformity correction in AIS surgery in all three planes, compared with IPS. Improved deformity correction results in better appearance outcomes. LEVEL OF EVIDENCE: 3.

Selection of distal fusion level in posterior instrumentation and fusion of Scheuermann kyphosis: is fusion to sagittal stable vertebra necessary?

PURPOSE: Distal junctional kyphosis (DJK) is a major instrumentation-related complication after the surgical correction of Scheuermann kyphosis (SK). The exact criteria to avoid DJK have been controversial. It has been recommended to include the SSV into the fusion by some authors, while others suggest that fusion to FLV is sufficient. The purpose of this study was to investigate the occurrence of DJK in relation to distal fusion level selection in SK surgery by investigating the relationship between the sagittal stable vertebra (SSV), first lordotic vertebra (FLV), and the lowest instrumented vertebra (LIV). METHODS: 54 patients (mean age: 21.2 years, range 12-43; male/female: 20/34) with SK who were treated by posterior segmental instrumentation and fusion were prospectively evaluated. Patients were allocated into 3 groups according to distal fusion level. In group 1, SSV was chosen as LIV (n = 20), and in group 2, LIV was the FLV (n = 16). Third group consisted of 18 patients in whom SSV and FLV was the same vertebra. Distal junctional angle, sagittal plane analysis, and clinical outcomes according to SF-36 were evaluated. RESULTS: Mean preoperative kyphosis angles were 77.2°, 73.4°, and 76.7° in groups 1, 2, and 3, respectively (p = 0.281), which decreased to 38.1°, 37.3°, and 37.8° postoperatively at final follow-up (p = 0.988). Mean follow-up time was 28.3 months. Correction amounts were similar between the groups (p = 0.409). 3 patients in SSV group, 5 patients in FLV group, and 3 patients in SSV-FLV group developed DJK, which was statistically insignificant. The C7 sagittal plumbline, lumbar lordosis, and pelvic parameters were not significantly different before or after surgery between the groups. Preoperative and postoperative results of SF-36 questionnaire were similar in all the groups. None of the patients who had DJK required revision surgery during the follow-up time. CONCLUSION: Proper selection of distal fusion level is important in order to prevent DJK after SK surgery. According to this study, it is not necessary to extend the fusion down to the SSV. Fusion to FLV is sufficient and saves a level.

Upper extremity acute compartment syndrome during tissue plasminogen activator therapy for pulmonary embolism in a morbidly obese patient.

INTRODUCTION: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are more frequently observed in morbidly obese patients. Tissue plasminogen activator (tPA) is a thrombolytic agent which dissolves the thrombus more rapidly than conventional heparin therapy and reduces the mortality and morbidity rates associated with PE. Compartment syndrome is a well-known and documented complication of thrombolytic treatment. In awake, oriented and cooperative patients, the diagnosis of compartment syndrome is made based on clinical findings including swelling, tautness, irrational and continuous pain, altered sensation, and severe pain due to passive stretching. These clinical findings may not be able to be adequately assessed in unconscious patients. PRESENTATION OF CASE: In this case report, we present compartment syndrome observed, for which fasciotomy was performed on the upper right extremity of a 46-year old morbidly obese, conscious female patient who was receiving tPA due to a massive pulmonary embolism. DISCUSSION: Compartment syndrome had occurred due to the damage caused by the repeated unsuccessful catheterisation attempts to the brachial artery and the accompanying tPA treatment. Thus, the bleeding that occurred in the volar compartment of the forearm and the anterior compartment of the arm led to acute compartment syndrome (ACS). After relaxation was brought about in the volar compartment of the forearm and the anterior compartment of the arm, the circulation in the limb was restored. CONCLUSION: As soon as the diagnosis of compartment syndrome is made, an emergency fasciotomy should be performed. Close follow-up is required to avoid wound healing problems after the fasciotomy.

Bilateral posterior shoulder dislocation after electrical shock: A case report.

INTRODUCTION: Posterior dislocation of the shoulder is a rare and commonly missed injury. Unilateral dislocations occur mostly due to trauma. Bilateral posterior shoulder dislocations are even more rare and result mainly from epileptic seizures. Electrical injury is a rare cause of posterior shoulder dislocation. Injury mechanism in electrical injury is similar to epileptic seizures, where the shoulder is forced to internal rotation, flexion and adduction. PRESENTATION OF CASE: This report presents a case of bilateral posterior shoulder dislocation after electrical shock. We were able to find a few individual case reports describing this condition. The case was acute and humeral head impression defects were minor. Our treatment in this case consisted of closed reduction under general anesthesia and applying of orthoses which kept the shoulders in abduction and external rotation. A rehabilitation program was begun after 3 weeks of immobilization. After 6 months of injury the patient has returned to work. 20 months postoperatively, at final follow-up, he was painless and capable of performing all of his daily activities. DISCUSSION: The amount of bilateral shoulder dislocations after electrical injury is not reported but is known to be very rare. The aim of this case presentation is to report an example for this rare entity, highlight the difficulties in diagnosis and review the treatment options. CONCLUSION: Physical examination and radiographic evaluation are important for quick and accurate diagnosis.

Prevention of proximal junctional kyphosis after posterior surgery of Scheuermann kyphosis: an operative technique.

STUDY DESIGN: A prospective randomized study. OBJECTIVE: To introduce an operative technique that prevents proximal junctional kyphosis (PJK) in Scheuermann disease after a segmental posterior spinal instrumentation and fusion. SUMMARY OF BACKGROUND DATA: PJK is the progression of kyphotic deformity at the proximal end of a construct >10 degrees, and it can be seen up to 30% after posterior Scheuermann kyphosis surgery. After posterior fusion the biomechanics of the spine changes and the loss of motion at the fused levels is compensated by increased motion at other unfused segments. As a result significant amount of additional force is placed on the proximal junction. With our operative technique, we aimed to have a smooth passage from rigid to mobile segments and to decrease the stress on proximal junction during cantilever reduction to prevent PJK. METHODS: A total of 60 consecutive patients (mean age: 18.27±3.19, male/female: 28/32) who were surgically treated for Scheuermann kyphosis in our institution were recruited into this study and were prospectively evaluated. Patients were divided into 2 groups according to upper-most screw fixation technique. In group 1, a standard screw insertion technique was used (ST group). The technique was modified in group 2 (MT group), leaving 2 threads out of the posterior cortex. There were 29 patients in group 1 (ST) and 31 patients in group 2 (MT). Patients had an average follow-up time of 24.2 months (range, 19-48 mo). Evaluated radiographic parameters were preoperative and postoperative kyphosis angle, and proximal junctional angle (PJA) at last visit. PJA was defined as the angle between the caudal endplate of the upper instrumented vertebra and the cephalad endplate of 2 suprajacent vertebrae above the upper instrumented vertebra. PJA exceeding 10 degrees was accepted as PJK. Quality of life measurement was assessed preoperatively and postoperatively with SF-36 questionnaire. RESULTS: Correction amounts in ST group and MT group were 46.8% and 43.7%, respectively, which was statistically insignificant. The mean PJA was 8.08±2.96 degrees and 4.44±1.55 degrees in ST and MT groups, respectively, which demonstrated a statistically significant difference (P=0.001). Five patients in ST group had a PJA exceeding 10 degrees (PJK), whereas PJK was not seen in MT group (P=0.022). The improvement in physical component summary of SF-36 was significantly better in MT group; however, mental component summary was similar in both groups. CONCLUSIONS: This study introduces a new technique that may have an effect in preventing PJK. Our results seem to be satisfactory, but additional studies with more patients and longer follow-up times are needed to further delineate the feasibility of this technique.