Minimally Invasive Surgery for Posterior Spinal Instrumentation and Fusion in Adolescent Idiopathic Scoliosis: Current Status and Future Application.

The posterior minimally invasive spine surgery (MISS) approach-or the paraspinal muscle approach-for posterior spinal fusion and segmental instrumentation in adolescent idiopathic scoliosis (AIS) was first reported in 2011. It is less invasive than the traditionally used open posterior midline approach, which is associated with significant morbidity, including denervation of the paraspinal muscles, significant blood loss, and a large midline skin incision. The literature suggests that the MISS approach, though technically challenging and with a longer operative time, provides similar levels of deformity correction, lower intraoperative blood loss, shorter hospital stays, better pain outcomes, and a faster return to sports than the open posterior midline approach. Correction maintenance and fusion rates also seem to be equivalent for both approaches. This narrative review presents the results of relevant publications reporting on spinal segmental instrumentation using pedicle screws and posterior spinal fusion as part of an MISS approach. It then compares them with the results of the traditional open posterior midline approach for treating AIS. It specifically examines perioperative morbidity and radiological and clinical outcomes with a minimal follow-up length of 2 years (range 2-9 years).

Subjective perception of spinal deformity after selective versus non-selective fusion of Lenke 1C curves.

PURPOSE: To assess the self-image perception and the Quality-of-Life (QoL) in female adolescents, with Lenke 1C scoliosis curves, treated with selective versus non-selective posterior spinal instrumentation and fusion (PSF). METHODS: Patients undergoing PSF for idiopathic adolescent scoliosis (AIS) were recruited and divided into two groups: patients managed with selective thoracic fusion (STF) were included in Group A, whereas patients treated with non-selective fusion (N-STF) in Group B. Each patient completed the Italian version of the Scoliosis Research Society-22R questionnaire (SRS-22R), the Quality-of-Life Profile for Spinal Deformities questionnaire (QLPSD) and the Spinal Appearance Questionnaire (SAQ), before surgery and at 24-month follow-up. RESULTS: One hundred and fifty seven female patients (mean age 16.38) were included in this study. 80 patients underwent STF, while 77 patients received N-STF. At 24-month follow-up, patients managed with N-STF showed better SRS-22R self-image mean score (p = .012), SRS-22R satisfaction mean score (p = .033), QLPSD body image mean score (p = .005), but worse SRS-22 function mean score (p = .006) and QLPSD back flexibility mean score (p = .007), compared with patients who underwent STF. In terms of self-image perception, patients undergoing STF showed significantly worse SAQ total mean score (p = .002), SAQ appearance mean score (p = .001) and SAQ expectation (p = .001). We found a significant correlation between SAQ appearance mean score and SRS-22R self-image (R = - 0.721), SRS-22 mental health (R = - 0.8), QLPSD psychosocial functioning (R = 0.7) and QLPSD back flexibility (R = 0.8). CONCLUSION: Although the STF of Lenke 1C curves provides better functional outcomes, in the present study, female patients receiving STF revealed a worse perceived body image, compared with patients treated with N-STF, at 24-month follow-up. Particular attention should be addressed to the preoperative patient's mental health and body image perception, when choosing between STF and N-STF.

Factors and predictive model associated with perioperative complications after long fusion in the treatment of adult non-degenerative scoliosis.

INTRODUCTION: Adult non-degenerative scoliosis accounts for 90% of spinal deformities in young adults. However, perioperative complications and related risk factors of long posterior instrumentation and fusion for the treatment of adult non-degenerative scoliosis have not been adequately studied. METHODS: We evaluated clinical and radiographical results from 146 patients with adult non-degenerative scoliosis who underwent long posterior instrumentation and fusion. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for perioperative complications. Potential and independent risk factors for perioperative complications were evaluated by univariate analysis and logistic regression analysis. RESULTS: One hundred forty-six adult non-degenerative scoliosis patients were included in our study. There were 23 perioperative complications for 21 (14.4%) patients, eight of which were cardiopulmonary complications, two of which were infection, six of which were neurological complications, three of which were gastrointestinal complications, and four of which were incision-related complication. The independent risk factors for development of total perioperative complications included change in Cobb angle (odds ratio [OR] = 1.085, 95% CI = 1.035 ~ 1.137, P = 0.001) and spinal osteotomy (OR = 3.565, 95% CI = 1.039 ~ 12.236, P = 0.043). The independent risk factor for minor perioperative complications is change in Cobb angle (OR = 1.092, 95% CI = 1.023 ~ 1.165, P = 0.008). The independent risk factors for major perioperative complications are spinal osteotomy (OR = 4.475, 95% CI = 1.960 ~ 20.861, P = 0.036) and change in Cobb angle (OR = 1.106, 95% CI = 1.035 ~ 1.182, P = 0.003). CONCLUSIONS: Our study indicate that change in Cobb angle and spinal osteotomy are independent risk factors for total perioperative complications after long-segment posterior instrumentation and fusion in adult non-degenerative scoliosis patients. Change in Cobb angle is an independent risk factor for minor perioperative complications. Change in Cobb angle and spinal osteotomy are independent risk factors for major perioperative complications.

Acute L1 chalkstick fracture post fall in a patient with known ankylosing spondylitis and previous instrumentation and fusion of T8-L1.

BACKGROUND: Patients with ankylosing spondylitis (AS) are especially prone to sustaining spinal fractures. A 72-year-old male with AS had a previous T10/11 chalkstick fracture requiring a T8-L1 fusion 1 year ago. He subsequently presented with a newly diagnosed acute chalkstick fracture of L1 which was treated without surgery. CASE DESCRIPTION: A 72-year-old male with AS and a T10/11 chalkstick fracture had undergone a T8-L1 thoracolumbar fusion 1 year ago. He newly presented after a fall from his bed with a new acute L1 chalkstick fracture that was successfully managed nonsurgically. CONCLUSION: Patients with AS are at high risk for spinal fractures. Here, elderly male, following an original T10/11 chalkstick fracture and a T8-L1 fusion 1 year ago, presented with a new acute L1 chalkstick fracture managed without surgery.

Plasma Technology Reduces Blood Loss in Adolescent Idiopathic Scoliosis Surgery: A Prospective Randomized Clinical Trial.

STUDY DESIGN: Prospective randomized clinical trial. OBJECTIVES: To assess the effectiveness of PEAK Plasmablade (PPB), compared with bipolar sealer and standard electrocautery, in the posterior spinal instrumentation and fusion (PSF) surgery performed for adolescent idiopathic scoliosis (AIS). METHODS: Ninety-three patients undergoing PSF surgery for AIS were randomized in 2 groups: group-A patients (n = 45) underwent PSF surgery using PPB; group-B patients (n = 48) were treated with bipolar sealer and standard electrocautery. Demographic and surgical data was recorded. All the patients underwent serial blood tests on the day before surgery (T0) and at 24 (T1), 48 (T2), 72 (T3), and 96 (T4) hours postoperatively. Visual analogue scale for pain (VAS) score, the percentage of paracetamol assumption, and the blood transfusion rate were recorded in the time-lapse T1 to T4. Intergroup variability was assessed. Pearson correlation test was performed. A P value <.05 was considered significant. RESULTS: In group A, a significantly shorter total operative time (P = .0087), a significantly lower total intraoperative blood loss (TBL) (P = .001), and a higher postoperative hemoglobin (Hb) (P = .01) were recorded. A significant higher mean Hb concentration and mean albumin value was recorded in group A at 24 and 48 hours postoperatively. A significant correlation between TBL and hospital stay was recorded in both groups (group A, P = .00 001; group B, P = .00 006); moreover, in both groups, a significant correlation was observed between TBL and mean VAS at 72 hours postoperatively (group A, P = .0009; group B, P = .0001) and at 96 hours postoperatively (group A, P = .000 044; group B, P = .00 001). CONCLUSIONS: PPB reduces the intraoperative blood loss in PSF performed for AIS, thus allowing a patient's faster recovery.

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study.

BACKGROUND: Although surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion. METHODS: Analysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications. RESULTS: Three hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903. CONCLUSIONS: Age, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients.

Quality, Safety, and Value of Innovating Classic Operative Techniques in Scoliosis Surgery: Intraoperative Traction and Navigated Sequential Drilling.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aims to measure and describe the clinical and financial implications of the systematic implementation of intraoperative skull-femoral traction (IOSFT) and navigated sequential drilling (NSD) for posterior spinal instrumentation and fusion (PSIF) in adolescent idiopathic scoliosis (AIS) at our institution. SUMMARY OF BACKGROUND DATA: PSIF has been the standard surgical treatment for AIS. This retrospective single-center quality improvement study describes the perioperative outcomes and impact on health resource utilization following the systematic application of two classic surgical strategies modified using current technology: IOSFT and NSD. METHODS: We reviewed the medical records of 125 patients who underwent a single-stage PSIF for AIS. We identified three cohorts based on surgical strategies used intraoperatively. Traditional techniques (n = 28), IOSFT (n = 45), and IOSFT plus NSD (n = 52). The primary outcome measures were operative time, prevalence of cases requiring extended operating room time, need for blood transfusion, length of hospital stay, and cost per surgery. Secondary outcomes included implant density, degree of spine deformity correction, and perioperative complications. RESULTS: All primary outcome measures improved significantly (p < .001). Median operating time decreased by 59%. Use of late operating room hours fell from 89% to 0% and transfusion rates from 64% to 1.9%. Length of hospital stay decreased from 6 to 4 days. Comprehensive cost per case decreased by 24%. DISCUSSION: Together, IOSFT and NSD improved the quality, safety, and value of care. These surgical strategies were performed without increased perioperative complications, while reducing cost per case by 24%. CONCLUSIONS: The data presented may have significant implications in health resource utilization for AIS surgery. LEVEL OF EVIDENCE: Level III.

A predictive scoring system for pulmonary complications after posterior instrumentation and fusion for non-degenerative scoliosis.

OBJECTIVES: The aim of this study was to identify perioperative risk factors of pulmonary complications (PC) after posterior instrumentation and fusion (PIF) for non-degenerative scoliosis and devise a predictive scoring system that could be used by spine surgeons to predict the level of risk requiring advanced measures. PATIENTS AND METHODS: A retrospective review was performed of 703 patients who underwent PIF at our center between January 2010 and January 2018. Preoperative, peri-operative, demographic data, surgical methods, and radiographic parameters were extracted to identify the predictors of PC, and a predictive scoring system was created using multiple logistic regression and receiver operator characteristic (ROC). RESULTS: There were statistically significant differences in revision surgery, preoperative pulmonary disease, Cobb angle and thoracoplasty between the patients who suffered from PC as compared to those who did not. The predictive scoring system included four dimensions. The area under the ROC curve for the system was 0.82 for PC after PIF at the optimal cut-off point, and the sensitivity was 79.2%, which demonstrated good diagnostic accuracy. CONCLUSION: We identified a significant relationship between perioperative parameters (revision surgery, preoperative pulmonary disease, Cobb angle and thoracoplasty) and PC after PIF for non-degenerative scoliosis and created a predictive scoring system that can be used to prepare measures to manage PC after PIF. The system was proven to be reliable in this study.

Utility of topical tranexamic acid for adult patients with spinal deformity and contraindications to systemic tranexamic acid: initial experience and report of 2 cases.

Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors' initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.

Why the Craniovertebral Junction?

The craniovertebral junction (CVJ) has unique anatomical bone and neurovascular structure architecture. It not only separates the skull base from the subaxial cervical spine but also provides a special cranial flexion, extension and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports, which allow a large degree of motion. Perfect knowledge of CVJ anatomy and physiology allows us to better understand instrumentation procedures of the occiput, atlas and axis, and the specific diseases that affect the region. Therefore, a review of the vascular, ligamentous and bony anatomy of the region, in relation to all possible surgical approaches to this anatomically unique segment of the cervical spine, appears to be absolutely mandatory in order to preview and to overcome possible anatomy-related complications of CVJ surgery; moreover, knowledge of the basic principles of instrumentation and of the kinematics of the region, since they interact with the anatomy, seems to be strategic in preoperative planning.Historically considered a no man's land, CVJ surgery, or the CVJ specialty, has recently attracted strong consideration as a symbol of challenging surgery as well as selective top-level qualifying surgery.Although many years have passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature, aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ, as well as the differences in all possible surgical exposures obtained by the 360° approach philosophy. In this paper the author provides a short but quite complete at-a-glance tour of personal experience and publications and the more recent literature available.

The Craniovertebral Junction in Rheumatoid Arthritis: State of the Art.

Rheumatoid arthritis (RA) is a chronic inflammatory disorder, characterized by polyarticular inflammation causing progressive joint damage and disability. The mechanisms underlying its pathogenesis involve activation of innate and adaptive immunity, microvascular endothelial cell activation, and inflammatory infiltration of lymphocytes and monocytes into the synovium. Spinal involvement in RA is not typical; when it occurs, the main radiological features are (1) atlantoaxial subluxation (AAS), which is the most typical form of cervical spine involvement; (2) cranial settling-also known as basilar impression, atlantoaxial impaction or superior migration of the odontoid-which is the most severe form of associated spinal instability; and (3) subaxial subluxation. A combination of these alterations may occur. Synovitis is characterized by infiltration of innate and adaptive immune cells; joint destruction is a consequence of activation of synovial fibroblasts, which acquire aggressive, inflammatory, invasive features, associated with increased chondrocyte catabolism and synovial osteoclastogenesis.Neck pain is the most frequent symptom of spinal involvement in RA; it occurs in 40-80% of patients and is mostly localized at the craniocervical junction. Other symptoms-caused by compression of neural structures such as the greater occipital nerve (at C2), the nucleus of the spinal trigeminal tract and the greater auricular nerve-are occipital neuralgia, facial pain and ear pain, respectively. Irritation of the lesser occipital nerve (at C1) can cause pain in the suboccipital region. Sometimes patients may complain of a sensation of their head falling down with flexion, weakness, reduced endurance, loss of ability, gait alterations, paraesthesias or other symptoms due to cord and medullary compression, and upper or lower motor neuron signs, or both. Surgical management of RA remains a challenging field.

A retrospective analysis of health-related quality of life in adolescent idiopathic scoliosis children treated by anterior instrumentation and fusion.

BACKGROUND: Idiopathic scoliosis is the most common type of spinal deformity. Scoliosis is defined as a lateral curvature of the spine greater than 10° accompanied by rotation of the vertebrae. The treatment available for adolescent idiopathic scoliosis is observation, orthosis, and surgery. The surgical options include open anterior release and instrumentation, posterior instrumentation, and thoracoscopic approaches. The Scoliosis Research Society Questionnaire (SRS-30) is a specific instrument to measure health-related quality of life in patients with scoliosis, who had or had not undergone surgery. The purpose was to assess the post-operative functional outcome using SRS-30 in children who underwent anterior release, instrumentation, and fusion using autogenous rib graft for adolescent idiopathic scoliosis (AIS). METHODS: In a retrospective cohort study, 25 patients between the ages of 11 and 17 years, who underwent anterior release, instrumentation, and fusion using autogenous rib graft for adolescent idiopathic scoliosis (AIS) between 2008 and 2014, were included in the study. RESULTS: The total average score was 4.26 with a SD of 0.014 and had maximum average score 4.5 (for pain) and minimum average score 3.8 (for self-image). CONCLUSION: Anterior release, instrumentation, and fusion using autogenous rib graft is having good functional outcome in all domains.

Ethnic Variation in Satisfaction and Appearance Concerns in Adolescents With Idiopathic Scoliosis Undergoing Posterior Spinal Fusion With Instrumentation.

STUDY DESIGN: Cohort analysis. OBJECTIVE: Document satisfaction with management and appearance concerns in children of different ethnicity who underwent spinal fusion/instrumentation for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Scoliosis Research Society Questionnaire (SRS-30) outcomes in AIS indicate a link between appearance and satisfaction as well as ethnic variation in appearance domain. Exploration of these findings in the Scoliosis Appearance Questionnaire (SAQ) will allow better understanding of ethnic variation in appearance concerns. METHODS: Children with AIS who underwent posterior-only operations and completed the SAQ's question 31 were identified. Univariate logistic regression of SAQ questions 12-30 was used to assess relationships with ethnicity. RESULTS: 1,977 children [boys: 281, girls: 1,290, unspecified: 406; average age 15.1 ± 2.0 years preoperatively and 817 children (boys: 113, girls: 569, unspecified: 135; average age 15.1 ± 2.0 years) at 2 years' follow-up met inclusion criteria. The majority were Caucasian (57.3%). Few were Hispanic (3.4%). Preoperatively, the largest percentage of patients in each ethnic group answered "very true" to "wanting to be more even." Preoperatively, Asians were least likely to be concerned about evenness of shoulders, hips, waist, ribs, and chest in back (p < .05); however, they expressed greatest concern about height (p < .05). African Americans and Hispanics were more likely to be concerned about breast evenness and anterior chest and looking better in clothes (p < .05). African Americans were most concerned about overall evenness and evenness of shoulders, hips, waist, ribs, posterior chest, leg length, and looking more attractive (p < .05). Surgical scar was most important postoperatively for all ethnicities. African Americans and Hispanics were more self-conscious about scar (p < .05). African Americans were most likely to want to be more even and have more even shoulders, hips, waist, leg lengths, ribs, breasts, and chest postoperatively. CONCLUSIONS: Ethnicity influenced appearance concerns in pre- and postoperative SAQ evaluation. Ethnic variation in appearance concerns should be taken into account and differentiated when counseling patients about AIS and surgical correction. LEVEL OF EVIDENCE: Level III.

Outcomes of Minimally Invasive Surgery Compared to Open Posterior Lumbar Instrumentation and Fusion.

INTRODUCTION: Degenerative spine disease is increasingly common. There are many spinal fusion techniques used to treat degenerative spine disease. This study aims to compare the functional outcome of open versus minimally invasive surgery (MIS) technique in posterior lumbar instrumentation and fusion in degenerative spine disease and to evaluate the perioperative outcome and complications between MIS and open surgery. MATERIALS AND METHODS: This is an observational cross-sectional study conducted on all degenerative spine disease patients who underwent both methods of posterior lumbar instrumentation and fusion from 2010 to 2014 by the Orthopedic and Neurosurgery Department, Sarawak General Hospital. The analyzed variables were method of surgery and the levels involved, demographic data, estimated blood loss, duration of operation, length of hospitalization, visual analog scale of back pain and radicular pain preoperative, postoperative 1 month, 3 months, 6 months, 1 year, and functional outcome. RESULTS: One hundred and twenty-two patients underwent posterior lumbar instrumentation and fusion from 2010 to 2014. Seventy patients were subjected to MIS transforaminal lumbar interbody fusion (TLIF) and 52 open TLIF. Total 89 patients underwent single level of lumbar fusion with sixty patients in MIS group and 29 in open surgeries. MIS TLIF has less estimated blood loss and shorter hospitalization and longer operation time compared to open TLIF, which were statistically significance. MIS TLIF has statistically significance better functional outcome based on Oswestry disability index, Modified NASS score, and RAND 36-item Health Survey 1.0 score. Complications such as infection, new onsets of neurological, and dural tear are equal in both methods of surgery. CONCLUSION: This study concluded that MIS has better functional outcome compared to open TLIF with shorter hospitalization, faster return to work, and less estimated blood loss.

[Effects of different pelvic incidence minus lumbar lordosis mismatch after long posterior instrumentation and fusion for adult degenerative scoliosis].

Objective: To evaluate the influence of PI-LL (pelvic incidence minus lumbar lordosis mismatch) on scoliosis correction, living quality and internal fixation related complications for adult degenerative scoliosis (ASD) after long posterior instrumentation and fusion. Methods: A total of 79 patients with ADS underwent long posterior instrumentation and fusion in the Department of Orthopedics at Beijing Chao Yang Hospital from January 2010 to January 2014 were retrospectively reviewed.There were 21 males and 58 females aging from 55 to 72 years with the mean age (63.4±4.8)years. The patients were divided into three groups according to immediately postoperative PI-LL: PI-LL<10°, 10°≤PI-LL≤20°, PI-LL>20°.Compare the Cobb's angles, PI-LL, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Lumbar Stiffness Disability Index (LSDI). Measurement data were compared via t test and ANOVA, enumeration data were compared via Kruskal-Wallis test, noncontiguous data was performed by χ(2) test. Univariate linear regression equation was performed to investigate the relative influences of postoperative PI-LL on postoperative radiographic parameters and clinical outcome. Results: All the operations were successful without intraoperative complications. The operation time was 145-310 minutes (235.3±42.0) minutes, the intraoperative blood loss was 300-5 300 ml (1 021±787) ml, the duration of hospital was 12-18 d (14.5±1.3) d. A total of 4 to 10 (7.0±1.1) vertebra levels were fused. Compared to preoperative, the Cobb's angle of scoliosis ((4.2±1.8)° vs. (20.1±2.7)°), PI-LL ((16.1±8.6)° vs. (36.0±4.3)°), JOA (3.0±1.3 vs. 5.5±1.2), ODI (24.4±8.1 vs. 62.9±2.7), VAS (3.0±1.0 vs. 6.8±1.3) were significantly decreased postoperative (t=18.539~53.826, P<0.01). Compared to preoperative, postoperative Cobb's angle of scoliosis ((4.1±2.7)° vs. (19.5±2.7)°, (4.0±1.4)° vs. (20.2±2.4)°, (4.7±0.9)° vs. (20.6±3.0)°) (t=21.148-45.355, P<0.01) and PI-LL ((5.2±2.8)° vs. (35.8±4.9)°, (17.9±2.9)° vs. (37.2±3.9)°, (25.8±2.7)° vs. (34.5±4.0)°) (t=7.227-38.250, P<0.01) were significantly reduced postoperative in PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group. Compared to preoperative, ODI (27.7±4.9 vs. 63.3±2.6, 17.7±5.9 vs. 63.1±2.8, 30.6±6.5 vs. 62.3±2.5) (t=21.218~50.858, P<0.01), JOA (2.8±1.2 vs. 5.2±1.2, 3.3±1.1 vs. 5.7±1.1, 2.8±1.7 vs. 5.7±1.2) (t=9.042-16.025, P<0.01) and VAS (2.9±1.2 vs.7.0±1.3, 3.3±0.9 vs.7.0±1.4, 2.9±0.8 vs. 6.3±1.2) (t=16.073-22.214, P<0.01) were all significantly reduced at last follow-up. There were statistic differences in ODI and LSDI (F=38.477, P<0.01; F=37.063, P<0.01) at the last follow-up among the three groups. There was a negative correlation in PI-LL and LSDI according to linear regression (B=-5.838, P<0.01) in the last follow-up. All the patients were followed up, the follow-up duration were 2 to 5 years with the mean (3.1±0.7) years. The internal fixation failure related complications in 3 years included proximal junctional kyphosis (PJK) in 19 cases, internal fixation loosening in 6 cases. Eight patients received reoperation for severe local pain and low extremity symptoms. PJK occurrences were significantly different among PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group. Conclusions: The PI-LL between 10° and 20° may be the best choice in ADS patients after long posterior instrumentation and fusion for its better clinical outcome and less proximal junctional kyphosis (PJK). The overcorrection of LL may lead to more serious postoperative lumbar stiffness.

Does spinal deformity correction of non-dystrophic scoliosis in neurofibromatosis type I with one-stage posterior pedicle screw technique produce outcomes similar to adolescent idiopathic scoliosis?

BACKGROUND CONTEXT: The efficacy of one-stage posterior pedicle screw instrument used in the treatment of non-dystrophic scoliosis in neurofibromatosis type I (NF-1) is unknown. Also, there is no study that has directly compared the results of spinal deformity correction between non-dystrophic scoliosis in NF-1 and adolescent idiopathic scoliosis (AIS). PURPOSE: The objectives of this study were to study the efficacy of a one-stage posterior pedicle screw instrument used in the treatment of non-dystrophic scoliosis in NF-1 and to compare non-dystrophic scoliosis in NF-1 with matched AIS to illustrate the differences. STUDY DESIGN: This is a retrospective case control study. PATIENT SAMPLE: Fifteen patients with non-dystrophic scoliosis in NF-1 and 15 patients with AIS underwent a one-stage posterior surgery with the pedicle screw system. OUTCOME MEASURES: Preoperative and postoperative whole-spine radiographs were used to determine coronal and sagittal Cobb angles. Also, the distance between the C7 plumb line and the center sacral vertical line and the sagittal vertebral axis was measured to assess spinal balance. The Scoliosis Research Society (SRS)-22 questionnaire was used to evaluate functional outcomes. METHODS: We matched 15 patients with non-dystrophic scoliosis in NF-1 with patients with AIS (ratio, 1:1) for age, sex, and degree of major deformity. The overall mean age was 13.4±2.0 and 14.0±2.1 years, respectively. The NF-1 group consisted of 10 boys and 5 girls, and the AIS group consisted of 9 boys and 6 girls. The mean follow-up was 37.6±3.9 and 33.5±5.0 months, respectively. The AIS group underwent end vertebra (EV) or EV+1 fusion. The NF-1 group underwent EV+1, 2, or 3 fusion. Both coronal and sagittal Cobb angles, trunk balance, operative time, blood loss, fusion levels, length of stay, and scores on the SRS-22 questionnaire were compared between the two groups. The study was supported by the National Natural Science Foundation of China (Grant No. 81401760). There were no study-specific conflict of interest-associated biases. RESULTS: The preoperative main curve magnitude was similar between the two groups; however, the flexibility of the NF-1 group tended to be less than that of the AIS group. The rate of correction of the main curve obtained surgically (79.8% compared with 81.1%) was similar in the NF-1 and AIS groups. There were no significant differences in the loss of correction between the two groups (p>.05). Also, there were no significant differences between the groups in operative time, blood loss, fusion levels, screw number, length of stay, trunk balance, and scores on the SRS-22. There were no serious complications related to surgery in both groups. CONCLUSIONS: Despite the differences in preoperative flexibilities and fusion strategies, non-dystrophic scoliosis in NF-1 can be treated with a satisfied correction rate and progression rate similar to comparable AIS by using the one-stage posterior pedicle screw technique. Dural ectasia or thin pedicles in non-dystrophic scoliosis could make pedicle screw placement challenging.

Effects of different pelvic incidence minus lumbar lordosis mismatch after long posterior instrumentation and fusion for adult degenerative scoliosis / 中华外科杂志

Objective@#To evaluate the influence of PI-LL (pelvic incidence minus lumbar lordosis mismatch) on scoliosis correction, living quality and internal fixation related complications for adult degenerative scoliosis (ASD) after long posterior instrumentation and fusion.@*Methods@#A total of 79 patients with ADS underwent long posterior instrumentation and fusion in the Department of Orthopedics at Beijing Chao Yang Hospital from January 2010 to January 2014 were retrospectively reviewed.There were 21 males and 58 females aging from 55 to 72 years with the mean age (63.4±4.8)years. The patients were divided into three groups according to immediately postoperative PI-LL: PI-LL<10°, 10°≤PI-LL≤20°, PI-LL>20°.Compare the Cobb′s angles, PI-LL, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Lumbar Stiffness Disability Index (LSDI). Measurement data were compared via t test and ANOVA, enumeration data were compared via Kruskal-Wallis test, noncontiguous data was performed by χ2 test. Univariate linear regression equation was performed to investigate the relative influences of postoperative PI-LL on postoperative radiographic parameters and clinical outcome.@*Results@#All the operations were successful without intraoperative complications. The operation time was 145-310 minutes (235.3±42.0) minutes, the intraoperative blood loss was 300-5 300 ml (1 021±787) ml, the duration of hospital was 12-18 d (14.5±1.3) d. A total of 4 to 10 (7.0±1.1) vertebra levels were fused. Compared to preoperative, the Cobb′s angle of scoliosis ((4.2±1.8)° vs. (20.1±2.7)°), PI-LL ((16.1±8.6)° vs. (36.0±4.3)°), JOA (3.0±1.3 vs. 5.5±1.2), ODI (24.4±8.1 vs. 62.9±2.7), VAS (3.0±1.0 vs. 6.8±1.3) were significantly decreased postoperative (t=18.539~53.826, P<0.01). Compared to preoperative, postoperative Cobb′s angle of scoliosis ((4.1±2.7)° vs. (19.5±2.7)°, (4.0±1.4)° vs. (20.2±2.4)°, (4.7±0.9)° vs. (20.6±3.0)°) (t=21.148-45.355, P<0.01) and PI-LL ((5.2±2.8)° vs. (35.8±4.9)°, (17.9±2.9)° vs. (37.2±3.9)°, (25.8±2.7)° vs. (34.5±4.0)°) (t=7.227-38.250, P<0.01) were significantly reduced postoperative in PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group. Compared to preoperative, ODI (27.7±4.9 vs. 63.3±2.6, 17.7±5.9 vs. 63.1±2.8, 30.6±6.5 vs. 62.3±2.5) (t=21.218~50.858, P<0.01), JOA (2.8±1.2 vs. 5.2±1.2, 3.3±1.1 vs. 5.7±1.1, 2.8±1.7 vs. 5.7±1.2) (t=9.042-16.025, P<0.01) and VAS (2.9±1.2 vs.7.0±1.3, 3.3±0.9 vs.7.0±1.4, 2.9±0.8 vs. 6.3±1.2) (t=16.073-22.214, P<0.01) were all significantly reduced at last follow-up. There were statistic differences in ODI and LSDI (F=38.477, P<0.01; F=37.063, P<0.01) at the last follow-up among the three groups. There was a negative correlation in PI-LL and LSDI according to linear regression (B=-5.838, P<0.01) in the last follow-up. All the patients were followed up, the follow-up duration were 2 to 5 years with the mean (3.1±0.7) years. The internal fixation failure related complications in 3 years included proximal junctional kyphosis (PJK) in 19 cases, internal fixation loosening in 6 cases. Eight patients received reoperation for severe local pain and low extremity symptoms. PJK occurrences were significantly different among PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group.@*Conclusions@#The PI-LL between 10° and 20° may be the best choice in ADS patients after long posterior instrumentation and fusion for its better clinical outcome and less proximal junctional kyphosis (PJK). The overcorrection of LL may lead to more serious postoperative lumbar stiffness.

Effect of Surgical Fusion on Volitional Weight-Shifting in Individuals With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective. OBJECTIVES: The goals of this study were to (1) evaluate the differences in weightbearing symmetry between individuals with adolescent idiopathic scoliosis (AIS) and typically developing controls; (2) observe the effect of posterior spinal fusion and instrumentation (PSFI) on volitional weight-shifting at 1 and 2 years postoperatively; and (3) evaluate whether lowest instrumented fusion level (ie, lowest instrumented vertebra [LIV]) in PSFI has an effect on volitional weight-shifting. SUMMARY OF BACKGROUND DATA: Previous studies have conflicting findings with regard to the effect of scoliosis on postural control tasks as well as the effect of surgery. They have also noted an inconsistent effect of PSFI at different LIVs, with more distal LIVs exhibiting greater reductions in postoperative range of motion. METHODS: The study was designed with an AIS group of 41 patients (8 males and 33 females) with AIS who underwent PSFI, along with a Control Group of 24 age-matched typically developing participants (12 male and 12 female). Both groups performed postural control tasks (static balance and volitional weight-shifting), with the AIS group repeating the tasks at 1 and 2 years postoperatively. RESULTS: At baseline, the AIS group showed increased weightbearing asymmetry than the Control Group (p = .01). The AIS group showed improvements in volitional weight-shifting at 2 years over baseline (p < .01). There was no effect of LIV on volitional weight-shifting by the second postoperative year. CONCLUSIONS: Individuals with AIS have greater weightbearing asymmetry but improved volitional weight-shifting over typically developing controls. PSFI improves volitional weight-shifting beyond preoperative baseline but does not differ significantly by LIV.