Posterior-Only T11 Vertebral Column Resection for Pediatric Congenital Kyphosis Surgical Correction.

Background: Congenital kyphosis is a spinal deformity that arises from the inadequate anterior development or segmentation of the vertebrae in the sagittal plane during the initial embryonic stage. Consequently, this condition triggers atypical spinal growth, leading to the manifestation of deformity. Concurrently, other congenital abnormalities like renal or cardiac defects within the gastrointestinal tract may co-occur with spinal deformities due to their shared formation timeline. In light of the specific characteristics of the deformity, the age range of the patient, deformity sizes, and neurological conditions, surgical intervention emerges as the optimal course of action for such cases. The selection of the appropriate surgical approach is contingent upon the specific characteristics of the anomaly. Case Presentation: This investigation illustrates the utilization of a surgical posterior-only strategy for correcting pediatric congenital kyphoscoliosis through the implementation of a vertebral column resection method along with spine reconstruction employing a mesh cage. The individual in question, a 16-year-old female, exhibited symptoms such as a progressive rib hump, shoulder asymmetry, and back discomfort. Non-invasive interventions like bracing proved ineffective, leading to the progression of the spinal curvature. After the surgical procedure, diagnostic imaging displayed a marked enhancement across all three spatial dimensions. After a postoperative physical assessment, it was noted that the patient experienced significant enhancements in shoulder alignment and rib hump prominence, with no discernible neurological or other adverse effects. Conclusions: Surgical intervention is considered the optimal approach for addressing such congenital anomalies. Typically, timely surgical intervention leads to favorable results and has the potential to halt the advancement of deformity and curvature enlargement.

Can hydroxyapatite charged collagen sponge help reduce perioperative blood loss in adolescent idiopathic scoliosis surgery? Preliminary results in 68 patients.

PURPOSE: Patient blood management has been recently emphasized to avoid perioperative blood transfusion in AIS surgery. Hydroxyapatite charged collagen sponge (HCS) is a bone substitute material made of collagen and ceramized hydroxyapatite, with associated haemostatic properties. The goal of this study was to assess the impact of HCS in the perioperative blood loss in AIS surgery. METHODS: After IRB approval, all AIS patients undergoing primary correction were prospectively included over a 15-month period. Patients receiving HCS at the end of the procedure were compared to a control group (matched for age, gender, and fusion levels) without any haemostatic agent or bone substitute. The same perioperative blood saving strategies were used in both groups. Two subfascial drains were used for 48 h in all patients. Perioperative blood loss and transfusion rates were analysed. RESULTS: A total of 34 patients were included in each group. No difference in drainage volume was observed at day 1, but the reduction was statistically different at day 3 (1135 mL [800-1640] versus 930 [480-1510], p = 0.028, 0.63 ml/Kg/h [0.4-0.92] versus 0.46 [0.29-0.7], p = 0.042). Multivariate analysis found that the use of HCS was associated with a decrease in the postoperative blood loss (OR = 1.17 [1.10-1.25]). The transfusion rate was lower in the HCS group [0 (0% vs. 3(8.8%), p = 0.076)]. No infection occurred, and no complication was reported. CONCLUSION: With 27% reduction in drain volume, hydroxyapatite charged collagen sponge can be considered as a blood salving strategy in AIS surgery. The role of the biomaterial in fusion rate still needs to be further assessed.

Effect of posterior decompression with and without fixation on a kyphotic cervical spine with ossification of the posterior longitudinal ligament.

STUDY DESIGN: Biomechanical study. OBJECTIVE: Cervical ossification of the posterior longitudinal ligament (C-OPLL) causes myelopathy. Though posterior decompression for C-OPLL showed positive results, poor outcomes were seen in patients with a kyphotic alignment. Posterior decompression with fusion (PDF) tends to show better results compared to posterior decompression. The aim of this study is to evaluate the effects of the posterior procedures for C-OPLL. SETTING: Yamaguchi University. METHODS: Based on 3D finite element C2-C7 spine created from medical images and a spinal cord, the following compression models were created: the intact model, K-line 0 mm model, and K-line 2 mm model. These models were used to analyze the effects of posterior decompression with varied lengths of fixation. The stress of the spinal cord was calculated for intact, K-line 0 mm, and K-line 2 mm as preoperative models, and laminectomy (LN)-K-line 0 mm, PDF (C4-C5)-K-line 0 mm, PDF (C3-C6)-K-line 0 mm, LN-K-line 2 mm, PDF (C4-C5)-K-line 2 mm, and PDF (C3-C6)-K-line 2 mm model as operative models in a neutral, flexion, and extension. RESULTS: As the compression increased, stress on the spinal cord increased compared to the intact model. In the neutral, posterior decompression decreased the stress of the spinal cord. However, in flexion and extension, the stress on the spinal cord for LN-K-line 0 or 2 mm, PDF (C4-C5)-K-line 0 or 2 mm, and PDF (C3-C6)-K-line 0 or 2 mm models decreased by more than 40%, 43%, and 70% respectively compared to the K-line 0 or 2 mm model. CONCLUSIONS: In kyphotic C-OPLL, it is essential to control intervertebral mobility in the posterior approach.

The Addition of Daytime Physiotherapeutic Scoliosis-specific Exercises to Adolescent Idiopathic Scoliosis Nighttime Bracing Reduces Curve Progression.

BACKGROUND: The effectiveness of physiotherapeutic scoliosis-specific exercises (PSSE) in addition to nighttime bracing compared with nighttime bracing alone is unknown. The purpose of this prospective comparative study was to evaluate the effectiveness of PSSE in skeletally immature patients with adolescent idiopathic scoliosis treated with nighttime bracing (PSSE group) compared with the standard of care of nighttime bracing alone (control group). METHODS: Patients with adolescent idiopathic scoliosis thoracolumbar or lumbar primary curves <35 degrees at Risser stage 0 who wore a Providence brace were prospectively enrolled into the PSSE or control group. A temperature sensor recorded the number of hours of brace wear. The PSSE group was instructed in the Schroth-based physical therapy method and a home exercise program for at least 15 minutes per day, 5 days per week, for 1 year. RESULTS: Seventy-four patients (37 PSSE, 37 controls) were followed until the final visit of skeletal maturity or surgery. The PSSE and control groups had similar baseline Cobb angles (24 vs. 25 degrees) and average hours of brace wear (8.0 vs. 7.3 h). The PSSE group had no change in curve magnitude at the final visit compared with curve progression in the control group (1 vs. 7 degrees, P <0.01). Furthermore, the PSSE group had a lower rate of curve progression >5 degrees at the final visit (14% vs. 43%, P <0.01). The PSSE group also had less conversion to full-time bracing after 1 year (5% vs. 24%, P =0.046), but differences were no longer significant at the final visit (14% vs. 27%). CONCLUSIONS: In this prospective series of patients in nighttime Providence braces, the addition of Schroth-based physical therapy reduced curve progression after 1 year and at skeletal maturity. These findings can educate motivated families interested in PSSE. LEVEL OF EVIDENCE: Level II.

[Thoracolumbar Compression Fractures in Children]. / Kompresivní zlomeniny thorakolumbální pátere u detí.

PURPOSE OF THE STUDY The study aimed to draw up a diagnosis and treatment guidelines for the management of the most common compression fractures of the thoracolumbar spine in children. MATERIAL AND METHODS Between 2015 and 2017, pediatric patients with a thoracolumbar injury aged 0-12 years were followed up in the University Hospital in Motol and the Thomayer University Hospital. The age and gender of the patient, injury etiology, fracture morphology, number of injured vertebrae, functional outcome (VAS and ODI modified for children), and complications were assessed. An X-ray was performed in all patients, in indicated cases also an MRI scan was done, and in more severe cases a CT scan was obtained as well. RESULTS The average vertebral body kyphosis in patients with one injured vertebra was 7.3° (range 1.1°-12.5°). The average vertebral body kyphosis in patients with two injured vertebrae was 5.5° (range 2.1°-12.2°). The average vertebral body kyphosis in patients with more than two injured vertebrae was 3.8° (range 0.2°-11.5°). All patients were treated conservatively in line with the proposed protocol. No complications were observed, no deterioration of the kyphotic shape of the vertebral body was reported, no instability occurred, and no surgical intervention had to be considered. DISCUSSION Pediatric spine injuries are in most cases treated conservatively. Surgical treatment is opted for in 7.5-18% of cases, in dependence on the evaluated group of patients, age of the patients and philosophy of the department concerned. In our group, all patients were treated conservatively. CONCLUSIONS 1. To diagnose F0 fractures, two unenhanced orthogonal view X-rays are indicated, whereas MRI examination is not routinely performed. In F1 fractures, an X-ray is indicated, and an MRI scan is considered based on the age and extent of injury. In F2 and F3 fractures, an X-ray is indicated and subsequently the diagnosis is confirmed by MRI, in F3 fractures also a CT scan is performed. 2. In young children (under 6 years of age), in whom an MRI procedure would require general anaesthesia, MRI is not routinely performed. 3. In F0 fractures, crutches or a brace are not indicated. In F1 fractures, verticalization using crutches or a brace is considered in dependence on the patient's age and extent of injury. In F2 fractures, verticalization using crutches or a brace is indicated. 4. In F3 fractures, surgical treatment is considered, followed by verticalization using crutches or a brace. In case of conservative treatment, the same procedures as in F2 fractures are applied. 5. Long-term bed rest is contraindicated. 6. Duration of spinal load reduction (restriction of sports activities, or verticalization using crutches or a brace) in F1 injuries is 3-6 weeks based on the age of the patient, it increases with the age, with the minimum being 3 weeks. 7. Duration of spinal load reduction (verticalization using crutches or a brace) in F2 and F3 injuries is 6-12 weeks based on the age of the patient, it increases with the age, with the minimum being 6 weeks. Key words: pediatric spine injury, thoracolumbar compression fractures, children trauma treatment.

Pediatric cervical kyphosis in the MRI era (1984-2008) with long-term follow up: literature review.

OBJECTIVE: Cervical kyphosis is rare in the pediatric population. It may be syndromic or acquired secondary to laminectomy, neoplasia, or trauma. Regardless, this should be avoided to prevent progressive spinal deformity and neurological deficit. Long-term follow-up is needed to evaluate fusion status, spine growth, potential instability, and neurological function. METHODS AND MATERIALS: A retrospective review of 27 children (6 months to 16 years) with cervical kyphotic deformity was performed and limited to the MRI era until 2008, to provide a long-term follow-up after which complex instrumentation was available. There were 27 patients, 19 syndromic (average age 5.36 years), and 8 non-syndromic (average age 14 years). Syndromes encountered were spondyloepiphyseal dysplasia (SED) 4, spondylometaphyseal dysplasia 1, unnamed collagen abnormality syndrome 1, osteogenesis imperfecta (OI) 2, Aarskog syndrome 1, Weaver syndrome 1, Larsen syndrome 1, multiple cervical level disconnection syndrome 1, Klippel-Feil 3, congenital absence of C2 pars 4. Non-syndromic cases; 2 with neurofibromatosis (NF1) and prevertebral tumors, fibromatosis 1, spontaneous kyphosis 1, and postlaminectomy 4. Factors considered were age, pathology, flexibility on cervical spine dynamic films, reduction with traction and spinal cord compression. Patients with flexible kyphosis underwent dorsal fixation. Children with non-flexible ventral compression/kyphosis had crown halo traction. Irreducible kyphosis had ventral decompression and fusion as well as dorsal fusion. Eleven of 19 syndromic children with flexible and reducible kyphosis underwent dorsal fixation alone. Four of 8 non-syndromic (2 NF1) needed ventral and dorsal approaches. RESULTS: The preoperative deformity (global and local Cobb angles) as well as neurological status improved. Growth during follow-up was not impaired, and we did not encounter instability or junctional kyphosis. The only complications were seen in syndromic patients. One patient with SED showed delayed cantilever bending of the ventral fusion mass requiring reoperation, and 1 other OI child had left C5 and C6 nerve root weakness after anterior C4 and C5 decompression which resolved over 1 year. One child with SED developed cervicothoracic junction scoliosis 18 years later after thoracic scoliosis surgery. CONCLUSIONS: Syndromic pathology presented early with neurological dysfunction and 24% had rigid kyphosis. An attempt at traction/reduction was successful as in Tables 1 and 2. The majority exhibited long-term improvement in kyphosis and function. A treatment algorithm and literature review is presented. Table 1 Motor function of the modified Japanese Orthopedic Association (JOA) score in children [24, 37] Score Upper extremity •Unable to move hands or feed oneself 0 •Can move hands; unable to eat with spoon 1 •Able to eat with spoon with difficulty 2 •Able to use spoon; clumsy with buttoning 3 •Healthy; no dysfunction 4 Lower extremity •Unable to sit or stand 0 •Unable to walk without cane or walker 1 •Walks independently on level floor but needs support on stairs 2 •Capable to walking, clumsy 3 •No dysfunction 4 Table 2 Pediatric cervical kyphosis-preoperative evaluations Case ID, year presented Age Sex Diagnosis Presentation Imaging Apex Cobb angle degree Reducibility Preop traction Syndromic #1 2003 4 years M SED Progressive quadriparesis Bladder incontinence Severe C2-4 kyphosis with cord compression C3-4 85° No No #2 2001 3 years M SED Progressive quadriparesis C2-3 kyphosis. No dorsal C2. Buckled cord C2-3 25° No No Recurrent weakness after recovery 2 years later Kyphosis at fusion site C2-3 33° No No #3 1997 13 years M SED Neck pain. Hand weakness. Thoracic scoliosis C1-3 kyphosis Os odontoideum C2-3 30° Yes No #4 2006 6 years F SED Tingling in hands Bladder incontinence Deformed C2 body and odontoid C1-2 instability C2-3 27° Yes No #5 1997 4 years M SMD Quadriparesis. Previous C2-3 kyphosis with O-C3 dorsal fusion elsewhere Fixed C1-2 dislocation. C2-3 kyphosis. O-C4 fusion C2 35° Partial Yes 4 days #6 2007 13 years F Syndromic collagen abnormality Neck pain. Leg length discrepancies. T-L scoliosis. Quadriparesis Bilateral C2 and partial C3 spondylolysis C-T levoscoliosis C2-3 35° Partial Yes 4 days #7 2003 14 years F Osteogenesis imperfecta (OI) Only able to use right upper extremity C3-5 kyphosis. Canal diameter 4 mm at C4 C4 25° No No #8 1989 3 years F OI - Bruck's syndrome Quadriparesis age 9 months. Had C1-C3 posterior decompression and fusion elsewhere Progressive kyphosis Worse weakness Bend in fusion C1-2 40° No No #9 1996 11 years M Aarskog syndrome Neck pain with limited neck motion Cervical myelopathy Psychomotor delay C4-5 spondylolysis C5-6 kyphosis C5 30° No Yes 3 days #10 1989 3½ years F Weaver syndrome Quadriparesis age 2 years. Elsewhere C1-C3 dorsal rib fusion and wires Fusion failure C2-3 subluxation Cord compression C2-3 3° Yes Yes 1 day #11 1986 11 years F Larsen syndrome Neck pain in extension Quadriparesis C2-3 kyphosis. Deformed bodies C2-5 Os odontoideum C1-2 instability C2-3 28° Yes Yes 1 day #12 1996 5 years M Multilevel cervical disconnect syndrome Horner pupil on right Small right arm Quadriparesis C4, C5 vertebral bodies behind C5 C5 body in canal Left vertebral artery in C5 body C4-5 35° No No #13 1985 3 years F Klippel-Feil Neck pain. Weak hands Atlas assimilation C3-4 kyphosis No posterior bony arches C3, C4 C3-4 40° Yes No #14 1994 3 years F Klippel-Feil Unable to sit. Floppy. Quadriparesis C2-3 kyphosis No posterior arches C2-3 and L4 C2-3 45° Yes No #15 1993 11 months F Tuberous sclerosis Spondylolysis C2 Salam seizures Quadriparesis No pars C2 C2-3 kyphosis C2-3 30° Yes No #16 1998 2 years M C2 spondylolysis Quadriparesis, arms worse than legs C2 spondylolysis C2-3 kyphosis C2-3 35° Yes No #17 1998 6 months M C2 spondylolysis Failure to thrive Apneic spells Weak in arms after endoscopy C2-3 kyphosis No C2 lamina Cord compression C3-4 on MRI C2-3 45° Yes No #18 1990 4 years F C2 spondylolysis Developmental delay Quadriparesis C2 spondylolysis C2-3 kyphosis C3 45° Yes No #19 1994 4 years F Klippel-Feil No posterior C2 Torticollis age 6 mo Quadriparesis C2-3 kyphosis No posterior arch C2 Fused C3-4 bodies C2-3 45° Yes No Non-syndromic #20 1996 15 years M NF1. Ventral prevertebral plexiform neurofibroma Neck pain Weak arms Cervical myelopathy C4-5 kyphosis Cord draped over C4-5 Enhanced prevertebral tumor C4-5 60° Partial Yes 4 days #21 1996 6 years M NF1 Age 6 mo had C1-3 laminectomies elsewhere Progressive kyphosis Quadriparesis C3-5 plexiform neurofibromas C2-4 kyphosis C3-4 45° No No #22 1993 11 years M "Fibromatosis" Neck pain Gag ↓ Right hemiparesis C2 body and odontoid curved dorsally C2-3 kyphosis C2 40° No Yes 3 days #23 2007 13 F Mid-cervical kyphosis Neck pain Unable to move neck C3-4 kyphosis C3-4 45° Yes Halo vest elsewhere 6 weeks Repeat traction on referral #24 1998 12 years M Chiari I Syringohydromyelia Difficulty swallowing Quadriparesis Previous posterior fossa and C1-3 decompression Basilar invagination C3-4 kyphosis C3-4 50° Yes Halo traction 3 days #25 1994 16 years M Chiari I. SHM Difficult speech Quadriparesis Previous posterior fossa and C1-4 laminectomies C3-4 kyphosis Basilar invagination C3-4 55° Yes Halo traction 3 days #26 2002 11 years M Chordoma C3-5 Initial quadriparesis improved after posterior decompression then worse Dorsal and lateral tumor C3-4 C3-4 20° Yes Traction 3 days #27 2006 13 years M C4 lamina Aneurysmal bone cyst Neck and shoulder pain C4 laminectomy for tumor resection Worse 4 months later C4-5 kyphosis C3-4 40° Yes No Table 3 Pediatric cervical kyphosis-postoperative evaluations Case ID Diagnosis Treatment-operation Complication PO orthosis F/U time Fusion status Preop Cobb Postop Cobb Preop JOA Postop JOA Comments Syndromic #1 SED Crown halo traction 1. Median mandibular glossotomy. Resection C2-3 bodies with rib graft fusion 2. Dorsal O-C3 rib graft fusion None Halo vest 3 months Soft collar 3 months 8 years Complete anterior and posterior fusion 85° 10° 2 8 Complete neurological recovery #2 SED Crown halo traction 1. Median mandibular glossotomy. C2-4 corpectomies. C2-5 anterior rib graft fusion Recurrent weakness 2 years s later Halo vest 3 months 2 years Fused 25° 20° 4 5 T. scoliosis. Cardiac abnormalities. Walking then quadriparesis Redo ventral resection and C1-4 iliac bone graft Worsening quadriparesis Minerva brace 1 year 18 years Fused 33° 15° 3 5 Much improved in 6 months #3 SED Crown halo traction Dorsal O-C4 fusion with loop and rib graft None Miami J collar 3 months 10 years Fused 30° 13° 4 7 Works in bookstore #4 SED Crown halo traction Dorsal O-C3 fusion with loop and rib graft 4 years later developed C-T scoliosis after T. scoliosis surgery Miami J collar 3 months 14 years Fused 27° 5° 5 7 C-T scoliosis developed after thoracic scoliosis correction #5 SMD Crown halo traction Transoral C2 odontoid resection None Minerva brace 6 months 20 years No from preop status 35° 10° 1 4 In wheelchair. Works as programmer #6 Collagen abnormality Crown halo traction C2-5 ACDF C2-5 plate with C3-4 lag screws Junctional kyphosis 7 years later after scoliosis correction Miami J collar 6 weeks 12 years Fused 36° 5° 4 7 Abnormal vertebral arteries. Thoracic outlet syndrome May-Thurner syndrome #7 OI Crown halo traction C3-5 corpectomies C2-6 Orion plate with iliac crest graft None Soft collar 4 years Fused 25° 30° 1 5 Restrictive lung disease. Multiple fractures Expired #8 OI - Bruck syndrome 1. Redo C1-2 dorsal rib graft fusion No change Molded Minerva brace 4 years Fused 40° 35° 3 4 Increased weakness age 7 2. 11 years age anterior C3-7 decompression and plate C3-7 Worsening left deltoid and biceps function Molded Minerva brace 30 years Fused 52° 34° 3 5 Lives alone. Wheelchair. Computer technologist Uses hands well #9 Aarskog syndrome Crown halo traction C2-6 anterior cervical fusion with iliac crest graft None Molded Minerva brace 20 years Fused 30° 14° 4 7 Works on a farm. No myelopathy. Syndrome in family #10 Weaver syndrome Crown halo traction Redo C1-4 dorsal rib graft fusion None Miami J collar 2 years Fused 3° 10° 2 5 Neuroblastoma age 3 months. Chemotherapy Stable #11 Larsen syndrome Crown halo traction O-C5 dorsal fusion None Halo vest 6 weeks Miami J 3 months 6 years Fused 28° 10° 3 7 Doing well #12 Multilevel cervical disconnect syndrome Crown halo traction C5 corpectomy C4-6 iliac bone fusion anteriorly Dorsal C4-6 fusion None Halo vest 3 months 5 years Fused 35° 5° 3 7 Persistent Horner pupil #13 Klippel-Feil Crown halo traction C2-6 posterior rib graft fusion None Halo vest 3 months 19 years Fused 40° 12° 3 7 Hearing loss Genitourinary abnormalities Sprengel's deformity #14 Klippel-Feil Crown halo C2-5 dorsal rib graft fusion None Halo vest 3 months 35 years Fused 45° 10° 1 6 Hearing loss Genitourinary abnormalities #15 Tuberous sclerosis Spondylolysis C2 C1-4 dorsal interlaminar rib fusion None Halo vest 3 months 6 years Fused 30° 5° 1 6 Psychomotor delay #16 C2 spondylolysis C1-4 dorsal interlaminar fusion None Halo vest 3 months 4 years Fused 35° 10° 2 6 Recovered full function in one year #17 C2 spondylolysis Tracheostomy Molded cervicothoracic brace None Mold brace 4 years 6 years Formed C2 posterior arches 45° 20° 1 3 Reformed C2 at 4 years on CT Parents did not wish surgery #18 C2 spondylolysis Intraoperative traction C1-3 dorsal rib graft fusion None Neck brace 4 months 8 years Fused 45° 12° 2 5 Developed C2 posterior elements #19 Klippel-Feil Intraoperative traction O-C4 fusion with rib graft None Molded brace 6 months 1 years Fused O-C2 dorsally 45° 16° 1 4 Able to sit and use hands Non-syndromic #20 NF1 Resection of ventral tumor C3-6 C4-5 corpectomies; C4-5 iliac graft; C3-7 Orion plate None Halo vest 6 weeks 14 years Fused 60° 15° 3 7 Recovered in 6 weeks. Works on a farm #21 NF1 Intraoperative traction Resect prevertebral tumor C2-5 kyphectomies; C2-6 anterior fusion iliac crest None Halo vest 3 months 2 years Fused 45° 20° 3 5 Initial C1-3 decompression done elsewhere #22 Fibromatosis 1. Transoral C2 decompression 2. Dorsal O-C3 fusion with loop None Brace 3 months 12 years Fused 40° 12° 4 6 Age 2 years had neck mass resected. Diagnosis "fibromatosis" #23 Mid-cervical kyphosis Traction C2-5 lateral mass fusion with screws, rods and rib grafts Worse after removal of initial traction Brace 3 months 8 years Fused 45° 15° 7 8 Doing well #24 Chiari I SHM Intraoperative traction O-C5 rib graft fusion None Halo vest 3 months 21 years Fused 50° 7° 2 6 Facets atrophied C2, C3 at surgery #25 Chiari I SHM Intraoperative traction O-C5 dorsal fusion with loop and rib None Miami J brace 4 months 22 years Fused 55° 10° 3 6 Facets atrophied C2-4 at surgery #26 Chordoma C3-4 1. Dorsal lateral C3-6 fusion 2. C2-5 anterior fusion with iliac bone None Miami J brace 6 months 18 years Fused 20° 12° 5 8 Weak in hands after initial surgery elsewhere #27 ABC tumor C4 Anterior C3-5 fusion with plate and bone None Miami J brace 4 weeks 12 years Fused 40° 15° 5 8 No recurrence SED spondyloepiphyseal dysplasia, SMD spondylometaphyseal dysplasia, JOA Japanese Orthopedic Association, MRI magnetic resonance imaging, SHM syringohydromyelia, NF1 neurofibromatosis type 1, f/u follow up, OI osteogenesis imperfecta, CT computed tomography, JK junctional kyphosis.

Ilizarov kyphectomy technique in the management of the gibbus deformity with an open wound in meningomyelocele patients: a case report with five years of follow-up.

PURPOSE: To propose an alternative method of surgical technique to address gibbus deformity in meningomyelocele with open wound simultaneously. METHODS: We report a rare case of an 8-year-old girl with a refractory skin breakdown on her gibbus deformity, which underwent an Ilizarov kyphectomy technique to address her skin breakdown, and spinal deformity at the same time, while planning a definitive fusion in the future. RESULTS: The patient was followed up for about 5 years. Her spine and overlying skin seem stable and no definite fusion has been offered to the patient so far. CONCLUSION: Ilizarov kyphectomy technique is an alternative procedure that can provide a safe and effactive method to address severe kyphosis deformity with skin breakdown. However, a comparison should be drawn to other procedures, while including more patients with longer follow-up.

Delayed aortic injury after thoracic corrective osteotomy: a case report.

PURPOSE: To present a case of delayed aortic perforation due to a nondisplaced fracture of the 9th rib after vertebral osteotomy for degenerative kyphoscoliosis in patients with osteoporosis. METHODS: A 78-year-old female patient with osteoporosis had undergone T9-iliac correction surgery for degenerative kyphoscoliosis. After 2 years, the patient underwent T10 pedicle subtraction osteotomy for a T10 vertebral fracture and progression of kyphosis. Postoperatively, the patient had been doing well for 3 weeks; however, just before the day of discharge, she died following a cardiopulmonary arrest. An autopsy was performed with the consent of her family. RESULTS: Autopsy revealed a large amount of blood and a clot in the left thoracic cavity. Aortic perforation was found just in front of a nondisplaced fracture of the left 9th rib. CONCLUSION: This report describes a new critical complication after spinal correction surgery. Even without pedicle screw malposition, aortic injuries can happen to patients with osteoporosis after corrective osteotomy for degenerative kyphoscoliosis due to positional change of aorta and fragility of the ribs. The spine surgeon should be aware of this type of complication, and rib fractures around the aorta after vertebral osteotomy should not be neglected even when there is no displacement.

Cervical rotational osteotomy for correction of axial deformity in a patient with ankylosing spondylitis.

PURPOSE: Severe cervical axial deformity associated with ankylosing spondylitis (AS) is rare in clinic, and there are little concerns about surgical treatment of axial deformity associated with AS. The case study aims to show the surgical technique to perform cervical rotational osteotomy. METHODS: We present the case of a young AS patient whose neck was fixed in a left-rotational posture at 18°, requiring his trunk to be turned to the right to look forward visually. This made his gait appear to be limping, inconveniencing him with great difficulty. In order to correct this deformity, we performed a novel cervical rotational osteotomy through a one-stage posterior-anterior-posterior approach. Firstly, we performed laminectomies of C7 and T1, followed by a C7/T1 facetectomy with release of the bilateral C8 nerve roots. Next, we performed C7/T1 discectomy, bony resection of the lateral body and uncovertebral joints. The head of the patient was then rotated manually, so that both his face and torso were simultaneously facing frontward. Finally, rods spanning the screws from C6 to T2 were fixed. RESULTS: Postoperatively, the patient's axial malalignment was significantly improved, and he was able to walk normally. Surgical outcomes were well maintained at a 3-year follow-up. CONCLUSION: Through this case, we hope to draw the attention to spinal axial deformity and provide a reference point in the surgical treatment of spinal axial deformity.

Meta-analysis of the efficacy of ketamine in postoperative pain control in adolescent idiopathic scoliosis patients undergoing spinal fusion.

PURPOSE: In this meta-analysis, we aim to compare ketamine use versus a control group (saline solution) during induction of anesthesia in adolescent idiopathic scoliosis patients undergoing fusion surgery in terms of postoperative opioid consumption, pain control, and side effects. METHODS: A PubMed search of studies published over the last 20 years using the descriptor/terms "ketamine AND scoliosis" was performed. Baseline characteristics of each article were obtained and efficacy measures analyzed (morphine equivalent treatment at 24, 48, and 72 h postoperatively, complications (vomiting/nausea and pruritus), length of hospital stay (days); and pain score (VAS)) (Review Manager 5.4 software package). RESULTS: Five randomized clinical trials were included. Morphine administration showed statistically significant differences at 24 and 48 h (MD - 0.15, 95% CI - 0.18 to - 0.12) and (MD - 0.26, 95% CI - 0.31 to - 0.21) between the ketamine and control (saline solution), respectively. No intergroup differences were found regarding nausea/vomiting and pruritus (OR 0.77, 95% CI 0.35 to 1.67) and (OR 0.71, 95% CI 0.31 to 1.62), respectively, same as for the pain score (MD - 0.75, 95% CI - 1.71 to 0.20). CONCLUSIONS: The use intraoperative and postoperative continuous low doses of ketamine significantly reduces opioid use throughout the first 48 h in patients with AIS who undergo posterior spinal fusion.

The efficacy of 3D personalized insoles in moderate adolescent idiopathic scoliosis: a randomized controlled trial.

BACKGROUND: Bracing and exercise methods were used in scoliosis rehabilitation and proven effective. There was little evidence about the efficacy of insoles on scoliosis. OBJECTIVE: This study aimed to investigate the effects of 3D personalized insoles on curve magnitude, postural stability, and quality of life (QOL) in moderate adolescent idiopathic scoliosis (AIS) patients. METHODS: Thirty-six volunteers with adolescent idiopathic scoliosis, who had moderate curves (20°-45°), were randomly divided into the experimental and control groups. The control group received traditional rehabilitation with bracing and exercises, and the experimental group received the insole interventions in addition to traditional rehabilitation. The outcome measures were Cobb angle, angle of trunk rotation (ATR), postural stability, and quality of life (Scoliosis Research Society-22 questionnaire). Measurements were conducted at baseline examination, two months and six months. RESULTS: After two and six months of treatment, the Cobb angle and ATR in both groups were significantly decreased as compared with the baseline (p < 0.05), but no significant group difference in Cobb angle and ATR was found in the study (p > 0.05). There was a significant difference in the sagittal balance index at six months compared to the control group (p < 0.05), and a significant difference in the coronal balance index was observed at six months compared to baseline in the experimental group (p < 0.05). Quality of life did not change in either group (p > 0.05). CONCLUSION: Combining bracing with exercise in patients with moderate AIS is effective. 3D personalized insoles cannot reduce the Cobb angle and angle of trunk rotation of patients with moderate AIS but might have the potential to improve postural stability.

Expert consensus on surgical treatment for adolescent idiopathic scoliosis in Japan.

BACKGROUND: Surgical treatment for adolescent idiopathic scoliosis (AIS) has changed significantly with the advent of new medical devices and surgical procedures. Today, pre- and postoperative management differs widely between institutions. The purpose of this study is to establish consensus regarding the surgical management of AIS in Japan through the use of a questionnaire survey of experienced spine deformity surgeons. METHODS: From February to March 2020, experienced spine deformity surgeons who perform more than 25 cases of AIS surgery annually were asked to respond to a questionnaire request regarding AIS surgical management formulated by the International Affairs Committee of the Japanese Scoliosis Society. For each of the questions, consensus was achieved upon a 70% agreement among respondents. RESULTS: Responses were received from 25 of the 32 (78%) experienced spine deformity surgeons. The average age of the responding surgeons was 52 years with an average practice experience of 28 year. Consensus was achieved on 74 (76%) of the 97 aspects of care presented in the questionnaire and is broken down as follows: 12 of 17 items for preoperative management, all 5 items for perioperative management, 11 of 14 items for surgical technique, 9 of 15 items for implant selection, 6 of 8 items for bone grafting, 7 of 10 items for blood conservation, 5 of 7 items for postoperative management, all 17 items for postoperative evaluation, and 2 of 4 items for aftercare. CONCLUSIONS: Expert consensus was achieved on 74 aspects of the surgical management of AIS in Japan. In implant selection and aftercare, consensus was obtained in less than 70% of the aspects, revealing differences in AIS management between institutions. These findings on AIS surgery in Japan, informed by expert opinion, will conceivably help spine deformity surgeons determine appropriate surgical management of AIS.

Treatment for tuberculosis of the subaxial cervical spine: a systematic review.

PURPOSE: To systematically review the clinical manifestations and treatment outcomes of patients with subaxial cervical spinal tuberculosis (SCS-TB) and evaluate the current evidence for surgical or nonsurgical treatment. METHOD: A systematic review was performed using the PubMed, ScienceDirect, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Studies published in English from January 2000 to December 2018 were included in the search. A reference lists search of relevant articles was also conducted for other potential references. The risk of bias was assessed with the 13-item criteria recommended by the Cochrane Back and Neck Group and the Methodological Index for Non-Randomized Studies. RESULTS: Fifteen articles were included with a total of 456 patients, of which only 1 study was randomized and fourteen were nonrandomized. The most common symptom reported was neck pain and stiffness, and the most common segment involved was C5. Of the 456 patients, 329 (72.1%) were treated surgically. Most experienced neurologic recovery after surgery. Instrumentation resulted in maintenance of the correction of alignment throughout the follow-up period. The use of radical debridement is still in debate. CONCLUSIONS: Anti-TB therapy is necessary for all SCS-TB patients, including those underwent surgical management. For patients with neurological dysfunction, the surgical method with decompression and instrumentation could provide better cervical spinal alignment and stability. For adult, the radical debridement remains in debate, while for children, radical debridement may cause the development of progressive kyphosis during growth. Larger randomized comparative studies with longer follow-up times are needed.

Systemic changes associated with quality of life after surgical treatment of kyphotic deformity in patients with ankylosing spondylitis: a systematic review.

PURPOSE: In addition to changes in the skeletal system after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other systemic changes associated with the patients' quality of life were reported. The purpose of this study was to conduct a systemic review of the literature to determine systemic changes associated with patients' quality of life following correction of kyphotic deformity secondary to ankylosing spondylitis. METHODS: We searched the databases PubMed, EMBASE, Clinicalkey and Cochrane Library without time restriction. Selected papers were assessed by published guidelines. We investigated systemic changes associated with patients' quality of life after surgical treatment of advanced ankylosing spondylitis. RESULTS: The initial search yielded 888 citations. Twelve of these studies met the inclusion and exclusion criteria. Two were level II evidence study, and ten were level III evidence studies. Changes were reported including aorta length, abdominal morphology, digestive function, cardiopulmonary function, psychological status, and sexual activity. CONCLUSIONS: In addition to skeletal changes after spinal osteotomy for treatment of kyphotic deformity in advanced-stage AS patients, many other changes were reported. Spine surgeons should pay more attention to these life quality-related changes and be aware of potential risks when performing surgery for advanced-stage AS patients. These slides can be retrieved under Electronic Supplementary Material.

Revision surgery in proximal junctional kyphosis.

INTRODUCTION: Proximal junctional kyphosis (PJK) is a relatively common complication following spinal deformity surgery that may require reoperation. Although isolating the incidence is highly variable, in part due to the inconsistency in how PJK is defined, previous studies have reported the incidence to be as high as 39% with revision surgery performed in up to 47% of those with PJK. Despite the discordance in reported incidence, PJK remains a constant challenge that can result in undesirable outcomes following adult spine deformity surgery. METHODS: A comprehensive literature review using Medline and PubMed was performed. Keywords included "proximal junctional kyphosis," "postoperative complications," "spine deformity surgery," "instrumentation failure," and "proximal junctional failure" used separately or in conjunction. RESULTS: While the characterization of PJK is variable, a postoperative proximal junction sagittal Cobb angle at least 10°, 15°, or 20° greater than the measurement preoperatively, it is a consistent radiographic phenomenon that is well defined in the literature. While particular studies in the current literature may ascertain certain variables as significantly associated with the development of proximal junctional kyphosis where other studies do not, it is imperative to note that they are not all one in the same. Different patient populations, outcome variables assessed, statistical methodology, surgeon/surgical characteristics, etc. often make these analyses not completely comparable nor generalizable. CONCLUSIONS: The goal of adult spine deformity surgery is to optimize patient outcomes and mitigate postoperative complications whenever possible. Due to the multifactorial nature of this complication, further research is required to enhance our understanding and eradicate the pathology. Patient optimization is the principal guideline in not only PJK prevention, but overall postoperative complication prevention. These slides can be retrieved under Electronic Supplementary Material.

Iatrogenic biological fracture of the cervical spine during gradual halo traction for kyphotic deformity correction: case report.

BACKGROUND: Severe kyphotic deformities carry high risk for neurological injuries as osteotomies are often required for correction. Surgeons often utilize a staged approach for dealing with these conditions starting with a period of halo traction to stretch tight soft tissues and partially correct the deformity, followed by surgery. Halo traction is a relatively safe procedure and complications are uncommon. We report a unique case of iatrogenic fracture of the cervical spine during gradual halo traction for deformity correction of a severe cervical kyphosis. CASE PRESENTATION: An 80-year-old female with previous cervical spine tuberculosis infection and C5-C6 anterior spinal fusion developed severe cervical kyphosis of 64° from C2-C6 and neck pain requiring deformity correction surgery. Gradual increase in traction weight was applied, aiming for a maximum traction weight of 45 pounds or half body weight. During the 1st stage halo-gravity traction, sudden neck pain and a loud cracking sound was witnessed during increase of the traction weight to 14 pounds. Imaging revealed a fracture through the C4 and reduction in kyphosis deformity to 11° from C2-C6. There was no neurological deficit. No further traction was applied and the patient underwent an in-situ occipital to T3 fusion without osteotomies. At 3-year follow-up, the patient was symptom-free and radiographs showed solid fusion and maintenance of alignment. CONCLUSIONS: Iatrogenic fracture may occur with halo traction. Elderly patients with osteoporotic and diseased bone should be closely monitored during the treatment. A fracture without complications was a fortunate complication as the patient was able to avoid any high-risk osteotomies for deformity correction. LEVEL OF EVIDENCE: IV.

Analysis of the Curative Effect of the Anterior Approach to the Lower Cervical Spine for Cervicothoracic Spinal Tuberculosis.

BACKGROUND: The purpose of this study was to explore the clinical effect of the anterior approach to the lower cervical spine for cervicothoracic spinal tuberculosis (CTSTB). METHODS: A total of 8 patients (6 males and 2 females) with CTSTB diagnosed by imaging examination and γ-interferon test, underwent the first stage lesion removal, bone grafting and internal fixation through the anterior approach to the lower cervical spine, were studied. Then, the clinical efficacy was evaluated using statistical analysis based on the materials about the Cobb angle of kyphosis, visual analog scale (VAS), Frankel grade, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). RESULTS: All patients' age ranged from 28 to 64 years (mean 46.2 ±â€Š16.3). The mean operation time was 145 minutes (range 90-180 mins), intraoperative blood loss was 425 mL (range 200-1000 mL), and the average bone fusion time was 7.4 months. Postoperative neurological function of Frankel grading was significantly improved compared with that of preoperative. At final follow-up, the kyphosis angle was significantly decreased to 10 ±â€Š2.1°, the mean VAS score was 1.6 ±â€Š0.9 showing significant improvement, ESR and CRP returned to normal. The incidence of complications within 3 months after surgery was 25%, and the incidence of complications directly related to surgery was 12.5% (cerebrospinal fluid leakage). CONCLUSION: On the basis of familiarity with the anatomical structure and combining with the experience of the surgeon, the anterior approach to the lower cervical spine can be an effective treatment method for CTSTB.

[Posttraumatic deformity of the thoracolumbar spine]. / Posttraumatische Fehlstellungen der Brust- und Lendenwirbelsäule.

Posttraumatic kyphotic deformities of the thoracolumbar spine may result in significant clinical complaints. If conservative treatment is not successful, surgical correction of the kyphosis becomes an option. In contrast to degenerative deformities, posttraumatic kyphotic deformities are usual limited to few segments and can be treated with shorter constructs. The surgical strategy depends on the rigidity and the localization of the posttraumatic kyphotic deformity. In this respect purely posterior approaches and combined posteroanterior surgical approaches are available each with different advantages and disadvantages.

Cervical alignment after single-level anterior cervical corpectomy and fusion using autologous bone graft without spinal instrumentation for cervical pyogenic spondylitis.

BACKGROUND: Subsidence in anterior cervical corpectomy and fusion (ACCF) for cervical degenerative disease (CDD) are constantly observed during the postoperative course. Although kyphotic change of cervical alignment occurred frequently in cervical pyogenic spondylitis (CPS) postoperatively, studies on the postoperative change in segmental angle for CPS are limited. This study aimed to analyze cervical alignment after single-level ACCF using autologous bone graft without spinal instrumentation for CPS compared with that for CDD. METHODS: Six patients underwent single-level ACCF using autologous bone graft without spinal instrumentation for CPS. The control group included 18 age-matched patients who underwent single-level ACCF using autologous bone graft for CDD without spinal instrumentation for the same duration. Cervical and lateral plain radiographs and computed tomography scans were taken. The Frankel classification was used to assess the neurological status preoperatively, postoperatively, and at 2-year follow-up for CPS. RESULTS: At 2-year follow-up, the average segmental angle at the fusion level was - 12.2° ± 6.9° for CPS and - 5.2° ± 7.6° for CDD (p = 0.04). Changes in segmental angle at the fusion level were - 7.2 ± 9.0° for CPS and - 1.1° ± 7.1° for CDD (p = 0.02). At 2-year follow-up, the average anterior segmental fusion height was 23.4 ± 1.7 mm for CPS and 29.1 ± 5.1 mm for CDD (p < 0.001). At 2-year follow-up, bone fusion in the CPS group was classified as grade 5 (complete fusion) in 4 patients (66.7%) and grade 4 (probable fusion) in 2 (33.3%). In the CDD group, it was grade 5 in 13 patients (72.2%) and grade 4 in 5 patients (27.8%). Overall, both groups achieved 100% bone fusion rate. The Frankel classification in all CPS cases improved or leveled off. CONCLUSION: Progression of segmental kyphosis angle and subsidence of graft bone were observed postoperatively on all CPS cases. However, the neurological recovery and bone union were satisfactory.

Bone manifestations in neuronopathic Gaucher disease while receiving high-dose enzyme replacement therapy.

Avascular necrosis (AVN), one type of bone infarction, is a major irreversible complication of Gaucher disease (GD). In this report, two pediatric patients with GD type 3, homozygous for the L483P pathogenic variant (formerly L444P), developed AVN despite treatment on long-term, high-dose enzyme replacement therapy (ERT). ERT was initiated in both patients, who had intact spleens, shortly after diagnosis with an initial dramatic response. However, both patients exhibited AVN after 5.5 and 11 years on high-dose ERT, respectively, despite good compliance and normalized hematological findings and visceral symptoms. This report demonstrates the importance of careful, regular surveillance of the musculoskeletal system in addition to monitoring the neurological symptoms associated with neuronopathic GD. Additionally, it highlights the limitations of ERT in terms of targeting certain sanctuary sites such as bone marrow and suggests the need for new treatment modalities other than ERT monotherapy to address these limitations.