Achieving Shoulder Balance Using Medial and Lateral Radiological Measures in Adolescent Idiopathic Scoliosis.

Background: Research has shown that postoperative shoulder imbalance is a common problem after spinal fusion in adolescent idiopathic scoliosis (AIS). The best radiographic predictor has not yet been determined and results are inconsistent. This study was to investigate whether using medial and lateral shoulder parameters can effectively achieve postoperative shoulder balance. Methods: A prospective database of AIS undergoing posterior spinal fusion were reviewed. Patient demographics and radiological parameters including radiographic shoulder height (RSH), clavicle angle, T1-tilt and first-rib angle at baseline, 6 weeks and last minimal follow up of 2 years were recorded. Correlations between radiological parameters were assessed using Pearson's correlation coefficients. Multivariable linear models identified predictors associated with increased RSH. Results: 219 patients (mean age:13.7 years; 81.7% female) were included. The mean follow-up time was 2.8 years (range:2.0-7.0). The mean RSH at baseline, 6 weeks and last follow up was improved significantly at 95.8%. Preoperative (r=0.8; p<0.001) and post-operative measurements of RSH at 6-week (r=0.9; p<0.001) and last follow up (r=0.9; p<0.001) correlated strongly with clavicle angle measured at respective time-points. In a multivariable linear model, we noted marginal increase in clavicle angle (+4.3°; p<0.001) to be associated with increased RSH. On the contrary, first rib angle and T1-tilt demonstrated moderate to weak correlation with RSH. Conclusion: Clavicle angle is strongly consistent with RSH. First rib angle and T1-tilt as demonstrate medial shoulder balance are moderate to weak correlation. Leveling T1 tilt and first rib angle do not guarantee the postoperative shoulder balance. Level of Evidence: IV.

Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis.

PURPOSE: Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique. METHODS: A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction. RESULTS: A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24-108 months). The RSH was significantly improved from - 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P < 0.0001). Clavicle angle was improved from 2.13° to 1.31° (P < 0.0001). T1 tilt was improved from 5.6° to 2.2° (P < 0.0001). At last follow-up, 95.8% of patients were shoulder balanced. There was a significant improvement of Cobb angle with an average correction of the upper thoracic curve of 42% and main thoracic curve of 67%. CONCLUSION: The PHDS demonstrates the potential for additional shoulder balance improvement. Extension of fusion to structural proximal thoracic spine is the key to success for shoulder balance. It remains to be seen whether these improvements will translate into improved clinical outcomes in the longer term.

A Progressive Paraplegic Patient with Thalassemia Because of Extramedullary Hematopoiesis and Vertebral Fracture: A Case Report.

CASE: We present a case of progressive paraplegia because of extramedullary hematopoiesis and pathological vertebral fracture in thalassemia patient. The various surgical techniques including larger pedicle screws, bicortical fixation, and convergent direction to improve pullout strength had been used secondary to osteoporotic bone and kyphotic deformity. CONCLUSION: Prompt diagnosis and awareness of the compromised bone quality of the thalassemic patient is essential to guide the proper management and produce the desire outcomes.

Late Presentation of Recurrent Symptomatic Amputation Neuroma.

INTRODUCTION: Post-traumatic amputation neuroma is one of the common complications that involve optimal functional outcomes. The current literature has a few examples of late presentation of traumatic stump neuroma. However, no available examples of late presentation of recurrent symptomatic amputation neuroma causing impaired functional outcomes have been reported. CASE REPORT: We present a case of recurrent symptomatic stump neuroma after above-knee amputation and neurectomy for 28 years. CONCLUSION: Late presentation of recurrent stump neuroma is an unusual condition, requiring early detection and treatment to gain better functionality. The patient scenario is unique and valuable for future management, including case awareness regarding this unique pathology.

A Child with a Rare Extraosseous Extension and Pathologic Fracture from a Vertebral Hemangioma: A Case Report.

CASE: We present a case of a pathologic vertebral fracture and encroachment into the spinal canal from a vertebral hemangioma in a 13-year-old boy. The original approach of embolization followed by an anterior-posterior resection and stabilization through a costotransversectomy had to be converted intraoperatively to a combined anterior and posterior approach secondary to excessive bleeding. CONCLUSION: Because of the hypervascularity and the extensive nature of aggressive vertebral hemangiomas, surgeons attempting procedures similar to the case described herein must be prepared to adapt to the circumstances when preoperative embolization is not totally effective. Surgical technique, proper anesthesia, and patient clotting capacity are important factors to consider.

Outcome of Single Event Multilevel Soft Tissue Release for Spastic Diplegic Cerebral Palsy.

Objective: We evaluated the results of single event multilevel surgery for treatment of contractures of lower extremities in spastic diplegic cerebral palsy patients in Phramongkutklao Hospital. Material and Method: The present study included 40 patients (23 boys, 17 girls, mean age 8.9 years) with spastic diplegic cerebral palsy, who underwent single event multilevel surgery for the treatment of soft tissue contractures in lower extremities secondary to spasticity between 2006 and 2009. Evaluations were based on pre- and post-operative (follow-up for three years), physical examination, and video observational gait pattern on the Gross Motor Function Classification System (GMFCS) scores and Functional Mobility scales (FMS). Results: Range of motion of all operated joints were increased post-operatively, resulting in significant improvement in posture, gait, and balance of patients. The mean GMFCS scores were 4.2 pre-operatively, 4.1 at post-operatively 1-year, 3.8 at post-operative 2-year, and 3.0 at post-operative 3-year, which were significantly improved two and three years post-operative period (p<0.05). The mean FMS scores were improved at 5 meters post-operative at 1-, 2-, and 3-year (p<0.05). The mean FMS scores at 50 meters were improved at 3-year post-operative period. Conclusion: Single event multilevel surgery can help spastic diplegic cerebral palsy patients improve range of motions, gait patterns, and mobility functions.