Midterm Results of Hemivertebrae Resection and Transpedicular Short Fusion in Patients Younger Than 5 Years: How Do Thoracolumbar and Lumbosacral Curves Compare?

STUDY DESIGN: Retrospective case series with comparative analysis. OBJECTIVE: To analyze a consecutive cohort of very young patients operated for congenital scoliosis secondary to a single hemivertebra (HV) and compare thoracolumbar (TL) versus lumbosacral (LS) curve results. SUMMARY OF BACKGROUND DATA: Despite the published successful results regarding early hemivertebra resection and short fusion for congenital hemivertebrae, literature lacks midterm results, especially in very young children. METHODS: Patients under 5 years of age, operated by HV resection and transpedicular short fusion, with follow-up longer than 5 years, were included. Preoperative, postoperative (1-year), final radiographic parameters, and complications were recorded. Midterm results were analyzed and TL versus LS curves were compared. RESULTS: Twenty-three patients were included (14 TL and 9 LS HV). The mean age was 3.5 ± 1.7 years and the mean follow-up was 7.6 years (4.7-13.7). The mean preoperative Cobb angle (40.3° ± 6.7°), corrected 65% postoperatively and 50% at final follow-up. The compensatory cranial curve improved spontaneously from 25.3° ± 14.8° to 13.5° ± 12° and finally to 19.9° ± 10.7°. Preoperative coronal balance corrected postoperatively but worsened at the final follow-up. TL curves corrected more initially than LS curves (TL: -29°, 68%, vs. LS: -22°, 59%; p = .043); however, both groups lost correction at the final follow-up (TL: 4°, 56%, vs. LS: 7°, 39%; p = .186). The LS group had a larger preoperative compensatory curve, which corrected with surgery but lost more correction at the final follow-up (p = .046). Segmental kyphosis was especially corrected in the TL group (TL: -14° vs. LS: -2°, p = .018) and was maintained over time. CONCLUSION: Early hemivertebra resection and transpedicular short fusion allowed good coronal correction initially, which was difficult to maintain at midterm, especially at the LS junction. Sagittal plane correction was excellent in TL deformities and was maintained over time. Results were more challenging in the LS group compared with TL deformities. Guidance to avoid unwanted results is proposed. LEVEL OF EVIDENCE: Level III.

Decision Making of Graduation in Patients With Early-Onset Scoliosis at the End of Distraction-Based Programs: Risks and Benefits of Definitive Fusion.

STUDY DESIGN: Retrospective comparative analysis. OBJECTIVE: Study early-onset scoliosis (EOS) graduated patients to establish founded criteria for graduation decision making and determine the risks and benefits of definitive fusion. SUMMARY OF BACKGROUND DATA: EOS is treated by growth-friendly techniques until skeletal maturity. Afterwards, patients can be "graduated," either by definitive fusion (posterior spinal fusion [PSF]) or by retaining the previous implants (Observation) with no additional surgery. Criteria for this decision making and the outcomes of definitive fusion are still underexplored. METHODS: We analyzed a consecutive cohort of "graduated" patients after a distraction-based lengthening program. We gathered demographic, radiographic, and surgical data. The results of the two final treatment options were compared after 2 years' follow-up. RESULTS: A total of 32 patients were included. Four patients had incomplete records. Thirteen underwent PSF, and 15 were observed. The mean age at initial treatment was 8 ± 3 years, with a mean follow-up of 8.3 ± 2.9 years. Both groups had similar preoperative and final radiographic parameters (p > .05). The criteria for undergoing PSF were as follows: implant-related complications, main curve magnitude (PSF = 63.2° ± 9° vs. OBS = 47.9° ± 15°; p = .008), curve progression >10°, and sagittal misalignment (SVA). During PSF 12/13 patients underwent multiple osteotomies, one vertebrectomy, and 3 costoplasties. Surgical time was 291.5 ± 58 minutes; blood loss was 946 ± 375 mL; and the number of levels fused was 13.7. Coronal deformity was corrected 31%, T1-S1 length gained was 31 ± 19.6 mm and T1-T12 length gained was 9.3 ± 39 mm; kyphosis was reduced by 22%. However, coronal balance worsened by 2.3 ± 30.8 mm. No major complications were encountered in these patients. CONCLUSIONS: Graduation by PSF depended on unacceptable or progressive major curve deformity, sagittal misalignment, or complications with previous implants. Observation depended on curve stabilization, Cobb <50°, and coronal misalignment <20 mm. Definitive fusion effectively corrected coronal and sagittal deformity and increased trunk height. However, it exposed patients to a very demanding surgery without improvement in coronal balance. LEVEL OF EVIDENCE: Level III, therapeutic.

Impact of Iliac Instrumentation on the Quality of Life of Patients With Adult Spine Deformity.

STUDY DESIGN: Retrospective comparative analysis of data collected prospectively in an adult spine deformity (ASD) multicenter database. OBJECTIVE: To evaluate the impact of the iliac screws on the quality of life of ASD patients compared with those instrumented above the pelvis (L5/S1/S2). SUMMARY OF BACKGROUND DATA: The impact on patient's daily activities and functions, of immobilizing the sacroiliac joint with iliac screws for the treatment of ASD is still underexplored. METHODS: Inclusion criteria were ASD patients with a long arthrodesis of at least eight levels and whose lowest instrumented vertebrae (LIV) were L5 or below. We analyzed the following preoperative and 2 years' follow-up variables: age, Cobb angle, coronal and sagittal alignment, number of instrumented levels, Oswestry Disability Index (ODI), Core Outcome Measures Index (COMI), Scoliosis Research Society-22 (SRS-22), and Short Form 36 (SF-36) questionnaires. Statistical analysis was performed with Mann-Whitney U test, and Wilcoxon test. RESULTS: A total of 129 patients were included, and separated into two groups: "Iliac Yes," with the LIV at the Ilium (N = 104), and "iliac No," with the LIV at L5/S1/S2 (N = 25). Patients instrumented with Iliac screws were older (x = 66 vs. 56 yr, P = 0.008), and had lower Cobb magnitude (x = 31° vs. 45°, P = 0.019). No statistically significant differences were found in the health related quality of life (HRQOL) questionnaires prior to surgery or at 2-years' follow up. The "Iliac Yes" group significantly improved all radiographic and HRQOL scores parameters 2 years after surgery (P < 0.005). While the "Iliac No" group failed to significantly improve (coronal balance, sagittal vertical axis, SF-36 Physical functioning, SF-36 General health, and COMI) (P > 0.05) CONCLUSION.: ASD patients instrumented with iliac screws significantly improved all their HRQOL questionnaires 2 years after surgery. The 2 years' postoperative HRQOL scores were similar in both groups, regardless of the sacroiliac joint immobilization. Therefore, with the currently available tools, we cannot state that iliac instrumentation has a negative influence on patient's quality of life. LEVEL OF EVIDENCE: 4.

Untreated Thoracic Curve in Adult Idiopathic Scoliosis: What Are Patients' Concerns?

STUDY DESIGN: Retrospective two-cohort comparative analysis of data collected prospectively. OBJECTIVES: To analyze a cohort of patients with untreated thoracic curves of an adult multicenter deformity database [European spine study group (ESSG)], describe patient characteristics and concerns, and establish the rate and motivations for surgical intervention. SUMMARY OF BACKGROUND DATA: Idiopathic thoracic curves have a significant clinical and socioeconomic impact during adolescence. However, little attention has been given to adult thoracic scoliosis. The complaints of patients that have reached adulthood with an untreated thoracic curve are still not well studied. METHODS: The database of 1,142 prospective consecutive adult patients with deformity was searched to identify patients with untreated thoracic idiopathic curves: Schwab Type T curves, and Schwab Type D with thoracolumbar/lumbar (TL/L) curves <40° and a difference between main thoracic (MT) and the TL/L ≥15°. Demographic data, different radiologic preoperative parameters, and health-related quality of life questionnaires were assessed. RESULTS: Forty-two patients met inclusion criteria, showing the following characteristics: age, 30.9 ± 12.5 years; thoracic Cobb, 55.6 ± 10.8°; lumbar Cobb, 28.1 ± 7.3°; sagittal vertical axis, 2.9 ± 19.3 cm; Core Outcome Measures Index (COMI), 4 ± 2.5; Oswestry Disability Index (ODI), 20.4 ± 17.4; Scoliosis Research Society-22 questionnaire (SRS-22) subtotal, 3.6 ± 0.7; 36-Item Short Form Health Survey (SF-36) mental health, 46.1 ± 10.1; SF-36 physical health, 47.3 ± 11.1. Only 13 of these patients underwent surgery. Compared with nonoperated patients, they were younger (24.3 ± 7.3 vs. 33.8 ± 13.4 years; p = .009), had larger MT curves (58.7° ± 9.6 vs. 50.6° ± 8.3; p = .012), and had worse SRS-22 self-image scores (2.9 ± 0.8 vs. 3.5 ± 0.8; p = .042). No patients older than 50 years underwent surgery, despite having worse SRS-22 function (3.0 ± 0.9 vs. 4.1 ± 0.9, p = .032) and worse ODI scores (42.4 ± 19.9 vs. 18.7 ± 18.0, p = .026). CONCLUSIONS: Very few adult deformity patients sought treatment because of untreated thoracic scoliotic curve. The probability of undergoing surgery was low (13/42), and it was associated with youth, curve magnitude, and poor self-image. The rate of surgical treatment of the thoracic curve appears to diminish with age, despite its being associated with poorer function and greater disability in the older patient.

The reliability of sagittal pelvic parameters: the effect of lumbosacral instrumentation and measurement experience.

STUDY DESIGN: Sagittal pelvic parameters (SPPs) of a representative patient sample drawn from a consecutive adult spinal deformity database were measured using Surgimap Spine. Estimated coefficient of reliability intraclass coefficient (95% confidence interval), standard error of measurement, and mean absolute deviation were used for the analysis. OBJECTIVE: The primary objective of this study was to assess the reliability of SPP measurements using Surgimap Spine. The secondary objective was to evaluate the impact of pelvic instrumentation as well as the impact of user expertise. SUMMARY OF BACKGROUND DATA: The radiographical measurement of SPP is increasingly recognized as playing a critical role in establishing the surgical goals and surgical strategy of many spinal disorders. Although instrumented flatback is a common cause of sagittal malalignment, to our knowledge, SPP measurement reliability has never been assessed in instrumented spines. METHODS: Sixty-three adult full-spine standing lateral radiographs (31 with lumbosacral instrumentation) were measured twice by 13 observers using Surgimap Spine. Observers were stratified into 3 levels of experience: high (research coordinators, 4), mid (senior surgeons, 5), and low (junior surgeons, 4). Research coordinators trained all surgeons for less than 30 minutes. Parameters measured were pelvic incidence, pelvic tilt, and sacral slope. RESULTS: Thirteen observers and 63 radiographs generated 817 observations (2 misses). Overall inter- and intraobserver reliability of SPP measurement was excellent (intraclass coefficient > 0.85). Lumbosacral instrumentation did not modify intraobserver reliability but reduced significantly interobserver reliability of pelvic tilt (P = 0.006) and sacral slope (P = 0.007). Experience did not affect intraobserver reliability but interobserver reliability of highly experienced observers was significantly lower (P < 0.05) than among less experienced observers. CONCLUSION: Measurement of SPP using Surgimap Spine equals or improves previously reported reliability data. Lumbosacral instrumentation reduces interobserver reliability taking it from excellent to moderate in the sacral slope measurement. Inexperienced observers can measure SPP reliably after a short tutorial. LEVEL OF EVIDENCE: 4.