Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates.

BACKGROUND: It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype. METHODS: We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups. RESULTS: We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups. CONCLUSIONS: Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype. LEVEL OF EVIDENCE: Level III, therapeutic.

Radiographic outcomes and complications of anterior column realignment (ACR): a systematic review.

BACKGROUND: Anterior Column Realignment (ACR) was introduced to serve as a powerful segmental kyphosis correction technique in minimally invasive Adult Spinal Deformity (ASD) surgery. Releasing the Anterior Longitudinal Ligament (ALL) and annulus allows opening of the disc space to accommodate hyperlordotic cages. The overall safety and efficacy of ACR has been difficult to determine due to the heterogenicity of surgical techniques, complications reporting, and a paucity of published studies leading to preliminary and controversial conclusions. PURPOSE: To determine the efficacy and complications rates associated with ACR. STUDY DESIGN: Systematic review. METHODS: We queried the MEDLINE, Google Scholar, and EMBASE databases for all literature related to ACR procedure with a publication cutoff start date of January 1, 2010. This systematic review was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. nonEnglish, nonhuman, case reports and review article publications were excluded. RESULTS: A total of 298 studies were identified. Following screening of title, abstract, and full text, 16 articles were included in the review with a total 756 patients. All the studies included in this systematic review were retrospective case series with a level of evidence IV. Ten studies reported ACR-related complications, with an average rate of 27.2%. The rate of reoperations was reported in 5 studies, for which the average reoperation rate was 9.5%. Cage Subsidence (CS) occurred in 13.7%, Proximal Junctional Kyphosis (PJK) in 12.2%, neurologic injury in 7.3%, and Proximal Junctional Failure (PJF) in 2.7%. The vascular injury rate was 0.5%, with bowel perforation and ureteric injury occurring in 0.2%. For the Patient Reported Outcome Measures (PROMs) and radiological outcome analysis we excluded studies with less than 12 months follow up leaving 8 studies eligible for the analysis. There was a significant improvement of both local Motion Segment Angle (MSA) and Intra Discal Angle (IDA) with a mean segmental correction of 20° lordosis in the 3 studies that reported these parameters. CONCLUSION: Based on the limited data available in this systematic review, the ACR technique has significant ability to restore and, when needed, correct the local segmental intervertebral angulation and thereby influencing the overall regional and global sagittal alignment. The associated risk of vascular, bowel, and nerve injury did not seem to be significantly higher in this review than other alternative lumbar interbody fusion techniques. Additional higher quality studies, including a consensus for reporting complications is required to reach definitive conclusions regarding its possible associated risks.

Proximal foundation anchor variations and their correlation with unplanned return to the operating room (UPROR) in children with EOS treated with magnetically controlled growing rods (MCGR).

INTRODUCTION: The evolution of MCGR technique has led to modifications in the configuration of the proximal construct to decrease the incidence of implant-related complications (IRC) and revision surgeries. However, there is no data characterizing the performance of the most used configurations reducing the risk of complications. METHODS: 487 patients were identified from an international multicenter EOS database. INCLUSION CRITERIA: EOS patients, primary dual MCGR, complete radiographs, and minimum of 2-year follow-up. 76 patients had incomplete X-rays, 5 had apical fusions, and 18 had inconclusive complications, leaving 388 patients for review. A digital spine template was created to document UIV; number of levels; number, type, and location of anchors; as well as implant configuration. First available postoperative and latest follow-up radiographs were reviewed by two senior surgeons and two spine fellows. UPROR due to IRC was defined as any change in proximal anchors between the postoperative and final follow-up radiographs. RESULTS: The most common proximal construct configuration: UIV at T2 (50.0%) with 17.5% UPROR, followed by T3 (34.0%) with 12.1% UPROR; number of levels was three (57.1%) with 16.8% UPROR and two (26.0%) with 17.0% UPROR; number of proximal anchors was six (49.9%) with 14.1% UPROR and four (27.0%) with 18.3% UPROR. The most common anchors were all screws (42.0%) with 9.9% UPROR, and all hooks (26.4%) with 31.4% UPROR (P < 0.001). The construct with the lowest rate of UPROR was a UIV at T2, with six anchors (all screws) across three levels (42 cases), with 0% UPROR. Other construct combinations that yielded 0% UPROR rates were UIV of T3, six anchors (all screws) across three levels (25 cases), and a UIV of T3 with six anchors (screws and hooks) across three3 levels (9 cases). CONCLUSION: Proximal anchor configuration impacts the incidence of UPROR due to IRC in MCGR. UIV at T2 and T3 compared to T4, and the use of all screws or combination of screws and hooks compared to all hooks were associated with a lower UPROR rate. The most common construct configuration was T2 UIV, three levels, six anchors, and all screws. The use of a combination of six anchors (screws or screws and hooks) across three levels with a UIV at T2 or T3 was associated with a lower UPROR rate. Additional research is needed to further evaluate the variables contributing to configuration selection and their association with IRC.

Thoracolumbar and Lumbar Posterior Vertebral Resection for the Treatment of Rigid Congenital Spinal Deformities in Pediatric Patients: A Long-Term Follow-up Study.

Objective: We sought to determine whether a posterior vertebral resection on congenital deformities of thoracolumbar and lumbar vertebrae leads to more complications and provides less correction. Methods: Twenty-three patients underwent a posterior vertebral resection for a rigid congenital spinal deformity, which included scoliosis (13 patients), kyphoscoliosis (6 patients), and pure kyphosis (4 patients). The surgeries involved removing 1 to 2 vertebrae using multiaxial pedicle screws in all but 2 of the patients. All surgeries were performed under intraoperative spinal cord monitoring. Thoracic curve, lumbar lordosis, focal kyphosis, shift, and sagittal vertical axis were collected at baseline and during the last follow-up (taking place after at least 3 years) and were then statistically analyzed. Results: The major curve correction was about 55% in cases of scoliosis, with focal kyphosis improving from 54.3 ± 19.1 degrees to 21.3 ± 15 degrees. Two patients experienced intraoperative neuromonitoring changes, with data returning to baseline without any surgical intervention. Sensory or motor palsy after the surgery was not reported in patients.Despite improving sagittal or coronal deformities, 8 patients experienced excessive sagittal decompensation during follow-up, 1 of whom underwent revision surgery. Sagittal decompensation was by far the most common complication. Larger kyphoscoliosis or focal kyphosis angles were preoperative risk factors for postoperative sagittal imbalance (P value < 0.05). Conclusions: Using a lumbar or thoracolumbar posterior vertebral resection enables surgeons to correct rigid curves in the pediatric population without major risk to nerve roots. The primary complications would be sagittal decompensation and the likelihood of undercorrection, which requires mindful addressing during the preoperative planning stages.

Magnetically controlled Growing Rods for Early-onset Scoliosis: A Multicenter Study of 23 Cases With Minimum 2 years Follow-up.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report 2-year clinical and radiographic results of patients treated with magnetically controlled growing rods (MCGR). SUMMARY OF BACKGROUND DATA: MCGR for early-onset scoliosis has been reported to provide adequate spinal growth and curve correction by eliminating surgical lengthening procedures. This study was designed to report the results of MCGR patients with 2-year follow-up. METHODS: A retrospective study of MCGR patients with the following inclusion criteria: (i) major curve size ≥30°, (ii) T1-T12 height <22 cm, (iii) <11-years old; all at the time of index surgery was performed. Of 54 patients enrolled, 23 had 2-year follow-up. Both primary and conversion patients were evaluated at baseline 6, 12, and 24 months. RESULTS: Mean preoperative age in the primary group was 6.6 ±â€Š2.6 years versus 8.3 ±â€Š2.2 years for the conversion group. A total of 41 adverse events occurred in 11 patients, of which 14 events were implant related. Major coronal curve magnitude improved from 61.3° to 34.3° from baseline to postoperation in primary cases and from 49.4° to 43.8° in conversion cases. Curve correction was maintained for 2 years in both groups. T1-S1 height improved from 252.7 to 288.9 mm in primary cases and was maintained for 2 years. However, conversion cases had some decline in T1- S1 height (270.3 at baseline to 294.4 mm post-MCGR and 290.2 mm at 2-year follow-up; mean loss of 4.2 mm (1.5%) from postoperation to 2 years, P > 0.05). CONCLUSION: This study showed satisfactory curve correction and growth is achieved among primary cases. T1-S1 height in conversion cases had a slight decline in 2 years. However, this decline was not statistically significant. LEVEL OF EVIDENCE: 3.

Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study.

INTRODUCTION: Traditional growing rod (TGR) surgery is a treatment technique commonly used for progressive early-onset scoliosis. Studies have shown that repeated TGR lengthenings can significantly increase the risk of complications. Magnetically controlled growing rods (MCGR) are currently available outside of the United States and early results have been promising. The purpose of this study was to compare the effectiveness of MCGR versus TGR for the treatment of early-onset scoliosis. METHODS: Magnetically controlled growing rod patients were selected based on the following criteria: aged less than 10 years, major curve greater than 30°, thoracic height less than 22 cm, no previous spine surgery, and minimum 2-year follow-up. A total of 17 MCGR patients met the inclusion criteria, 12 of whom had complete data available for analysis. Each MCGR patient was matched with a TGR patient by etiology, gender, single versus dual rods, preoperative age, and preoperative major curve. RESULTS: Magnetically controlled growing rod patients had a mean age of 6.8 years and mean follow-up of 2.5 years. Mean follow-up was greater for TGR patients by 1.6 years. Major curve correction was similar between MCGR and TGR patients throughout treatment. The MCGR patients experienced an average of 8.1 mm/year increase in T1-S1 during the lengthening period, compared with 9.7 mm/year for TGR patients (p = .73). There was a mean increase in T1-T12 of 1.5 mm/year for MCGR patients and 2.3 mm/year for TGR patients (p = .83). The TGR patients had 73 open surgeries, 56 of which were lengthenings. The MCGR patients had 16 open surgeries and 137 noninvasive lengthenings. Three TGR patients underwent 5 unplanned revision surgeries whereas 3 MCGR patients underwent 4 unplanned revisions. CONCLUSIONS: Major curve correction was similar between MCGR and TGR patients throughout treatment. Annual T1-S1 and T1-12 growth was also similar between groups. The MCGR patients had 57 fewer surgical procedures than TGR patients. Incidence of unplanned surgical revisions as a result of complications was similar between groups.

Next generation of growth-sparing techniques: preliminary clinical results of a magnetically controlled growing rod in 14 patients with early-onset scoliosis.

STUDY DESIGN: Prospective nonrandomized study. OBJECTIVE: To report the preliminary results of magnetically controlled growing rod (MCGR) technique in children with progressive early-onset scoliosis. SUMMARY OF BACKGROUND DATA: The growing rod (GR) technique is a viable alternative for treatment of early-onset scoliosis. High complication rate is attributed to frequent surgical lengthening. The safety and efficacy of MCGR were recently reported in a porcine model. METHODS: Multicenter study of clinical and radiographical data of patients who underwent MCGR surgery and at least 3 distractions. Distractions were performed in clinic without anesthesia/analgesics. T1-T12 and T1-S1 heights and the distraction distance inside the actuator were measured after lengthening. RESULTS: Fourteen patients (7 girls, 7 boys) with a mean age of 8 years, 10 months (3 yr, 6 mo to 12 yr, 7 mo) had 14 index surgical procedures. Of the 14, 5 had single-rod (SR) surgery and 9 had dual-rod (DR) surgery, with overall 68 distractions. Diagnoses were idiopathic (N = 5), neuromuscular (N = 4), congenital (N = 2), syndromic (N = 2), and neurofibromatosis (N = 1). Mean follow-up was 10 months (5.8-18.2). The Cobb angle changed from 60° to 34° after initial surgery and 31° at latest follow-up. During distraction period, T1-T12 height increased by 7.6 mm for SR (1.09 mm/mo) and 12.12 mm for DR (1.97 mm/mo). T1-S1 height gain was 9.1 mm for SR (1.27 mm/mo) and 20.3 mm for DR (3.09 mm/mo). Complications included superficial infection in 1 SR, prominent implant in 1 DR, and minimal loss of initial distraction in 3 SR after index. Partial distraction loss observed after 14 of the 68 distractions (1 DR and 13 SR) but regained in subsequent distractions. There was no neurological deficit or implant failure. CONCLUSION: Preliminary results indicated MCGR was safe and provided adequate distraction similar to standard GR. DR achieved better initial curve correction and greater spinal height during distraction compared with SR. No major complications were observed during the follow-up.

In vivo distraction force and length measurements of growing rods: which factors influence the ability to lengthen?

STUDY DESIGN: Prospective, intraoperative force measurement in consecutive lengthening procedures in a series of growing-rod patients undergoing lengthening. OBJECTIVE: The purpose of this study was to measure the forces and amount of distraction over time in early onset scoliosis patients treated with growing rods. SUMMARY OF BACKGROUND DATA: Growing rods are one of the current techniques used in the treatment of early onset scoliosis, and the goal of the growing-rod technique is to achieve deformity correction, maintaining spinal growth at the same time. Gradual stiffening or spontaneous fusion of the spine can interfere with the ability to lengthen. In addition, diminished acquired length with serial distraction are common observations and need to be evaluated and quantified. METHODS: Distraction forces were measured prospectively during 60 consecutive lengthening procedures in 26 patients. All patients had single submuscular rod constructs with side-to-side connectors. For each measurement, output from a transducer on a dedicated pair of distraction calipers was recorded at zero load status and the force was then recorded at every 1 mm lengthening; length was obtained at each event and was recorded in millimeters. RESULTS: The force required to distract the spine doubled at the 5th lengthening procedure (mean 368 N ± 54 N), and the distraction force was significantly higher at the fifth lengthening compared with the previous lengthening (P <0.01). Mean length achieved at each distraction decreased over time such that by the fifth lengthening, consistently 8 mm or less was achieved. CONCLUSION: Distraction forces increase significantly after repeated lengthening of growing-rod constructs, and the length obtained at each procedure exhibits a decreasing trend.

Anterior instrumentation and correction of congenital spinal deformities under age of four without hemivertebrectomy: a new alternative.

STUDY DESIGN: Retrospective clinical and radiologic evaluation of a single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion. OBJECTIVE: To determine the safety and efficacy of a new technique in the management of progressive congenital spinal deformities due to failure of formation in the very young age. SUMMARY OF BACKGROUND DATA: Several techniques have been reported for the surgical treatment of young children with congenital spinal deformities. There have been concerns regarding epidural bleeding, neurologic complications, pedicle screws placement, implant failure, and prominence of posterior constructs in this very young age group. A single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion can offer a new alternative which can avoid these concerns. METHODS: Twelve patients with progressive congenital spinal deformities due to failure of formation were retrospectively reviewed after adopting the above mentioned technique. All patients included in the study presented with a single hemivertebra. The mean age at time of surgery was 2 years 7 months (range, 1 year and 9 months to 3 years and 10 months). The average follow-up period was 3 years and 1 month (range, 2 years to 4 years and 5 months). RESULTS: There were no cases of intra or postoperative neurologic or implant related complications. There was 1 superficial infection. All patients showed solid radiologic fusion. The mean scoliosis angle improved from 48.3° (range, 34°-58°) preoperative to 17.2° (range, 11°-25°). The mean angle of kyphosis improved from 23.2° (range, 16°-57°) before surgery to 11.7° (range, 4°-16°). CONCLUSION: A single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion offers a safe alternative method in treating patients with congenital hemivertebra under the age of 4 years.

The surgical treatment of congenital kyphosis.

STUDY DESIGN: Retrospective study with clinical and radiologic evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebra (HV). The management of congenital kyphosis has been described in the literature using a variety of techniques. The presentation of patients at diagnosis is discussed. The question of when to begin treatment is reviewed. The pitfalls in the management and how to avoid these are discussed. The different published techniques are reviewed. We present our own techniques and our results of treatment of congenital kyphosis in very young children. OBJECTIVE: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurologic compromise. We aim to systematically review the literature and to present our own experience in the management of these deformities, so that the issues common to treating physicians may be explored. SUMMARY OF BACKGROUND DATA: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique. METHODS: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. Thirteen patients had a single posterolateral HV and 2 patients had a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range, 8-33). Mean follow-up period was 6.8 years. Thirteen HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine. RESULTS: The average operating time of procedure was 150 minutes (range, 130-210 minutes). The average blood loss was 180 mL (range, 100-330 mL), equivalent to a mean external blood volume loss of 15% (range, 11%-24%).Preoperative segmental Cobb angle averaging 34 degrees at last follow-up. Compensatory coronal cranial and caudal curves were corrected by 50%. The angle of segmental kyphosis averaged 39 degrees (range, 20 degrees-80 degrees) before surgery and 21 degrees (range, 11 degrees-40 degrees) at last follow-up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last follow-up. One case with initial kyphosis of 80 degrees continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

All pedicle screw instrumentation for Scheuermann's kyphosis correction: is it worth it?

BACKGROUND CONTEXT: Scheuermann's kyphosis has long been treated by a two-staged fusion and instrumentation with a hybrid construct using hooks, pedicle screws, and sublaminar wires. Recent interest in all pedicle screw constructs led to its use in the treatment of Scheuermann's kyphosis. Evaluation of this newly described application is needed. PURPOSE: To compare the results of segmental all pedicle screw constructs versus two-staged hybrid instrumentation in patients with Scheuermann's kyphosis analyzing the amount of correction and incidence of complications. STUDY DESIGN: Retrospective case series reporting on two groups of patients with Scheuermann's kyphosis treated with single-staged all pedicle screws technique versus two-staged anterior release and posterior hybrid instrumentation followed-up for a minimum of 2 years. PATIENT SAMPLE: The study included 33 patients divided into two groups. The average age was 15 years+9 months and 16 years+8 months, respectively. The average preoperative dorsal kyphosis was 85.5 degrees (Group 1) and 79.8 degrees (Group 2). OUTCOME MEASURES: The deformity was measured by Cobb's method preoperatively, postoperatively, and at final follow-up. Operative time and blood loss were also measured and recorded. The results of the Scoliosis Research Society (SRS)-30 questionnaire were also reviewed. METHODS: The study included 16 patients who underwent a single-staged correction by segmental all pedicle screw constructs and multiple-level posterior osteotomies (Group 1) and 17 who underwent a two-staged fusion and instrumentation with a hybrid construct (Group 2). RESULTS: Both groups were followed for a minimum of 2 years. The deformity correction of Group 1 had an average of 52.2% postoperatively with 2.4% loss at final follow-up in comparison to Group 2 where the correction was 48.7% postoperatively with 3.1% loss at final follow-up. The operative time was considerably less in Group 1 with an average of 215 minutes than Group 2 with an average of 315 minutes. The average blood loss was 620cc in Group 1 and 910cc in Group 2. The SRS-30 questionnaire in Group 1 averaged 134 and in Group 2 averaged 120. CONCLUSIONS: The use of multiple-level all pedicle screws technique allowed a rigid anchor for posterior correction of the deformity with less operative time, blood loss, and hospital stay without the need for anterior release. A better correction was achieved and preserved with the use of all pedicle screw constructs. This technique is a useful modality in the treatment of Scheuermann's kyphosis.

Neuromuscular scoliosis treated by segmental third-generation instrumented spinal fusion.

We aimed to investigate whether the outcome and complications of surgical treatment of neuromuscular curves with segmental third-generation instrumentation could compare with those reported with standard second-generation instrumentation. The clinical and radiologic data of a single surgeon's consecutive series of patients with neuromuscular scoliosis treated with two types of newer-generation instrumentation and posterior or anteroposterior approaches were retrospectively and independently reviewed. The results of this study support the concept that third-generation instrumentation is able to provide at least as good results as second-generation instrumentation in the treatment of neuromuscular scoliosis patients, at the expense of a lower complication rate.

Congenital spinal deformity: a comprehensive assessment at presentation.

STUDY DESIGN: A series of 126 consecutive patients with congenital spinal deformity is presented. OBJECTIVE: To assess the incidence of intraspinal anomaly and other organic defects associated with different types of spine deformity at presentation. SUMMARY OF BACKGROUND DATA: A high incidence of intraspinal abnormalities and other organ defects is reported in relation to congenital spine deformity. The prevalence of these problems with different types of deformities is to be determined. METHODS: All patients had MRI, echocardiography, renal ultrasound, and a thorough clinical assessment. RESULTS: Intraspinal abnormalities were found in 47 patients (37%). These abnormalities were significantly more common in patients with congenital kyphosis ( = 0.0048), and in those with scoliosis resulting from mixed and segmentation defects. Scoliosis patients with cervical and thoracic hemivertebrae had significantly more intraspinal abnormalities ( = 0.0253) than those with lumbar hemivertebrae. In 64 (55%) patients other organic defects were found. These defects were more common in patients with congenital scoliosis resulting from mixed defects ( = 0.002). Cardiac defects were detected in 26% and urogenital anomalies in 21% of the patients. CONCLUSIONS: Magnetic resonance imaging and echocardiography should be an essential part in the evaluation of patients with congenital spinal deformity, and special attention should be paid to patients with segmentation abnormalities, mixed defects, and kyphosis.