Comparison and Evaluation of the Accuracy for Thoracic and Lumbar Pedicle Screw Fixation in Early-Onset Congenital Scoliosis Children.

BACKGROUND: Compared to adult scoliosis, correcting scoliosis in children often presents greater challenges. This is attributed to two key factors. Firstly, it involves accounting for the growth potential of children. Secondly, the thinner pedicles in children can complicate screw insertion, particularly when dealing with existing deformities. The utilization of intraoperative navigation technology offers a modest improvement in the precision of screw placement but does come with the drawback of increased radiation exposure. The aim of this study is to investigate and assess the accuracy of manually inserting pedicle screws in the thoracic and lumbar spine to rectify deformities in children with early-onset congenital scoliosis. METHODS: In this retrospective study, 26 hospitalized patients diagnosed with early-onset congenital scoliosis between December 2014 and December 2019 were selected. The cohort comprised 16 boys and 10 girls, aged between 2 and 10 years, with an average age of 4.68 ± 2.42 years. Pedicle screw fixation was applied in the segment spanning from T1 to L5. Pedicle screws were inserted manually, guided by the positioning of the C-arm and anatomical markers. The assessment of pedicle screw placement was based on the distance of penetration into the medial, lateral, or anterior bone cortex of the vertebral body, including the pedicle, categorized into three grades: Grade 1 (placement <2 mm), Grade 2 (placement between 2-4 mm), and Grade 3 (placement >4 mm). Grade 1 indicates accurate pedicle screw placement, while Grades 2 and 3 signify abnormal pedicle screw placement. Complications related to pedicle screw insertion were also recorded, both during and after the surgical procedure. RESULTS: A total of 173 pedicle screws were inserted in this study, with an average of 6.65 screws per patient. Accurate screw placement was achieved in 143 cases (82.7%), while 30 pedicle screws were found to be abnormal. Among the abnormal screws, 24 were categorized as Grade 2 (13.9%), and 6 as Grade 3 (3.5%). Grade 2 abnormalities were distributed across 20 thoracic vertebrae and 4 lumbar vertebrae, while Grade 3 abnormalities affected 5 thoracic vertebrae and 1 lumbar vertebra. When comparing the lumbar and thoracic vertebral regions, a significant difference in the rate of abnormal screw placement was observed (χ2 = 5.801, p < 0.05). The rate of abnormal screw placement was higher in the thoracic vertebral region with abnormal vertebral bodies than in the lumbar vertebral regions. Furthermore, a statistically significant difference in the rate of abnormal screw placement was found between the concave and convex sides (χ2 = 23.047, p < 0.05). The concave side of the abnormal vertebral body had a higher rate of abnormal screw placement (55.6%, 15/27) compared to the convex side (20.1%, 7/34), and this difference was statistically significant (p < 0.05). Throughout the intraoperative and postoperative follow-up period, spanning from 12 to 56 months, only one patient experienced issues with wound healing, and no complications related to pedicle screw placement occurred, such as hemopneumothorax, pedicle fracture, nerve root injury, aortic injury, screw loosening, pullout or breakage, or spinal cord injury. CONCLUSIONS: In children under 10 years of age with early-onset congenital scoliosis, the freehand placement of thoracic and lumbar pedicle screws demonstrates a high level of accuracy. Moreover, complications associated with pedicle screw insertion are infrequent following surgery. It is advisable to exercise caution when placing pedicle screws in thoracic vertebral bodies and morphologically abnormal vertebral bodies, with particular attention to the concave side when screw placement is required in these regions.

Treatment of Atlantoaxial Dislocation in Children with Down Syndrome Using Posterior Atlantoaxial Screw Fixation.

Background: To investigate the effect of posterior atlantoaxial screw fixation for the treatment of atlantoaxial dislocation in children with Down syndrome (DS). Methods: Children diagnosed with DS who underwent posterior atlantoaxial screw fixation or occipitocervical fusion from January 2017 to January 2020 in Hebei Children's Hospital were retrospectively included. Preoperative CT and MRI were performed to check the os odontoideum (OsO) and spinal cord compression, signal changes and spinal cord injury grade (ASIA grade). Results: All 5 children have atlantoaxial dislocation and OsO. Among which 60% (3/5) of children had changes in spinal cord signals and 40% (2/5) had dural sac compression. Every child underwent posterior atlantoaxial screw fixation (3.5-mm diameter), and the average fusion level was 1.8 (1-2). All 5 cases wore the head-neck-chest brace for 3-6 months after the operation. 1 case had dural tear and recovered well after timely suturing. 1 case had internal fixation breakage of the prosthetic joint and underwent revision surgery. At the last follow-up, all cases were fused and the neurological function were all ASIA grade E. Conclusion: After posterior atlantoaxial screw fixation, fusion and nerve recovery were achieved in all children with atlantoaxial dislocation and OsO. Postoperative head-neck-chest braces are necessary for children, especially those with occipitocervical fusion.