Esophageal Perforation Caused by a Posterior Pedicle Screw: A Case Report.

BACKGROUND: Posterior spinal instrumented fusion has received widespread acceptance in adolescent idiopathic scoliosis (AIS) treatment, there have been some potential complications resulted from screw misplacement. Esophagus is one of the vital structures close to the upper thoracic vertebras and is at risk for potential injury. METHODS: A 15-year-old girl who underwent posterior instrumented fusion for AIS was admitted to our department 10 years later with a complaint of dysphagia due to an esophageal perforation from a malpositioned T4 pedicle screw (PS). After implant removal and nasogastric tube placement, oral feeding was started after 3 days and the patient was discharged from hospital after 1 week. RESULTS: In 12 weeks, the esophageal perforation healed without complications. CONCLUSIONS: This is the first case report of esophageal perforation by a posterior PS in an AIS patient. Esophagus is close to the upper thoracic vertebras and an anterior cortical perforation can cause esophageal injury if longer than 35 mm PSs are used. This unusual but potential complication must be kept in mind in scoliosis surgery. LEVEL OF EVIDENCE: Level IV-case report.

Growing rod instrumentation in the treatment of early onset scoliosis.

The goal of the treatment of early onset scoliosis (EOS) is correction of the deformity while still allowing for spinal growth. The aim of this study was to determine the safety and effectiveness of the single and dual growing rod techniques and which technique was the most effective in the management of EOS respectively. From 2003 to 2009, 23 patients underwent single (15) or dual (8) growing rod procedures using a pedicle screw construct and tandem connectors. The etiology of the patients' spinal deformities were as follows; infantile, juvenile idiopathic, congenital and neuromuscular. Clinical evaluation included age, sex, diagnosis, follow-up, number and frequency of lengthenings, and complications. Radiographic evaluation included measured changes in Cobb angle, kyphosis, lordosis, frontal and sagittal balance. Overall 46 lengthening procedures were performed, the average number of lengthening procedures being 2.1 +/- 1.14 per patient. The average time between two lengthening procedures was 13 (2-28) months. Average follow-up time was 40.8 +/- 20.6 months.The mean coronal Cobb angle was improved from 64.8° +/- 16.6° to 39.7°+/- 16.4°.Statistically, at the final follow-up, early postoperative measurements in the coronal plane were better in the dual growing rod group than in the single rod group. Nine patients underwent fusion surgery. Their mean age was 11 (10-14) years, with a follow-up of 34.6 (14-54) months. The mean Cobb angle before fusion was 58.7° (40°-75°). There were 0.9 complications per patient in all groups, 0.38 in the dual rod and 1.2 in the single rod group, respectively. Dual growing rods result in better deformity correction and stability of correction with an acceptable complication rate.

Does Thoracic Kyphosis Have any Importance in Selective Versus Nonselective Fusion Preference in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis?

AIM: To investigate the importance of thoracic kyphosis (TK) for treatment preference in patients with Lenke Type 5C adolescent idiopathic scoliosis by comparing radiological outcomes of the patients who underwent selective fusion (SF) or nonselective fusion (NSF). MATERIAL AND METHODS: Twenty-nine patients with Lenke Type 5C AIS were included and then divided into two groups as per the fusion procedure used in the surgical treatment. SF group including 16 patients (14 female patients; mean age = 15.56 yr; age range, 14?18) with normal TK and NSF group including 13 patients (nine female patients; mean age = 15.54 yr, age range, 13?18) with thoracic hyperkyphosis. Thoracolumbar/lumbar (TL/L) Cobb, thoracic (T) Cobb, TK and lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured on standing spine radiographs preoperatively and at the final follow-up. The correction rates (CRs) of Cobb angles and the difference in each other radiological parameters were calculated. RESULTS: No significant differences were observed in the mean CRs of TL/L Cobb and T Cobb angles, PI, SS, and PT (p=0.313, p=0.444, p=0.51, p=0.472, and p=0.14, respectively). However, significant differences were observed in the mean TK angle, which was ?2.13° ± 13.52° (range, 29?27°) in SF group and 28.46° ± 15.05° (range, ?4°?°47°) in NSF group (p=0.001), and LL angle was 0.88° ± 14.23° (range, ?21°?32°) in SF group and 11.54° ± 17.79° (range, ?31°?34°) in NSF group (p = 0.016). CONCLUSION: In patients in whom Lenke?s sagittal modifier is N, SF can be performed efficiently. NSF can be preferred for those with (+) Lenke?s sagittal modifiers as it provides better TK control.

Does pedicle screw density matter in Lenke type 5 adolescent idiopathic scoliosis?

The aim of this study is to compare the effects of high versus low implant density on correction in Lenke type 5 adolescent idiopathic scoliosis (AIS) patients. A retrospective study of 59 Lenke type 5 AIS patients treated at a single institution were divided into to 2 groups according to implant density. Implant density, preoperative, early postoperative, and last follow-up thoracolumbar/lumbar (TL/L) curves were measured. Thirty-one constructs were high and 28 constructs were low density. The groups were similar in terms of age, sex, Cobb angle, and follow-up time. Mean implant density in low density group and high density group was 75.4% and 96.6%, respectively. High versus low-density comparison showed that there is no significant difference with regard to curve correction in early postoperative and last follow-up periods. The results show that pedicle screw density being low or high, does not affect curve correction rates in the short and long term in our patients.

Selection of distal fusion level in terms of distal junctional kyphosis in Scheuermann kyphosis. A comparison of 3 methods.

OBJECTIVE: The aim of this study was to investigate the effect of distal fusion level selection on the distal junctional kyphosis (DJK) in Scheuermann kyphosis (SK) patients who underwent posterior fusion. METHODS: Thirty-nine SK patients who underwent posterior fusion with a minimum follow-up of 3 years were retrospectively evaluated. According to the distal fusion level, patients were divided into 3 groups. Group S; lowest instrumented vertebra (LIV) was the sagittal stable vertebra (SSV), Group F; LIV was the first lordotic vertebra (FLV) and, Group L; LIV was the lower end vertebra (LEV). DJK was evaluated according to distal level selection. RESULTS: Thoracic kyphosis (TK) decreased from 73.3° (SD ± 7.9°) to 39° (SD ± 8.7°) postoperatively, with a mean correction rate of 46% (SD ± 13) (p < 0.0001). In 11 patients, FLV and SSV was the same vertebra. In remaining 28 patients, 10 patients were in Group S, 15 patients were in Group F and 3 patients were in Group L. In Group S, none of them developed DJK, however, DJK was observed 9 of 15 patients in Group F. DJK was developed in all cases in Group L. There is a statistically higher risk for developing DJK when FLV or LEV was selected as LIV (p < 0.05). CONCLUSION: Selecting SSV for the distal fusion level has been found to be effective for preventing DJK. Selecting distal fusion level proximal to SSV will increase the risk of DJK which may become symptomatic and require revision surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Aarskog-Scott syndrome: An unusual cause of scoliosis.

A 16-year-old boy who had been diagnosed previously as Aarskog-Scott syndrome (AAS), referred to our clinic with shoulder asymmetry for 1 year. Results of spine examination showed a 52° right thoracic curve at T3-T11. Surgery was planned, and T1-L1 posterior instrumentation and fusion were performed. After surgery, satisfactory correction was achieved, and during 10 years follow-up, the patient had no complaints. AAS is a X-linked genetic disorder with facial, genital, and skeletal manifestations. Scoliosis is not reported as a typical finding of AAS, and there is no reported case in the English literature. Due to mutation affecting the developing skeleton tissue, spinal deformities may develop. In our case, concave side fusion was seen at the deformity. Although we do not know any specific pattern of the scoliotic deformity of this syndrome, surgical correction of the deformity can be difficult because of the premature fusion at these levels.

Analysing the change of sagittal balance in patients with Lenke 5 idiopathic scoliosis.

OBJECTIVE: The aim of this study was to evaluate preoperative and postoperative spinopelvic parameters and the influence of lowest instrumented vertebrae on sagittal parameters in Lenke 5 Adolescent Idiopathic Scoliosis (AIS) patients. METHODS: A total of 42 patients (37 females, 5 males; mean age: 16.71 ± 3.46 years) were included in the study. Preoperative and postoperative last follow up lumbar lordosis (LL), thoracic kyphosis (TK), pelvic tilt (PT), pelvic incidence (PI) and sacral slope (SS) angles measured. By stopped fusion in L3, L4 or L5 we divided the group into three parts. RESULTS: Mean follow-up was 43 months. Preoperatively, the mean TK and LL were 36.8° and 55.3°. At the last follow up, the mean TK and LL were 27.1° and 49.0° degrees, respectively. Preoperatively, the mean PI, PT and SS were 53.3°, 16.1° and 37.4° degrees. At the last follow up, the mean PI, PT and SS were 52.7°, 19.9° and 33.0° respectively. Significant differences were observed for SS (p = 0.003), TK (p = 0.004), LL (p = 0.012) and PT (p = 0.013) postoperatively for all patients. According the L3 and L4 groups there is significant difference in SS, LL (p = 0.013) and PT (p = 0.018) which means a significant decrease occurs in SS and LL when the distal fusion level changes from L3 to L4 but significant increase in PT in L3 group to compensate spinopelvic change after surgery. CONCLUSION: The selection of more distal level for fusion adversely affects the compensation mechanisms of sagittal balance in Lenke 5 AIS patients. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Results of closing wedge osteotomy in the treatment of sagittal imbalance due to ankylosing spondylitis.

OBJECTIVE: Ankylosing spondylitis is a systemic disease which affects the axial skeleton and may cause rigid spinal deformities in advanced cases. Clinical and radiological results of patients with ankylosing spondylitis who underwent pedicle subtraction osteotomy (PSO) were evaluated. METHODS: Twelve (3 female, 9 male) patients who were treated for rigid spinal deformities due to ankylosing spondylitis were evaluated. All patients were treated with the same surgical technique, which included PSO and pedicle screw-rod combination. For radiological results, thoracic kyphosis, lumbar lordosis, pelvic parameters (pelvic incidence, sacral inclination, pelvic tilt), and the distance between the central sagittal line (CSVL) and the sacrum were measured from pre- and postoperative radiograms. For functional results, SF-36 and Oswestry Disability Index (ODI) were used. RESULTS: Mean age of the patients was 39.8±8.4 years, and mean follow-up was 85.6±39.1 months. Mean angle of lordosis was improved from 6.6°±13.7° preoperatively to 43.8°±8.4° postoperatively (p<0.0001). Mean CSVL was improved from 19.7±9.7 cm preoperatively to 7.45±3.8 cm postoperatively (p=0.0005). Mean local angular change around the osteotomy site was 30.2°±6.2°. The pelvic parameters were not significantly changed after the surgeries. Mean ODI, SF-36 mental, and SF-36 physical scores were 30.16±9.7, 41.2±9.9 and 35.3±7.1, respectively. CONCLUSION: In patients with rigid sagittal spinal deformities due to ankylosing spondylitis, lumbar lordosis and sagittal balance can be obtained using PSO.

Effect of growing rod on sagittal and spinopelvic parameters in early-onset scoliosis patients.

Growing rod is a commonly used surgery for early-onset scoliosis (EOS). However, the effect of growing-rod lengthening on the spinopelvic alignment is unclear. In this study, 21 EOS patients treated by growing rod were evaluated retrospectively and thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI) , sacral slope (SS), pelvic tilt (PT), and sagittal vertical axis (SVA) were measured. Preoperatively, the mean TK, LL, PI, PT, SS, and SVA were 27.4°, 35.2°, 43.8°, 7.5°, 33.8°, and 47.7 mm respectively. After the last lengthening, TK, LL, PI, PT, SS, and SVA were 28.3°, 28.06°, 41.4°, 7°, 5.2°, and 42.6 mm, respectively. The sagittal plane parameters in our EOS patients were not significantly altered during the lengthening period.

The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases.

Long periods of immobilization, progressive kyphosis and graft failure are the major postoperative problems encountered after anterior radical surgical treatment for tuberculosis of the spine. Posterior fusion and instrumentation can be an effective solution for these problems. Effectiveness of posterior fusion and instrumentation was investigated in this study on the basis of the cases with anterior procedure only, and with combined anterior-posterior procedures. One hundred twenty-seven cases of tuberculosis of the spine were surgically treated between 1987 and 1995. All had either 1 or more of conditions such as spinal cord compression and neurological deficit, vertebral body collapse and kyphosis, or wide paravertebral abscess unresponsive to medical treatment. Of these, 57 had only anterior radical procedure between the years 1987 and 1993. Seventy cases had posterior instrumentation and fusion after the anterior procedure between the years 1991 and 1995. In about two third of the patients (81) autogenous iliac strut graft and in one third of them (40) autogenous fibular strut graft (cases with more than 2 level involvement) was used along with rib grafts after debridement. Twenty-one of the 57 patients who had only anterior procedure demonstrated a postoperative increase of kyphosis of more than 10 degrees. Increased kyphosis was due to graft slippage in 3, resorption in 2 and subsidence in 16 patients. No such increase or graft failure was noted in cases of combined anterior-posterior procedure. The difference in terms of kyphosis was found to be statistically significant (P=0.047). Anterior radical debridement and strut graft is the golden standard in the surgical treatment of spinal tuberculosis, but it should always be accompanied by posterior instrumentation and fusion to shorten the immobilization period and hospital stay, obtain good and long lasting correction of kyphosis, and prevent further collapse and graft failure.

Assessment of curve flexibility in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective comparative evaluation of the commonly accepted or described radiologic techniques to determine curve flexibility in adolescent idiopathic scoliosis (AIS), comparison of the results to those obtained by supine traction radiographs taken with the patient under general anesthesia (UGA) just before surgery and correlation of all findings to surgical correction. OBJECTIVE: To determine if supine traction radiographs taken with the patient UGA help provide better assessment of curve flexibility and better predicting surgical correction. SUMMARY OF BACKGROUND DATA: Supine lateral bending radiographs are the standard methods of evaluating curve flexibility before surgery in idiopathic scoliosis. Supine traction radiographs have also been used at the authors' institution in addition to the supine lateral bending radiographs before surgery, believing that it is usually more helpful to analyze the response of the main and compensatory curves to corrective forces. METHODS: A total of 34 consecutive patients with AIS who had surgical treatment were studied. Preoperative radiologic evaluation consisted of standing anteroposterior and lateral, supine lateral bending and traction, fulcrum bending radiographs, and also supine traction radiographs taken with the patient UGA just before surgery. All structural curves were measured, and the flexibility ratio was determined on each radiograph. The amount of correction obtained by all radiographic methods was compared with the amount of surgical correction by evaluating the differences from surgery as absolute values. Mean absolute differences from surgery were used to determine the confidence intervals. Statistical differences were calculated with the comparison of the exact 95% confidence intervals for the mean. RESULTS: Curves were accepted to be moderate if between 40 degrees and 65 degrees (29 patients) and severe if >65 degrees (5 patients). In these 29 patients, average frontal Cobb angle of the thoracic and lumbar curves were 49.7 degrees (range 40 degrees-60 degrees) and 39.4 degrees (range 22 degrees-58 degrees), respectively. For the moderate thoracic curves, fulcrum radiographs provided the best amount of flexibility, with no significant difference from traction with the patient UGA but with significant difference from bending radiographs. For the moderate lumbar curves, flexibility obtained by fulcrum and bending radiographs were significantly better than traction radiographs with the patient UGA. For the lumbar and thoracic curves more than 65 degrees, traction radiographs with the patient UGA provided clearly better flexibility compared to bending and fulcrum radiographs, however, the number of patients is not enough to determine whether the differences are statistically significant. Better flexibility in traction radiographs with the patient UGA helped us eliminate the need for anterior release in all 5 patients who had severe and rigid curves more than 65 degrees, which did not bend to less than 40 degrees and were planned to have anterior release. CONCLUSION: Fulcrum higher than bending higher than traction with the patient UGA is the order of radiographs for better predicting flexibility and correction in curves between 40 degrees and 65 degrees. Flexibility obtained at traction radiographs with the patient UGA is clearly better in numerical values, and closer to the amount of surgical correction than the amount of flexibility at fulcrum and side-bending radiographs for curves larger than 65 degrees, although not statistically significant as a result of the small number of patients in this group. However, pedicle screw instrumentation provides even more correction than the traction radiographs with the patient UGA. Thus, traction radiographs with the patient UGA may show much better flexibility, especially in more than 65 degrees and rigid curves.

Surgical correction of kyphosis: posterior total wedge resection osteotomy in 32 patients.

BACKGROUND: Many surgical procedures have been developed for the treatment of kyphoscoliosis. We present our experience of one technique for posterior total wedge resection osteotomy, with clinical and radiographic results. This is a one-stage solution which results in a shortened posterior column and reduced tension on the spinal cord in rigid angular kyphosis. PATIENTS AND METHODS: Between 1990 and 2000, we treated 32 patients with rigid local kyphosis by posterior wedge osteotomy and instrumentation. The etiology was congenital malformation in 17 cases, infection in 11 and previous laminectomy in 4 cases. The osteotomy is performed at the apex of the kyphotic deformity and covers two vertebrae. The upper and lower borders of the osteotomy are right inferior to the transverse processes of the upper and lower vertebrae respectively. The apex of the posteriorly based triangular osteotomy is either at the anterior vertebral body or anterior longitudinal ligament. RESULTS: The mean preoperative angle of local kyphosis was 72 (25-112) degrees mainly at the thoracolumbar region, and it improved to a mean of 23 (0-48) degrees after an average follow-up of 57 (24-108) months. The mean preoperative sagittal plumbline imbalance of 5.5 (2-12) cm was improved to 1.2 (-2-3.5) cm postoperatively. The mean loss of correction since operation was 3.4 (0-11) degrees. Radiographically, solid anterior and posterior fusion was achieved in all patients by 6 months. 1 patient had irreversible paraplegia and 2 others had transient nerve root injury postoperatively. INTERPRETATION: Posterior total wedge resection osteotomy eliminates the need for anterior procedure and does not cause tractional force on the spinal cord, since the posterior column is shortened. This is an effective one-stage procedure, especially for the treatment of sharp and rigid kyphosis.