Minimally invasive surgery versus standard posterior approach in the treatment of adolescent idiopathic scoliosis: a 2-year follow-up retrospective study.

PURPOSE: This is a monocentric retrospective controlled study that compares the safety and efficacy of posterior minimally invasive surgery (MISS) to standard posterior spinal fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS). METHODS: We retrospectively collected 111 patients with Lenke type 1-6 AIS who were treated with MIS (n = 47) or PSF (n = 64) between February 2019 and January 2021 with a 2-year clinical and radiological follow-up. MIS technique was applied via two midline noncontiguous skin incisions ranging from 3 to 7 cm in length, so we obtained the arthrodesis only in the exposed tract, passing the rods below the fascia, avoiding the complete muscular sparing. Values of Cobb angles degrees were collected to study the correction rate of the structural major curve. Postoperative AP direct radiography and preoperative AP direct radiography were compared with the last follow-up examination. Operative time, preoperative hemoglobin (Hb) and second postoperative day Hb, full length of hospitalization, time to achieve verticalization and time to remove the drainage were recorded. NRS medium score was assessed immediately after surgery and during the whole postoperative rehabilitation treatment to estimate pain reduction. Complications were collected postoperatively and throughout the whole follow-up period. RESULTS: There was no significant difference between the two groups in terms of radiographic and clinical features. The correction rates of the structural curve resulted to be not significantly different between MISS and PSF (64.6 ± 11.7 vs 60.9 ± 13.2, p = 0.1292) as well as for the correction rate of the secondary curve between the two compared techniques (59.1 ± 13.2 vs 59.2 ± 12.4, p = 0.9865). The two groups had comparable operative time (210 min vs 215 min). The MIS group had a significantly lower reduction of postoperative Hb in comparison with PSF group (2.8 ± 1.3 mg/dl vs 4.3 ± 1.5 mg/dl, p < 0.0001). The postoperative NRS score was lower in MIS group (1.9 ± 0.8 vs 3.3 ± 1.3). PSF group was observed to have a significantly longer period of hospitalization than MIS (5.2 ± 1.4 days vs 6.3 ± 2.9 days, p = 0.206). Complications were more frequent in PSF group rather than in MFS group. CONCLUSIONS: MISS is a safe and capable alternative to PSF for AIS patients with curves < 70°, with analogue capacity of scoliosis correction and same operative time and with advantages in blood loss, length of stay and postoperative pain.

Fast-track protocols for patients undergoing spine surgery: a systematic review.

BACKGROUND CONTEXT: Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm. PURPOSE: The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field. METHODS: We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery. RESULTS: We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery. CONCLUSIONS: According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.

5.5-mm Cobalt-Chrome vs 6-mm Titanium Alloy Rods in Surgical Treatment of Lenke 1 Adolescent Idiopathic Scoliosis With High-Density Pedicle Screws and Direct Vertebral Rotation on Differently Shaped Rods: A Retrospective Comparative Cohort Study.

BACKGROUND: The gold standard of surgical treatment of adolescent idiopathic scoliosis (AIS) consists of a posterior approach requiring complex 3-dimensional correction with multisegmental pedicle screws and 2 contoured rods. The substantial corrective forces and the ability of the rod to withstand these forces rely on its biomechanical properties. The aim of this study is to compare outcomes of 5.5-mm cobalt-chrome (CoCr) and 6-mm titanium alloy (TiAl) rods in surgical correction in Lenke 1 AIS patients. TiAl has greater elasticity, which may facilitate the correction maneuver, whereas the stiffness of CoCr may result in stronger correction forces. The literature provides no clear indications about which rod may allow better correction and safety. METHODS: A total of 64 consecutive patients (30 CoCr vs 34 TiAl) with Lenke 1 AIS <100°, with 2 years minimum follow-up, requiring correction and posterior fusion at our institution were included. The primary outcome measure was coronal and sagittal correction and loss of correction at 2-year follow-up. Secondary outcome measures compared peri- and postoperative complications. RESULTS: The mean coronal correction was higher in the CoCr group: -73.6% ± 7.4 vs -65.5% ± 11 (P = 0.001). Mean T5-T12 kyphosis did not change significantly after surgery. In patients with hypokyphosis (<10°), an improvement in thoracic kyphosis was observed in both groups, but the improvement was significantly higher in the TiAl group (P = 0.038). In patients with hyperkyphosis (>40°), a similar reduction in thoracic kyphosis was observed in both groups. At follow-up, no coronal correction loss occurred. The sagittal correction loss was slight (0.5° ± 1.5 for the CoCr group, 1.5° ± 3 for the TiAl group) but statistically higher in the TiAl group (P = 0.032). There were no mechanical complications. One revision was required for infection in the CoCr group. CONCLUSION: In this series of Lenke 1 AIS, with the limitations of the study, 5.5-mm CoCr rods have provided better correction in the coronal plane than 6-mm TiAl rods. However, TiAl rods have been found to be associated with higher increase of thoracic kyphosis in hypokyphotic curves, although the clinical relevance of this finding could be questionable. CLINICAL RELEVANCE: This article provides surgeons with more information regarding rod material options when correcting Lenke 1 AIS.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review.

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Does use of pre-operative low-dose CT-scan in adolescent idiopathic scoliosis improve accuracy in screw placement? Results of a retrospective study.

PURPOSE: To evaluate the efficacy of pre-operative low-dose radiation computed tomography (CT) in optimizing screw placement in patients with adolescent idiopathic scoliosis (AIS). METHODS: 49 patients with AIS who required correction and posterior fusion between January 2018 and December 2019 were included in this retrospective study. All patients underwent surgery performed by the same team of experienced surgeons. Patients were divided in two groups. The study group received a pre-operative low-dose CT scan (CT group, n = 25), differently from the control group (CG, n = 24). Patients of both groups received a post-operative low-dose CT scan. The primary outcome measure was the accuracy of screw placement on the Gertzbein-Robbins scale (grades A and B were considered acceptable). Secondary outcome measures included a comparison of perioperative complications. RESULTS: A total of 1045 screws were placed. In CT group (n = 25, screws = 528) and CG (n = 24, screws = 517), trajectories were grade A or B in 94.5% and 93.6% of screws, respectively. Two screws (one for each group) were removed because of intra-operative-evoked potentials alteration and one screw required revision after post-operative imaging. No correlation was found between the malpositioning rate and the proximity to the apex of the curve, conversely a significative peak of misplacements was observed at T3 (p < 0.01). No neurological and vascular complications related to screw placement were recorded. There was not intergroup difference neither in screw accuracy (Chi-Square, 2-tailed Fisher's exact, p = 0.63), nor in complications rate. CONCLUSION: Pre-operative low-dose CT scan as surgical plan does not contribute in reducing pedicle screw misplacement rate. STUDY DESIGN: Retrospective comparative cohort study. LEVEL OF EVIDENCE: III.

High grade isthmic spondylolisthesis; can reduction always re-align the unbalanced pelvis?

BACKGROUND: Recently, various studies have reported the importance of distinguishing between balanced and unbalanced SL, sustaining the importance of SL reduction in unbalanced cases. In this study we present our experience in the treatment of isthmic spondylolisthesis in young patients, observing the correlation between SL reduction and sagittal correlation between spine and pelvis. METHODS: This is a retrospective study of a series of patients treated surgically for isthmic spondylolisthesis. Inclusion criteria were L5-S1 isthmic spondylolisthesis of III° or IV°, pediatric age, clinical and radiographic follow up of at least 1 year. Radiographic evaluation included the following elements: grade and percentage of listhesis (%L), lumbar lordosis (LL), lumbar-sacral angle (LSA), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT) distinguishing between "balanced" and "unbalanced" patients. Radiographic values were confronted by using Student's t- test, obtaining a statistically significant difference for values inferior to 0,05. RESULTS: Based on inclusion criteria, 28 patients were selected for our retrospective analysis, 19 female and 9 male. Mean age at surgery was 15,6 years. Mean follow up was 3 years and 3 months (min. 1 year - max 6 years and 7 months). Spondylolisthesis reduction was statistically significant both in balanced and in unbalanced patients, but pelvic incidence values did not improve significantly. We observed fewer mechanical complications in patients treated with interbody support. CONCLUSION: In our study, differences between pre-op and post-op spinopelvic alignment values were not statistically significant, even though spondylolisthesis reduction was statistically significant in all cases. Our study could be considered an initial attempt to correlate spinopelvic changes to spondylolisthesis reduction in a progressive manner, and possibly in the future, generate threshold values of reduction for ideal spinopelvic alignment in every different patient.

Does surgery for Scheuermann kyphosis influence sagittal spinopelvic parameters?

PURPOSE: To analyze changes in sagittal spinopelvic parameters (SSPs) after surgical treatment of Scheuermann's Kyphosis (SK). METHODS: We analyzed 20 patients affected by SK and subjected to posterior correction of the kyphosis by facetectomy, Ponte osteotomy, fusion and multilevel instrumentation with pedicle screw system. Four spinal and three pelvic parameters were measured: sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis, lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT). Analysis of changes in postprocedural SSPs compared to preoperative values was performed. RESULTS: TK passed from 78.6° preoperatively to 45.8° (p = 0.003). LL passed from 74.5° preoperatively to 53.5° (p = 0.01). No significant changes occurred in SVA, SS, PT and PI compared to preoperative values. CONCLUSION: We confirm the positive effect of surgery by Ponte osteotomy and posterior spinal fusion on TK and LL in patients with SK. In our experience, pelvic parameters did not change after surgery.

Long-term systemic metal distribution in patients with stainless steel spinal instrumentation: a case-control study.

STUDY DESIGN: Case-control study. OBJECTIVE: To verify whether metal ions in the serum of patients bearing spinal stainless steel instrumentation were elevated over the long-term period after implantation of stainless steel prostheses and to determine whether these levels could predict potential unfavorable outcomes. SUMMARY OF BACKGROUND DATA: Instrumented spinal arthrodesis, the standard procedure to correct scoliosis, routinely remains in situ for the lifetime of the patient. Elevated metal ion levels have been reported at short-term follow-up, but the long-term status, possibly related to systemic toxic effects, is unknown. METHODS: Twenty-two patients treated for scoliosis with posterior spinal arthrodesis using stainless steel instrumentation were included. Minimum follow-up was 10 years. Oswestry Disability Index and visual analog scale were recorded. Chromium (Cr) and nickel (Ni) levels were measured (ng/mL) and compared with levels in a control group including 30 healthy subjects. A receiver-operating characteristic curve was calculated on the basis of the clinical assessment (pain and disability) and the x-ray picture; the cutoff values for the parameters were settled, and the ion-testing potential was considered as a surrogate marker for failure. RESULTS: The level of Cr was significantly increased in patients, compared with controls (P=0.018). A remarkable Cr release without any clinical-radiologic sign was recorded in some female patients. A high specificity (93%), positive likelihood ratio (7.00), and overall accuracy (77%) were calculated for Cr; these indicate a high risk of failure when the levels exceeded the cutoff value, which was 0.6 ng/mL. No significant difference between the groups was found for Ni (P=0.7). CONCLUSIONS: Cr testing is suggested as a reliable marker for the malfunctioning assessment and as a support for standard procedures, especially with doubtful diagnosis. Furthermore, high levels of Cr ions were observed in female patients. This finding deserves attention especially when counseling young fertile women.

Transforaminal Lumbar Interbody Fusion in Degenerative Disk Disease and Spondylolisthesis Grade I: Minimally Invasive Versus Open Surgery.

BACKGROUND: Interbody fusion represents an efficient surgical treatment in degenerative lumbar disease, achieving satisfying outcome in >90% of cases. Various studies have affirmed the advantages of percutaneous and minimally invasive techniques with regard to minimized damage on soft tissues during surgical procedure, but their efficacy in comparison with the classic open surgical procedures has not yet been demonstrated. MATERIALS AND METHODS: This is a retrospective study. We compared 30 consecutive patients affected by disk degenerative disease or grade I degenerative spondylolisthesis that were treated with minimally invasive transforaminal lumbar interbody fusion (mini-TLIF) to a group of 34 consecutive patients presenting similar pathologic findings and demographic characteristics that underwent interbody fusion by traditional open approach (open-TLIF). All patients were treated between 2006 and 2010. Patients' mean age was 46 years (min 28-max 56) and 51 years (min 32-max 58), respectively. Mean follow-up was 23 months (min 12-max 38) and 25 months (min 12-max 40), respectively. Clinical evaluation was performed by using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) questionnaires. Radiographic evaluation was performed on standing and dynamic x-rays before operation and at final follow-up. RESULTS: There was a statistically significant improvement in clinical scores (VAS and ODI) in both groups. Early postoperative VAS score was significantly lower in the mini-TLIF group. Mean hospital stay and mean blood loss were significantly higher in the open-TLIF group than in the mini-TLIF group (7.4 vs. 4.1 d and 620 vs. 230 mL, respectively). Surgical time length of the procedure was higher in the mini-TLIF group. There were no major neurological complications in any of the patients. At final follow-up, radiographic evaluation showed good implant stability in both groups. CONCLUSIONS: Mini-TLIF is a safe and efficient procedure and, when correctly and carefully performed, can reach good results, similar to those obtained with traditional open surgical techniques, even though it may require a longer surgical time at least during the first stages of the learning curve. Reduced surgical invasiveness, short hospital stay, and limited blood loss represent the major advantages of minimally invasive technique.

Surgical treatment of early onset scoliosis in neurofibromatosis.

Case series report of twenty-three patients, aged between 4 and 11 years, were surgically treated at the Authors' Spine Surgery Division in the past 15 years. Mean follow-up is 5 years (range, 18 months to 15 years). Mean age at the time of surgical procedure was 9.1 years (range, 4 years to 11 years). Average scoliosis was 48° (range, 38° to 82°) and skeletal maturity according to Risser sign was 0 in all of the patients. Patients were divided into 2 Groups according to the surgical procedure adopted. Posterior only instrumentation was performed in 16 patients that presented with a thoracic kyphosis lower than 50° (Group A), in the remaining 7 patients showing thoracic kyphosis exceeding 50°, combined anterior and posterior instrumented arthrodesis was performed (Group B). One patient, belonging to Group A, was instrumented with growing rod without fusion. Average correction of scoliosis was 60%, overall complication rate 24% and major 7%. Crankshaft phenomenon was observed in 21% (Group A): in these cases, anterior arthrodesis was performed after a mean 15-month from first surgical procedure. Fusion failure was observed in 1 (Group B) patient who underwent revision of posterior instrumentation. Clinical and radiographic evaluation at F-up showed good outcome in terms of deformity progression and quality of life. Early and aggressive surgery is the most effective management for dystrophic curves in neurofibromatosis has been proven to be. Our experience confirms the need for spinal stabilization even in pediatric age in rapidly progressive spinal deformities.

Thoracic pedicle subtraction osteotomy in the treatment of severe pediatric deformities.

The traditional surgical treatment of severe spinal deformities, both in adult and pediatric patients, consisted of a 360° approach. Posterior-based spinal osteotomy has recently been reported as a useful and safe technique in maximizing kyphosis and/or kyphoscoliosis correction. It obviates the deleterious effects of an anterior approach and can increase the magnitude of correction both in the coronal and sagittal plane. There are few reports in the literature focusing on the surgical treatment of severe spinal deformities in large pediatric-only series (age <16 years old) by means of a posterior-based spinal osteotomy, with no consistent results on the use of a single posterior-based thoracic pedicle subtraction osteotomy in the treatment of such challenging group of patients. The purpose of the present study was to review our operative experience with pediatric patients undergoing a single level PSO for the correction of thoracic kyphosis/kyphoscoliosis in the region of the spinal cord (T12 and cephalad), and determine the safety and efficacy of posterior thoracic pedicle subtraction osteotomy (PSO) in the treatment of severe pediatric deformities. A retrospective review was performed on 12 consecutive pediatric patients (6 F, 6 M) treated by means of a posterior thoracic PSO between 2002 and 2006 in a single Institution. Average age at surgery was 12.6 years (range, 9-16), whereas the deformity was due to a severe juvenile idiopathic scoliosis in seven cases (average preoperative main thoracic 113°; 90-135); an infantile idiopathic scoliosis in two cases (preoperative main thoracic of 95° and 105°, respectively); a post-laminectomy kypho-scoliosis of 95° (for a intra-medullar ependimoma); an angular kypho-scoliosis due to a spondylo-epiphisary dysplasia (already operated on four times); and a sharp congenital kypho-scoliosis (already operated on by means of a anterior-posterior in situ fusion). In all patients a pedicle screws instrumentation was used, under continuous intra-operative neuromonitoring (SSEP, NMEP, EMG). At an average follow-up of 2.4 years (range, 2-6) the main thoracic curve showed a mean correction of 61°, or a 62.3% (range, 55-70%), with an average thoracic kyphosis of 38.5° (range, 30°-45°), for an overall correction of 65% (range, 60-72%). Mean estimated intra-operative blood loss accounted 19.3 cc/kg (range, 7.7-27.27). In a single case (a post-laminectomy kypho-scoliosis) a complete loss of NMEP occurred, promptly assessed by loosening of the initial correction, with a final negative wake-up test. No permanent neurologic damage, or instrumentation related complications, were observed. According to our experience, posterior-based thoracic pedicle subtraction osteotomies represent a valuable tool in the surgical treatment of severe pediatric spinal deformities, even in revision cases. A dramatic correction of both the coronal and sagittal profile may be achieved. Mandatory the use of a pedicle screws-only instrumentation and a continuous intra-operative neuromonitoring to obviate catastrophic neurologic complications.

Vertebroplasty: benefits are more than risks in selected and evidence-based informed patients. A retrospective study of 59 cases.

Vertebral compression fractures represent a frequent pathology among elderly population, with potentially devastating consequences. More than 20 years have passed since percutaneous vertebroplasty was initially used in the treatment of angiomas, representing nowadays a widely used treatment for osteoporotic vertebral fractures. The authors present a retrospective review of 59 consecutive patients (in total 94 fractured levels) that underwent polymethylmethacrylate percutaneous vertebroplasty for vertebral compression fractures due to senile or secondary osteoporosis. All fractures were free from neurologic involvement and were classified as A1 type according to Magerl classification. All of patients were initially treated conservatively, by application of orthosis that allows immediate deambulation. At control, patients who complained of pain and limitation of daily activities underwent MRI. If presence of marrow signal changes, especially hypertense signal in T2-weighted images was confirmed, percutaneous vertebroplasty procedure was performed (we could call it "sub-acute" procedure). A limited group of patients that did not tolerate brace and had an insufficient pain control underwent vertebroplasty "in acute", few days after fracture. Immediate post-operative pain reduction and follow-up clinical outcome (estimating quality of life and residual back pain) were evaluated by means of Visual Analogue Scale, SF-36 and Oswestry Disability Index. In the immediate post-operative course a significant pain relief was found in 39 patients (66.1%), moderate pain relief in 17 (28.8%), while 3 (5.1%) did not achieve relevant pain improvement. Pain intensity and life quality was maintained within satisfactory limits after a mean follow-up of 16 months. In conclusion, percutaneous vertebroplasty is an effective and safe procedure for treating vertebral compression fractures in the elderly. It provides immediate pain relief and allows early mobilization, thus avoiding potentially severe complications related to persistent back pain and prolonged bed rest. When performed by experienced surgeon complication rate is low, representing a safe procedure, able to provide a satisfactory outcome.

Surgical treatment of scoliosis in a rare disease: arthrogryposis.

BACKGROUND: The reported incidence of scoliosis in arthrogryposis varies from 30% to 67% and, in most cases, the curves progress rapidly and become stiff from early age.The authors report six cases of scoliosis in arthrogryposis to assess the role of surgical treatment. METHODS: Six cases (3 males, 3 females; mean age at surgery 13.2 years) with arthrogryposis multiplex congenita associated with the characteristic amyoplasia were reviewed: they were operated on for scoliosis at the authors' Spine Surgery Department between 1987 and 2008.Surgery was performed using the Harrington-Luque instrumentation (2 cases), the Luque system (1), a hybrid segmental technique with hooks and screws (1) and spinal anchoring with pedicle screws (2). RESULTS: The patients were clinically and radiologically reviewed at a mean follow-up of 4.2 years, ± 2.7 (range, 1 to 9 years). Three minor postoperative complications were encountered; a long-term pulmonary complication was seen in one case after reintervention and was successfully resolved after 10 days. Surgery was successful in the other 5 cases, where solid arthrodesis was achieved and no significant curve progression was observed at follow-up. CONCLUSIONS: The experience acquired with the present case series leads the authors to assert that prompt action should be taken when treating such aggressive forms of scoliosis. In case of mild spinal deformities in arthrogryposis, brace treatment should be attempted, the evolution of the curves being unpredictable; however, when the curve exceeds 40° and presents with marked hyperkyphosis, hyperlordosis or pelvic obliquity, surgery should not be delayed.

Treatment of scoliosis in patients affected with Prader-Willi syndrome using various techniques.

BACKGROUND: The incidence of spinal deformity in children with Prader-Willi syndrome (PWS) is high, with 86% of these patients found to have a significant structural scoliosis; however, there are very few case reports describing surgical treatment for this deformity. METHODS: The authors reviewed a case series consisting of 6 patients who underwent spine surgery for scoliosis. Children's mean age at index surgery was 12 years and 10 months (range, 10 to 15 yrs). Clinical evaluation revealed the typical phenotypic features of the PWS in all of the patients; 4 subjects had a karyotype confirmation of PWS. Major structural curves showed preoperative mean Cobb angles of 80.8 degrees (range, 65 degrees to 96 degrees ). Hybrid instrumentation with sublaminar wires, hooks and screws was used in the first 2 patients, while the remaining 4 were treated with titanium pedicle screw constructs. RESULTS: The mean clinical and radiological follow-up was 3 years and 10 months (range, 2 years to 9 years). Major complication rate was 50%. One patient who developed a major intraoperative complication (paraparesis) prevented spinal fusion to be obtained: the neurologic deficit resolved completely after instrumentation removal. Solid arthrodesis and deformity correction in both coronal and sagittal plane was, however, achieved in the other 5 cases and no significant curve progression was observed at follow-up. Another major short-term complication was encountered 3 months after surgery in a patient who experienced the detachment of a distally located rod and required correction through revision surgery and caudal extension by one level. Cervico-thoracic kyphosis was seen in 1 patient who did not require revision surgery. CONCLUSIONS: Spine reconstructive surgery in patients with PWS is rare and highly demanding.The best method of reconstruction is posterior multilevel pedicle screw fixation. Moreover, even with modern techniques, the risk of complications is still high. These new techniques, however, have shown to improve the postoperative course by allowing for immediate mobilization without any brace or cast. The use of the growing rod techniques, requiring repeated surgeries, should be carefully evaluated in each single case.

Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80 degrees: pedicle screws versus hybrid instrumentation.

The treatment of thoracic adolescent idiopathic scoliosis (AIS) of more than 80 degrees traditionally consisted of a combined procedure, an anterior release performed through an open thoracotomy followed by a posterior fusion. Recently, some studies have reassessed the role of posterior fusion only as treatment for severe thoracic AIS; the correction rate of the thoracic curves was comparable to most series of combined anterior and posterior surgery, with shorter surgery time and without the negative effect on pulmonary function of anterior transthoracic exposure. Compared with other studies published so far on the use of posterior fusion alone for severe thoracic AIS, the present study examines a larger group of patients (52 cases) reviewed at a longer follow-up (average 6.7 years, range 4.5-8.5 years). The aim of the study was to evaluate the clinical and radiographic outcome of surgical treatment for severe thoracic (>80 degrees) AIS treated with posterior spinal fusion alone, and compare comprehensively the results of posterior fusion with a hybrid construct (proximal hooks and distal pedicle screws) versus a pedicle screw instrumentation. All patients (n = 52) with main thoracic AIS curves greater than 80 degrees (Lenke type 1, 2, 3, and 4), surgically treated between 1996 and 2000 at one institution, by posterior spinal fusion either with hybrid instrumentation (PSF-H group; n = 27 patients), or with pedicle screw-only construct (PSF-S group; n = 25 patients) were reviewed. There were no differences between the two groups in terms of age, Risser's sign, Cobb preoperative main thoracic (MT) curve magnitude (PSF-H: 92 degrees vs. PSF-S: 88 degrees), or flexibility on bending films (PSF-H: 27% vs. PSF-S: 25%). Statistical analysis was performed using the t test (paired and unpaired), Wilcoxon test for non-parametric paired analysis, and the Mann-Whitney test for non-parametric unpaired analysis. At the last follow-up, the PSF-S group, when compared to the PSF-H group had a final MT correction rate of 52.4 versus 44.52% (P = 0.001), with a loss of -1.9 degrees versus -11.3 degrees (P = 0.0005), a TL/L correction of 50 versus 43% (ns), a greater correction of the lowest instrumented vertebra translation (-1.00 vs. -0.54 cm; P = 0.04), and tilt (-19 degrees vs. -10 degrees; P = 0.005) on the coronal plane. There were no statistically significant differences in sagittal and global coronal alignment between the two groups (C7-S1 offset: PSF-H = 0.5 cm vs. PSF-S = 0 cm). In the hybrid series (27 patients) surgery-related complications necessitated three revision surgeries, whereas in the screw group (25 patients) one revision surgery was performed. No neurological complications or deep wound infection occurred in this series. In conclusion, posterior spinal fusion for severe thoracic AIS with pedicle screws only, when compared to hybrid construct, allowed a greater coronal correction of both main thoracic and secondary lumbar curves, less loss of the postoperative correction achieved, and fewer revision surgeries. Posterior-only fusion with pedicle screws enabled a good and stable correction of severe scoliosis. However, severe curves may be amenable to hybrid instrumentation that produced analogous results to the screws-only constructs concerning patient satisfaction; at the latest follow-up, SRS-30 and SF-36 scores did not show any statistical differences between the two groups.