Transient Monoplegia as a Result of Unilateral Femoral Artery Ischemia Detected by Multimodal Intraoperative Neuromonitoring in Posterior Scoliosis Surgery: A Case Report.

This is to report a case of 16-year-old girl with transient right lower limb monoplegia as a result of femoral artery ischemia detected by multimodal intraoperative spinal cord neuromonitoring (MISNM) during posterior correction surgery of adolescent idiopathic scoliosis.A patient with a marfanoid body habitus and LENKE IA type scoliosis with the right thoracic curve of 48° of Cobb angle was admitted for posterior spinal fusion from Th6 to L2. After selective pedicle screws instrumentation and corrective maneuvers motor evoked potentials (MEP) began to decrease with no concomitant changes in somato-sensory evoked potentials recordings.The instrumentation was released first partially than completely with rod removal but the patient demonstrated constantly increasing serious neurological motor deficit of the whole right lower limb. Every technical cause of the MEP changes was eliminated and during the wake-up test the right foot was found to be pale and cold with no popliteal and dorsalis pedis pulses palpable. The patient was repositioned and the pelvic pad was placed more cranially. Instantly, the pulse and color returned to the patient's foot. Following MEP recordings showed gradual return of motor function up to the baseline at the end of the surgery, whereas somato-sensory evoked potentials were within normal range through the whole procedure.This case emphasizes the importance of the proper pelvic pad positioning during the complex spine surgeries performed in prone position of the patient. A few cases of neurological complications have been described which were the result of vascular occlusion after prolonged pressure in the inguinal area during posterior scoliosis surgery when the patient was in prone position. If incorrectly interpreted, they would have a significant impact on the course of scoliosis surgery.

Direct Vertebral Rotation Versus Single Concave Rod Rotation: Low-dose Intraoperative Computed Tomography Evaluation of Spine Derotation in Adolescent Idiopathic Scoliosis Surgery.

STUDY DESIGN: A comparative clinical study of two main corrective manoeuvres in scoliosis surgery. OBJECTIVE: To compare the effectiveness of two main corrective manoeuvres: single concave rod rotation (SCRR) and direct vertebral rotation (DVR) in regard to apical vertebral rotation (AVR) and rib hump correction in adolescent idiopathic scoliosis (AIS) surgery. SUMMARY OF BACKGROUND DATA: It remains unclear whether SCRR manoeuvre alone causes apical vertebral derotation (AVD) and rib hump correction. Although the influence of DVR on AVD and rib hump change has been described, it has been evaluated mainly with indirect methods. This is the first study to evaluate separately the derotational effectiveness of these two manoeuvres during the low-dose intraoperative computed tomography (ICT). METHODS: A study group consisted of 38 AIS patients treated by posterior scoliosis surgery (PSS) with all pedicle screw constructs. All examined patients had dow-dose ICT evaluation (before correction, after SCRR, and after DVR). RESULTS: We found SCRR ineffective - mean postcorrectional AVR increased insignificantly 1.5° (16.1% worsening) P = 0.170. On the contrary, an average postcorrectional AVR after DVR decreased significantly mean 3.1° (33.3% improvement) P = 0.049. Precorrectional rib hump angle was 19.3°, after SCRR 15°, and after DVR 12.3°. It was found that despite the lack of true derotation after SCRR there was a significant 22.3% decrease of the rib hump P = 0.043. Although the rib hump decreased significantly 36.3% after DVR as well P = 0.023. There was also significant difference between a rib hump angle after SCRR and DVR (P = 0.049). CONCLUSION: SCRR does not lead to AVD. The true spinal derotation is possible only when DVR systems are used. The decrease of rib hump is achieved after both SCRR and DVR, but the improvement is significantly better after DVR. LEVEL OF EVIDENCE: 3.