Ponte osteotomies for treatment of spinal deformities: they are not all made equal.

PURPOSE: To compare surgical outcomes of Ponte's osteotomies for treatment of adolescent idiopathic scoliosis (AIS), Scheuermann's kyphosis (SK), and adult scoliosis (AdS). METHODS: We conducted a retrospective review of patients with AIS, SK, and AdIS who underwent posterior spinal instrumented fusion (PSIF) at our Institution from January 2019 to December 2022. Demographics, imaging, and intraoperative data (including number of osteotomies performed, blood losses, surgical timing, and complications) were extracted from patient charts. RESULTS: A total of 80 patients (62 AIS, 7 SK, and 11 AdS) were enrolled in the study. All patients were treated with a PSIF and a total of 506 Ponte osteotomies were performed (5.8 ± 4.1, 9.3 ± 2.4, and 7.5 ± 2.5 average osteotomies per patient in the AIS, SK, and AdS group, respectively; p = 0.045). Average time per osteotomy was 6.3 ± 1.5 min in the AIS group, and 5.8 ± 2.1 and 8.7 ± 4.0 in the SK and AdS group, respectively (p = 0.002). Blood loss was significantly smaller in the SK group (8.6 ± 9.6 ml per osteotomy) compared to AIS group (34.9 ± 23.7 ml) and AdS group (34.9 ± 32.7 ml) (p = 0.001). A total of 4 complications were observed in the AIS group (1.1%) and 2 complications in the AdS group (2.4%), but this was not statistically significant. CONCLUSIONS: Our study shows that Ponte's osteotomies are safe and effective in surgical treatment of AIS, SK, and AdS. Blood loss and execution time per osteotomy are significantly smaller in the SK group compared to AIS and AdS. No significant differences were noted in terms of complications between the three groups.

Using Proximal Hooks as a Soft-Landing Strategy to Prevent Proximal Junctional Kyphosis in the Surgical Treatment of Scheuermann's Kyphosis.

AIM: To evaluate the occurrence of proximal junctional kyphosis (PJK) as well as both the clinical and radiologic outcomes of patients who underwent surgery for Scheuermann?s Kyphosis (SK) using either exclusively pedicle screws or a combination of proximal hooks and pedicle screws constructs. MATERIAL AND METHODS: Surgically treated 37 patients with the diagnosis of SK were evaluated retrospectively. The patients were divided into two groups based on the type of instrumentation employed. The first group contained 22 patients with only pedicle screws (PP) while the second group consisted of 15 patients with mixed constructs that were proximal hooks and pedicle screws (HP) at the rest of the levels. The clinical and radiological data were compared in patients who were followed up for a minimum of 2 years. RESULTS: The average duration of follow-up for the PP group was approximately 94.7 ± 53.1 months, whereas the HP group had an average follow-up period of around 103 ± 64.4 months. After conducting the analyses, no statistically significant findings were identified in the measurements taken for the SRS-22 scores in preoperative, postoperative, and the most recent follow-up radiographs (p > 0.05). It is worth noting that among patients who exclusively utilized pedicle screws, both the proximal (p=0.045) and distal (p=0.030) junctional kyphosis angles experienced more pronounced increases compared to hybrid structures. CONCLUSION: While no notable distinction was observed between the two groups, patients with pedicle screws fixation had a higher PJK angle. Conversely, the use of hooks at the upper end seems to be a preventive measure against the development of PJK.

Scheuermann's Disease.

Scheuermann's disease is a rigid progressive kyphosis occurring in late childhood to adolescence. It is the most common cause of sagittal imbalance and angular progressive kyphosis in adolescents associated with back pain. The exact etiology of the disease is unclear, but it is characterized by defective growth of the end plate that may result from excessive mechanical stress on a weakened end plate during spinal growth. Several other theories have been proposed, and it is thought to be a multifactorial disease occurring as a result of the interplay of multiple factors. The radiographic features consist of anterior vertebral body wedging, irregular end plates, Schmorl's nodes, and intervertebral disk degeneration. The natural history and evolution of this disease is also unknown. Conservative management with physiotherapy, rehabilitation, and bracing is the first line of treatment. Mechanical bracing helps prevent further progression of the kyphotic deformity. Surgery is mostly indicated in patients with failure of conservative management, with neurologic compromise, and for cosmetic reasons.

Selecting the Vertebra above Sagittal Stable Vertebra as the Distal Fusion Level in Scheuermann's Kyphosis: A Prospective Study with a Minimum of 2-Year Follow-Up.

OBJECTIVE: The proper selection of the lower instrumented vertebra (LIV) remains controversial in the surgical treatment of Scheuermann's disease and there is a paucity of studies investigating the clinical outcomes of fusion surgery when selecting the vertebra one level proximal to the sagittal stable vertebra (SSV-1) as LIV. The purpose of this study is to investigate whether SSV-1 could be a valid LIV for Scheuermann kyphosis (SK) patients with different curve patterns. METHODS: This was a prospective study on consecutive SK patients treated with posterior surgery between January 2018 and September 2020, in which the distal fusion level ended at SSV-1. The LIV was selected at SSV-1 only in patients with Risser >2 and with LIV translation less than 40 mm. All of the patients had a minimum of 2-year follow-up. Patients were further grouped based on the sagittal curve pattern as thoracic kyphosis (TK, n = 23) and thoracolumbar kyphosis (TLK, n = 13). Radiographic parameters including global kyphosis (GK), lumbar lordosis (LL), sagittal vertical axis (SVA), LIV translation, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured preoperatively, postoperatively, and at the latest follow-up. The intraoperative and postoperative complications were recorded. The Scoliosis Research Society (SRS)-22 scores were performed to evaluate clinical outcomes. RESULTS: A total of 36 patients were recruited in this study, with 23 in the TK group and 13 in the TLK group. In TK group, the GK was significantly decreased from 80.8° ± 10.1° to 45.4° ± 7.7° after surgery, and was maintained at 45.3° ± 8.6° at the final follow-up. While in the TLK group, GK was significantly decreased from 70.7° ± 9.2° to 39.1° ± 5.4° after surgery (p < 0.001) and to 39.3° ± 4.5° at the final follow-up. Meanwhile, despite presenting with different sagittal alignment, significant improvement was observed in LL, SVA, and LIV translation for both TK and TLK groups (p < 0.05). Self-reported scores of pain and self-image in TK group and scores of self-image and function in TLK group showed significant improvement at the final follow-up (all p < 0.05). Distal junctional kyphosis (DJK) was observed in two patients (8.7%) in TK group, and one patient (7.7%) in TLK group. No revision surgery was performed. CONCLUSION: Selecting SSV-1 as LIV can achieve satisfactory radiographic and clinical outcomes for SK patients with different curve patterns without increasing the risk of DJK. This selection strategy could be a favorable option for SK patients with Risser sign >2 and LIV translation less than 40 mm.

Assessment of Quality of Life for Scheuermann's Kyphosis Patients with Cobb's Angle 50°-65° Treated Conservatively or Surgically in North Jordan: A Prospective Comparative Study.

Background: Scheuermann's disease is the most common cause of hyperkyphosis of the thoracic spine during the adolescence period. It causes neck and lower back pain, restriction of lung expansion, traction of the spinal cord, increased vulnerability to vertebral fracture, and a hump. Patients with curves < 60° are treated conservatively, while surgery is used for patients with curves > 60°. The purpose of this prospective cohort study was to assess the quality of life and functional changes in conservatively or surgically treated Scheuermann's disease patients with a curve size of 50°-65° in north Jordan. Methods: Sixty-three adolescent patients with Scheuermann's kyphosis (aged between 10 and 18 years) were treated at our hospital between January 2014 and August 2018. All patients were investigated clinically, radiologically (Cobb's angle), and functionally (Oswestry Disability Index [ODI], Scoliosis Research Society 22 revision [SRS-22r] questionnaire, and pulmonary function test [PFT]) pre- and post-treatment (final follow-up). Patients were randomly selected for treatment method (conservative versus surgical). Results: There were 31 patients (mean age, 15.48 ± 2.50 years) and 32 patients (mean age, 16.19 ± 1.51 years) treated conservatively and surgically, respectively. Mean ± standard deviation of ODI, SRS-22r, and Cobb's angle of the surgical group improved from 16.8% ± 14.3%, 3.5 ± 0.5, and 58.75° ± 3.59°, respectively, pre-surgery to 13.4% ± 10.8%, 4.2 ± 0.5, and 41.53° ± 3.94°, respectively, post-surgery, while those of the conservative group became worse from 12.6% ± 13.4%, 3.9 ± 0.7, and 56.1° ± 3.3°, respectively, to 20.1% ± 13.6%, 3.5 ± 0.7, and 58.8° ± 5.8°, respectively. The surgical group showed better improvement in all scores than the conservative group (p < 0.05), as well as in PFT. Conclusions: Surgical treatment of Scheuermann's kyphosis with curves of 50°-65° resulted in better QOL, Cobb's angle, and PFT than conservative treatment. This was because of lower patient cooperation in the conservative management group, which made the curve less flexible for exercises and bracing.

Combined surgical correction of pectus carinatum and juvenile kyphosis.

Pectus carinatum may rarely be associated with kyphosis. However, the correlation between both conditions is not well reported. Therefore, there are no reports for combined correction of both deformities in the same patient. Moreover, studies estimating the kyphosis prevalence in patients with pectus carinatum are lacking. To our knowledge, this is the first paper to present such a case. We report an 18-year-old boy with both pectus carinatum and kyphosis that were surgically corrected in a combined procedure. The indication of surgery is cosmetic, and the postoperative recovery included pneumothorax but was otherwise uneventful and satisfactory.

Selection of the optimal distal fusion level for Scheuermann kyphosis with different curve patterns: when can we stop above the sagittal stable vertebra?

PURPOSE: To investigate the optimal lowest instrumented vertebra (LIV) in the treatment of Scheuermann kyphosis (SK) with different curve patterns. METHODS: Fifty-two SK patients who underwent posterior surgery between January 2010 and December 2017 with a minimum follow-up of 2 years were retrospectively reviewed. Patients were divided into two groups based on the curve pattern: the Scheuermann thoracic kyphosis (STK group) or Scheuermann thoracolumbar kyphosis (STLK group). Based on the relationship between the sagittal stable vertebra (SSV) and LIV, both groups were further divided into the SSV group and SSV-1 group. Radiographic parameters, distal junctional kyphosis (DJK) incidence and SRS-22 questionnaire scores were evaluated. RESULTS: In STK and STLK groups, there were no significant differences in most pre- and postoperative radiographic assessments between SSV and SSV-1 subgroups. DJK incidence showed no significant differences between groups during follow-up (P > 0.05). LIV-PSVL was significantly more negative in the SSV-1 group than that in the SSV group (P < 0.001). Within the SSV-1 group, patients with DJK showed a more negative LIV-PSVL (P = 0.039). Moderate correlation was observed between preoperative LIV-PSVL and DJK with a Spearman coefficient of - 0.474 (P = 0.035). Receiver operative characteristic curve analysis showed that the threshold value of preoperative LIV-PSVL to predict DJK was - 37.35 mm (area under the curve 0.882). CONCLUSION: Shorter fusion stopping at SSV-1 achieved comparable clinical outcomes and did not increase the risk of DJK for both STK and STLK patients. For patients whose preoperative LIV-PSVL < - 37.35 mm, extending fusion to SSV is an acceptable solution to prevent DJK.

Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

STUDY DESIGN: A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK). OBJECTIVE: Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. METHODS: 51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. RESULTS: The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort. CONCLUSION: The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

Long-term follow-up of untreated Scheuermann's kyphosis.

STUDY DESIGN: Long-term cross-sectional study. OBJECTIVES: To investigate the long-term effects of untreated Scheuermann's kyphosis on quality of life, and its relationship to radiographic parameters of spinal deformity. Previous studies reported reduced self-image, increased pain and impaired physical status. Little is known of the long-term impact of sagittal plane deformity in untreated SK. METHODS: One hundred and thirteen consecutive untreated patients with SK were identified from a national service database prior to 2000, when surgery was not offered at this unit. 81 of these patients were available for evaluation; 66 (81%) consented to questionnaire and clinical evaluation, and 47 (58%) consented to additional radiological evaluation. Health-related quality of life (HRQoL) was compared to normative population values. Mean age was 45.1 years (31-65), and mean follow-up was 27 years (16-36). 57 patients had thoracic kyphosis and 9 had thoracolumbar deformity. RESULTS: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative population values. Kyphosis progressed from mean 66° at skeletal maturity to 78° (p < 0.001) after mean follow-up of 27 years. Long-term progression of untreated SK was 0.45°/year (n = 47). Multilinear regression showed good correlation between increasing SVA and worse ODI scores (r = 0.59; p = 0.001). Increasing SVA also correlated with worse function, pain and mental health scores reported by SRS-22, and with worse physical function and bodily pain scores reported by SF-36. Increasing CL correlated with worse SF-36 physical function scores. Increasing cSVA and increasing TK correlated with worse SRS-22 self-image scores. CONCLUSION: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative data. Long-term progression of untreated SK was 0.45°/year (n = 47). Increasing SVA correlated with worse SF-36 physical function, SRS-22 function, SRS-22 pain and higher ODI scores. Total kyphosis (TK) and cSVA were independent predictors of low SRS self-image. LEVEL OF EVIDENCE: III.

The effect of pedicle subtraction osteotomy for the correction of severe Scheuermann thoracolumbar kyphosis on sagittal spinopelvic alignment.

PURPOSE: To analyze how pedicle subtraction osteotomy (PSO) treatment of severe Scheuermann thoracolumbar kyphosis (STLK) using pedicle screw instrumentation affects sagittal spinopelvic parameters. BACKGROUND: The medical literature on the post-surgical effects of treatments such as Ponte osteotomy is limited, but suggests few effects on spinopelvic profiles. Currently, there is no research regarding changes in sagittal spinopelvic alignment upon PSO treatment in STLK patients. METHODS: We performed a retrospective study on 11 patients with severe STLK. These patients underwent posterior-only correction surgeries with PSO and pedicle screw instrumentation between 2012 to 2017 in a single institute. Patients were measured for the following spinopelvic parameters: global kyphosis (GK), thoracic kyphosis (TK), thoracolumbar kyphosis (TL), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tile (PT), sacral slope (SS), and administered a Scoliosis Research Society-22 questionnaire (SRS-22) pre-operation, post-operation and at final follow-up. RESULTS: GK improved from a median of 74.1° to 40.0° after surgery, achieving a correction rate of 48.8% with a median correction loss of 0.8°. TK, TL and LL all showed significant difference (P < 0.05) and SVA improved 22.7 (11.6, 30.9) mm post operation. No significant difference was found in pelvic parameters (PI, PT, SS, all P < 0.05). The absolute value of LL- PI significantly improved from a median of 26.5° pre-operation to 6.1° at the final follow-up. 72.7% in this series showed an evident trend of thoracic and lumbar apices migrating closer to ideal physiological segments after surgery. Self-reported scores of pain, self-image, and mental health from SRS-22 revealed significant improvement at final follow-up (all P < 0.05). CONCLUSIONS: PSO treatment of severe STLK with pedicle screw instrumentation can improve spine alignment and help obtain a proper alignment of the spine and the pelvis.

Enfermedad de Scheuermann lumbar / Lumbar Scheuermann's disease

La osteocondrosis lumbar juvenil o enfermedad lumbar de Scheuermann comparte características con la enfermedad de Scheuermann clásica, pero se localiza en la columna dorsal baja y lumbar (D10-L4), y es menos frecuente. La forma lumbar atípica consiste en la aparición de hernias de Schmorl en uno o dos cuerpos vertebrales con estrechamiento del espacio interdiscal y cambios en los platillos vertebrales. Presentamos el caso de un adolescente de 18 años que fue recibido en el Cuerpo de Guardia a causa de un accidente de tránsito, y refirió dolor lumbar. Se le indicaron estudios de imagen donde no se identificaron lesiones secundarias al trauma. Sin embargo, se evidenció una vértebra en limbo a nivel de L1, así como irregularidad de los platillos vertebrales de los segmentos lumbares altos, correspondientes con nódulos de Schmorl. Todos estos hallazgos son compatibles con enfermedad lumbar de Scheuermann. El paciente se mantuvo en observación sin que presentara complicaciones y se remitió a la Consulta de Reumatología(AU)

Juvenile lumbar osteochondrosis or Scheuermann's lumbar disease shares characteristics with classical Scheuermann's disease but it is located in the lower and lumbar spine (D10-L4) and is less frequent. The atypical lumbar form consists of the appearance of Schmorl hernias in one or two vertebral bodies with narrowing of the intradiscal space and changes in the vertebral plates. The case is presented of an 18-year-old teenager who was received in emergency service because of a traffic accident, referring to low back pain. Imaging studies were indicated where no injuries secondary to trauma were identified. However, there was evidence of a limb vertebra at the level of L1 as well as irregularity of the vertebral plates of the corresponding upper lumbar segments with Schmorl nodules. All these findings are consistent with lumbar Scheuermann's disease(AU)

Two-stage anterior and posterior fusion versus one-stage posterior fusion in patients with Scheuermann's kyphosis.

AIMS: Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann's kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion. METHODS: A retrospective review of patients treated surgically for Scheuermann's kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable. RESULTS: There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches. CONCLUSION: A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368-1374.

Scheuermann's Disease as a Risk Factor for Lumbar Disc Herniation Recurrence.

OBJECTIVE: To verify whether Scheuermann's disease (SD) is a risk factor for patients with recurrent lumbar disc herniation (rLDH) than in patients without recurrence. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Department of Orthopaedics, Yantaishan Hospital, China, from December 2016 to September 2019. METHODOLOGY: The demographics (age, gender, body mass index [BMI], alcohol abuse, and current smoking), diabetes mellitus, and radiological data (affected levels, herniated side, herniation type, Pfirrmann grade, and the presence of SD) of 602 patients were retrospectively analysed, who underwent surgery for symptomatic LDH from December 2016 to August 2018. They were underwent one-year follow-up and were divided into LDH and rLDH groups. Both typical and atypical SD criteria were used to diagnose SD. Independent-sample t-test was used to analyse the role of age and BMI in both groups, and the Chi-square test was conducted to analyse other parameters. Logistic regression analysis was performed to evaluate various factors. RESULTS: There was a significant difference in age (p=0.026), BMI (p=0.007), current smoking (p=0.001), and SD (p<0.001) between the groups. When these parameters were included in the logistic regression analysis, age, current smoking status, and SD were found to be risk factors for rLDH. CONCLUSION: Age, current smoking, and SD are risk factors for rLDH. Older patients with radiological characteristics of SD should quit smoking to prevent rLDH. Key Words: Scheuermann's disease, Kyphosis, Disc herniation, Recurrence, Age, Smoking, Risk factor.

Comparison of the accuracy of the cannulated pedicle screw and the classical pedicle screw in the treatment of Scheuermann's kyphosis: A retrospective study.

OBJECTIVES: This study aims to investigate if use of cannulated pedicle screw (CPS) in the dysplastic pedicles in Scheuermann's kyphosis (SK) increases the accuracy rate of the screw and reduces screw-related complications. PATIENTS AND METHODS: This retrospective study included 21 patients (11 males, 10 females; mean age 19.1 years; range, 13 to 22 years) (550 screws) who received correction with pedicle screws due to SK deformity between May 2015 and January 2019. Between 2017 and 2018, classical pedicle screws were used in addition to CPSs in the upper thoracic region (T2, T3, T4) and thin pedicles (group 1). However, during the years 2015 to 2016, only classical pedicle screws were used for the patients who underwent posterior instrumentation for SK (group 2). Computed tomography scanning was used to investigate the accuracy of the screws. RESULTS: There were 12 patients (316 screws) in group 1 and nine patients (234 screws) in group 2. Seventy-four (13.4%) of all screws were inserted incorrectly. Incorrect screw rate in group 1 was significantly lower than group 2; 21 (6.6%) and 53 (22.6%), respectively (p<0.001). There were no complications related to the use of CPSs after a mean follow-up of two-and-a-half years. CONCLUSION: The use of CPS in the surgical treatment of SK does not increase the complication rate; instead it increases the accuracy of the screw. For this reason, we believe that CPS may be an effective and reliable option in the treatment of SK.

Postoperative sagittal alignment of congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis: a minimum 10-year follow-up study.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To elucidate the postoperative course of sagittal alignment in patients with congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis. Acquisition of acceptable sagittal alignment is essential to treat spinal deformity. Little evidence exists regarding long-term surgical outcomes on sagittal alignment in congenital kyphosis or kyphoscoliosis. METHODS: Sixteen consecutive patients (mean age 10.5 ± 3.5 years) with congenital kyphosis or kyphoscoliosis who underwent vertebra resection and osteotomy with instrumentation by single posterior or combined anterior and posterior approach were included. Preoperative radiographs identified kyphosis in 3 patients and kyphoscoliosis in 13 patients. All patients had clinical and radiologic follow-up for > 10 years (mean 16.3 ± 4.0 years). RESULTS: Segmental kyphosis was significantly improved from 33.9° ± 20.1° to 14.9° ± 17.6° by surgery and was finally maintained at 16.8° ± 22.2° and sagittal vertical axis (SVA) of 13.1 ± 33.7 mm at preoperation and 18.3 ± 22.1 mm at postoperation significantly increased to 26.8 ± 45.7 mm during follow-up. Of the 16 patients, 5 (31%) were identified as those with SVA > 40 mm, and SVA increases > 30 mm during follow-up. In patients with sagittal malalignment, radiographs demonstrated decreased lumbar lordosis at the lower foundation from 28.8° ± 39.0° to 17.0° ± 17.6°, significant increased pelvic tilt from 25.8° ± 5.4° to 37.4° ± 7.4° during follow-up (p < 0.05), and larger residual segmental kyphosis than those in the 11 patients without sagittal malalignment with statistical significance. Of the five cases, progression of local kyphosis (one case) and sagittal decompensation, including decreased lumbar lordosis with disc degeneration (four cases), increased pelvic tilt (three cases), or proximal junctional kyphosis (two cases), were observed. CONCLUSION: Based on this > 10-year follow-up study, residual kyphosis and sagittal decompensation are revealed to be risk factors for postoperative sagittal malalignment in patients with congenital thoracolumbar to lumbar kyphosis or kyphoscoliosis. LEVEL OF EVIDENCE: Level IV, case series.

Sternoclavicular dislocation as a possible complication for surgical Scheuermann's deformity correction: a case report.

OBJECTIVE: We present a sternoclavicular dislocation as a non-reported complication after spinal kyphotic deformity surgical correction. BACKGROUND: The sternocostal complex seems to have an important role in the pathology of Scheuermann's kyphotic deformity. A role for the sternoclavicular complex has never been reported in association with Scheuermann's disease pathology but could explain anterior sternoclavicular dislocation after spinal kyphotic deformity correction. METHODS: A 19-year-old male patient underwent surgery for a 74° thoracic kyphosis associated with a 35° thoracic and a 50° lumbar scoliotic curve. In the early post-operative period, the patient developed pain over the left sternoclavicular joint articulation, with a very obvious lump. An X-ray disclosed an anterior sternoclavicular dislocation. After surgical treatment failed, the dislocation was repaired in a second surgical procedure with a flexion and lengthening osteotomy of the middle third of the clavicle followed by capsular repair reinforced with sternocleidomastoid fascia. RESULTS: At an 8-year follow-up after his spine procedure and 6 years after his clavicular surgery, the patient had full shoulder range of motion and no joint pain, despite the presence of a new sternoclavicular anterior dislocation. CONCLUSION: Sternoclavicular dislocation after spine kyphotic deformity correction is presented for the first time; however, it is not possible to establish a causative association. Additional studies are necessary to delineate the role of the sternoclavicular complex in Scheuermann's disease.

Curve patterns deserve attention when determining the optimal distal fusion level in correction surgery for Scheuermann kyphosis.

BACKGROUND CONTEXT: The surgical strategy to decide distal fusion level for Scheuermann kyphosis (SK) is controversial. Some spinal surgeons advocate that instrumentation should end at the first lordotic vertebra (FLV), whereas others recommend extending spinal fusion to the sagittal stable vertebra (SSV). Scheuermann kyphosis has two curve patterns: Scheuermann thoracic kyphosis (STK), with the curve apex above or at T10; and Scheuermann thoracolumbar kyphosis (STLK), with the curve apex below T10. To our knowledge, curve patterns have not been taken into consideration when determining the distal fusion level. PURPOSE: This study aims to analyze the clinical and radiographic outcomes, including the distal junctional problems, in pediatric patients with STK and STLK who underwent fusion with different distal fusion levels. STUDY DESIGN: This is a retrospective, single-center, institutional review board-approved study. PATIENT SAMPLE: A total of 45 consecutive pediatric patients with STK or STLK. OUTCOME MEASURES: The following parameters were evaluated: global kyphosis (GK), deformity angular ratio (DAR), correction rate of GK and DAR, thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sagittal vertical axis (SVA), T1 pelvic angle (TPA), the distance from the center of the lower instrumented vertebra (LIV) to the posterior sacral vertical line, pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and distal junctional kyphosis (DJK). METHODS: This work was supported by the National Natural Science Foundation of China (Grant No. 81171672), Nanjing Clinical Medical Center, and Jiangsu Provincial Key Medical Center. Patients with STK were fused to SSV at the distal level (Group STK), whereas patients with STLK were fused to FLV (Group STLK). Whole spine x-rays obtained before surgery, immediately after operation, and at the latest follow-up were evaluated. The radiographic and clinical data were compared between Groups STK and STLK. All patients had a minimum of 2 years of follow-up. RESULTS: Before surgery, Groups STK and STLK were comparable in terms of age, gender, body mass index, fusion levels, follow-up time, some radiographic parameters and the 22-item Scoliosis Research Society questionnaire (SRS-22) evaluation. DAR and TLK were significantly smaller, whereas PI was significantly greater, in Group STK than those in Group STLK. Despite different distal fusion strategies, STK and STLK were corrected to an equivalent extent, with similar GK, correction rate, LL, SVA, TPA, PT, and SS immediately after operation and at the final follow-up. The DAR and TLK retained were smaller, whereas the PI retained was greater, in Group STK than STLK after surgery. Distal junctional kyphosis complications were found in five patients with STK curve type. In Group STK, patients with DJK were found to have significantly larger preoperative GK (87.5±7.0 vs. 77.5±9.0, p=.024), correction rate of GK (62.9±10.2% vs. 51.3±8.5%, p=.021), and correction rate of DAR (55.9±4.5% vs. 36.6±13.7%, p=.011) than those without DJK. Pre- and postoperative SRS-22 assessments did not show any significant difference between Groups STK and STLK or between patients with and without DJK. CONCLUSIONS: Curve patterns should be taken into attention when determining the optimal distal fusion level in correction surgery for SK. For patients with STLK, relatively shorter fusion stopping at FLV is enough to correct SK with the preservation of more lumbar motility and less development of DJK. For patients with STK, we suggest extending fusion to the SSV, which could restrict more distal junctional problems than fusion to the FLV. Large GK and correction degree might be the associated factors of developing DJK in STK patients.

Posterior-only versus combined anterior/posterior fusion in Scheuermann disease: a large retrospective study.

PURPOSE: The literature shows controversies concerning surgical treatment of Scheuermann's kyphosis between posterior-only fixation and combined anterior/posterior fusion. The aim of this study is to compare the clinical and radiological results and the rate of complications between these two techniques. METHODS: We performed a multicentric retrospective review of 131 patients who underwent primary fusion for Scheuermann's kyphosis divided into two groups: 67 patients operated via posterior approach only and 64 operated via combined anterior/posterior approach. Classical clinical, surgical and radiological data were collected. A descriptive and statistical analysis was performed between the two groups to evaluate the influence of the surgical procedure on the rate of complications, the functional results and radiological correction. RESULTS: The average age was 23 and the average kyphosis was 77 degrees. The mean follow-up was 4.2 years (range 0.1-27.3). There was no difference regarding demographic data, preoperative radiographic data and length of fusion between the two groups. Functional results were good in 81% of cases. Kyphosis correction was on average 15° and the correction of the compensatory lumbar lordosis was 20°. The correction was stable at final follow-up. There was no difference between the two groups in terms of functional results, the complications rate and radiological correction. CONCLUSION: Surgery for Scheuermann's kyphosis gives good and stable functional and radiological results. Given the fact that the two surgical strategies give the same results, it appears that the anterior/posterior fusion technique to treat Scheuermann's kyphosis should be reserved for major deformations. These slides can be retrieved under Electronic Supplementary Material.

Reciprocal Changes in Sagittal Alignment With Operative Treatment of Adolescent Scheuermann Kyphosis-Prospective Evaluation of 96 Patients.

INTRODUCTION: Sagittal alignment abnormalities in Scheuermann kyphosis (SK) strongly correlate with quality of life measures. The changes in spinopelvic parameters after posterior spinal fusion have not been adequately studied. This study is to evaluate the reciprocal changes in spinopelvic parameters following surgical correction for SK. METHODS: Ninety-six operative SK patients (65% male; age 16 years) with minimum 2-year follow-up were identified in the prospective multicenter study. Changes in spinopelvic parameters and the incidence of proximal (PJK) and distal (DJK) junctional kyphosis were assessed as were changes in Scoliosis Research Society-22 (SRS-22) questionnaire scores. RESULTS: Maximum kyphosis improved from 74.4° to 46.1° (p < .0001), and lumbar lordosis was reduced by 10° (-63.3° to -53.3°; p < .0001) at 2-year postoperation. Pelvic tilt, sacral slope, and sagittal vertical axis remained unchanged. PJK and DJK incidence were 24.2% and 0%, respectively. In patients with PI <45°, patients who developed PJK had greater postoperative T2-T12 (54.8° vs. 44.2°, p = .0019), and postoperative maximum kyphosis (56.4° vs. 44.6°, p = .0005) than those without PJK. In patients with PI ≥45°, patients with PJK had less postoperative T5-T12 than those without (23.6° vs. 32.9°, p = .019). Thoracic and lumbar apices migrated closer to the gravity line after surgery (-10.06 to -4.87 mm, p < .0001, and 2.28 to 2.10 mm, p = .001, respectively). Apex location was normalized to between T5-T8 in 68.5% of patients with a preoperative apex caudal to T8, whereas 90% of patients with a preoperative apex between T5 and T8 remained unchanged. Changes in thoracic apex location and lumbar apex translation were associated with improvements in the SRS function domain. CONCLUSION: PJK occurred in 1 in 4 patients, a lower incidence than previously reported perhaps because of improved techniques and planning. Both thoracic and lumbar apices migrated closer to the gravity line, and preoperative apices caudal to T8 normalized in more than two-thirds of patients, resulting in improved postoperative function. Individualizing kyphosis correction to prevent kyphosis and PI mismatch may be protective against PJK.

Severe rigid Scheuermann kyphosis in adult patients; correction with posterior-only approach.

PURPOSE: Scheuermann kyphosis is the most common structural kyphosis among adolescence and young people. Surgical treatment may be performed through combined anterior and posterior or posterior-only approaches; to our knowledge, the efficacy of posterior-only approach as less invasive procedure is not well studied in case of severe rigid Scheuermann kyphosis. MATERIALS AND METHODS: Eighteen patients with severe rigid Scheuermann kyphosis operated through only posterior approach from 2013 to 2016 were evaluated. All information regarding demographic data, curve size before and after the surgery, surgical time, amount of blood loss, correction loss during follow-up and also complications was collected. RESULT: There were six females and 12 males. Mean age of the patients was 22.4 years (range 17-38). Mean kyphosis angle before surgery was 87.2° (range 85-105), and that reduced to 47.4° (range 45-55) after the surgery. Mean curve size in hyperextension view was 73.8°. Mean postoperative Cobb angle was 50-55 percent of preoperative curves. Mean hospital admission duration was 3.5 days after the index surgery (range 3-5 days). Mean blood loss during the surgery was 250 ml. Mean surgical duration time was 150 min. Mean follow-up period was 9 months (range 8-48 months). No complication was found among the patients. CONCLUSION: Posterior-only approach using advanced osteotomy techniques and posterior release is a safe and reliable approach for treatment of patients suffering from severe rigid Scheuermann kyphosis and provides acceptable deformity correction.