Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates.

BACKGROUND: It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype. METHODS: We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups. RESULTS: We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups. CONCLUSIONS: Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype. LEVEL OF EVIDENCE: Level III, therapeutic.

Quantifying Anesthesia Exposure in Growing Rod Treatment for Early Onset Scoliosis.

BACKGROUND: Growing rod (GR) treatment for early-onset scoliosis requires repeated anesthesia exposure (AE). At a minimum, GR treatment requires AE for diagnostic imaging, index GR surgery, periodic lengthenings, and final fusion. Adjunct procedures and complication-related procedures also increase AE. To our knowledge, this is the first study to quantify AE in GR treatment and to establish preoperative expectations. METHODS: A single-center retrospective review of 16 patients who completed GR treatment and underwent final fusion. Duration of all AE related to GR treatment for "standard" care procedures (ie, advanced imaging, index surgery, lengthenings, final fusion) and "associated" care procedures (ie, revisions, adjunctive surgical procedures, wound-related complications) were reviewed. Etiologies were classified per the classification of early-onset scoliosis. Mean total anesthesia time (TAT) was tallied and analyzed for standard care and associated care procedures. RESULTS: There were 5 syndromic, 8 neuromuscular, and 3 idiopathic patients. The mean age at the first AE event related to GR treatment was 7.4 years (range, 3.8 to 11 y). Mean age at the index GR surgery and final fusion was 8.1 years (range, 3.9 to 14.4 y) and 12.8 years (range, 9.7 to 19 y), respectively. The percentage of TAT for each procedural category was 7% for advanced imaging, 14% for index GR, 14% for lengthenings, 21% for final fusion, 27% for revisions, 9% for adjunct surgery, and 9% for wound complications. Standard care procedures accounted for 55% of TAT, whereas associated care procedures accounted for 45%. CONCLUSIONS: This study quantified expected duration of AE in GR treatment. Revisions and final fusion contributed most to TAT. Given the recent controversy of repeated AE in young children, efficiency measures should be implemented to reduce AE and avoid duplication without compromising the goals of surgical treatment. Associated care procedures accounted for 45% of the total AE. LEVEL OF EVIDENCE: Level IV.

Traumatic complete lateral dislocation at the lumbosacral junction: a case report.

STUDY DESIGN: This is a case report. OBJECTIVE: To present a novel case of lumbosacral dislocation and its surgical management. SUMMARY OF BACKGROUND DATA: Complete lumbosacral dislocations are rare injuries that ensue as a result of high-energy trauma. Anatomic stabilization of these injuries can be challenging and often involves open fixation and arthrodesis. METHODS: We present the case of a 22-year-old male who was involved in a high-velocity motorcycle accident with neurological deficit in the lower extremities. Radiographic analysis demonstrated a complete lateral dislocation of L5 vertebral body over the sacrum. The patient was surgically managed with a combined anterior and posterior arthrodesis, posterior decompression, and instrumentation. RESULTS: Successful arthrodesis and spinal alignment was achieved. The patient regained partial neurological function in the lower extremities with an improved Visual Analogue Scale score of 1 and was able to ambulate semi-independently at latest follow-up. CONCLUSIONS: A combined anterior and posterior arthrodesis with decompression and instrumentation is an effective method for the treatment of this type of lumbosacral dislocation.

Effects of posterior distraction forces on anterior column intradiscal pressure in the dual growing rod technique.

BACKGROUND: Little evidence is available addressing biomechanical properties of posterior distraction forces and their effects on anterior spinal column in the growing rod technique. The question is often asked if posterior distraction forces may be kyphogenic. The goal of this study is to determine whether posterior distraction forces transmitted anteriorly through different foundation constructs (i.e., screws vs. hooks) affect intradiscal pressure. METHODS: Six skeletally immature porcine spines were harvested leaving soft tissues and rib heads intact. Pedicle screws served as the lower foundation on a L3-L4 motion segment while pedicle screws and laminar hooks were randomly used at T3-T4 levels. Proximal constructs (hook vs. screw) were switched after initial distraction testing. The dual rod distractor was instrumented with strain gauges and calibrated using a custom force transducer. During distraction, intradiscal pressures immediately inferior to the superior foundation and the level equidistant between foundations were measured using needle pressure transducers. Maximum distraction force and maximum anterior disc pressure change were compared between hook and pedicle screw anchors using one-way ANOVA (p < 0.05). RESULTS: Upper foundations with pedicle screws had significantly greater distraction forces (416 ± 101 N) than those with upper level hooks (349 ± 100 N). There were no significant differences in disc pressures between levels or between upper foundation constructs. Disc pressures adjacent to the upper foundation demonstrated greater reduction (disc expansion) than the level equidistant within the construct. Pedicle screw constructs demonstrated greater endplate separation (distraction) compared to hook constructs. CONCLUSIONS: Posterior distraction forces result in anterior disc separation (distraction) and are distributed across multiple levels rather than delivered to the disc immediately adjacent to a foundation. Constructs with upper foundation hooks had lower distraction forces possibly due to hook motion during distraction. The load distribution at multiple levels may assist with curve control and may affect vertebral growth. The distraction forces may not be kyphogenic as is commonly believed.

Anterior column realignment (ACR) for focal kyphotic spinal deformity using a lateral transpsoas approach and ALL release.

STUDY DESIGN: Retrospective case series. OBJECTIVES: Introduce and evaluate the safety of a new technique of anterior column realignment (ACR) using a lateral transpsoas approach with release of anterior longitudinal ligament and annulus for correction of focal kyphotic deformity. SUMMARY OF BACKGROUND DATA: Spinal sagittal imbalance can adversely affect the long-term outcomes of patients with spinal deformity. METHODS: Clinical and radiographic review of patients who underwent ACR. RESULTS: Seventeen consecutive patients (12 females; 5 males) with a mean age of 63 years (range, 35-76 y) and a mean follow-up of 24 months (range, 12-82 mo) were identified. Fourteen of 17 (82%) had previous spine surgery and 12/17 (71%) had previous fusion. Twelve of the 17 (71%) underwent ACR for adjacent segment disease. Fifteen patients (88%) had Smith-Petersen osteotomies at the ACR level.The mean motion segment angle was 9 degrees preoperatively, which corrected to -19 degrees after ACR and to -26 degrees after posterior instrumentation. Motion segment angle was maintained at -23 degrees at the latest follow-up. The mean lumbar lordosis was -16 degrees preoperatively, which improved to -38 degrees after ACR and to -45 degrees after posterior instrumentation. Lumbar lordosis was maintained at -51 degrees at the latest follow-up. Pelvic tilt averaged 34 degrees before ACR and improved to 24 degrees after ACR and posterior instrumentation and maintained at 25 degrees at the latest follow-up. Patients with preoperative negative T1 spinopelvic inclination (T1SPI) corrected from -6 to -2 degrees and those with 0 or positive T1SPI corrected from 5 to -3 degrees after ACR at the latest follow-up.Eight patients (47%) had 10 complications. Four complications occurred after ACR. Two of 4 were neurological (1 persistent weakness) and 1 was vascular injury during anterior plate removal. CONCLUSION: Compared with posterior-based techniques, our preliminary results of ACR showed similar correction capacity and similar rate of morbidities for the treatment of focal kyphotic spinal deformity. Careful case selection, attention to the details of the technique, and enough experience are prudent elements for a desirable outcome.

Progressive early-onset scoliosis in Conradi disease: a 34-year follow-up of surgical management.

BACKGROUND: Conradi-Hunermann syndrome (CHS) is a rare metabolic syndrome with several orthopaedic problems. Early-onset scoliosis is of great importance because of often rapidly progressive nature and high risk of postoperative complications. OBJECTIVES: To report the 34-year follow-up and outcome of a patient with CHS treated with combined anterior and posterior fusion without instrumentation. METHODS: All available clinical and radiographs of a female patient with CHS retrospectively reviewed. Overall health status, sagittal and coronal deformity, pulmonary function test, and outcome questionnaires were evaluated. RESULTS: Initial films at the age of 4 months showed a curve of 37 degrees from T6-T11 and a curve of 17 degrees from T11-L2. Thoracic kyphosis was measured at 43 degrees. Standing films at the age of 2 years and 2 months showed progression of both the curves to 50 and 66 degrees, respectively, and a significant spinal imbalance. The kyphosis also progressed to 57 degrees. She underwent a staged anterior inlay graft spinal fusion with autograft and allograft ribs from T8-L1 and posterior in situ fusion from T6-L1 with corticocancellous allograft. Solid radiographic fusion was observed 18 months after surgery. She was 36 years old at her latest follow-up, 34 years after surgery, with neutral clinical coronal and sagittal balance. No significant pain and respiratory complaint at moderate sports and normal daily life activity. "Vital capacity" and "total lung capacity" were 65% and 75%, respectively, of the normal. Thoracic curve of 35 degrees (T6-T11) and right thoracolumbar curve of 53 degrees from T11-L2 with a solid fusion fromT6-L1 with kyphosis measured over the fused area of 40 degrees were observed. Her overall mean Scoliosis Research Society-22 score was 3.68. She is an MBA graduate from a competitive school and currently works full-time. CONCLUSIONS: Although the treatment of early-onset scoliosis has significantly evolved over the past 3 decades, the traditional method of anterior release and fusion and staged in-situ posterior fusion posterior fusion with postoperative immobilization showed acceptable deformity correction and maintenance of the pulmonary function over the 34 years.

Angiotensin Receptor Blockers Were Not Associated With Decreased Arthrofibrosis After Total Knee Arthroplasty.

Stiffness after total knee arthroplasty (TKA) remains a challenging problem. Angiotensin receptor blockers (ARBs) have been associated with decreased muscle fibrosis. The aim of this study was to evaluate whether perioperative use of ARBs was associated with a reduction in arthrofibrosis and manipulation under anesthesia (MUA) in patients undergoing primary TKA at 90 days and 1 year postoperative. In this retrospective study, the authors used a national database to evaluate patients undergoing TKA for primary osteoarthritis from 2007 to 2017. They evaluated patients with filled prescriptions for ARBs within the study time frame and the specific type of ARB and its association with arthrofibrosis and MUA. After adjusting for age, sex, a comorbidity index, and obesity, any ARB or specific ARBs were not associated with a reduction in the rate of arthrofibrosis or MUA after TKA (P≥.05). Male sex, age 55 years or older, and obesity were associated with a reduction in the rate of arthrofibrosis and MUA after TKA (P≤.05). Studies should be performed to evaluate ARBs to see whether there is a more specific role in preventing joint stiffness in certain patient subpopulations following TKA. [Orthopedics. 2021;44(2):e274-e280.].

Restoring Condylar Width: Radiographic Relationship Between the Lateral Tibial Plateau and Lateral Femoral Condyle in Normal Adult Knees.

OBJECTIVES: We hypothesized that a constant radiographic relationship exists between the lateral tibial and femoral condyles and that no side-to-side variation exists. METHODS: We reviewed anteroposterior x-rays of 217 uninjured adults ages 18-65, Included 109 unilateral and 108 bilateral radiographs with no or minimal osteoarthrosis (Kellgren-Lawrence grades 0-1). The perpendicular distance between the lateral-most margins of the tibial plateau articular surface (A) and the lateral femoral epicondyle (B) and the lateral femoral condyle articular surface (C) was measured in millimeters (mm). Medial and lateral measurements to point (A) were recorded as (-) and (+), respectively. First, the average of measured distances in all unilateral knees and randomly selected either right or left knees from the bilateral group (n = 217) was calculated. Comparison was made between both sexes. Next, A-B and A-C distances were compared between right and left knees in the bilateral group (n = 108) to find any significant difference (2-tailed t test, alpha = 0.05). RESULTS: The average A-B distance was 0.60 ± 2.40 mm (-4.82 to +6.49 mm). The mean A-C distance was -3.96 ± 2.07 mm (-8.51 to +3.98 mm). No significant difference was found between A-B and A-C distances between males (0.40 ± 2.62 mm and -3.91 ± 2.05 mm) and females (0.70 ± 2.28 mm and -3.99 ± 2.09 mm). Similarly, no significant difference was found between A-B and A-C distances between right (1.08 ± 2.31 mm and -3.90 ± 1.73 mm) and left knees (0.90 ± 2.38 mm and -4.31 ± 1.7 mm). Concordance coefficient for interobserver and intraobserver reliability showed substantial agreement. CONCLUSION: In conclusion, this study provided a "normal" range for the relationship of the proximal lateral tibial plateau relative to the lateral femoral condyle. The lateral femoral epicondyle is generally aligned with the lateral tibial articular margin. The relationship between the lateral tibial plateau, lateral femoral epicondylar surface, and lateral femoral articular surface is constant from side to side. This technique is reproducible in the setting of fracture, and templating off of the contralateral uninjured knee may be beneficial in tibial plateau fracture surgery.

Anterior Column Realignment has Similar Results to Pedicle Subtraction Osteotomy in Treating Adults with Sagittal Plane Deformity.

OBJECTIVE: Anterior column realignment (ACR) is a minimally invasive surgical technique used for the correction of adult sagittal plane deformity. ACR is performed via a minimally invasive lateral transpsoas approach with anterior longitudinal ligament release and hyperlordotic cage placement. The objective of this study was to compare radiographic outcomes and complications in patients treated by ACR or Pedicle subtraction osteotomy (PSO). METHODS: Patients who underwent ACR were matched with patients from a retrospective PSO dataset, by pelvic incidence, lumbar lordosis, and thoracic kyphosis. Inclusion criteria included pelvic incidence and lumbar lordosis mismatch > 10°, pelvic tilt > 25°, and/or C7 sagittal vertical axis >5 cm, and minimum 1-year follow-up. RESULTS: All (n = 17) patients who underwent ACR underwent second-stage open posterior instrumented fusion. There were no differences in baseline demographic or radiographic parameters. Both groups were found to have significant improvement from preoperative to final follow-up for lumbar lordosis, T1 spinopelvic inclination, and T1 pelvic angle. Pelvic tilt did not improve with PSO (31° to 28°) at final follow-up but did improve in ACR group (34° to 25°). No differences were identified at 3-month or final follow-up for lumbar lordosis (51° vs. 47°), pelvic tilt (25° vs. 28°), and T1 pelvic angle (23° vs. 24°). The group undergoing PSO achieved greater T1 spinopelvic inclination correction (8° vs. 1.9°). Patients who underwent ACR had significantly less estimated blood loss than patients who underwent PSO (1.6 vs. 3.6 L, respectively), but no difference in the overall major complication rates was found (35.3% vs. 41.2%, respectively). CONCLUSIONS: ACR achieved similar radiographic results as PSO in a matched cohort with significantly less estimated blood loss and similar overall complication rate.

Paper #20: Vertebral Column Resection for Early-Onset Scoliosis: Indications, Utilization and Outcomes.

EOS treated with VCR were predominantly congenital or myelomeningocele with 84% performed at index surgery and 70% definitive fusion. Correction of major curve was 69% and increases in spinal and thoracic height. Complication rate was 33% with 57% being IONM/neuro related.

Dual Growing Rods for the Treatment of Early-Onset Scoliosis.

INTRODUCTION: The dual growing-rod technique involves implantation of a set of two rods and two anchor groups (upper and lower foundations) to exert frequent distractions to allow for spinal growth. STEP 1 INITIAL SURGERY POSITIONING: Pay special attention to the effect of positioning on sagittal alignment. STEP 2 INITIAL SURGERY NEUROMONITORING: Use multimodality intraoperative neuromonitoring, including SSEPs, MEPs, EMG, and H-Reflexes. STEP 3 INITIAL SURGERY EXPOSURE: Avoid broad exposure of uninstrumented levels to prevent the risk of spontaneous fusion. STEP 4 INITIAL SURGERY PREPARATION OF FOUNDATIONS: The foundation is an assembly of at least four anchors at two or three vertebrae along with one or two rods. STEP 5 INITIAL SURGERY CHOOSING THE ANCHORS: Use hooks or pedicle screws for the proximal foundation and use bilateral pedicle screws (a four-anchor construct) for the distal foundation. STEP 6 INITIAL SURGERY ROD CONTOURING AND ROD ASSEMBLY: Cut two 4.5-mm rods and contour them to the appropriate sagittal and coronal alignment, being careful not to overcorrect in the sagittal and coronal planes. STEP 7 INITIAL SURGERY TANDEM CONNECTOR ATTACHMENT: Place a tandem connector at the thoracolumbar junction to allow for future lengthening. STEP 8 INITIAL SURGERY FINAL IMPLANT ASSEMBLY: Pass the preassembled rods and tandem connector from caudad to cephalad beneath the fascia, securing them to the foundation and performing the first lengthening. STEP 9 INITIAL SURGERY WOUND CLOSURE: Gentle handling of the skin and associated deeper tissues is essential to avoid complications. STEPS 1 AND 2 LENGTHENING POSITIONING AND NEUROMONITORING: These are the same as those for the initial surgery. STEP 3 LENGTHENING EXPOSURE: Make one incision between the two connectors on or in line with the original incision. STEP 4 LENGTHENING LENGTHENING INSIDE VERSUS OUTSIDE THE TANDEM CONNECTOR: Lengthening can be performed inside or outside the tandem connector. STEP 5 LENGTHENING CLOSURE: See Step 9 for the initial surgery. RESULTS: The quantity and quality of research on growth-sparing techniques for early-onset scoliosis have increased substantially in the past three years. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Biomechanical Evaluation of 4 Different Foundation Constructs Commonly Used in Growing Spine Surgery: Are Rib Anchors Comparable to Spine Anchors?

STUDY DESIGN: In vitro animal model. OBJECTIVE: To compare the strength of 4 different anchor constructs commonly used as foundations in growing spine surgery. SUMMARY OF BACKGROUND DATA: Children with progressive early-onset scoliosis often require surgical intervention to control the deformity and allow continued growth. The foundation sites of growing spine constructs take a significant load and can fail. This study compares the strength of 4 commonly used constructs applying the same load in a porcine model. METHODS: Forty immature porcine specimens including soft tissues (10 per group) were instrumented with 1 of 4 bilateral proximal anchors at T5-T6. The four groups were: screw-screw (SS), lamina hook-hook (HH), rib hook-hook (RR), and transverse process to lamina hook-hook (TPL). The entire specimen was kept intact except for surgical site exposure. A unique fixture was designed to brace the specimen and provide a counterforce. The ultimate load was identified as the greatest load recorded for a construct and analyzed by a set of 1-way analysis of variance using the SPSS 12.0 statistical package. RESULTS: All specimens eventually failed at the bone-anchor interface. No failures were observed in the instrumentation used. The means and standard deviations of ultimate loads were measured as RR (429 ± 133 N), SS (349 ± 89 N), HH (283 ± 48 N), and TPL (236 ± 60 N). There was no statistically significant difference between the following construct pairs: RR/SS, SS/HH, and HH/TPL. Young's modulus was calculated for each construct type and no statistically significant difference was determined. CONCLUSIONS: This study showed that RR and SS constructs had the greatest ultimate strength but also the greatest variability among the foundations tested. However, the HH and TPL constructs had lower ultimate strength but were less variable. Rib-based anchors may be considered as an alternative in upper foundation constructs in growing rod techniques.

Do Thoracolumbar/lumbar Curves Respond Differently to Growing Rod Surgery Compared With Thoracic Curves?

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare radiographic outcomes between primary thoracic and primary thoracolumbar/lumbar curves in patients with early-onset scoliosis (EOS) after growing rod (GR) surgery. SUMMARY OF BACKGROUND DATA: Previous studies have shown the efficacy of GR surgery for progressive EOS. However, there is no information on the behavior of different curve patterns in EOS after GR surgery. METHODS: A multicenter international EOS database query identified 175 patients who met the following inclusion criteria: non-congenital etiology, GR surgery, ≤ 10 years of age at index surgery, minimum 2-year follow-up, and at least 3 lengthenings. Patients were categorized into 2 groups based on the Scoliosis Research Society definition of the anatomical location of primary curves: group 1 included thoracic apices (T2 to T11/12 disc) and group 2 included thoracolumbar (T12 to L1) and lumbar (L1/2 disc to L4) apices. Radiographic measurements were performed before and after index surgery and at latest follow-up. RESULTS: A total of 139 patients (79%) had primary thoracic (group 1) and 36 (21%) had primary thoracolumbar or lumbar curves (group 2). Mean number of levels instrumented was statistically greater in group 2 (15.0) versus group 1 (13.6) (p < .05). Group 2 had statistically better mean curve correction than group 1 after the index GR surgery (51% and 44%, respectively; p < .05). However, there was no significant difference in mean percent curve correction at latest follow-up (46% and 39%, respectively; p > .05). Implant complication rate was 45% and 47% for groups 1 and 2, respectively. Preoperative curve flexibility was greater in group 2 (45%) compared with group 1 (40%) (p > .05). CONCLUSIONS: Overall, thoracolumbar/lumbar and thoracic curves achieve similar major curve correction and have a similar complication profile.

Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences.

BACKGROUND: Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment. METHODS: A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention. RESULTS: Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05). CONCLUSIONS: The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique: case report.

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

Next generation of growth-sparing techniques: preliminary clinical results of a magnetically controlled growing rod in 14 patients with early-onset scoliosis.

STUDY DESIGN: Prospective nonrandomized study. OBJECTIVE: To report the preliminary results of magnetically controlled growing rod (MCGR) technique in children with progressive early-onset scoliosis. SUMMARY OF BACKGROUND DATA: The growing rod (GR) technique is a viable alternative for treatment of early-onset scoliosis. High complication rate is attributed to frequent surgical lengthening. The safety and efficacy of MCGR were recently reported in a porcine model. METHODS: Multicenter study of clinical and radiographical data of patients who underwent MCGR surgery and at least 3 distractions. Distractions were performed in clinic without anesthesia/analgesics. T1-T12 and T1-S1 heights and the distraction distance inside the actuator were measured after lengthening. RESULTS: Fourteen patients (7 girls, 7 boys) with a mean age of 8 years, 10 months (3 yr, 6 mo to 12 yr, 7 mo) had 14 index surgical procedures. Of the 14, 5 had single-rod (SR) surgery and 9 had dual-rod (DR) surgery, with overall 68 distractions. Diagnoses were idiopathic (N = 5), neuromuscular (N = 4), congenital (N = 2), syndromic (N = 2), and neurofibromatosis (N = 1). Mean follow-up was 10 months (5.8-18.2). The Cobb angle changed from 60° to 34° after initial surgery and 31° at latest follow-up. During distraction period, T1-T12 height increased by 7.6 mm for SR (1.09 mm/mo) and 12.12 mm for DR (1.97 mm/mo). T1-S1 height gain was 9.1 mm for SR (1.27 mm/mo) and 20.3 mm for DR (3.09 mm/mo). Complications included superficial infection in 1 SR, prominent implant in 1 DR, and minimal loss of initial distraction in 3 SR after index. Partial distraction loss observed after 14 of the 68 distractions (1 DR and 13 SR) but regained in subsequent distractions. There was no neurological deficit or implant failure. CONCLUSION: Preliminary results indicated MCGR was safe and provided adequate distraction similar to standard GR. DR achieved better initial curve correction and greater spinal height during distraction compared with SR. No major complications were observed during the follow-up.