Short fusion versus long fusion for degenerative lumbar scoliosis.

The extent of fusion for degenerative lumbar scoliosis has not yet been determined. The purpose of this study was to compare the results of short fusion versus long fusion for degenerative lumbar scoliosis. Fifty patients (mean age 65.5 +/- 5.1 years) undergoing decompression and fusion with pedicle screw instrumentation were evaluated. Short fusion was defined as fusion within the deformity, not exceeding the end vertebra. Long fusion was defined as fusion extended above the upper end vertebra. The lower end vertebra was included in the fusion in all the patients. The short fusion group included 28 patients and the long fusion group included 22 patients. Patients' age and number of medical co-morbidities were similar in both the groups. The number of levels fused was 3.1 +/- 0.9 segments in the short fusion group and 6.5 +/- 1.5 in the long fusion group. Before surgery, the average Cobb angle was 16.3 degrees (range 11-28 degrees ) in the short fusion group and 21.7 degrees (range 12-33 degrees ) in the long fusion group. The correction of the Cobb angle averaged 39% in the short fusion group and 72% in the long fusion group with a statistical difference (P = 0.001). Coronal imbalance improved significantly in the long fusion group more than in the short fusion group (P = 0.03). The correction of lateral listhesis was better in the long fusion group (P = 0.02). However, there was no difference in the correction of lumbar lordosis and sagittal imbalance between the two groups. Ten of the 50 patients had additional posterolateral lumbar interbody fusion at L4-5 or L5-S1. The interbody fusion had a positive influence in improving lumbar lordosis, but was ineffective at restoring sagittal imbalance. Early perioperative complications were likely to develop in the long fusion group. Late complications included adjacent segment disease, loosening of screws, and pseudarthrosis. Adjacent segment disease developed in ten patients in the short fusion group, and in five patients in the long fusion group. In the short fusion group, adjacent segment disease occurred proximally in all of the ten patients. Loosening of distal screws developed in three patients, and pseudarthrosis at L5-S1 in one patient in the long fusion group. Reoperation was performed in four patients in the long fusion group and three patients in the short fusion group. In conclusion, short fusion is sufficient for patients with small Cobb angle and good spinal balance. For patients with severe Cobb angle and rotatory subluxation, long fusion should be carried out to minimize adjacent segment disease. For patients who have severe sagittal imbalance, spinal osteotomy is an alternative technique to be considered. As long fusion is likely to increase early perioperative complications, great care should be taken for high-risk patients to avoid complications.

Thoracoplasty in thoracic adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw instrumentation in the treatment of thoracic adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Some spine surgeons recently think more correction of hump deformity using pedicle screws without thoracoplasty. Although thoracoplasty has been conventional treatment of rib hump, there are few papers about the results of pedicle screw instrumentation and concomitant thoracoplasty. METHODS: Eighty-seven patients with thoracic AIS (mean age, 14.4 years) treated by pedicle screw instrumentation were retrospectively analyzed after a minimum follow-up of 2 years. Patients were divided into 3 groups; N-T group (no thoracoplasty with iliac bone graft, n = 37), T+N-DVR [thoracoplasty without direct vertebral rotation (DVR), n = 20] and T+DVR group (thoracoplasty with DVR, n = 30). In the T (T+N-DVR and T+DVR) group, 4 to 8 ribs were resected and used for bone graft. Patients were evaluated for deformity correction, balance, pulmonary function, height and angle of rib hump, clinical outcomes (SRS-30), and complications. RESULTS: In the N-T group, the thoracic curve was corrected from 53 degrees to 16 degrees (69% correction), in the T+N-DVR group from 55 degrees to 18 degrees (69%) and in the T+DVR group from 54 degrees to 10 degrees (81%). There was no difference in postoperative spinal balance and pulmonary function among the 3 groups. The correction rates of hump height and angle were 35% and 38% in the N-T group, respectively, 57% and 58% in the T+N-DVR, and 70% and 72% in the T+DVR. The T group showed significantly better correction of rib hump and self-image score in the SRS-30 questionnaire than the N-T group. There were 8 iliac donor site problems in the N-T group and 3 hemothorax in the T group, which had no adverse effect in the final result. CONCLUSION: Thoracoplasty showed significantly better rib hump correction, satisfactory clinical outcomes without pulmonary function compromise, or iliac bone graft site morbidity in the treatment of thoracic AIS with pedicle screw instrumentation.

Is anterior release necessary in severe scoliosis treated by posterior segmental pedicle screw fixation?

With the advent of segmental pedicle screw fixation that enables more powerful corrective forces, it is postulated that an additional anterior procedure may be unnecessary even in severe deformities. The purpose of this paper is to evaluate the results of a posterior procedure alone using segmental pedicle screw fixation in severe scoliotic curves over 70 degrees . Thirty-five scoliosis patients treated by pedicle screw fixation and rod derotation were retrospectively analyzed after a minimum follow-up of 2 years (range 2-10.4). The mean age of patients was 15.3 years (range 9.8-34.2). Diagnoses were idiopathic scoliosis in 29, neuromuscular scoliosis in 3 and scoliosis associated with Marfan syndrome in 3. Scoliosis consisted of single thoracic curve in 18, double thoracic in 5 and double major in 12. Twenty-five patients showed a major thoracic curve greater than 70 degrees (range 70-100), and different ten patients showed a major lumbar curve greater than 70 degrees (range 70-105), pre-operatively. The deformity angle, lowest instrumented vertebral tilt (LIVT) and spinal balance were measured. Pre-operatively there were nine patients with coronal decompensation. The pre-operative thoracic curve of 80 +/- 9 degrees with the flexibility of 45 +/- 11% (45 +/- 11 degrees in side-bending film) was corrected to 27 +/- 10 degrees at the most recent follow-up, showing a correction of 66% (53 degrees) and loss of correction of 3.0% (3.7 degrees). The pre-operative lumbar curve of 79 +/- 12 degrees with the flexibility of 62 +/- 14% (30 +/- 11 degrees in side-bending film) was corrected to 33 +/- 14 degrees at the most recent follow-up [59% (46 degrees) curve correction, 3.5% (3.0 degrees) loss of curve correction]. The pre-operative LIVT of 30 +/- 8 degrees was corrected to 11 +/- 6 degrees, showing a correction of 62% (19 degrees). Residual coronal decompensation was observed in three patients postoperatively. Pre-operative thoracic kyphosis of 27 degrees (range 0-82) improved postoperatively to 31 degrees (range 14-53). In conclusion, posterior segmental pedicle screw fixation without anterior release in severe scoliosis had satisfactory deformity correction without significant loss of curve correction. In this series a posterior procedure alone obviated the need for the anterior release and avoided complications related anterior surgery.

Stress fracture of the pelvic wing-sacrum after long-level lumbosacral fusion: a case report.

STUDY DESIGN: A case report of transverse stress fracture of the pelvic wing-sacrum after long-level lumbosacral fusion. OBJECTIVE: To report this rare complication of long-level lumbosacral fusion. SUMMARY OF BACKGROUND DATA: There are a number of well-described complications of instrumented lumbosacral fusion, including delayed stress fracture of the pelvis. A bilateral pelvic wing-sacrum transverse stress fracture after long-level lumbosacral fusion has not been previously reported to our knowledge. METHODS: Radiography and computed tomography were used to confirm the diagnosis. Long lumbosacral fusion and a pelvic wing-sacrum fracture were shown. RESULTS: A 48-year-old woman underwent several revision spinal surgeries for collapse or instability occurring at the adjacent levels. She presented with low back and bilateral buttock pain with slow progression after last surgery. A bilateral transverse pelvic wing-sacrum stress fracture was found on plain radiographs 7 months later. CONCLUSIONS: Stress fracture of bilateral pelvic wing-sacrum can occur as a potential source of late pain after long fusions of the lumbosacral spine. A better understanding of the related biomechanical forces and preoperative risk factors may identify patients at risk and may aid in surgical planning. There are few reports of pelvic stress fracture as a complication of lumbosacral fusion, and it is typically described as a late occurrence. We present the occurrence of a bilateral pelvic wing-sacrum transverse stress fracture, not previously discussed to our knowledge.

Hybrid external fixation of distal tibial fractures: new strategy to place pins and wires without penetrating the anterior compartment.

INTRODUCTION: Impalement of the anterior compartment musculature remains a problem in the hybrid external fixation of distal tibial fractures. The purposes of this study were to develop a tensioned wire configuration which does not violate the anterior compartment and to analyze the biomechanical implications of new wire configuration. MATERIALS AND METHODS: Thirty-seven adult volunteers without known pathology around either tibia were recruited. Axial computed tomography of the distal tibia was performed at 5-mm slices from the plafond to the upper margin of the syndesmosis. The wire convergence angle was measured at the 1-, 2-, and 2.5-cm levels using the following landmarks: tibialis anterior tendon (TA), tibialis posterior tendon (TP), peroneus brevis tendon (PB), anterolateral border of the lateral malleolus (LM). Two straight lines were drawn by connecting TA and PB and connecting TP and LM. The wire convergence angle was defined as an acute angle between these two lines. Then the orientation of the bisector axis of the wires was measured. As a second part of this study, a validated three-dimensional hybrid external fixator model was developed using finite elements modeling to analyze the stiffness of the frames constructed according to the measured wire convergence angle and orientation. Five simulated configurations were tested. The stiffness of each frame was analyzed under four load conditions: torsion, axial compression, side bending, and anteroposterior bending. RESULTS: The mean convergence angle was 30 degrees irrespective of the level. The bisector axis was oriented towards the anterolateral direction about 20 degrees from the coronal plane. The stiffness of the frame constructed with a wire convergence angle of 30 degrees and an anterolateral wire orientation of 20 degrees was 20-30% less than that of the frame constructed with 60 degrees wires oriented in a coronal plane. The addition of an anteromedial half-pin increased the stiffness significantly. CONCLUSIONS: Two tensioned wires may be placed without violating the anterior compartment by using the above four clinically identifiable landmarks. Addition of a half-pin on the anteromedial surface of the distal articular fragment makes the frame markedly stiffer than is possible using the standard wire configuration.

Mucociliary differentiation according to time in human nasal epithelial cell culture.

Knowledge of the state of differentiation, cell phenotype, and expression of genes for mucus production at the time of study is important because these may vary at different times during the culture period. The primary purpose of this study was to determine whether the number of ciliated cells increases as a function of differentiation in NHNE cells. If we observed an increase in the number of ciliated cells, the composition ratio of ciliated and secretory cells according to the culture duration was determined. The levels of mucin and lysozyme secretion and their gene expression at this time were also examined. The presence of ciliated cells was not evident up to 2 days after confluence. However, 3.1 +/- 0.2 %, 7.4 +/- 0.5 %, and 14.5 +/- 0.6 % of the cells were ciliated on the 7th, the 14th, and the 28th day after confluence, respectively. Meanwhile, the percentage of secretory cells were 35.6 +/- 2.8 %, 32.8 +/- 2.5 %, 32.8 +/- 2.5 %, and 49.4 +/- 1.4 % on the 2nd, the 7th, 14th, and 28th day after confluence. The amount of secreted mucin showed an abruptly increasing pattern by the 14th day after confluence but showed no significant changes thereafter. The amount of secreted lysozyme increased as a function of differentiation. MUC5AC and MUC5B mRNA were mainly expressed between the 7th and the 14th day after confluence with relatively weak MUC8 and lysozyme expression. By the 28th day after confluence however, as the MUC5AC mRNA expression became weaker, MUC5B, MUC8, and lysozyme mRNA expression became stronger. In conclusion, we speculate that in in vitro studies with NHNE cells, the time point of treatment should vary according to the purpose of the study. In addition, the MUC5B and MUC8 gene may play an important role in mucin secretion in fully differentiated human nasal epithelial cells.