Giant cell tumour of bone in os sacrum of a prepubertal girl - Surgical and medical treatment with zoledronate and denosumab.

A giant cell tumour of bone presented in the os sacrum of a prepubertal girl. Surgery with reconstruction was performed, but total resection was impossible. Zoledronate failed to avoid tumour regrowth, and treatment was changed to denosumab, despite not being recommended for use in growing children. Denosumab treatment for 21 months reduced and stabilized tumour size, the girl became pain free with asymptomatic side effects as mild hypocalcemia, hypophosphatemia and sclerosis of newly formed bone.

New growth rod concept provides three dimensional correction, spinal growth, and preserved pulmonary function in early-onset scoliosis.

INTRODUCTION: This study aims to describe a novel minimal invasive early-onset scoliosis (EOS) growth rod concept, the Cody Bünger (CB) Concept, which combines concave interval distraction and contralateral-guided growth with apical control and to investigate the 3D deformity correction, the spinal growth, and the pulmonary development. METHOD: A series of 38 children with progressive EOS and growth potential, receiving a highly specialized surgical treatment, including primary and conversion cases. Mean age was 10.2 years (4.4-15.8) with a mean follow-up of 5.6 years, and they underwent 168/184 open/magnetic lengthening procedures. Outcomes were as follows: scoliosis, kyphosis, and lordosis angles; apical rotation; spinal length; apical translation; coronal and sagittal vertical alignment; complications; and pulmonary function in a subgroup. RESULTS: Scoliosis improved from mean 76° (46-129) to 35° (8-74) post-op and was 42° (13-83) at end of treatment. Apical rotation was reduced by 30% but was partially lost during treatment. Thoracic kyphosis initially decreased by mean 15° and was partially lost during treatment. Lordosis was largely unaltered during treatment. Mean T1-S1 height increased from 30.7 cm (22.7-39.2) to 34.6 cm (27.8-45.1) postop and further increased to 38.5 cm (30.1-48.1) during treatment. This corresponded to a T1-S1 growth rate of 12 mm/year, and positive growth rates were found in all height parameters evaluated. Frontal balance and apical translation improved, whereas sagittal balance was unaltered. Complications occurred in 22/38 patients, and 11/38 had an unintended reoperation. Pulmonary function (FVC and FEV) increased but the relative lung function was unchanged. CONCLUSION: The new growth rod concept provided 3D correction and spinal growth at complication rates comparable with other growth-friendly techniques for EOS, while pulmonary function was preserved. Single magnetic rod distraction was incorporated successfully, replacing surgical elongations.

Major destructive asymptomatic lumbar Charcot lesion treated with three column resection and short segment reconstruction. Case report, treatment strategy and review of literature.

Charcot's spine is a long-term complication of spinal cord injury. The lesion is often localized at the caudal end of long fusion constructs and distal to the level of paraplegia. However, cases are rare and the literature relevant to the management of Charcot's arthropathy is limited. This paper reviews the clinical features, diagnosis, and surgical management of post-traumatic spinal neuroarthropathy in the current literature. We present a rare case of adjacent level Charcot's lesion of the lumbar spine in a paraplegic patient, primarily treated for traumatic spinal cord lesion 39 years before current surgery. We have performed end-to-end apposition of bone after 3 column resection of the lesion, 3D correction of the deformity, and posterior instrumentation using a four-rod construct. Although the natural course of the disease remains unclear, surgery is always favorable and remains the primary treatment modality. Posterior long-segment spinal fusion with a four-rod construct is the mainstay of treatment to prevent further morbidity. Our technique eliminated the need for more extensive anterior surgery while preserving distal motion.

Health-care costs of conservative management of spine fractures in trauma patients.

BACKGROUND AND PURPOSE: There is a lack of evidence on the broad health-care costs of treating spine trauma patients without neurological deficits conservatively. The aim of the present study was to estimate the primary and secondary health-care sector costs associated with conservative treatment of spine fractures as well as their determinants. METHODS: Patients were identified between 1999 and 2008 in the hospital's administrative system based on relevant diagnostic codes. Inclusion criteria were: (1) spine fractures (C1-L5); (2) age >18; and (3) conservative treatment. Exclusion criteria were: (1) neurological involvement and (2) fractures secondary to osteoporosis/malignancy. Health-care utilization and costs were retrieved from national administrative databases covering the entire health-care sector. RESULTS: 201 cervical, 150 thoracic, and 140 lumbar fracture patients were included in the study. The total health cost was estimated at €18,919 (16,199; 21,756), €8571 (6062; 11,733), €5526 (3473; 7465) for cervical, thoracic, and lumbar regions, respectively. Hospital admissions accounted for the vast majority of costs while primary health care accounted for less than 3 % and prescription medication for less than 2 %. The determinants of costs included fracture site (p < 0.001) and concomitant lower limb injuries (p = 0.009). CONCLUSIONS: Spinal fractures, even mild ones, appear to incur substantial health-care utilization and costs. Health-care costs in conjunction with cervical fractures are more than two-fold of those affiliated with thoracic and lumbar fractures. Among the concomitant injuries, lower limb injuries exert a substantial influence over health-care costs.

Cost-Effectiveness of Surgical Versus Conservative Treatment for Thoracolumbar Burst Fractures.

STUDY DESIGN: Historical, register-based cohort study following 85 patients in the course of a time frame extending from 2 years before to 2 years after trauma occurrence. OBJECTIVE: To investigate the cost-effectiveness of surgery versus conservative management for thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: Despite the prevalence of thoracolumbar burst fractures, consensus has still not been reached in terms of their clinical management and whereas from a health policy point of view, efficient use of resources is equally important, literature pertaining to this aspect is limited. METHODS: Consecutive patients who were admitted to a university clinic between 2004 and 2008 because of CT-verified AO type A3 fractures (T11-L2), age 18 to 65 years Patients with neurological compromise, osteoporosis, or malignancy were not included. The cost parameter defined primary and secondary health-care use (2010 &OV0556;) and the effect parameter was based on three alternative measures of pain medication: morphine milligram and defined daily doses (DDD) of narcotic and nonnarcotic analgesics. For cost-effectiveness analysis, we employed a difference-in-difference approach, including control for treatment selection (age, sex, and fracture type). Nonparametric bootstrapping was used to estimate conventional 95% confidence intervals of mean estimates. RESULTS: When taking into consideration all health-care consumption, surgical management was observed to cost an additional &OV0556;10,734 (4215; 15,144) as compared with conservative management. The differences on morphine at 527(-3031; 6,016) milligram, narcotic analgesics at -8(-176; 127) DDD, and nonnarcotic analgesics at -3(-72; 58) DDD were all insignificant The probability for surgery being cost-effective did not exceed 50% for any value of willingness to pay for effect. CONCLUSION: Surgical management does not seem to be a cost-effective strategy as compared with conservative management for traumatic thoracolumbar burst fractures without neurological deficits. In addition, higher-volume studies examining the clinical effect of alternative management strategies would be valuable. LEVEL OF EVIDENCE: 3.

Do postoperative radiographically verified technical success, improved cosmesis, and trunk shift corroborate with patient-reported outcomes in Lenke 1C adolescent idiopathic scoliosis?

PURPOSE: To examine correlation between postoperative radiographic and cosmetic improvements in Lenke 1C adolescent idiopathic scoliosis (AIS) with patients' self-rated outcomes of health and disability at follow-up as determined by the Scoliosis Research Society questionnaire (SRS-30), Oswestry Disability Index score (ODI) and measure of overall health quality Euroqol-5d (EQ-5D). METHODS: 24 Lenke 1C scoliosis patients, mean age 16.5 (12.8-38.1) years, treated with posterior pedicle screw-only construct, were included. The coronal profile indices (radiographic and cosmetic) regarding magnitude of spinal deformity and truncal balance were measured preoperatively, postoperatively and at final follow-up. A comprehensive index of overall back symmetry was also measured by means of the Posterior Trunk Symmetry Index (POTSI). Pearson's correlation analysis determined the association between the radiographic-cosmetic indices and patient-rated outcomes. RESULTS: Mean follow-up for the cohort was 4.4 (±1.86) years. The thoracic apical vertebra-first thoracic vertebra horizontal distance (AV-TI) correction had significant correlation with function, self-image, and mental health SRS-30 scores (0.55, 0.54, 0.66). Similarly, thoracic apical vertebra horizontal translation from central sacral vertical line (AV-CSVL) correction at follow-up had significant correlation with self-image and management domains (0.57, 0.50). Follow-up POTSI correlated well with SRS-30 and EQ-5D scores (r = -0.64, -0.54). Postoperative leftward trunk shift/spinal imbalance did not influence overall cosmesis and outcomes; significant spinal realignment was evident in follow-up resulting in physiological balance and acceptable cosmesis and outcomes. CONCLUSION: Significant, but less than "perfect" correlations were observed between the radiographic, cosmetic measures and patient-rated outcomes. Thoracic AV-CSVL, AV-T1 correction and POTSI associated significantly with SRS-30 scores. Whereas, thoracic Cobb angle, Cobb correction, and coronal balance did not correlate with any patient-rated outcome measure. It is, therefore, inferred that the patients-rated subjective outcomes are only poorly reflected by the objectively measured radiographic and cosmetic measures of deformity correction.

Distal Adding on in Lenke 1A Scoliosis: What Causes It? How Can It Be Prevented?

PURPOSE: To investigate the causes and prevention of distal adding on in Lenke 1A scoliosis. METHODS: Sixty Lenke 1A patients were included. The authors selected 10 potential risk factors for distal adding on. Postoperative increase in 5 radiographic parameters was used to indicate the extent of distal adding on. The authors then performed correlation analysis between the 10 potential risk factors and the extent of distal adding on, with the aim of identifying the causes of distal adding on. To predict 2-year outcome using preoperative parameters, linear regression models were established. The authors selected 2-year Cobb angle, thoracic apical vertebra center sacral vertical line (CSVL) distance and lowest instrumented vertebra (LIV)-CSVL distance to represent 2-year outcome. Their correlations with 8 preoperative parameters were tested. RESULTS: Potential risk factors representing either LIV selection or skeletal immaturity were highly correlated with the 5 radiographic parameters, which suggests that LIV selection and skeletal immaturity are causative in connection with distal adding on. The formula for predicting 2-year LIV-CSVL distance was: 2-year LIV-CSVL distance = 9.9 + 0.8 (preoperative LIV-CSVL distance) - 4.2 (Risser sign grade). The model adjusted R2 = 0.77. CONCLUSIONS: In Lenke 1A scoliosis, both LIV selection and skeletal immaturity are highly correlated with distal adding on. In other words, the shorter the extent is of distal fusion, the larger is the distal adding on; the less skeletally mature the patient is, the larger is the distal adding on. When treating skeletally immature patients (Risser sign ≤3) with 1A curves, performing fusion surgeries should be avoided when possible; growing rod treatment may be the optimal treatment choice. For skeletally mature patients, LIV selection should be the first consideration; the preoperative LIV-CSVL distance should be ≤21 mm when the Risser sign grade is 4 and ≤ 26 mm when the Risser sign grade is 5.

Transforaminal lumbar interbody fusion (TLIF) versus posterolateral instrumented fusion (PLF) in degenerative lumbar disorders: a randomized clinical trial with 2-year follow-up.

PURPOSE: The aim of the present study was to analyze outcome, with respect to functional disability, pain, fusion rate, and complications of patients treated with transforaminal lumbar interbody fusion (TLIF) in compared to instrumented poserolateral fusion (PLF) alone, in low back pain. Spinal fusion has become a major procedure worldwide. However, conflicting results exist. Theoretical circumferential fusion could improve functional outcome. However, the theoretical advantages lack scientific documentation. METHODS: Prospective randomized clinical study with a 2-year follow-up period. From November 2003 to November 2008 100 patients with severe low back pain and radicular pain were randomly selected for either posterolateral lumbar fusion [titanium TSRH (Medtronic)] or transforaminal lumbar interbody fusion [titanium TSRH (Medtronic)] with anterior intervertebral support by tantalum cage (Implex/Zimmer). The primary outcome scores were obtained using Dallas Pain Questionnaire (DPQ), Oswestry disability Index, SF-36, and low back pain Rating Scale. All measures assessed the endpoints at 2-year follow-up after surgery. RESULTS: The overall follow-up rate was 94 %. Sex ratio was 40/58. 51 patients had TLIF, 47 PLF. Mean age 49(TLIF)/45(PLF). No statistic difference in outcome between groups could be detected concerning daily activity, work leisure, anxiety/depression or social interest. We found no statistic difference concerning back pain or leg pain. In both the TLIF and the PLF groups the patients had significant improvement in functional outcome, back pain, and leg pain compared to preoperatively. Operation time and blood loss in the TLIF group were significantly higher than in the PLF group (p < 0.001). No statistic difference in fusion rates was detected. CONCLUSIONS: Transforaminal interbody fusion did not improve functional outcome in patients compared to posterolateral fusion. Both groups improved significantly in all categories compared to preoperatively. Operation time and blood loss were significantly higher in the TLIF group.

Lowest instrumented vertebra selection for Lenke 5C scoliosis: a minimum 2-year radiographical follow-up.

STUDY DESIGN: A radiographical follow-up and analysis. OBJECTIVE: To investigate the postoperative curve change in Lenke 5C scoliosis, and to discuss how to select lowest instrumented vertebra (LIV). SUMMARY OF BACKGROUND DATA: 5C curves are relatively rare in adolescent idiopathic scoliosis, and few studies have focused on this type of adolescent idiopathic scoliosis. Such questions as "How does the curve change over time in the postoperative period?" "Is LIV selection correlated with final correction and balance?" and "How should we select LIV for Lenke 5C curves?" need to be answered. METHODS: We reviewed all the adolescent idiopathic scoliosis cases surgically treated in an institution from 2002 through 2008. Inclusion criteria were as follows: (1) patients with Lenke 5C curves who were treated with selective lumbar fusion; (2) minimum 2-year radiographical follow-up.All image data were available and all measurements were performed in picture archiving and communication systems. Standing posteroanterior and lateral digital radiographs were reviewed at 4 junctures: preoperative, immediate postoperative, 3 months, and 2 years postoperatively. RESULTS: Thirty patients met the inclusion criteria. The following results were observed: (1) From the perspectives of both Cobb angle and vertebral translation, significant correction was achieved; (2) The correction obtained by surgery was well retained in the postoperative period; (3) Although preoperative spinal imbalance was common in this group of patients, the majority eventually attained balance at 2 years; (4) LIV selection was significantly correlated with the 2-year correction and balance; (5) In the literature as well as in this study, the overall preoperative LIV-center sacral vertical line distance is 28 mm and the overall preoperative LIV tilt is 25°. CONCLUSION: In Lenke 5C scoliosis, preoperative spinal imbalance is common, although the majority of patients attain balance at 2 years. Significant correction loss is not common in the postoperative period. LIV selection significantly correlates with 2-year correction and balance. A translation of 28 mm and a tilt of 25° may be used as a general criterion for selecting LIV. LEVEL OF EVIDENCE: 2.

Distal adding-on in Lenke 1A scoliosis: how to more effectively determine the onset of distal adding-on.

STUDY DESIGN: A radiographical follow-up and analysis. OBJECTIVE: To identify appropriate radiographical parameters for measuring the extent of distal adding-on and to discuss criteria for determining the onset of distal adding-on. SUMMARY OF BACKGROUND DATA: There is no consensus on how to determine the onset of distal adding-on in Lenke 1A scoliosis. Such questions as: "Which radiographical parameters should be used for measuring the extent of distal adding-on?" and "What criteria should be applied in determining the onset of distal adding-on?" need to be answered. METHODS: We reviewed all the AIS cases surgically treated in an institution from 2003 through 2009. Inclusion criteria were as follows: (1) patients with Lenke 1A curves who were treated with selective thoracic fusion; (2) age less than 30 years; (3) 2-year radiographical follow-up. Eight radiographical parameters were tested to see if they are potential instruments in the detection of distal adding-on. RESULTS: Fifty-three patients met the inclusion criteria. No pseudarthrosis or crankshaft phenomenon was observed in the current cohort. Five out of 8 radiographical parameters: thoracic Cobb, LIV-CSVL distance, LIV + 1-CSVL distance, thoracic AV-CSVL distance and LIV + 1 tilt angle, in the 2 years after surgery, showed significant increase. The remaining 3 parameters: LIV tilt angle, T1-CSVL distance and number of vertebrae within Cobb, however, did not show significant increase. In regard to the 5 parameters that have the potential to detect the onset of distal adding-on, we found a high correlation between every 2 of them. The correlation coefficients range from 0.504 to 0.962 (P = 0.001), suggesting that all of them are in a positive linear relationship. Regarding the criterion for determining the onset of distal adding-on, an increase of more than 10 mm in LIV-CSVL distance in the postoperative period can be considered as a the main criterion because it is unlikely to be induced by measurement errors. CONCLUSION: LIV-CSVL distance could be an ideal parameter for measuring the extent of distal adding-on. Distal adding-on can be determined when the LIV-CSVL distance increases by 10 mm in the postoperative period.

Prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past 15 years.

PURPOSE: Our objectives were primarily to review the published literature on complications in neuromuscular scoliosis (NMS) surgery and secondarily, by means of a meta-analysis, to determine the overall pooled rates (PR) of various complications associated with NMS surgery. METHODS: PubMed and Embase databases were searched for studies reporting the outcomes and complications of NMS surgery, published from 1997 to May 2011. We focused on NMS as defined by the Scoliosis Research Society's classification. We measured the pooled estimate of the overall complication rates (PR) using a random effects meta-analytic model. This model considers both intra- and inter-study variation in calculating PR. RESULTS: Systematic review and meta-analysis were performed for 68 cohort and case-control studies with a total of 15,218 NMS patients. Pulmonary complications were the most reported (PR = 22.71 %) followed by implant complications (PR = 12.51 %), infections (PR = 10.91 %), neurological complications (PR = 3.01 %) and pseudoarthrosis (PR = 1.88 %). Revision, removal and extension of implant had highest PR (7.87 %) followed by malplacement of the pedicle screws (4.81 %). Rates of individual studies have moderate to high variability. The studies were heterogeneous in methodology and outcome types, which are plausible explanations for the variability; sensitivity analysis with respect to age at surgery, sample size, publication year and diagnosis could also partly explain this variability. In regard to surgical complications affiliated with various surgical techniques in NMS, the level of evidence of published literature ranges between 2+ to 2-; the subsequent recommendations are level C. CONCLUSION: NMS patients have diverse and high complication rates after scoliosis surgery. High PRs of complications warrant more attention from the surgical community. Although the PR of all complications are affected by heterogeneity, they nevertheless provide valuable insights into the impact of methodological settings (sample size), patient characteristics (age at surgery), and continual advances in patient care on complication rates.

Failure modes in conservative and surgical management of infectious spondylodiscitis.

PURPOSE AND METHODS: We reviewed the management, failure modes, and outcomes of 196 patients treated for infectious spondylodiscitis between January 1, 2000 and December 31, 2010, at the Spinal Unit, Aarhus University Hospital, Aarhus, Denmark. Patients with infectious spondylodiscitis at the site of previous spinal instrumentation, spinal metastases, and tuberculous and fungal spondylodiscitis were excluded. RESULTS: Mean age at the time of treatment was 59 (range 1-89) years. The most frequently isolated microorganism was Staphylococcus aureus. The lumbosacral spine was affected in 64% of patients and the thoracic in 21%. In 24% of patients, there were neurologic compromise, four had the cauda equina syndrome and ten patients were paraplegic. Ninety-one patients were managed conservatively. Treatment failed in 12 cases, 7 patients required re-admission, 3 in-hospital deaths occurred, and 5 patients died during follow-up. Posterior debridement with pedicle screw instrumentation was performed in 75, without instrumentation in 19 cases. Seven patients underwent anterior debridement alone, and in 16 cases, anterior debridement was combined with pedicle screw instrumentation, one of which was a two-stage procedure. Re-operation took place in 12 patients during the same hospitalization and in a further 12 during follow-up. Two in-hospital deaths occurred, and five patients died during follow-up. Patients were followed for 1 year after treatment. Eight (9%) patients treated conservatively had a mild degree of back pain, and one (1%) patient presented with mild muscular weakness. Among surgically treated patients, 12 (10%) had only mild neurological impairment, one foot drop, one cauda equine dysfunction, but 4 were paraplegic. Twenty-seven (23%) complained of varying degrees of back pain. CONCLUSIONS: Conservative measures are safe and effective for carefully selected patients without spondylodiscitic complications. Failure of conservative therapy requires surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment, and correction of instability. Surgeons should master various techniques to achieve adequate debridement, and pedicle screw instrumentation may safely be used if needed.

Postoperative trunk shift in Lenke 1C scoliosis: what causes it? How can it be prevented?

STUDY DESIGN: A risk factor analysis study. OBJECTIVE: To identify the causative factors for postoperative trunk shift in Lenke 1C scoliosis and investigate how to prevent it. SUMMARY OF BACKGROUND DATA: When selective thoracic fusion is performed, postoperative trunk shift is a significant problem in the management of Lenke 1C scoliosis. It is often accompanied by unsatisfactory clinical outcomes and a risk of reoperation. METHODS: We reviewed all the patients with adolescent idiopathic scoliosis (AIS) surgically treated in our institution from 2002 through 2008. Inclusion criteria were as follows: (1) patients with Lenke 1C curves who were treated with selective thoracic fusion using posterior pedicle screw-only constructs; (2) the lowest instrumented vertebra (LIV) ending at L1 level or above; and (3) 2-year radiographical follow-up. Eighteen radiographical parameters were chosen as potential risk factors. The 18 parameters measured (1) amount of correction obtained by surgery; (2) preoperative position of LIV; (3) magnitude of major thoracic and thoracolumbar/lumbar (MT and TL/L) curves and ratio of MT: TL/L curve; and (4) curve flexibility. Both comparative and correlation analyses were performed. Those parameters that had shown highest correlation with the 2-year thoracic apical vertebra-center sacral vertical line (AV-CSVL) distance were selected to form a linear regression model, by which the correlations were quantified. RESULTS: Of the 278 patients reviewed, 44 met the inclusion criteria. The parameters that measured the preoperative position of LIV and ratio of MT: TL/L curve showed high correlation with the 2-year thoracic AV-CSVL distance. With regard to the parameters that measured the amount of correction obtained by surgery, only the correction of the thoracic AV-T1 distance showed low correlation. Among the 18 parameters, preoperative lowest instrumented vertebra-lower end vertebra (LIV-LEV) difference and ratio of MT: TL/L Cobb angle were selected to form a formula to help predict postoperative trunk shift. The formula was as follows: 2-year thoracic AV-CSVL distance = -26.6 + 22.7 (ratio of MT: TL/L Cobb angle) - 3.9 (preoperative LIV-LEV difference). The model R2 = 0.55. CONCLUSION: Both LIV selection and ratio of MT: TL/L curve were found to be highly correlated with the onset of postoperative trunk shift in Lenke 1C scoliosis. Amount of correction obtained by surgery, however, did not seem to be an independent causative factor. Postoperative trunk shift is less likely to occur when selecting LEV as LIV and the ratio of MT: TL/L Cobb angle of 1.2° or more.

Extensive fusion for Lenke 3C and 6C scoliosis: a two year radiographic follow-up.

PURPOSE: To investigate the correction effectiveness, incidence rate of distal adding on, and post-operative spinal balance in Lenke 3C and 6C AIS treated with extensive fusion using posterior pedicle screw-only constructs. METHODS: We reviewed all AIS cases surgically treated in our institution between 2002 and 2008. The inclusion criteria were as follows: (1) Lenke 3C or 6C scoliosis patients who were treated with extensive fusion using posterior pedicle screw-only constructs; (2) minimum two year radiographic follow-up; (3) the lowest instrumented vertebra (LIV) ended at L2, L3 or L4 level. All image data were available in our picture archiving and communication systems (PACSs) , and all radiographic measurements were performed. Standing anteroposterior (AP) and lateral digital radiographs were reviewed at four different time points (pre-op, post-op, three months, and two years). In each standing AP radiograph, CSVL (center sacral vertical line, the vertical line bisecting the proximal sacrum) was first drawn, followed by measurement of the translation (deviation from the CSVL) of some key vertebrae, such as the lowest instrumented vertebra (LIV), LIV + 1 (the first vertebra below LIV), lumbar apical vertebra, thoracic apical vertebra and T1, enabling depiction of how translation of different parts of the spine changes over time. Additionally, the Cobb angles of major thoracic and lumbar curves were measured at the different time points and the correction rate was calculated. RESULTS: Of the 278 patients reviewed, 25 met the inclusion criteria. Immediately after surgery, satisfactory corrections were achieved from the perspective of not only Cobb angle but also vertebral translation. And the corrections were well retained in the following two years. The incidence rate of distal adding-on was low in this group of patients. In the course of two years following surgery, only six patients had an increase of greater than 5 mm in LIV + 1 translation, and among which only two patients had greater than 10 mm. Regarding global balance, overall, it neither improved nor deteriorated after extensive fusion. Furthermore, trunk shift was found in only three patients at two year follow-up. CONCLUSIONS: In Lenke 3C and 6C scoliosis, extensive fusion can produce satisfactory corrections from the perspectives of both Cobb angle and vertebral translation and rarely causes significant distal adding-on, global imbalance or trunk shift.

Lowest instrumented vertebra selection in Lenke 3C and 6C scoliosis: what if we choose lumbar apical vertebra as distal fusion end?

PURPOSE: The aim of this study was to investigate whether or not post-op curve behaviour differs due to different choices of lowest instrumented vertebra (LIV) with reference to lumbar apical vertebra (LAV) in Lenke 3C and 6C scoliosis. METHODS: We reviewed all the AIS cases surgically treated in our institution from 2002 through 2008. Inclusion criteria were as follows: (1) patients with Lenke 3C or 6C scoliosis who were treated with posterior pedicle screw-only constructs; (2) 2-year radiographic follow-up. All the included patients were categorized into three groups based on the relative position of LIV and LAV: Group A-the LIV was above the LAV; Group B-the LIV was at the LAV; Group C-the LIV was below the LAV. All the radiographic parameters were then compared among the groups. All image data were available in our picture archiving and communication systems. Standing anteroposterior (AP) and lateral digital radiographs were reviewed at four times (pre-op, post-op, 3-month and 2-year). In each standing AP radiograph, centre sacral vertical line (CSVL, the vertical line that bisects the proximal sacrum) was first drawn, followed by measuring T1-CSVL, LIV-CSVL, (LIV + 1)-CSVL, LAV-CSVL and thoracic AV-CSVL distance. In addition, the Cobb angles of major thoracic and lumbar curves were measured at the four times and the correction rates were then calculated. RESULTS: Of the 278 patients reviewed, 40 met the inclusion criteria; 11 of these were included in Group A (LIV above LAV), another 11 in Group B (LIV at LAV) and the remaining 18 in Group C (LIV below LAV). At 2-year follow-up, the lumbar vertebrae such as LIV, LIV + 1 and LAV were all more deviated than before surgery in Group A (LIV above LAV), whereas in Group B and C (LIV at and below LAV) they were all less deviated than before surgery. No significant differences were found in thoracic or lumbar correction rate, global coronal balance and incidence rate of trunk shift among the three groups. CONCLUSION: In conclusion, in Lenke 3C and 6C scoliosis, post-op lumbar curve behaviour differs due to different choices of LIV with reference to LAV, that is, the deviation of lumbar curve improves when the LIV is either at or below the LAV but deteriorates when the LIV is above the LAV. Although the greatest correction occurs when the LIV is below the LAV, choosing LAV as LIV can still be the optimal option in certain cases, since it can yield similar correction while preserving more lumbar mobility and growth potential.

Predictive value of Tokuhashi scoring systems in spinal metastases, focusing on various primary tumor groups: evaluation of 448 patients in the Aarhus spinal metastases database.

STUDY DESIGN: We conducted a prospective cohort study of 448 patients with spinal metastases from a variety of cancer groups. OBJECTIVE: To determine the specific predictive value of the Tokuhashi scoring system (T12) and its revised version (T15) in spinal metastases of various primary tumors. SUMMARY OF BACKGROUND DATA: The life expectancy of patients with spinal metastases is one of the most important factors in selecting the treatment modality. Tokuhashi et al formulated a prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy in 1990 and revised it in 2005 to a total sum of 15 points. There is a lack of knowledge about the specific predictive value of those scoring systems in patients with spinal metastases from a variety of cancer groups. METHODS: We included 448 patients with vertebral metastases who underwent surgical treatment during November 1992 to November 2009 in Aarhus University Hospital NBG. Data were retrieved from Aarhus Metastases Database. Scores based on T12 and T15 were calculated prospectively for each patient. We divided all the patients into different groups dictated by the site of their primary tumor. Predictive value and accuracy rate of the 2 scoring systems were compared in each cancer group. RESULTS: Both the T12 and T15 scoring systems showed statistically significant predictive value when the 448 patients were analyzed in total (T12, P < 0.0001; T15, P < 0.0001). The accuracy rate was significantly higher in T15 (P < 0.0001) than in T12. The further analyses by primary cancer groups showed that the predictive value of T12 and T15 was primarily determined by the prostate (P = 0.0003) and breast group (P = 0.0385). Only T12 displayed predictive value in the colon group (P = 0.0011). Neither of the scoring systems showed significant predictive value in the lung (P > 0.05), renal (P > 0.05), or miscellaneous primary tumor groups (P > 0.05). The accuracy rate of prognosis in T15 was significantly improved in the prostate (P = 0.0032) and breast group (P < 0.0001). CONCLUSION: Both T12 and T15 showed significant predictive value in patients with spinal metastases. T15 has a statistically higher accuracy rate than T12. Among the various cancer groups, the 2 scoring systems are especially reliable in prostate and breast metastases groups. T15 is recommended as superior to T12 because of its higher accuracy rate.

Distal adding-on phenomenon in Lenke 1A scoliosis: risk factor identification and treatment strategy comparison.

STUDY DESIGN: Retrospective study. OBJECTIVE: To identify risk factors for the presence of distal adding-on in Lenke 1A scoliosis and compare different treatment strategies. SUMMARY OF BACKGROUND DATA: Distal adding-on is often accompanied by unsatisfactory clinical outcome and high risk of reoperation. However, very few studies have focused on distal adding-on and its attendant risk factors and optimal treatment strategies remain controversial. METHODS: All surgically treated patients with adolescent idiopathic scoliosis were retrieved from a single institutional database. Inclusion criteria included: (1) Lenke 1A scoliosis patients treated with posterior pedicle screw-only constructs, (2) minimum 1-year radiographic follow-up. Distal adding-on was defined as a progressive increase in the number of vertebrae included distally within the primary curve combined with either an increase of more than 5 mm in deviation of the first vertebra below instrumentation from the center sacral vertical line (CSVL), or an increase of more than 5° in the angulation of the first disc below the instrumentation at 1 year follow-up. Wilcoxon rank sum test, Fisher exact test, and Spearman correlation test were used to identify the risk factors for adding-on. A multiple logistic regression model was built to identify independent predictive factor(s). Risk factors included: (1) age at surgery; (2) preoperative Cobb angle; (3) correction rate; (4) the gap difference of stable vertebra-lowest instrumented vertebra (SV-LIV), neutral vertebra-lowest instrumented vertebra (NV-LIV), and end vertebra-lowest instrumented vertebra (EV-LIV). Gap difference means, for example, if SV is at L2 and LIV is at Th12, then the difference of SV-LIV is 2; (5) the preoperative deviation of LIV+1 (the first vertebra below the instrumentation) from the CSVL (the vertical line that bisects proximal sacrum). Five methods for determining LIV were compared in both the adding-on group and no adding-on group. RESULTS: Out of the 278 patients reviewed, 45 met the inclusion criteria; 23 of these met the definition for distal adding-on, and were included in the adding-on group. The remaining 22 patients were included in the no adding-on group. The average follow-up was 3.6 years. Age, SV-LIV difference, EV-LIV difference, and LIV+1 deviation from CSVL were significantly different (P<0.05) between the two groups, and were also found to be significantly correlated with the presence of adding-on (P<0.05). Preoperative Cobb angle, correction rate, and NV-LIV difference were not found to be affiliated with the presence of adding-on. Multiple logistic regression results indicated that preoperative LIV+1 deviation from CSVL was an independent predictive factor. Among the five methods, choosing EV as LIV was nearly unable to prevent distal adding-on; choosing EV+1 as LIV resulted in fusing many more segments than necessary; only choosing DV as LIV showed satisfactory outcome from both perspectives. CONCLUSION: In Lenke 1A type scoliosis, the selection of LIV is highly correlated with the presence of adding-on; incidence increases dramatically when the preoperative LIV+1 deviation from CSVL is more than 10 mm. Choosing DV (the first vertebra in cephalad direction from sacrum with deviation from CSVL of more than 10 mm) as LIV may provide the best outcome as it not only prevents adding-on but also conserves more lumbar motion.

Fusion mass bone quality after uninstrumented spinal fusion in older patients.

Older people are at increased risk of non-union after spinal fusion, but little is known about the factors determining the quality of the fusion mass in this patient group. The aim of this study was to investigate fusion mass bone quality after uninstrumented spinal fusion and to evaluate if it could be improved by additional direct current (DC) electrical stimulation. A multicenter RCT compared 40 and 100 µA DC stimulation with a control group of uninstrumented posterolateral fusion in patients older than 60 years. This report comprised 80 patients who underwent DEXA scanning at the 1 year follow-up. The study population consisted of 29 men with a mean age of 72 years (range 62-85) and 51 women with a mean age of 72 years (range 61-84). All patients underwent DEXA scanning of their fusion mass. Fusion rate was assessed at the 2 year follow-up using thin slice CT scanning. DC electrical stimulation did not improve fusion mass bone quality. Smokers had lower fusion mass BMD (0.447 g/cm(2)) compared to non-smokers (0.517 g/cm(2)) (P = 0.086). Women had lower fusion mass BMD (0.460 g/cm(2)) compared to men (0.552 g/cm(2)) (P = 0.057). Using linear regression, fusion mass bone quality, measured as BMD, was significantly influenced by gender, age of the patient, bone density of the remaining part of the lumbar spine, amount of bone graft applied and smoking. Fusion rates in this cohort was 34% in the control group and 33 and 43% in the 40 and 100 µA groups, respectively (not significant). Patients classified as fused after 2 years had significant higher fusion mass BMD at 1 year (0.592 vs. 0.466 g/cm(2), P = 0.0001). Fusion mass bone quality in older patients depends on several factors. Special attention should be given to women with manifest or borderline osteoporosis. Furthermore, bone graft materials with inductive potential might be considered for this patient population.

The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 1: functional outcome.

STUDY DESIGN: Randomized, controlled, multi-center trial. OBJECTIVE: To investigate the effect of direct current (DC) electrical stimulation on functional and clinical outcome after lumbar spinal fusion in patients older than 60 years. SUMMARY OF BACKGROUND DATA: Older patients have increased complication rates after spinal fusion surgery. Treatments which have the possibility of enhancing functional outcome and fusion rates without lengthening the procedure could prove beneficial. DC-stimulation of spinal fusion has proven effective in increasing fusion rates in younger and "high risk" patients, but functional outcome measures have not been reported. METHODS: A randomized, clinical trial comprising 5 orthopedic centers. The study included a total of 107 patients randomized to uninstrumented posterolateral lumbar spinal fusion with or without DC-stimulation. Functional outcome was assessed using Dallas Pain Questionnaire, SF-36, Low Back Pain Rating Scale pain index, and walking distance. RESULTS: Follow-up after 1 year was 95/107 (89%). DC-stimulated patients had significant better outcome in 3 of 4 categories in the Dallas Pain Questionnaire, better SF-36 scores (not significantly), but no difference in pain scores were observed. Median walking distance at latest follow-up was better in the stimulated group (not significant). Walking distance was significantly associated with functional outcome. There was no difference in any of the functional outcome scores between patients who experienced a perioperative complication and those without complications. CONCLUSION: The achievement of a good functional outcome was heavily dependent on the obtained walking distance. DC-stimulated patients tended to have better functional outcome as compared to controls. No negative effects of perioperative complications could be observed on the short-term functional outcome.

The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 2: fusion rates.

STUDY DESIGN: Randomized, controlled, multi-center trial. OBJECTIVE: To investigate the effect of direct current (DC) electrical stimulation on fusion rates after lumbar spinal fusion in patients older than 60 years. SUMMARY OF BACKGROUND DATA: Older patients have increased complication rates after spinal fusion surgery. Treatments which have the possibility of enhancing functional outcome and fusion rates without lengthening the procedure could prove beneficial. DC-stimulation of spinal fusion has proven effective in increasing fusion rates in younger and "high risk" patients, but little information exist on the effect in older patients. METHODS: A randomized clinical trial comprising 5 orthopedic centers. The study included a total of 107 patients randomized to uninstrumented posterolateral lumbar spinal fusion with or without DC-stimulation. Fusion rate was assessed at 2 year follow-up using thin slice CT. Functional outcome was assessed using Dallas Pain Questionnaire and Low Back Pain Rating Scale pain index. RESULTS.: Available follow-up after 2 years was 89% (84 of 95 patients). Fusion rates were surprisingly low. DC-stimulation had no effect on fusion rate: 35% versus 36% in controls. Other factors associated with low fusion rates were female gender (32% vs. 42% in males, P = 0.050) and smoking (21% vs. 42% in nonsmokers, P = 0.079). Patients who achieved a solid fusion as determined by CT had superior functional outcome and pain scores at their latest follow-up. CONCLUSION: Thin slice CT revealed very high nonunion rates after uninstrumented spinal fusion in older patients. DC-stimulation was not effective in increasing fusion rates in this patient population. The achievement of a solid fusion was associated with superior functional outcome.