Posterior scoliosis correction with thoracoplasty: effect on pulmonary function with a mean follow-up of 4.8 years.

PURPOSE: To perform a study to investigate the influence of posterior scoliosis surgery and thoracoplasty on pulmonary function. METHODS: This was a retrospective observational study of 37 patients with AIS who underwent posterior instrumented surgical correction with thoracoplasty. There was a minimum of 2 years follow-up. Clinical outcomes were measured using the SRS-22 questionnaires. Radiological outcomes were evaluated using standing posteroanterior and lateral radiographs. All patients had pulmonary function tests to evaluate pulmonary volume and flow (forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC)) both before surgery and at the final follow-up. RESULTS: There were three males and 34 females. The mean age of patients was 14.6 years (range 11-21 years). The mean length of follow was 58 months (range 24-124 months). The average main thoracic Cobb angle in the coronal plane was corrected from 50.0° ± 12.4° preoperatively to 16.6° ± 6.3° postoperatively. The average thoracolumbar Cobb angle in the coronal plane was corrected from 28.2° ± 10.6° preoperatively to 10.1° ± 7.2°. The average thoracic kyphosis angle was corrected from 17.4° ± 11.0° preoperatively to 21.8° ± 10.5°. In terms of the Quality of life Outcomes (QoL), there was a significant increase (p < 0.001) in the mean SRS 22 scores from 3.8 preoperatively to 4.3 postoperatively. A statistically significant increase in the absolute forced expiratory volume in one second (FEV1) from pre-operative values with a p value < 0.001 was seen. There was a statistically significant increase in percentage predicted forced expiratory volume in one second from preoperative values with a p value of 0.008. There was also a statistically significant increase in the absolute forced vital capacity (FVC) from preoperative values with a p value < 0.001. The average percentage predicted forced vital capacity did increase on final follow-up from before surgery, but the increase was not statistically significant. CONCLUSIONS: We have demonstrated that pulmonary function post-thoracoplasty not only reaches pre-operative levels, but significantly surpasses it with regards to the majority of the pulmonary parameters measured in this study. We also demonstrated satisfactory radiological correction and clinical outcomes.

Systematic Review of School Scoliosis Screening.

OBJECTIVES: The aim of this study was to review the literature on school screening and its reported effectiveness. SUMMARY OF BACKGROUND DATA: There is no worldwide consensus concerning the mandating of school screening for scoliosis. This remains a controversial issue. METHODS: The following databases were employed: Medline, Premedline, CINAHL, CENTRAL, AMED, Embase, SCOPUS, Ovid nursing, and Web of Science. These data were generated from the Forward Bend Test, the angle of trunk rotation and Moire topography. The first and second authors each independently screened titles and abstracts for potential studies. Fulltext papers of potential studies were also independently read by the first two authors to identify studies to be included based on strict inclusion/exclusion criteria. A heterogeneity test was performed by testing for the significance of the between-study variance. Publication bias was examined by a funnel plot. RESULTS: We found 20 studies that met our inclusion criteria. The pooled estimate of prevalence of scoliosis curves in the population was 1.1% for curves greater than 10°, and 0.2% for curves greater than 20°. The pooled referral rate to radiography during the screening process was 6.6%. The pooled positive predictive values for detecting curves >10° and >20° were 32.3% and 6.5% respectively. Analysis of data demonstrated significant heterogeneity between studies but was not suggestive of the presence of publication bias. CONCLUSIONS: We support the implementation of scoliosis screening as a means of detecting curves at an early treatable stage. The current available evidence in the literature for routine scoliosis screening is low to moderate. Challenges exist to the school scoliosis screening including a high referral rate to radiology.

Results of the 2014 SRS Survey on PJK/PJF: A Report on Variation of Select SRS Member Practice Patterns, Treatment Indications, and Opinions on Classification Development.

STUDY DESIGN: An electronic survey administered to Scoliosis Research Society membership. OBJECTIVE: To characterize surgeon views regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) management providing the framework in which a PJK/PJF classification system and treatment guidelines could be established. SUMMARY OF BACKGROUND DATA: PJK/PJF are common complications of adult spinal deformity surgery. To date, there is no consensus on PJK/PJF definitions, classification, and indications for revision surgery. There is a paucity of data on deformity surgeon practice pattern variations and consensus opinion on treatment and prevention. METHODS: An electronic 19-question survey regarding PJK/PJF was administered to members of the Scoliosis Research Society who treat adult spinal deformity. Determinants included the surgeons' type of practice, number of years in practice, agreement with given PJK/PJF definitions, importance of key factors influencing prevention and revision, prevention methods currently used, and the importance of developing a classification system. RESULTS: A total of 226 surgeons responded (38.8% response rate). Both 44.4% of surgeons selected "extremely important" and 40.8% selected "very important" that PJK in adult spinal deformity surgery is a very important issue and that a Scoliosis Research Society PJK/PJF classification system and guidelines for detection and prevention of PJK/PJF is a "must have" (18.1%) and "very likely helpful" (31.9%). Both 86.2% and 90.7% of surgeons agreed with the provided definitions of PJK and PJF, respectively. Top 5 revision indications included neurological deficit, severe focal pain, translation or subluxation fracture, a change in kyphosis angle of greater than 30°, chance fracture, spondylolisthesis greater than 6 mm, and instrumentation prominence. The majority of respondents use a PJK/PJF prevention strategy 60% of the time or more, the most common were terminal rod contour, preoperative bone mineral density testing, and frequent radiographical studies during first 3 months postoperative, preoperative bone mineral density medication for low bone mineral density. CONCLUSION: The results of this study provide insight from the practicing surgeons' perspective of the management of PJK and PJF that may aid in the validation of current definitions and consensus-based treatment decisions and prevention guidelines. LEVEL OF EVIDENCE: 5.

Subaxial injury classification scoring system treatment recommendations: external agreement study based on retrospective review of 185 patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To test validity of subaxial injury classification (SLIC) treatment recommendations. SUMMARY OF BACKGROUND DATA: Although SLIC has been tested for reliability, external studies that test the validity of its treatment recommendations are lacking. METHODS: The SLIC score was determined by reviewing imaging studies and clinical records in a consecutive series of 185 patients with subaxial cervical spine trauma presenting to a level 1 spinal injury referral center. Details including attending surgeon responsible for treatment decision, treatment received, and surgical approach were collected. RESULTS: Treatment received matched SLIC guidelines in 93.6% nonsurgically managed patients and 96.3% surgically managed patients. The mean SLIC score of the surgically treated group of patients was significantly higher than that of the nonsurgical group (7.14 vs. 2.22; P<0.001). Sixty-six patients had a SLIC score of 3 or less, and 94% of them were nonsurgically managed (P<0.001). One hundred two patients had a SLIC score of 5 or more, and 95% of them were surgically managed (P<0.001). Seventeen patients had a SLIC score of 4, and 65% were nonsurgically managed (P=0.032). Injury morphology scores were not predictive of surgical approach. Increasing SLIC scores correlated with increasing complexity of treatment (r=0.77; P<0.001). The distribution of patients with regard to severity of injuries and treatment delivered by the 7 spinal surgeons was comparable. The past practice of these 7 fellowship-trained spine surgeons was individually in agreement with SLIC treatment recommendations. CONCLUSION: Our past practice reflects SLIC treatment recommendations for nonsurgical treatment of patients with SLIC scores of 3 or less and surgical treatment of patients with SLIC scores of 5 or more. The use of SLIC as an ordinal severity scale is validated as increasing SLIC scores correlated with increasing complexity of treatment. The injury morphology score did not predict a surgical approach. Significantly higher numbers of patients with a SLIC score of 4 were treated nonsurgically. LEVEL OF EVIDENCE: 3.

Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development.

STUDY DESIGN: Systematic review of literature. OBJECTIVE: To perform a comprehensive English language systematic literature review of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), concentrating on incidence, risk factors, health related quality of life impact, prevention strategy, and classification systems. SUMMARY OF BACKGROUND DATA: PJK and PJF are well described clinical pathologies and are a frequent cause of revision surgery. The development of a PJK classification that correlates with clinical outcomes and guides treatment decisions and possible prevention strategies would be of significant benefit to patients and surgeons. METHODS: The phrases "proximal junctional," "proximal junctional kyphosis," and "proximal junctional failure" were used as search terms in PubMed for all years up to 2014 to identify all articles that included at least one of these terms. RESULTS: Fifty-three articles were identified overall. Eighteen articles assessed for risk factors. Eight studies specifically reviewed prevention strategies. There were no randomized prospective studies. There were 3 published studies that have attempted to classify PJK. The reported incidence of PJK ranged widely, from 5% to 46% in patients undergoing spinal instrumentation and fusion for adult spinal deformity. It is reported that 66% of PJK occurs within 3 months and 80% within 18 months after surgery. The reported revision rates due to PJK range from 13% to 55%. Modifiable and nonmodifiable risk factors for PJK have been characterized. CONCLUSION: PJK and PJF affect many patients after long segment instrumentation after the correction of adult spinal deformity. The epidemiology and risk factors for the disease are well defined. A PJK and PJF scoring system may help describe the severity of disease and guide the need for revision surgery. The development and prospective validation of a PJK classification system is important considering the prevalence of the problem and its clinical and economic impact. LEVEL OF EVIDENCE: N/A.

Atlantoaxial and craniocervical arthrodesis in children: a tomographic study comparing suitability of C2 pedicles and C2 laminae for screw fixation.

STUDY DESIGN: Analysis of C1-C2 tomographic anatomy in a cohort of healthy children. OBJECTIVE: Compare suitability of C2 laminae and C2 pedicles for screw placement. SUMMARY OF BACKGROUND DATA: Surgeons have applied several techniques for craniocervical and atlantoaxial spondylodesis to address congenital or developmental abnormalities in children. Constructs with pedicle or transarticular screws are effective to stabilize the craniocervical junction; however, these fixation points are not suitable in all patients. Translaminar screw placement in C2 has been safely performed in children; yet, suitability of C2 laminae and C2 pedicles has not been systematically compared. METHODS: Applying chi2 test, we compared suitability for screw placement in 46 C2 pedicles and 46 C2 laminae on digital images of axial reconstructions of cervical CT scans of 23 children who had been admitted to the same hospital due to head or neck injury. On the same scans, we estimated suitability for screw placement in 46 lateral masses of C1. RESULTS: Twenty-four percent of C2 pedicles and 65% of C2 laminae were deemed suitable for 3.5-mm screw placement, and the difference was statistically significant (P < or = 0.0001, chi2 15.88). Forty-one percent of C2 pedicles and 80% of C2 laminae were deemed suitable for 3.0-mm screw placement, and the difference was statistically significant (P < or = 0.0001, chi2 14.78). Ninety-five percent of C1 lateral masses were deemed suitable for 3.5-mm screw placement. CONCLUSION: C2 laminae represent a viable fixation point for C1-C2 and craniocervical arthrodesis in children. This information can be useful for preoperative planning.

Transcranial motor-evoked potentials combined with response recording through compound muscle action potential as the sole modality of spinal cord monitoring in spinal deformity surgery.

STUDY DESIGN: This study is a prospective review of all spinal cord monitoring procedures in our unit from 1999 to 2004 in patients undergoing spinal deformity correction surgery. OBJECTIVE: To report the sensitivity and specificity of transcranial motor-evoked potentials (MEP) and compound muscle action potential (CMAP) monitoring as the sole modality in spinal deformity correction surgery. SUMMARY OF BACKGROUND DATA: Combined spinal cord monitoring with somatosensory-evoked potentials and MEP has been widely used. The use of CMAP as the only modality has not been widely used and its efficacy has not been fully elucidated. METHODS: The intraoperative monitoring outcomes were compared with patient's postoperative clinical outcomes. The sensitivity and specificity were calculated and determined for our monitoring protocol. RESULTS: Transcranial MEPs were measured in 144 patients in 172 procedures. In 2 patients (3 procedures), we were unable to record any CMAPs. There were 15 intraoperative monitoring changes. There were no new postoperative neurological deficits. CONCLUSION: The monitoring criteria are sufficiently strict to achieve a sensitivity of 1.0 and a specificity of 0.97. Monitoring of CMAPs alone has been adequate to avoid clinical neurological deficits.