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1.
Med Princ Pract ; 29(1): 46-53, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31266026

RESUMO

OBJECTIVE: Congenital heart disease (CHD) is associated with the development of scoliosis. Improvements in cardiac care have extended survival of children with cyanotic CHD which possess a need for correction of scoliosis. There is limited information on spinal care for these patients. We present 3 patients with CHD who underwent surgical correction of scoliosis. MATERIALS AND METHODS: We reviewed demographic and clinical data on patients with cyanotic CHD. RESULTS: Patient 1 underwent posterior spinal fusion T3-L3 at the age of 16 years. He had a double inlet left ventricle and was treated with completion of a Fontan circulation. Hypotensive anaesthesia was used but he lost 3,000 mL of blood. The operative time was 370 min and most of the blood loss occurred in the second half of the procedure. Patient 2 underwent posterior spinal fusion T5-T12 when aged 14 years. She had transposition of the great vessels corrected over multiple surgeries. Hypotensive anaesthesia was used, she had blood loss of 300 mL, and the surgical time was 282 min. Patient 3 underwent posterior spinal fusion extending from T5-T12 when he was 17 years old. He had a double inlet left ventricle and was treated with completion of a Fontan circulation. Hypotensive anaesthesia was used, he had blood loss of 1,021 mL, and a surgical time of 342 min. CONCLUSION: Scoliosis surgery in patients with complex cardiac disease may be indicated to treat progressive deformities which produce severe symptoms. A multidisciplinary approach including a spinal surgeon as well as a cardiologist, haematologist, respiratory paediatrician, and spinal anaesthetist can evaluate the general medical condition and weigh the benefits and risks of surgery. Deformity correction can be performed using a meticulous technique and has produced a series of satisfactory outcomes.

2.
Med Princ Pract ; 29(1): 6-17, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31158841

RESUMO

OBJECTIVE: This study aims to present the diagnostic characteristics of multimodal intraoperative monitoring (IOM) in spinal deformity surgery and to define and categorise the neuromonitoring events, as well as propose an algorithm of action. MATERIALS AND METHODS: We reviewed 1,155 consecutive patients (807 female, 348 male) who underwent deformity correction using standardised perioperative care, cortical/cervical somatosensory evoked potentials (SSEPs), and upper/lower limb transcranial electrical motor evoked potential (MEPs) by a single surgeon. The mean age at surgery was 13.8 years (range 10-23.3). We categorised IOM events as true, transient true, and false positive or negative. Diagnostic performance criteria were calculated. RESULTS: The most common diagnosis was adolescent idiopathic scoliosis in 717 (62%) patients. We identified 3 true positive monitoring events occurring in 2 patients (0.17%), 8 transient true positive (0.69%), and 8 transient false positive events (0.69%). There were no false negative events and no patient had postoperative neurological complications. The multimodal IOM technique had a sensitivity of 100%, specificity of 99.3%, positive predictive value of 55.6%, and negative predictive value of 100%. Sensitivity was 100% for MEPs and multimodal monitoring compared to 20% for cortical or cervical SSEPs. The frequency of true or transient true positive events was higher (p = 0.07) in Scheuermann's kyphosis (3/91 patients, 3.3%) compared to adolescent idiopathic scoliosis (6/717 patients, 0.84%). CONCLUSION: Multimodal IOM is highly sensitive and specific for spinal cord injury. This technique is reliable for the assessment of the condition of the spinal cord during major deformity surgery. We propose an algorithm of intraoperative action to allow close cooperation between the surgical, anaesthetic, and neurophysiology teams and to prevent neurological deficits.

3.
J Back Musculoskelet Rehabil ; 32(6): 955-988, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31524137

RESUMO

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

4.
JBJS Essent Surg Tech ; 9(1): e9, 2019 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-31333899

RESUMO

Background: We describe our convex segmental pedicle screw technique for the treatment of adolescent idiopathic scoliosis. We developed this technique to achieve optimum 3-dimensional deformity correction while reducing the surgical risks of an inherently dangerous procedure. Description: The surgery involves a wide posterior subperiosteal exposure across the deformity levels to the tips of the transverse processes. Posterior releases are performed through facetectomies. Pedicle screws are placed using a freehand technique based on anatomical landmarks. Adequate screw positioning is assessed with an image intensifier before rod engagement. Segmental pedicle screws are placed across the convexity of each curve included in the fusion. Proximal and distal fixation of the rods on the contralateral side is performed across 2 pedicle screw anchors. We use titanium rods bilaterally. Curve correction is done using the convex pedicle screws by applying segmental vertebral translation and derotation starting with the main thoracic curve followed by the lumbar curve. Segmental compression or distraction is performed at the proximal and distal ends of the construct to level the end vertebrae included in the fusion. Maximum correction of the main thoracic scoliosis is done, whereas the lumbar scoliosis (which is usually more flexible) is corrected to the point that results in a globally balanced spine in the coronal plane. The rod attached on the convex side of the main thoracic scoliosis is overbent to restore thoracic kyphosis, and the aim is always to achieve regional and global sagittal balance. An interfacetal, intertransverse, and interlaminar fusion is performed with use of locally harvested bone supplemented by allograft bone. Alternatives: With previous techniques, the use of bilateral segmental pedicle screw fixation has been advocated as a requirement to achieve adequate deformity correction in patients with adolescent idiopathic scoliosis. Rationale: This technique is associated with low risks of neurological and vascular complications because the screws are placed at the convex pedicles, away from the spinal cord/cauda equina and the aorta. The use of far fewer pedicle screws compared with previous techniques reduces surgical time and blood loss, which is related to lower postoperative morbidity. It may also decrease the risk of deep wound infection, which is associated with the number of implants used. Low implant density (1.2, with a density of 2 representing placement of pedicle screws bilaterally at every instrumented segment) with our technique can achieve satisfactory scoliosis correction, improved thoracic kyphosis, and normal global sagittal balance. Our use of this technique has resulted in excellent patient satisfaction and functional outcomes with no neurological complications or intraoperative neuromonitoring events, deep wound infections, detected nonunions, or need for revision surgery.

5.
World J Orthop ; 9(9): 138-148, 2018 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-30254970

RESUMO

AIM: To present our results on the use of a single rod instrumentation correction technique in a small number of patients with major medical co-morbidities. METHODS: This study was a prospective single surgeon series. Patients were treated with single rod hybrid constructs and had a minimum 2-year follow-up. Indications included complex underlying co-morbidities, conversion of growing rods to definitive fusion, and moderate adolescent idiopathic primarily thoracic scoliosis with severe eczema and low body mass index (BMI). RESULTS: We included 99 consecutive patients. Mean age at surgery was 12.8 years (SD 3.5 years). Mean scoliosis correction was 62% (SD 15%) from 73° (SD 22°) to 28° (SD 15°). Mean surgical time was 153 min (SD 34 min), and blood loss was 530 mL (SD 327 mL); 20% BV (SD 13%). Mean clinical and radiological follow-up was 3.2 years (range: 2-12) post-operatively. Complications included rod failure, which occurred in three of our complex patients with severe syndromic or congenital kyphoscoliosis (3%). Only one of these three patients required revision surgery to address a non-union. Our revision rate was 2% (including a distal junctional kyphosis in a Marfan's syndrome patient). CONCLUSION: The single rod technique has achieved satisfactory deformity correction and a low rate of complications in patients with specific indications and severe underlying medical conditions. In these children with significant co-morbidities, where the risks of scoliosis surgery are significantly increased, this technique has achieved low operative time, blood loss, and associated surgical morbidity.

6.
J Cent Nerv Syst Dis ; 10: 1179573518819484, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30627004

RESUMO

Aim of the study: Neurofibromatosis type 1 (NF-1) is associated with the development of scoliosis or kyphoscoliosis. The deformity is rapidly progressive in the presence of dystrophic changes producing bone erosion. Vertebral subluxation or dislocation can occur in children with highly dystrophic kyphoscoliosis and carries an increased risk of paralysis. There is no standardised treatment for this extreme deformity with very few patients currently reported in the literature. Methods: Retrospective review of a patient with NF-1 who developed a dystrophic upper thoracic kyphoscoliosis with segmental displacement of T2 on T3. Results: We report a patient with NF-1 who presented at 8.9 years with a progressive upper thoracic kyphoscoliosis. At 18.8 years, the deformity had deteriorated to scoliosis 65° and kyphosis 78° with fixed segmental rotatory dislocation at T2-T3. He underwent posterior cervico-thoracic fusion with concave pedicle screw/hook/rod instrumentation and iliac crest bone. Minimum correction was achieved due to curve rigidity and inability to reduce the T2/T3 displacement by halo-femoral traction. At 7 months, an elective posterior re-grafting procedure was performed followed by anterior fusion with rib strut grafts between T2-T6 through a midline sternotomy. The patient is now 3.5 years after anterior surgery and remains neurologically intact with stable residual deformity and computed tomographic evidence of circumferential fusion. He has no back pain and resumed non-contact physical activities. Conclusions: Patients with NF-1 can develop dystrophic kyphoscoliosis with segmental spinal subluxation/dislocation. Circumferential fusion is a technically challenging procedure which often requires a multi-disciplinary surgical team but produces satisfactory clinical outcome preventing paraplegia.

7.
J Child Neurol ; 32(7): 657-662, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28395573

RESUMO

This study aims to identify the risk factors leading to the development of severe scoliosis among children with cerebral palsy. A cross-sectional descriptive study of 70 children (aged 12-18 years) with severe spastic and/or dystonic cerebral palsy treated in a single specialist unit is described. Statistical analysis included Fisher exact test and logistic regression analysis to identify risk factors. Severe scoliosis is more likely to occur in patients with intractable epilepsy ( P = .008), poor gross motor functional assessment scores ( P = .018), limb spasticity ( P = .045), a history of previous hip surgery ( P = .048), and nonambulatory patients ( P = .013). Logistic regression model confirms the major risk factors are previous hip surgery ( P = .001), moderate to severe epilepsy ( P = .007), and female gender ( P = .03). History of previous hip surgery, intractable epilepsy, and female gender are predictors of developing severe scoliosis in children with cerebral palsy. This knowledge should aid in the early diagnosis of scoliosis and timely referral to specialist services.


Assuntos
Paralisia Cerebral/complicações , Epilepsia/complicações , Escoliose/etiologia , Adolescente , Paralisia Cerebral/fisiopatologia , Criança , Estudos Transversais , Epilepsia/fisiopatologia , Feminino , Humanos , Masculino , Fatores de Risco , Escoliose/fisiopatologia , Fatores Sexuais
8.
Eur Spine J ; 26(8): 2103-2111, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-27554347

RESUMO

PURPOSE: To compare measurements of motor evoked potential latency stimulated either magnetically (mMEP) or electrically (eMEP) and central motor conduction time (CMCT) made pre-operatively in conscious patients using transcranial and intra-operatively using electrical cortical stimulation before and after successful instrumentation for the treatment of adolescent idiopathic scoliosis. METHODS: A group initially of 51 patients with adolescent idiopathic scoliosis aged 12-19 years was evaluated pre-operatively in the outpatients' department with transcranial magnetic stimulation. The neurophysiological data were then compared statistically with intra-operative responses elicited by transcranial electrical stimulation both before and after successful surgical intervention. MEPs were measured as the cortically evoked compound action potentials of Abductor hallucis. Minimum F-waves were measured using conventional nerve conduction methods and the lower motor neuron conduction time was calculated and this was subtracted from MEP latency to give CMCT. RESULTS: Pre-operative testing was well tolerated in our paediatric/adolescent patients. No neurological injury occurred in any patient in this series. There was no significant difference in the values of mMEP and eMEP latencies seen pre-operatively in conscious patients and intra-operatively in patients under anaesthetic. The calculated quantities mCMCT and eCMCT showed the same statistical correlations as the quantities mMEP and eMEP latency. CONCLUSIONS: The congruency of mMEP and eMEP and of mCMCT and eCMCT suggests that these measurements may be used comparatively and semi-quantitatively for the comparison of pre-, intra-, and post-operative spinal cord function in spinal deformity surgery.


Assuntos
Potencial Evocado Motor , Monitorização Neurofisiológica Intraoperatória/métodos , Assistência Perioperatória/métodos , Escoliose/cirurgia , Estimulação Magnética Transcraniana , Adolescente , Criança , Estimulação Elétrica , Feminino , Humanos , Masculino , Escoliose/fisiopatologia , Resultado do Tratamento , Adulto Jovem
9.
J Back Musculoskelet Rehabil ; 30(2): 339-346, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27858696

RESUMO

BACKGROUND: Quality of life measurements evaluate surgical results from patients' reported outcomes. OBJECTIVE: To assess the impact of spinal deformity treatment using the Scoliosis Research Society-22 questionnaire. METHODS: SRS-22 data was collected in 545 consecutive patients (425 females-120 males) pre-operatively, 6-, 12- and 24-months post-operatively. Variables included type and age of surgery (mean: 15.14 ± 2.07 years), gender, diagnosis and year of surgery. Age at surgery was divided in: 10-12, 13-15, and 15-19 years. RESULTS: Mean pre-operative SRS-22 scores for the whole group were: function 3.77 ± 0.75; pain 3.7 ± 0.97; self-image 3.14 ± 0.66; mental health 3.86 ± 0.77; total 3.62 ± 0.66. Mean 2-year post-operative scores were: function 4.39 ± 0.42; pain 4.59 ± 0.56; self-image 4.39 ± 0.51; mental health 4.43 ± 0.56; satisfaction 4.81 ± 0.40; total 4.52 ± 0.37 (p< 0.0001). Males performed better at 2-years post-surgery (4.62 ± 0.25) compared to females (4.49 ± 0.39), (p= 0.004). Patients with spondylolisthesis performed worse pre-operatively (2.93 ± 0.26) compared to other diagnoses (p< 0.0001). This did not impact 2-year post-operative outcomes. There were no significant changes regarding age or year of surgery, type of operation or between the 3 age groups. CONCLUSIONS: All individual domains and total SRS-22 scores improved significantly with incremental change during post-operative follow-up. Patient satisfaction was very high for all individual diagnosis. 2-year post-operative outcomes compared favorably to reported SRS-22 scores in healthy adolescents.


Assuntos
Saúde Mental , Satisfação do Paciente , Qualidade de Vida/psicologia , Escoliose/cirurgia , Autoimagem , Adolescente , Criança , Feminino , Humanos , Masculino , Dor Pós-Operatória/psicologia , Período Pós-Operatório , Escoliose/psicologia , Inquéritos e Questionários , Resultado do Tratamento
10.
Case Rep Orthop ; 2016: 7186258, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27413564

RESUMO

Spinal deformity in patients with cystic fibrosis (CF) is usually mild requiring no treatment. These patients are rarely considered as surgical candidates for scoliosis correction, as the pulmonary condition and other comorbidities increase the risk of general anaesthesia and recovery. This paper reviews all the literature up to date with regard to scoliosis in patients with CF and reports this unique case of a 14-year-old Caucasian girl with progressive scoliosis, who was treated surgically at the age of 17. She underwent a posterior spinal fusion T2-L3 with the use of unilateral segmental instrumentation. Preoperative workup included respiratory, cardiac, anaesthetic, endocrine, and dietician reviews, as well as bone density optimisation with zoledronic acid and prophylactic antibiotics. Surgical time was 150 minutes and intraoperative blood loss was 47% of total blood volume. Postoperative intensive care included noninvasive ventilation, antibiotic cover, pain management, chest physiotherapy, pancreatic enzyme supplementation, and nutritional support. She was discharged on day 9. At follow-up she had a good cosmetic outcome, no complaints of her back, and stable respiratory function. Multidisciplinary perioperative care and meticulous surgical technique may reduce the associated risks of major surgery in CF patients, while achieving adequate deformity correction and a good functional outcome.

11.
J Back Musculoskelet Rehabil ; 29(4): 613-623, 2016 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-26966821

RESUMO

Neuromuscular scoliosis (NMS) is the second most prevalent spinal deformity (after idiopathic scoliosis) and is usually first identified during early childhood. Cerebral palsy (CP) is the most common cause of NMS, followed by Duchenne muscular dystrophy (DMD). Progressive spinal deformity causes difficulty with daily care, walking and sitting, and can lead to back and rib pain, cardiac and pulmonary complications, altered seizure thresholds, and skin compromise. Early referral to specialist spinal services and early diagnosis of NMS is essential to ensure appropriate multidisciplinary patient management. The most important goals for patients are preservation of function, facilitation of daily care, and alleviation of pain. Non-operative management includes observation or bracing for less severe and flexible deformity in young patients as a temporising measure to provide postural support. Surgical correction and stabilisation of NMS is considered for patients with a deformity >40-50°, but may be performed for less severe deformity in patients with DMD. Post-operative intensive care, early mobilisation and nutritional supplementation aim to minimise the rate of post-surgical complications, which are relatively common in this patient group. However, surgical management of NMS is associated with good long-term outcomes and high satisfaction rates for patients, their relatives and carers.


Assuntos
Escoliose/diagnóstico , Escoliose/terapia , Progressão da Doença , Humanos , Procedimentos Ortopédicos , Aparelhos Ortopédicos , Satisfação do Paciente , Assistência Perioperatória , Modalidades de Fisioterapia , Qualidade de Vida , Respiração , Fatores de Risco , Escoliose/classificação
12.
J Neurosurg Spine ; 24(3): 402-6, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26588497

RESUMO

Surgical correction for kyphoscoliosis is increasingly being performed for patients with mucopolysaccharidosis (MPS). Reported case series have predominantly included patients with Type I (Hurler) and Type IV (Morquio) MPS. To their knowledge, the authors describe the first case report of surgical management of thoracolumbar kyphoscoliosis in Hunter syndrome (MPS Type II) and the rare occurrence of lumbar spondylolisthesis following surgical stabilization. A 12-year-old boy with Hunter syndrome presented with severe thoracolumbar kyphoscoliosis and no associated symptoms. Spinal radiographs demonstrated kyphosis of 48° (T11-L3) and scoliosis of 22° (T11-L3) with an anteriorly hypoplastic L-1 vertebra. The deformity progressed to kyphosis of 60° and scoliosis of 42° prior to surgical intervention. Spinal CT scans identified left T12-L1 facet subluxation, causing anterior rotatory displacement of the spine proximal to L-1 and bilateral L-5 isthmic spondylolysis with no spondylolisthesis. A combined single-stage anterior and posterior instrumented spinal arthrodesis from T-9 to L-4 was performed. Kyphosis and scoliosis were corrected to 4° and 0°, respectively. Prolonged ventilator support and nasogastric feedings were required for 3 months postoperatively. At 2.5 years following surgery, the patient was asymptomatic, mobilizing independently, and had achieved a solid spinal fusion. However, he had also developed a Grade II spondylolisthesis at L4-5; this was managed nonoperatively in the absence of symptoms or further deterioration of the spondylolisthesis to the 3.5-year postoperative follow-up visit. Satisfactory correction of thoracolumbar kyphoscoliosis in Hunter syndrome can be achieved by combined anterior/posterior instrumented arthrodesis. The risk of developing deformity or instability in motion segments adjacent to an instrumented fusion may be greater in patients with MPS related to the underlying connective tissue disorder.


Assuntos
Cifose/cirurgia , Região Lombossacral/cirurgia , Mucopolissacaridose II/complicações , Escoliose/cirurgia , Fusão Vertebral/métodos , Criança , Humanos , Cifose/diagnóstico por imagem , Cifose/etiologia , Região Lombossacral/diagnóstico por imagem , Masculino , Complicações Pós-Operatórias/terapia , Escoliose/diagnóstico por imagem , Escoliose/etiologia , Espondilolistese/terapia , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X
13.
J Med Case Rep ; 9: 10, 2015 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-25596810

RESUMO

INTRODUCTION: Rubinstein-Taybi syndrome is an autosomal dominant disorder resulting in congenital craniofacial deformities, and divided into types 1 and 2. Scoliosis has not been reported as one of the extra-cranial manifestations of Rubinstein-Taybi syndrome type 2. CASE PRESENTATION: We present a 14-year-old British Caucasian girl with Rubinstein-Taybi type 2 syndrome who developed a severe double thoracic scoliosis measuring 39° and 68° respectively. Her scoliosis was associated with thoracic hypokyphosis, causing a marked reduction in the anteroposterior diameter of her chest and consequent severe restrictive lung disease. The deformity was noted by her local pediatrician as part of a chest infection assessment when she was aged 13 years, and gradually progressed as the result of spinal growth. Our patient underwent a posterior spinal arthrodesis using a single concave pedicle hook and screw rod construct and locally harvested autologous graft supplemented by allograft bone. This spinal fixation technique was selected because of our patient's low body weight to avoid prominence of the instrumentation causing skin healing problems and pain. Her scoliosis was corrected to 18° and 30° and we achieved a balanced spine in the coronal and sagittal planes. An underarm spinal jacket was provided for six months after surgery. During her latest follow-up at skeletal maturity, our patient had an excellent cosmetic outcome with no loss of deformity correction or detected pseudoarthrosis and a normal level of activities. CONCLUSION: Scoliosis can develop in young children with Rubinstein-Taybi syndrome type 2, with the deformity deteriorating around the pubertal growth spurt. Surgical treatment can correct the deformity, balance the spine and prevent mechanical back pain. It can also stabilize the chest area and avoid respiratory complications developing as the scoliosis progresses, which can result in severe restrictive pulmonary disease. The use of single concave instrumentation is indicated in very slim patients with poor muscle bulk; in our patient, this produced satisfactory deformity correction and a favorable outcome at completion of growth. Peri-operative care in this group of patients can be very challenging because of associated co-morbidities as well as the presence of severe behavioral issues that result in poor patient compliance.


Assuntos
Dispositivos de Fixação Ortopédica , Síndrome de Rubinstein-Taybi/cirurgia , Escoliose/cirurgia , Fusão Vertebral/instrumentação , Adolescente , Feminino , Seguimentos , Humanos , Síndrome de Rubinstein-Taybi/fisiopatologia , Escoliose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
14.
J Med Case Rep ; 8: 446, 2014 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-25524572

RESUMO

INTRODUCTION: Treacher Collins syndrome is an autosomal dominant disorder resulting in congenital craniofacial deformities. Scoliosis has not been previously reported as one of the extracranial manifestations of this syndromic condition. CASE PRESENTATION: We present a 15-year-old British Caucasian girl with Treacher Collins syndrome who developed a severe double thoracic scoliosis measuring 102° and 63° respectively. The deformity was noted at age 14 years by the local general practitioner and gradually progressed until she was referred to our service and subsequently was scheduled for surgical correction. There were no congenital vertebral anomalies. As part of the condition, she had bilateral conductive hearing impairment. She also had reduced respiratory reserves and a restrictive lung disease. Both curves were rigid on supine maximum traction radiographs. She underwent a single-stage anterior and posterior spinal arthrodesis with pedicle hook/sublaminar wire/screw and rod instrumentation and autologous rib graft, supplemented by allograft bone and made a good postoperative recovery. Her scoliosis was corrected to 25° and 24° and a balanced spine in the coronal and sagittal planes was achieved. At latest follow-up beyond skeletal maturity (3 years post-surgery) she had an excellent cosmetic outcome with no loss of deformity correction, no detected pseudarthrosis and a normal level of activities. CONCLUSIONS: Scoliosis can occur in patients with Treacher Collins syndrome with the deformity demonstrating significant deterioration around the adolescent growth spurt. A high index of awareness will allow for an early diagnosis and scoliosis correction at a stage when this can be safer and performed through a single-stage posterior procedure. If the deformity is detected at a later age and stage of growth as occurred in our patient, more complex surgery is required and this increases the risk for major morbidity and potential mortality. Surgical treatment can correct the deformity, balance the spine and restore cosmesis, as well as prevent mechanical back pain and respiratory complications if the scoliosis progressed to cause severe thoracic distortion. A thorough preoperative assessment can diagnose associated comorbidities and reduce the risk for postoperative complications.


Assuntos
Disostose Mandibulofacial/complicações , Escoliose/cirurgia , Fusão Vertebral , Vértebras Torácicas/cirurgia , Adolescente , Parafusos Ósseos , Fios Ortopédicos , Feminino , Humanos , Escoliose/etiologia , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Fatores de Tempo , Resultado do Tratamento
15.
Indian J Orthop ; 47(4): 408-12, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23960287

RESUMO

We report Ogilvie's syndrome following posterior spinal arthrodesis on a patient with thoracic and lumbar scoliosis associated with intraspinal anomalies. Postoperative paralytic ileus can commonly complicate scoliosis surgery. Ogilvie's syndrome as a cause of abdominal distension and pain has not been reported following spinal deformity correction and can mimic post-surgical ileus. 12 year old female patient with double thoracic and lumbar scoliosis associated with Arnold-Chiari 1 malformation and syringomyelia. The patient underwent posterior spinal fusion from T4 to L3 with segmental pedicle screw instrumentation and autogenous iliac crest grafting. She developed abdominal distension and pain postoperatively and this deteriorated despite conservative management. Repeat ultrasounds and abdominal computer tomography scans ruled out mechanical obstruction. The clinical presentation and blood parameters excluded toxic megacolon and cecal volvulus. As the symptoms persisted, a laparotomy was performed on postoperative day 16, which demonstrated ragged tears of the colon and cecum. A right hemi-colectomy followed by ileocecal anastomosis was required. The pathological examination of surgical specimens excluded inflammatory bowel disease and vascular abnormalities. The patient made a good recovery following bowel surgery and at latest followup 3.2 years later she had no abdominal complaints and an excellent scoliosis correction. Ogilvie's syndrome should be included in the differential diagnosis of postoperative ileus in patients developing prolonged unexplained abdominal distension and pain after scoliosis correction. Early diagnosis and instigation of conservative management can prevent major morbidity and mortality due to bowel ischemia and perforation.

16.
Indian J Orthop ; 47(3): 219-29, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23798750

RESUMO

A new era in the surgical treatment of adolescent idiopathic scoliosis (AIS) opened with the introduction of pedicle screw instrumentation, which provides 3-column vertebral fixation and allows major deformity correction on the coronal, sagittal, and axial planes. A steep learning curve can be expected for spinal surgeons to become familiar with pedicle screw placement and correction techniques. Potential complications including injury to adjacent neural, vascular, and visceral structures can occur due to screw misplacement or pull-out during correction maneuvers. These major complications are better recognized as pedicle screw techniques become more popular and may result in serious morbidity and mortality. Extensive laboratory and clinical training is mandatory before pedicle screw techniques in scoliosis surgery are put to practice. Wider application, especially in developing countries, is limited by the high cost of implants. Refined correction techniques are currently developed and these utilize a lesser number of pedicle anchors which are strategically positioned to allow optimum deformity correction while reducing the neurological risk, surgical time, and blood loss, as well as instrumentation cost. Such techniques can be particularly attractive at a time when cost has major implications on provision of health care as they can make scoliosis treatment available to a wider population of patients. Pedicle screw techniques are currently considered the gold standard for scoliosis correction due to their documented superior biomechanical properties and ability to produce improved clinical outcomes as reflected by health-related quality-of-life questionnaires. Ongoing research promises further advances with the future of AIS treatment incorporating genetic counseling and possibly fusionless techniques.

17.
Indian J Orthop ; 47(2): 117-28, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23682172

RESUMO

Adolescent idiopathic scoliosis is the most common spinal deformity encountered by General Orthopaedic Surgeons. Etiology remains unclear and current research focuses on genetic factors that may influence scoliosis development and risk of progression. Delayed diagnosis can result in severe deformities which affect the coronal and sagittal planes, as well as the rib cage, waistline symmetry, and shoulder balance. Patient's dissatisfaction in terms of physical appearance and mechanical back pain, as well as the risk for curve deterioration are usually the reasons for treatment. Conservative management involves mainly bracing with the aim to stop or slow down scoliosis progression during growth and if possible prevent the need for surgical treatment. This is mainly indicated in young compliant patients with a large amount of remaining growth and progressive curvatures. Scoliosis correction is indicated for severe or progressive curves which produce significant cosmetic deformity, muscular pain, and patient discontent. Posterior spinal arthrodesis with Harrington instrumentation and bone grafting was the first attempt to correct the coronal deformity and replace in situ fusion. This was associated with high pseudarthrosis rates, need for postoperative immobilization, and flattening of sagittal spinal contour. Segmental correction techniques were introduced along with the Luque rods, Harri-Luque, and Wisconsin systems. Correction in both coronal and sagittal planes was not satisfactory and high rates of nonunion persisted until Cotrel and Dubousset introduced the concept of global spinal derotation. Development of pedicle screws provided a powerful tool to correct three-dimensional vertebral deformity and opened a new era in the treatment of scoliosis.

18.
Indian J Orthop ; 47(6): 621-3, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24379470

RESUMO

We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain.

19.
J Spinal Disord Tech ; 25(7): 401-8, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21738076

RESUMO

STUDY DESIGN: Retrospective review of a prospectively collected single surgeon's series. OBJECTIVE: To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. In addition to assess quality-of-life and functional improvement after deformity correction as perceived by the parents of our patients. SUMMARY OF BACKGROUND DATA: All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. METHODS: We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardized surgical technique. All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. RESULTS: Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range: 9 to 18.3 y) and mean postoperative follow-up was 3.5 years (range: 2.8 to 5 y). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5 to 21.4 degree (74.1%). Pelvic obliquity was corrected from mean 24 to 4 degree (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, intensive care unit stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, intensive care unit stay 8.9 days, and hospital stay 27.4 days. Major complications included 1 deep infection and 1 reoperation to remove prominent implants but no deaths, no neurological deficit, and no detected pseudarthrosis. Parents' survey showed 100% satisfaction rate. CONCLUSIONS: Pedicle screw instrumentation can achieve excellent correction of spinal deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction.


Assuntos
Paralisia Cerebral/cirurgia , Vértebras Lombares/cirurgia , Escoliose/cirurgia , Fusão Vertebral/instrumentação , Vértebras Torácicas/cirurgia , Adolescente , Parafusos Ósseos , Criança , Feminino , Humanos , Masculino , Pelve/cirurgia , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento
20.
Spine (Phila Pa 1976) ; 36(22): E1497-500, 2011 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-21221055

RESUMO

STUDY DESIGN: A case report. OBJECTIVE: We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. SUMMARY OF BACKGROUND DATA: Body piercing has become increasingly more common because of change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following orthopedic or spinal procedures associated with body piercing have not been reported. METHODS: We reviewed the medical notes and radiographs of an adolescent patient with Scheuermann kyphosis and multiple body piercings who underwent a posterior spinal arthrodesis and developed septic shock. RESULTS: Septic shock developed on postoperative day 2 after reinsertion of all piercings following the patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteremia and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. CONCLUSION: The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery.


Assuntos
Piercing Corporal/efeitos adversos , Doença de Scheuermann/cirurgia , Choque Séptico/etiologia , Fusão Vertebral/efeitos adversos , Adolescente , Antibacterianos/uso terapêutico , Feminino , Humanos , Radiografia , Doença de Scheuermann/complicações , Doença de Scheuermann/diagnóstico por imagem , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Resultado do Tratamento
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