Presence of compensatory curve predicts postoperative curve progression in congenital scoliosis after thoracolumbar hemivertebra resection and short fusion.

PURPOSE: To investigate the impact of preoperative compensatory curve on the postoperative curve progression in congenital scoliosis (CS) patients following thoracolumbar hemivertebra (HV) resection and short fusion. METHODS: This study retrospectively reviewed a consecutive cohort of patients with CS who underwent thoracolumbar HV resection and short fusion with a minimum of 2 years follow-up. According to the preoperative curve pattern, patients were divided into compensatory curve group non-compensatory curve group. Based on the postoperative coronal curve evolution, patients were further divided into the progressed group (Group P, with curve decompensation ≥ 20°) and the non-progressed group (Group NP, characterized by well-compensated curves). RESULTS: A total of 127 patients were included in this study, with 31 patients in the compensatory curve group and 96 patients in the non-compensatory curve group. The incidence of postoperative coronal curve progression was significantly higher in the compensatory curve group than that in non-compensatory curve group (35.5% vs. 13.5%, p = 0.007). In the compensatory curve group, patients who experienced postoperative curve progression showed fewer fusion segments (p = 0.001), greater preoperative UIV translation (p = 0.006), greater preoperative LIV tilt (p = 0.017), and larger postoperative UIV tilt (p < 0.001) compared with patients in group NP. Multiple logistic regression demonstrated that the shorter fusion segments and greater postoperative UIV tilt were two independent risk factors for postoperative curve progression. CONCLUSION: The presence of the compensatory curve was associated with a higher incidence of postoperative curve progression in patients with CS who underwent thoracolumbar HV resection and short fusion. Shorter fusion segments and greater postoperative UIV tilt were found to be the risk factors for postoperative curve progression.

Dropped head syndrome: a treatment strategy and surgical intervention.

PURPOSE: The pathology of dropped head syndrome (DHS) is diverse, and reports of surgery for DHS are scarce. We aimed to describe surgery for DHS and to investigate the surgical outcomes thereof. METHODS: We enrolled 40 consecutive patients (six males and 34 females; average age at surgery, 72.0 years) with DHS who underwent correction surgeries at a single institute. Short fusion (SF), with the extent of fixation mainly at the cervical region, was performed for 27 patients; long fusion (LF), involving the cervical and thoracic spine, for 13. Clinical and radiological outcomes were investigated, and factors analyzed using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). RESULTS: All patients were able to gaze horizontally at the follow-up. Instances of five transient C5 palsy results, and five distal junctional kyphosis results were found, but no revisions were reported due to recurrence. Patients whose T1 slope-20° was smaller than the C2-7 angle postoperatively exhibited better clinical outcomes in the three domains of the JOACMEQ, regardless of the extent of fixation. CONCLUSION: For cases where the T1 slope is relatively small, and approximately 10° of cervical lordosis is predicted to be obtained postoperatively, SF is appropriate. Alternatively, for cases with higher T1 slope, obtaining a cervical lordosis over 20° has a risk of postoperative complications. For such cases, it is an option to perform an LF involving the cervical and thoracic spine.

Curve progression in de novo degenerative lumbar scoliosis combined with degenerative segment disease after short-segment fusion.

PURPOSE: To validate the reliability of Berjano and Lamartina classification system of surgical planning in cases of de novo degenerative lumbar scoliosis (DNDLS) combined with degenerative segment disease and identify factors contributing to curve progression. METHODS: Fifty-four cases of type I or II DNDLS were retrospectively reviewed. Health-related quality of life (HRQOL) was assessed using visual analogue scale (VAS) scores for the back and leg, Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores. Radiographic parameters were obtained from X-rays. Improvements in HRQOL were confirmed by a paired t test. Changes in radiographic parameters were confirmed by paired t test and Wilcoxon signed-rank test. Clinical relevance between spinopelvic parameters and Cobb angle progression was analyzed by Spearman correlation coefficient. RESULTS: The mean follow-up period was 36.8 ± 14.8 months. The scores taken preoperatively versus at the last follow-up were as follows: mean VAS back score, 4.5 ± 2.4 versus 1.8 ± 1.5 (p < 0.01); and mean VAS leg score, 5.2 ± 2.5 versus 1.7 ± 2.1 (p < 0.01). The ODI score improved from 25.3 ± 8.9% to 10.1 ± 5.4% (p < 0.01), whereas the mean JOA score improved from 14.3 ± 4.9 to 21.0 ± 3.7 (p < 0.01). The mean Cobb angle decreased from 17.1° ± 7.4° to 9.4° ± 4.5° postoperatively but worsened to 14.1° ± 6.4° at the last follow-up with a mean progression of 2.1° per year. Cobb angle correction was lost at a mean 2.1° ± 3.3° per year with correlation to T1 pelvic angle and sagittal vertical axis preoperatively. CONCLUSIONS: Selective decompression and short-segment fusion were effective for treating type I and II cases DNDLS. The Cobb angle increased relative to preoperative sagittal spine alignment. These slides can be retrieved under Electronic Supplementary Material.

Short-Segment versus Long-Segment Spinal Fusion Constructs for the Treatment of Adult Degenerative Scoliosis: A Comparison of Clinical Outcomes.

OBJECTIVE: To compare clinical outcomes of patients diagnosed with degenerative scoliosis undergoing short-segment versus long-segment spinal fusion. METHODS: A retrospective cohort study was conducted of patients with degenerative thoracolumbar scoliosis undergoing elective spinal fusion at a single academic medical center. Cohorts were divided into short-segment (<3) or long-segment (≥3) groups. RESULTS: A total of 197 patients (122 short, 75 long) were included. Patients undergoing short-segment fusion more frequently presented with radiculopathy (P < 0.001) and had greater baseline visual analog scale (VAS) leg scores (P < 0.001). Patients with long-segment fusions had longer hospital length of stay (short, 3.82 ± 2.98 vs. long, 7.40 ± 6.85 days; P < 0.001), lower home discharge rates (short, 80.3% vs. long, 51.8; P = 0.003), higher revision surgery rates (short, 10.77% vs. long, 25.3%; P = 0.012), and greater percentage curve correction (short, 37.3% ± 25.9% vs. long, 45.1% ± 23.9%; P = 0.048). No significant differences were noted in postoperative complication rates (short, 1.64% vs. long, 5.33%; P = 0.143). At 1 year, patients with long fusions had worse ΔOswestry Disability Index (ODI) (P = 0.024), ΔVAS leg score (P = 0.002), and VAS leg minimum clinically important difference % (P = 0.003). Multivariate regression found that short-segment fusions were associated with greater improvements in ODI (P = 0.029), Physical Component Summary-12 (P = 0.024), and VAS leg score at 1 year (P = 0.002). CONCLUSIONS: Patients undergoing short-segment fusions more frequently presented with radiculopathy and had higher preoperative VAS leg scores compared with those receiving long constructs. Short-construct fusions in appropriately selected patients may provide satisfactory improvements in patient-reported outcome measures, particularly ΔODI and ΔVAS leg score, and mitigate hospital length of stay, revision surgery rates, and nonhome discharge.

Hybrid technique versus traditional dual growing rod technique to treat congenital early-onset scoliosis: a comparative study with more than 3 years of follow-up.

OBJECTIVE: The authors' objective was to compare the intermediate outcomes of patients with severe congenital early-onset scoliosis (CEOS) treated with posterior vertebrectomy/hemivertebrectomy with short fusion and dual growing rods (hybrid technique [HT]) and those treated with traditional dual growing rods (TDGRs). METHODS: A retrospective study of patients who underwent the HT and TDGR technique for CEOS was conducted. The inclusion criteria were CEOS (age < 10 years), Risser stage 0, treatment with HT or TDGR, index surgery performed between 2004 and 2017, and minimum follow-up of 3 years. For patients who completed lengthening procedures, the last lengthening procedure was considered the latest follow-up. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups. RESULTS: Sixty-one patients with CEOS were included in this study, with 16 treated with HT and 45 with TDGR technique. There were no differences in age at index surgery, duration of treatment, or number of lengthening procedures. The lengthening interval was longer in the HT group. The preoperative mean ± SD main curve was 81.8° ± 17.1° for the HT group and 63.3° ± 16.9° for the TDGR group (p < 0.05). However, main curve correction was better in the HT group, and no differences in residual curve were found between groups. Although the preoperative apex vertebral translation (AVT) of the HT group was greater, the correction of AVT was better in the HT group (p < 0.05). No differences in T1-S1 and T1-12 height were found between groups at the latest follow-up. The growth of T1-S1 height was less in the HT group (p < 0.05), whereas the growth of T1-12 height was similar between groups. Patients in the HT group had a lower risk of mechanical complications but higher risks of dural tears and neurological complications. CONCLUSIONS: HT may provide better correction and apex control ability than TDGR for EOS patients with severe and rigid deformity at the apex level, and it significantly decreased the risk of mechanical complications with little influence on growth of the thoracic spine. HT may be an option for patients with severe CEOS with large asymmetrical growth potential around the apex of the curve.

Short fusion with vertebrectomy during growth in congenital spinal deformity: is early surgical intervention recommended?

STUDY DESIGN: This was a multi-center retrospective cohort study included consecutive pediatric patients who were admitted to 8 institutions for the treatment of congenital spinal deformity from 1991 to 2012. OBJECTIVE: The purpose of this study was to compare curve corrections and balances, reoperations, and complications at 2-year follow-up between those treated early vs. late. Although early intervention has been recommended, no empirical study has examined the optimal timing of short fusion among patients with congenital spinal deformity. METHODS: Patients with congenital spinal deformity with formation failure undergoing vertebrectomy with short fusion (≤ 6 fusion segments) were categorized as early (surgery at ≤ 6 years) and late (7-18 years) fusion. Outcomes included coronal and sagittal curve corrections at immediate and 2-year evaluations; loss of curve correction from immediate to 2-year follow-up; coronal and sagittal balance at 2 years; and inter-operative, major and minor short-term postoperative, and long-term postoperative complications and reoperations. RESULTS: Early fusion (N = 79) compared to late fusion (N = 96) was associated with greater percent curve correction at immediate (71% vs. 60%, p = 0.0046) and 2-year (63% vs. 52%, p = 0.0153) evaluations adjusting for surgeon experience and preoperative coronal balance. These associations were significant for males and those with 3-level fusions but not 4 to 6-level fusions. Early fusion compared with late fusion had more intraoperative (6% vs. 1%) and postoperative long-term complications (27% vs. 18%), as well as unplanned reoperations (13% vs. 9%). Early vs. late fusion had fewer short-term complications, both major (6% vs. 15%) and minor (6% vs. 15%). CONCLUSIONS: Patients who underwent early treatment achieved larger major curve correction by 10% compared to patients with late treatment when assessed at 2-year postoperative evaluation. However, early fusion should be considered with careful attention to possible increased risk of reoperations. LEVEL OF EVIDENCE: Level III.

Can we use shorter constructs while maintaining satisfactory sagittal plane alignment for adult spinal deformity?

OBJECTIVE: Issues with spinopelvic fixation for adult spinal deformity (ASD) include loss of the physiological mobility of the entire lumbar spine, perioperative complications, and medical costs. Little is known about the factors associated with successful short fusion for ASD. The authors evaluated radiographic and clinical outcomes after shorter fusion for different subtypes of ASD at 2 years postoperatively and examined factors associated with successful short fusion. METHODS: This was a single-center study of 37 patients who underwent short fusion and a minimum 2 years of follow-up for ASD in which lumbar kyphosis was the main deformity. The exclusion criteria were 1) age < 40 years, 2) previous lumbar vertebral fracture, 3) severe osteoporosis, 4) T10-L2 kyphosis > 20°, 5) scoliotic deformity with an upper end vertebra (UEV) above T12, and 6) concomitant Parkinson's disease or neurological disease. The surgical procedures, radiographic course, and Oswestry Disability Index (ODI) were assessed, and correlations between radiographic parameters and postoperative ODI at 2 years were analyzed. RESULTS: A mean of 3.5 levels were fused. The mean radiographic parameters preoperatively, at 2 weeks, and at 2 years, respectively, were as follows: coronal Cobb angle: 22.9°, 11.5°, and 12.6°; lumbar lordosis (LL): 12.9°, 35.8°, and 32.2°; pelvic incidence (PI) minus LL: 35.5°, 14.7°, and 19.2°; pelvic tilt: 29.4°, 23.1°, and 25.0°; and sagittal vertical axis 85.3, 36.7, and 59.2 mm. Abnormal proximal junctional kyphosis occurred in 8 cases. Revision surgery was performed to extend the length of fusion from a lower thoracic vertebra to the pelvis in 2 cases. The mean ODI scores preoperatively and at 2 years were 50.7% and 24.1%, respectively. Patient age, number of fused intervertebral segments, and radiographic parameters were analyzed by the stepwise method to identify factors contributing to the ODI score at 2 years, preoperative PI, and sagittal vertical axis at 2 years. On receiver operating characteristic curve analysis of the minimal clinically important difference of ODI (15%) and preoperative PI, the cutoff value of the preoperative PI was 47° (area under the curve 0.75). CONCLUSIONS: In terms of subtypes of ASD in which lumbar kyphosis is the main deformity, if the PI is < 47°, then the use of short fusion preserving mobile intervertebral segments can produce adequate LL for the PI, improving both postoperative global spinal alignment and quality of life.

[Effectiveness of short fusion versus long fusion for degenerative scoliosis with a Cobb angle of 20-40° combined with spinal stenosis].

OBJECTIVE: To compare the effectiveness of decompression and short fusion or long fusion for degenerative scoliosis (DS) with a Cobb angle of 20-40° combined with spinal stenosis. METHODS: The clinical data of 50 patients with DS who were treated with decompression combined with short fusion or long fusion between January 2015 and May 2017 were retrospectively analysed. Patients were divided into long fusion group (fixed segments>3, 23 cases) and short fusion group (fixed segments≤3, 27 cases). There was no significant difference in gender, age, disease duration, and preoperative visual analogue scale (VAS) score of leg pain, Oswestry disability index (ODI), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), pelvic incidence (PI), pelvic title (PT), and sacral slope (SS) between the two groups ( P>0.05); however, the VAS score of low back pain, Cobb angle, and sagittal vertical axis (SVA) in long fusion group were significantly higher than those in short fusion group ( P<0.05), and the lumbar lordosis (LL) was significantly lower than that in short fusion group ( t=2.427, P=0.019). The operation time, intraoperative blood loss, fluoroscopy times, hospital stay, and complications were recorded and compared. The VAS scores of low back pain and leg pain and ODI score were used to evaluate the clinical outcomes before operation and at last follow-up. X-ray films of the whole spine in standard standing position were taken before operation, at 6 months after operation, and at last follow-up, and the spino-pelvic parameters were measured. RESULTS: The operation time, intraoperative blood loss, and fluoroscopy times in the short fusion group were significantly less than those in the long fusion group ( P<0.05); there was no significant difference in hospital stay between the two groups ( t=0.933, P=0.355). The patients were followed up 12-46 months with an average of 22.3 months. At last follow-up, the VAS scores of low back pain and leg pain and ODI score significantly improved when compared with those before operation ( P<0.05). Except for the improvement of VAS score of low back pain ( t=8.332, P=0.000), the differences of the improvements of the other scores between the two groups were not significant ( P>0.05). The Cobb angle, SVA, TLK, and PT significantly decreased, while SS and LL significantly increased in the long fusion group ( P<0.05), while the Cobb angle and PT significantly decreased and SS significantly increased in the short fusion group at last follow-up ( P<0.05). There was no significant difference in spino-pelvic parameters between the two groups at 6 months after operation and at last follow-up ( P>0.05). The improvements of Cobb angle, SVA, LL, PT, and SS in the long fusion group were significantly higher than those in the short fusion group at last follow-up ( P<0.05). There was no perioperative death in both groups. The incidence of complications in the long fusion group was 34.8% (8/23), which was significantly higher than that in the short fusion group [11.1% (3/27)] ( χ 2=4.056, P=0.034). CONCLUSION: The DS patients with the Cobb angle of 20-40°can achieve satisfactory clinical outcomes and improve the spino-pelvic parameters by choosing appropriate fixation levels. Short fusion has less surgical trauma and fewer complications, whereas long fusion has more advantages in enhancing spino-pelvic parameters and relieving low back pain.

A short-segment fusion strategy using a wide-foot-plate expandable cage for vertebral pseudarthrosis after an osteoporotic vertebral fracture.

OBJECTIVE: Various surgical treatments have been reported for vertebral pseudarthrosis after osteoporotic vertebral fracture (OVF). However, the outcomes are not always good. The authors now have some experience with combined anterior-posterior short-segment spinal fusion (1 level above and 1 level below the fracture) using a wide-foot-plate expandable cage. Here, they report their surgical outcomes with this procedure. METHODS: Between June 2016 and August 2018, 16 consecutive patients (4 male and 12 female; mean age 75.1 years) underwent short-segment spinal fusion for vertebral pseudarthrosis or delayed collapse after OVF. The mean observation period was 20.1 months. The level of the fractured vertebra was T12 in 4 patients, L1 in 3, L2 in 4, L3 in 3, and L4 in 2. Clinical outcomes were assessed using the lumbar Japanese Orthopaedic Association (JOA) scale and 100-mm visual analog scale for low-back pain. Local kyphotic angle, intervertebral height, bone union rate, and instrumentation-related adverse events were investigated as imaging outcomes. The data were analyzed using the Wilcoxon signed-rank test. RESULTS: The mean operating time was 334.3 minutes (range 256-517 minutes), and the mean blood loss was 424.9 ml (range 30-1320 ml). The only perioperative complication was a superficial infection of the posterior wound that was cured by irrigation. The lumbar JOA score and visual analog scale value improved from 11.2 and 58.8 mm preoperatively to 20.6 and 18.6 mm postoperatively, respectively. The mean local kyphotic angle and mean intervertebral height were 22.6° and 28.0 mm, respectively, before surgery, -1.5° and 40.5 mm immediately after surgery, and 7.0° and 37.1 mm at the final observation. Significant improvement was observed in both parameters immediately after surgery and at the final observation when compared with the preoperative values. Intraoperative endplate injury occurred in 8 cases, and progression of cage subsidence of 5 mm or more was observed in 2 of these cases. Proximal junctional kyphosis was observed in 2 cases. There were no cases of screw loosening. No cases required reoperation due to instrument-related adverse events. Bone union was observed in all 14 cases that had CT evaluation. CONCLUSIONS: This short-segment fusion procedure is relatively minimally invasive, and local reconstruction and bone fusion have been achieved. This procedure is considered to be attempted for the surgical treatment of osteoporotic vertebral pseudarthrosis after OVF.

Midterm surgical outcomes of a short fusion strategy for adolescent idiopathic scoliosis with Lenke 5C curve.

BACKGROUND CONTEXT: A previous study examined the short-term (2 years) outcomes of a short fusion strategy for Lenke type 5C curves. This strategy had a little less correction rate with no difference in coronal and sagittal balance and SRS-22 scores to those of a conventional strategy and was superior in operative time and intraoperative bleeding. However, its effectiveness in longer follow-up periods was unknown. PURPOSE: To assess midterm surgical outcomes of a short fusion strategy for adolescent idiopathic scoliosis (AIS) with Lenke type 5C curve, involving posterior correction and fusion surgery (PSF) using pedicle-screw constructs. STUDY DESIGN: Retrospective case series. PATIENT SAMPLE: Twenty-nine patients who underwent PSF for AIS with Lenke type 5C curve with a minimum 5-year follow-up. OUTCOME MEASURES: Radiographic parameters and SRS-22. METHODS: We compared radiographic parameters and clinical outcomes between patients with an upper instrumented vertebra (UIV) at the end vertebra (EV) (n=12) and those treated by short fusion (S), with a UIV one level caudal to the EV (n=17). RESULTS: A preoperative mean Cobb angle of 51.9±13.8° was corrected to 11.7±7.7° in the EV group, and an angle of 46.0±6.6° was corrected to 9.3±5.2° in the S group. The correction was maintained in both groups at the final follow-up, and the mean correction loss was 2.8±6.8° in the EV and 6.5±6.5° in the S group (p=.143). The mean correction rate at the final follow-up was not significantly different between the EV (71.4±11.8%) and S (64.9±13.7%) groups (p=.199). A Cobb angle of a thoracic curve was significantly improved immediately after surgery and maintained during the follow-up period in the both groups. Coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, L4 tilt, UIV/LIV tilt, shoulder balance, and SRS-22 had no difference between the two groups. CONCLUSIONS: There was no difference in radiographic parameters and SRS-22 between patients treated with a UIV at the UEV and patients treated using a short fusion strategy, in which the UIV was one level caudal to the UEV. The short fusion strategy can be one of the alternatives in PSF for Lenke type 5C curves, at least in 5-year time frame.

Short Lumbosacral Decompression Plus Fixation Does Not Change the Spinopelvic Balance on Patients With Moderate Degenerative Spondylolisthesis and Associated Spinal Stenosis.

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To investigate whether decompression plus short segment lumbosacral fixation changes the sagittal baseline spinopelvic parameters in patients with moderate degenerative spondylolisthesis (DS) and associated degenerative lumbar spinal stenosis (DLSS). SUMMARY OF BACKGROUND DATA: Spinal decompression and fusion are commonly performed in DS with associated DLSS. Spinopelvic alignment after surgery for DS is an important research topic. The effect of short lumbosacral instrumented fusion on the global sagittal spinal balance has not been sufficiently studied. METHODS: Thirty-four consecutive adult patients (21 women, 13 men) aged 62 ± 11 years with balanced spines [sagittal vertical axis (SVA) ≤ 40 mm] received decompression and two to three vertebrae fixation plus fusion for DS grades I and II, associated with symptomatic DLSS. Age, gender, number of segments fused, posterolateral fusion (PLF) versus PLF plus posterior lumbar interbody fusion (PLIF) and segmental lordosis (SL) in the free segment above instrumentation were studied for a minimum follow-up of 60 months. The roentgenographic variables measured are T12-S1 lumbar lordosis (LL), SVA, sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), SL, and anterior (ADH) and posterior disc height (PDH) in the suprajacent free lumbar segment. Clinical outcomes were assessed with visual analog scale and Oswestry Disability Index. RESULTS: SVA significantly (p = .05) decreased postoperatively but returned to the baseline value at the final observation. Younger individuals (≤59 years) stood with greater SS (p = .036) 6 months postoperatively and with less SVA in all 3 periods of observation (p = .013, .046, and .024) than their older (>59 years) counterparts. Patients with monosegmental stenosis showed on baseline less SVA (p = .028), PT (p = .031), and PI (p = .004) than their two-segmental stenosis counterparts. PI preoperatively to the last evaluation was significantly smaller in the patients who received 360° fusion (p<.016). CONCLUSIONS: Short lumbosacral fixation does not significantly change the preoperative sagittal spinopelvic balance in adult patients with preoperatively balanced spines who have DS and DLSS. LEVEL OF EVIDENCE: Level III.

Monosegmental vs bisegmental pedicle fixation for the treatment of thoracolumbar spine fractures.

INTRODUCTION: The anatomy and biomechanics of the thoracolumbar spine place these segments at high risk of trauma injuries. Treatment options are either conservative or surgical, and there is a lack of consensus about the right indications. International scientific publications agree only on basic surgical principles: vertebral stability, deformity correction, protection of neurological structures and fast functional recovery. The most commonly used approach is the posterior approach, which allows the best management of most vertebral fracture patterns. The aim of this study was to compare clinical and radiological outcomes of monosegmental stabilisation with those of bisegmental stabilisation and fusion in the treatment of traumatic thoracolumbar spine fractures. MATERIALS AND METHODS: This retrospective clinical and radiological study evaluated 48 consecutive patients treated with monosegmental (Group M; n=14) or bisegmental (Group B; n=34) posterior pedicular instrumentation for thoracolumbar fractures. Fractures were classified by the new AO Spine TLIC system. Average follow-up was 30 months. Clinical outcomes in both groups were statistically compared. Radiological outcomes were evaluated in terms of vertebral anterior body height restoration and correction of the kyphotic deformity. RESULTS: Radiographical results showed no statistically significant difference between the two groups in vertebral body height restoration and correction of the kyphotic deformity. The mean postoperative somatic vertebral anterior body height in Group M was 25.8±4.52mm and in Group B it was 24.43±4.27mm. In Group M the mean postoperative kyphotic deformity was 11.10±5.71°, in Group B it was 9.09±4.93°. CONCLUSIONS: The results of this study confirm the validity of short and very short instrumentation for the treatment of well-selected type A and B vertebral fractures. In C type fractures correct surgical indication must be evaluated on an individual basis.

Short fusion strategy for thoracolumbar and lumbar adolescent idiopathic scoliosis using anterior dual-rod instrumentation.

AIMS: A total of 30 patients with thoracolumbar/lumbar adolescent idiopathic scoliosis (AIS) treated between 1989 and 2000 with anterior correction and fusion surgery using dual-rod instrumentation were reviewed. PATIENTS AND METHODS: Radiographic parameters and clinical outcomes were compared among patients with lowest instrumented vertebra (LIV) at the lower end vertebra (LEV; EV group) (n = 13) and those treated by short fusion (S group), with LIV one level proximal to EV (n = 17 patients). RESULTS: The allocation of the surgical technique was determined by the flexibility of the TL/L curves and/or neutral vertebrae located one level above LEV as determined on preoperative radiographs. If these requirements were met a short fusion was performed. The mean follow-up period was 21.4 years (16 to 27). The mean correction rate at final follow-up was significantly lower in the S group (74 sd 11%) than in the EV group (88 sd 13%) (p = 0.004).Coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, and clinical outcomes evaluated by the Scoliosis Research Society-22 questionnaire scores were equivalent between the two groups. CONCLUSION: Short fusion strategy, which uses LIV one level proximal to LEV can be considered as an alternative to the conventional strategy, which includes LEV in the fusion, when highly flexible TL/L curves are confirmed and/or neutral vertebrae are located one level above LEV in patients with thoracolumbar/lumbar AIS curves. TAKE HOME MESSAGE: Short fusion strategy can be considered as an alternative to the conventional strategy in patients with thoracolumbar/lumbar AIS curves undergoing anterior spinal fusion with dual-rod instrumentation. Cite this article: Bone Joint J 2016;98-B:402-9.

Emerging S-shaped curves in congenital scoliosis after hemivertebra resection and short segmental fusion.

BACKGROUND CONTEXT: Posterior hemivertebra resection with short fusion has gradually become the mainstream treatment for the congenital scoliosis due to single fully segmented hemivertebra. A kind of unexpected emerging S-shaped scoliosis was found secondary to this surgery, and that has not been reported yet. PURPOSE: The aim of the present study was to analyze the possible pathogenesis, clinical feature, and treatment of the emerging S-shaped scoliosis after posterior hemivertebra resection and short fusion. STUDY DESIGN: This study is a retrospective case series. PATIENT SAMPLE: A total of 128 patients participated. OUTCOME MEASURES: Preoperative and postoperative whole spine radiographs were used to measure the Cobb angle of main curve, compensatory curve, and emerging curves. And the hemivertebra location, the fused segment, the apical and ending vertebrae of postoperative-emerging curve (and preoperative compensatory curves) were assessed. METHODS: Both the demographics and radiographic data were reviewed. Postoperative-emerging scoliosis was defined as the curve with an increasing angle of 20° and an apical vertebra locating at least two levels away from fusion region. RESULTS: Of the 128 patients, 9 (7%) showed postoperative-emerging S-shaped scoliosis. The mean age was 11.4 years old. The mean main curve was 36.1±14.4° preoperatively and been significantly corrected to 6.9±6.1° (p<.001). No significant difference was found in the main curve, kyphosis, coronal balance, or sagittal balance during follow-up. The emerging scoliosis occurred at 3 months (in four patients) or 6 months (in five patients) after initial surgery with an average angle of 42.6±12.9° at last follow-up. All patients underwent bracing or observation when the S-shaped scoliosis was arising, and four patients underwent a revision surgery because of deformity developing. CONCLUSIONS: The emerging S-shaped scoliosis was an extraordinary complication that may be developing from the preoperative compensatory scoliosis and usually occurred at 3-6 months after hemivertebra resection. The feature of these curves was similar to the adolescent idiopathic scoliosis (AIS) and brace or revision surgeries were suitable for therapy.

Selection of the upper vertebra to be instrumented in the treatment of thoracolumbar and lumbar adolescent idiopathic scoliosis by anterior correction and fusion surgery using dual-rod instrumentation: a minimum 12-year follow-up study.

BACKGROUND CONTEXT: Consensus regarding the optimal upper vertebra to be instrumented during surgical treatment of Lenke 5C thoracolumbar and lumbar adolescent idiopathic scoliosis (AIS) remains limited. PURPOSE: This study aimed to assess whether a short fusion strategy is appropriate for correction of a Lenke 5C AIS curve by anterior correction and fusion surgery using dual-rod instrumentation. STUDY DESIGN: This study design used retrospective comparative analysis of a prospectively collected, consecutive, non-randomized series of patients at a single institution. PATIENT SAMPLE: Thirty consecutive patients with Lenke 5C AIS treated with anterior correction and fusion surgery using dual-rod instrumentation were included. OUTCOME MEASURES: Patient demographics, radiographic measurements, and Scoliosis Research Society-22 questionnaire (SRS-22) scores were the outcome measures for this study. METHODS: Thirty patients were treated surgically for AIS with a Lenke 5C curve (mean age, 14.4 years [11-19 years)]) and followed up for a mean period of 17.2 years (12-23 years). Radiographical parameters and clinical outcomes were compared between patients treatment with the end vertebra (EV) instrumented (n=14) and those treated by short fusion (S group) with instrumentation starting at the vertebra one level caudal to the EV (n=16 patients). There were no study-specific biases related to conflicts of interest. RESULTS: In the EV group, a mean preoperative Cobb angle of 56° was corrected to 5° after surgery and to 8° at the final follow-up. In the S group, a mean preoperative Cobb angle of 55° was corrected to 10° after surgery and 14° at the final follow-up. The mean correction rate at the final follow-up was significantly lower in the S group (74%) than in the EV group (86%; p=.020). The coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, and clinical outcomes evaluated using SRS-22 did not differ between the two groups. CONCLUSIONS: The short fusion strategy, which involves instrumentation of the vertebra one level caudal to the upper EV, can be considered as an alternative to the conventional strategy, which includes instrumentation of the upper EV, for treating Lenke 5C curves via anterior spinal fusion.

The evaluation of short fusion in idiopathic scoliosis.

BACKGROUND: Selective thoracic fusion in type II curve has been recommended by King et al. since 1983. They suggested that care must be taken to use the vertebra that is neutral and stable so that the lower level of fusion is centered over the sacrum. Since then there has been the trend to do shorter and selective fusion of the major curve. This study was conducted to find out whether short posterior pedicle instrumentation alone could provide efficient correction and maintain trunk balance comparing to the anterior instrumentation. MATERIALS AND METHODS: A prospective study was conducted during 2005-2007 on 39 consecutive cases with idiopathic scoliosis cases King 2 and 3 (Lenke 1A, 1B), 5C and miscellaneous. Only the major curve was instrumented unless both curves were equally rigid and of the same magnitude. The level of fusion was planned as the end vertebra (EVB) to EVB fusion, although minor adjustment was modified by the surgeons intraoperatively. The most common fusion levels in major thoracic curves were T6-T12, whereas the most common fusion levels in the thoraco-lumbar curves were T10-L3. Fusion was performed from the posterior only approach and the implants utilized were uniformly plate and pedicle screw system. All the patients were followed at least 2 years till skeletal maturity. The correction of the curve were assessed according to type of curve (lenke IA, IB and 5), severity of curve (less than 450, 450-890 and more than 900), age at surgery (14 or less and 15 or more) and number of the segment involved in instrumentation (fusion level less than curve, fusion level as of the curve and fusion more than the curve) RESULTS: The average long-term curve correction for the thoracic was 40.4% in Lenke 1A, 52.2% in Lenke 1B and 56.3% in Lenke 5. The factors associated with poorer outcome were younger age at surgery (<11 years or Risser 0), fusion at wrong levels (shorter than the measured end vertebra) and rigid curve identified by bending study. However, all patients had significant improved trunk balance and coronal hump at the final assessment at maturity. Two patients underwent late extension fusion because of junctional scoliosis. CONCLUSIONS: With modern instrumentations, the EVB of the major curve can be used at the end of the instrumentation in most cases of idiopathic scoliosis. In those cases with either severe trunk shift, younger than 11 years old, or extreme rigid curve, an extension of one or more levels might be safer. In particular situations, the concept of centering the lowest vertebra over the sacrum should be adopted.