Suprascapular nerve release for treatment of shoulder and periscapular pain following intracranial spinal accessory nerve injury

Iatrogenic injury to the spinal accessory nerve is one of the most common causes of trapezius muscle palsy. Dysfunction of this muscle can be a painful and disabling condition because scapular winging may impose traction on the soft tissues of the shoulder region, including the suprascapular nerve. There are few reports regarding therapeutic options for an intracranial injury of the accessory nerve. However, the surgical release of the suprascapular nerve at the level of the scapular notch is a promising alternative approach for treatment of shoulder pain in these cases. The author reports on 3 patients presenting with signs and symptoms of unilateral accessory nerve injury following resection of posterior fossa tumors. A posterior approach was used to release the suprascapular nerve at the level of the scapular notch, transecting the superior transverse scapular ligament. All patients experienced relief of their shoulder and scapular pain following the decompressive surgery. In 1 patient the primary dorsal branch of the C-2 nerve root was transferred to the extracranial segment of the accessory nerve, and in the other 2 patients a tendon transfer (the Eden-Lange procedure) was used. Results from this report show that surgical release of the suprascapular nerve is an effective treatment for shoulder and periscapular pain in patients who have sustained an unrepairable injury to the accessory nerve.     

Spinal accessory nerve injury

Injury to the spinal accessory nerve can lead to dysfunction of the trapezius. The trapezius is a major scapular stabilizer and is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating, and retracting the scapula. The superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury. Iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Dysfunction of the trapezius can be a painful and disabling condition. The shoulder droops as the scapula is translated laterally and rotated downward. Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. If diagnosed within 1 year of the injury, microsurgical reconstruction of the nerve should be considered. Conservative treatment of chronic trapezius paralysis is appropriate for older patients who are sendentary. Active and healthy patients in whom 1 year of conservative treatment has failed are candidates for surgical reconstruction. Studies have shown the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.     

A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis

STUDY DESIGN: A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis undergoing surgical correction. OBJECTIVES: 1) To evaluate prospectively, at regular intervals, the changes in pulmonary function after surgical arthrodesis of primary thoracic and double primary thoracic-lumbar (double major) types of adolescent idiopathic scoliosis in a homogeneous population; 2) to compare the changes in pulmonary function after surgical correction relative to the surgical approach used for spinal arthrodesis; and 3) to determine if short- to midterm morbidity with respect to pulmonary function is associated with the type of surgical approach used for spinal arthrodesis. SUMMARY OF BACKGROUND DATA: The effect of surgical correction on the pulmonary function of patients with adolescent idiopathic scoliosis is controversial. Studies have shown improvement, decline, or no change in pulmonary function after surgical correction of idiopathic scoliosis. METHODS: Ninety-eight patients with adolescent idiopathic scoliosis undergoing surgical treatment at the authors' institution were prospectively evaluated with pulmonary function tests assessing volume (forced vital capacity and total lung capacity) and flow (forced expiratory volume in 1 second). Pulmonary functions were evaluated before surgery and after surgery at 3 months, 1 year, 2 years, and at the final follow-up visit. All patients were divided into four groups depending on the surgical approach used for spinal fusion: Group 1 (n = 47) underwent a posterior spinal fusion with iliac crest bone graft; Group 2 (n = 33) underwent a posterior spinal fusion with rib resection thoracoplasty; Group 3 (n = 7) underwent an anterior spinal fusion with a rib resection thoracotomy; and Group 4 (n = 11) underwent a combined anterior and posterior spinal fusion with autogenous rib and iliac crest graft used, respectively. RESULTS: Patients in Group 1 had improved pulmonary function values at 3 months after surgery, whereas patients in Groups 2, 3, and 4 showed a decline at 3 months after surgery. Two years after surgery, Group 1 had significantly improved pulmonary function values (P < 0.0001), whereas the pulmonary function values of patients in Groups 2, 3, and 4 had returned to preoperative values. CONCLUSIONS: 1) Patients with chest cage disruption during surgical treatment showed a decline in pulmonary function at 3 months after surgery. 2) In contrast, patients without chest cage disruption showed an improvement in pulmonary function at 3 months after surgery. 3) Irrespective of the surgical approach used for spinal arthrodesis, postoperative pulmonary function tests (absolute values) returned to preoperative values at 2 years after surgery. 4) Patients who had no chest cage disruption experienced a significantly greater improvement in two of their pulmonary function values at 2 years after surgery than patients with chest cage disruption.     

Video-assisted thoracoscopic surgery: the Cincinnati experience

Video-assisted thoracoscopic surgery is an alternative to open thoracotomy. We analyzed our experience during a consecutive series of 100 patients who had this procedure and who were available for study at 3-year followup. Video-assisted thoracoscopic surgery was done on patients with the following diagnoses: idiopathic scoliosis (n = 49), neuromuscular spinal deformity (n = 15), Scheuermann kyphosis (n = 15), congenital and infantile scoliosis (n = 5), neurofibromatosis (n = 5), Marfan (n = 1), postradiation scoliosis (n = 1), and repair of pseudoarthrosis (n = 1). Four patients had excision of the first rib to treat thoracic outlet syndrome. One patient had excision of an intrathoracic neurofibroma and one a benign rib tumor. One had anterior arthrodesis after fracture-dislocation of the thoracic spine and another had anterior fusion for vertebral osteomyelitis. The average operative time for the thoracoscopic anterior release with discectomy and arthrodesis was 253 minutes. The average number of discs excised was 8. Final postoperative scoliosis and kyphosis corrections were 68% and 90%, respectively. Complications related to thoracoscopy occurred in eight patients. Video-assisted thoracoscopic surgery provides a safe and effective alternative to open thoracotomy in the treatment of thoracic pediatric spinal deformities.     

Surgical treatment of a long thoracic nerve palsy

A 17-year-old patient presented with a long thoracic nerve palsy following an idiopathic onset of weakness to the serratus anterior muscle. With no evidence of recovery 3.5 months following onset of serratus anterior weakness, the patient underwent a thoracodorsal to long thoracic nerve transfer to reinnervate the serratus anterior muscle. Follow-up examination 6.5 years following the nerve transfer revealed no scapular winging, full range of motion of the shoulder and no reported functional shoulder restriction. We conclude that a thoracodorsal to long thoracic nerve transfer results in good functional recovery of the serratus anterior muscle.     

Pulmonary function in adolescent idiopathic scoliosis relative to the surgical procedure

BACKGROUND: The long-term pulmonary function of patients with adolescent idiopathic scoliosis undergoing surgical correction is uncertain. To our knowledge, no report has demonstrated the changes in pulmonary function five years or more following spinal arthrodesis with use of modern segmental spinal instrumentation techniques for the treatment of all types of adolescent idiopathic scoliosis in a similar adolescent population. METHODS: One hundred and eighteen patients with adolescent idiopathic scoliosis undergoing surgical treatment at a single institution were evaluated with pulmonary function tests to assess the absolute and percent-predicted value of forced vital capacity and forced expiratory volume in one second at the preoperative examination and at regular intervals postoperatively. The patients were divided into four groups depending upon the surgical procedure: Group 1 comprised forty-nine patients who had posterior spinal arthrodesis with iliac crest bone graft; Group 2, forty-one patients who had posterior spinal arthrodesis with thoracoplasty; Group 3, sixteen patients who had open anterior spinal arthrodesis with a rib resection thoracotomy; and Group 4, twelve patients who had combined anterior and posterior spinal arthrodesis with a rib resection thoracotomy and iliac crest bone graft, respectively. RESULTS: A comparison of absolute pulmonary function values from the preoperative and final follow-up evaluations demonstrated a significant (p < 0.0001) increase in both the forced vital capacity and the forced expiratory volume in one second for Group 1, whereas no change was seen in those values for Groups 2, 3, and 4. A comparison of the changes in the percent-predicted pulmonary function values demonstrated significant (p < 0.05) decreases in forced vital capacity and forced expiratory volume in one second for Groups 2, 3, and 4, except for the latter value for Group 4, whereas Group 1 had no change. CONCLUSIONS: Patients who have had any type of chest cage disruption during the surgical treatment of adolescent idiopathic scoliosis demonstrate no change in the absolute value and a significant decline in the percent-predicted value of pulmonary functions at five years following surgery. Chest cage preservation is recommended to maximize both absolute and percent-predicted pulmonary function values after surgical treatment of adolescent idiopathic scoliosis.     

Contralateral trapezius transfer to treat scapular winging: A case report and review of literature

BACKGROUND No dynamic technique, such as tendon transfer, has been described for scapular winging due to levator scapulae or rhomboid major and minor palsies resulting from an isolated dorsal scapular nerve injury. Thus, we evaluated how the contralateral trapezius compound osteomuscular flap transfer would work in stabilizing lateral scapular winging, and the case is reported here. A literature review was also conducted, and articles relevant to the case are presented.CASE SUMMARY A 37-year-old male patient who had sustained an isolated dorsal scapular nerve injury underwent reconstructive surgery using the contralateral trapezius compound osteomuscular flap transfer technique to treat scapular winging and the consequent pain, and to restore function from the shoulder impairment. As a result, the involved shoulder showed an improved Constant-Murley score, from19.5% to 81.88%.CONCLUSION Contralateral trapezius osteomuscular flap transfer succeeded in stabilizing scapular winging in this case, improving shoulder function and affording pain relief.     

单纯后路经椎弓根截骨或脊椎切除的临床分析

目的探讨一期单纯后路经椎弓根脊柱截骨和脊椎切除操作的可行性和如何避免手术并发症的发生。方法回顾125例重度僵硬性脊柱畸形患者的临床资料,分析采用经椎弓根脊柱截骨技术或经椎弓根扩大蛋壳技术进行脊椎切除操作的可行性、手术时间、出血量、术中术后并发症。所有患者均采用经椎弓根内固定系统矫形固定。结果平均手术时间210min,术中失血平均1400ml。术中发生13例胸神经根损伤,术后无明显不适主诉。6例血气胸,经胸腔闭式引流治愈。6例硬膜撕裂,术后自然愈合。术后1例强直性脊柱炎患者腹部皮肤出现较大张力和水泡,经外敷硫酸镁2周治愈。1例术后发生伤口深部感染,经伤口清创冲洗,4周后治愈。1例发生截骨平面以下瘫痪,经脱水消炎治疗,4个月后完全恢复。并发症主要与初期手术操作有关,特别是椎体外侧壁和后壁截骨时,更易发生并发症。结论单纯后路经椎弓根脊柱截骨和脊椎切除操作简单,可行性好,明显缩短了手术时间,小心操作和掌握操作要点,能够避免手术并发症的发生。     

One-stage and posterior approach for correction of moderate to severe scoliosis in adolescents associated with Chiari I malformation: is a prior suboccipital decompression always necessary?

Priority of neurological decompression was regarded as necessary for scoliosis patients associated with Chiari I malformation in order to decrease the risk of spinal cord injury from scoliosis surgery. We report a retrospective series of scoliosis associated with Chiari I malformation in 13 adolescent patients and explore the effectiveness and safety of posterior scoliosis correction without suboccipital decompression. One-stage posterior approach total vertebral column resection was performed in seven patients with scoliosis or kyphosis curve >90° (average 100.1° scoliotic and 97.1° kyphotic curves) or presented with apparent neurological deficits, whereas the other six patients underwent posterior pedicle screw instrumentation for correction of spinal deformity alone (average 77.3° scoliotic and 44.0° kyphotic curves). The apex of the scoliosis curve was located at T7–T12. Mean operating time and intraoperative hemorrhage was 463 min and 5,190 ml in patients undergoing total vertebral column resection, with average correction rate of scoliosis and kyphosis being 63.3 and 71.1%, respectively. Mean operating time and intraoperative hemorrhage in patients undergoing instrumentation alone was 246 min and 1,450 ml, with the average correction rate of scoliosis and kyphosis being 60.8 and 53.4%, respectively. The mean follow-up duration was 32.2 months. No iatrogenic neurological deterioration had been encountered during the operation procedure and follow-up. After vertebral column resection, neurological dysfunctions such as relaxation of anal sphincter or hypermyotonia that occurred in three patients preoperatively improved gradually. In summary, suboccipital decompression prior to correction of spine deformity may not always be necessary for adolescent patients with scoliosis associated with Chiari I malformation. Particularly in patients with a severe and rigid curve or with significant neurological deficits, posterior approach total vertebral column resection is likely a good option, which could not only result in satisfactory correction of deformity, but also decrease the risk of neurological injury secondary to surgical intervention by shortening spine and reducing the tension of spinal cord.     

Unusual presentation of osteoblastoma in a patient with idiopathic scoliosis after posterior spinal fusion

BACKGROUND CONTEXT: Few studies have described the diagnosis of osteoblastoma of the spine as a cause of scoliosis. These reports have described the tumor in conjunction with initial presentation of painful scoliosis. This case report presents a case of osteoblastoma 9 years removed from diagnosis and fusion of idiopathic scoliosis in the thoracic spine. PURPOSE: To report the late presentation of an osteoblastoma of the thoracic spine 9 years after posterior spinal fusion for scoliosis. STUDY DESIGN: Case report. METHODS: A 25-year-old man presented with thoracolumbar back pain and progressive neurological deficit 9 years after posterior spinal fusion for idiopathic scoliosis. Magnetic resonance imaging of the thoracic spine indicated the presence of a mass in the spinal canal causing cord compression. The patient underwent decompression with resection of the mass which was found to be an aggressive osteoblastoma. RESULTS: The patient enjoyed a full neurological recovery and has subsequently developed a recurrence at 13 months. CONCLUSIONS: We present osteoblastoma as a possible cause of low back pain and neurological deficit postfusion that should be considered in a differential diagnosis.     

Ogilvie's syndrome following posterior spinal arthrodesis for scoliosis

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.     

Cortical somatosensory-evoked potentials during spine surgery in patients with neuromuscular and idiopathic scoliosis under propofol-remifentanil anaesthesia

BACKGROUND: Intraoperative monitoring of the spinal cord via cortical somatosensory-evokedpotentials (SSEP) is a routine during spinal surgery. However,especially in neuromuscular scoliosis, the reliability of corticalSSEP has been questioned. Therefore, we compared the feasibilityof cortical SSEP in idiopathic and neuromuscular scoliosis usinganaesthetics known to have only minimal effect on SSEP recordings. METHODS: Total intravenous anaesthesia with propofol and remifentanilas continuous infusion was standardized for all the patients.Median and tibial nerve cortical SSEP were monitored in 54 patientswho underwent surgery for spinal deformity. Twenty-seven hadidiopathic scoliosis and 27 had neuromuscular scoliosis. Theportion of reproducible results and intraoperative changes werecompared between the groups. RESULTS: In both groups, cortical SSEP could be monitored with sufficientreliability. Only in two patients with idiopathic and four patientswith neuromuscular scoliosis no reproducible traces could beobtained. The amplitudes in patients with neuromuscular scoliosiswere lower than in those with idiopathic scoliosis, but notstatistically significant. There were no postoperative neurologicaldeficits. The number of false positive and true positive didnot differ between the groups. CONCLUSIONS: Assessment of cortical SSEP during spine surgery was equallyeffective and reliable in patients with neuromuscular scoliosisand in patients with idiopathic scoliosis, possibly as a resultof propofol–remifentanil anaesthesia.     

Pseudo-winging of the scapula caused by scapular osteochondroma: review of literature and case report

A 20-year-old male was evaluated for winging of the scapula and an enlarging axillary mass of 4 months’ duration. Imaging demonstrated a multiloculated cystic lesion that extended into the axilla and superiorly displaced the brachial plexus and axillary vessels surrounding an exostotic mass arising from the scapula. Surgery confirmed the mass to be a benign osteochondroma with a reactive bursa. The long thoracic nerve was intact and the serratus anterior muscle contracted normally with nerve stimulation. The scapular winging resolved completely following resection of the osteochondroma, and shoulder and arm function remained normal. A literature review of causes of pseudo-winging of the scapula was performed. Scapular osteochondroma is a rarely reported cause of scapula winging.     

Scoliosis correction maintenance in skeletally immature patients with idiopathic scoliosis. Is anterior fusion really necessary?

STUDY DESIGN: A retrospective evaluation of the occurrence of the crankshaft phenomenon in skeletally immature patients with idiopathic scoliosis. OBJECTIVE: To determine what factors, if any, contribute to a decreased occurrence of crankshaft phenomenon in patients treated with posterior surgery only. SUMMARY OF BACKGROUND DATA: Reports have described the progression of scoliotic deformity, termed the crankshaft phenomenon, in a region of solid posterior arthrodesis in skeletally immature patients. This has led some authors to advocate the use of concomitant anterior discectomy and fusion to prevent crankshaft. METHODS: From 1989 through 1994, 18 Risser 0 patients with thoracic or thoracolumbar idiopathic scoliosis underwent Isola (De Puy-Acromed, Raynham, MA) posterior instrumentation and fusion. They were assessed for evidence of the crankshaft phenomenon, identified by coronal plane deformity progression of 10 degrees or more, or a rib vertebra angle difference of 10 degrees or more. The average age of the patients was 12.5 years (range, 10.5-15.5 years), and the average follow-up period was 39 months (range, 24-68 months). RESULTS: Eleven patients (10 girls and 1 boy) had closed triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 21 degrees after surgery, and 22 degrees at follow-up assessment. No patients in this group met the criteria for crankshaft. Seven patients (6 girls and 1 boy) had open triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 18 degrees after surgery, and 20 degrees at follow-up evaluation. No patient had a 10 degrees or more increase in rib vertebra angle difference. One patient had more than a 10 degrees increase in her Cobb angle (11 degrees) from postoperative to latest follow-up assessment. Her instrumentation construct, performed in 1989, used sublaminar wires as the caudal anchors. Hooks and pedicle screws are now used. Two of the seven patients with open triradiate cartilage underwent surgery during or before their peak height velocity and displayed no evidence of crankshaft. No deaths, neurologic complications, or infections occurred in either group. CONCLUSIONS: These findings suggest that scoliotic deformity progression can be prevented in skeletally immature patients with idiopathic scoliosis as young as 10 years of age with the use of stiff segmental posterior instrumentation, without the necessity of concomitant anterior arthrodesis.     

The position of the aorta relative to the spine: a comparison of patients with and without idiopathic scoliosis

BACKGROUND: There is little information documenting the relationship of the aorta to the thoracic scoliotic spine. Recent studies have suggested that the ends of screws placed during an anterior spinal arthrodesis, and pedicle screws used for the treatment of right thoracic scoliosis, may be in proximity to the aorta. The purpose of this study was to analyze the anatomical relationship between the aorta and the spine in a comparison of patients with idiopathic right thoracic scoliosis and patients with a normal spine. METHODS: Thirty-six patients with adolescent idiopathic scoliosis with a right thoracic curve and forty-three with a normal straight spine were studied. Radiographs were analyzed to determine the Cobb angle, the apex of the curve, and the apical vertebral rotation for the patients with scoliosis. Axial magnetic resonance images from the fourth thoracic vertebra to the third lumbar vertebra at the midvertebral body level were used to measure the distance from the aorta to the closest point of the vertebral body cortex, the distance from the posterior edge of the aorta to the spinal canal, and the aorta-vertebral angle. RESULTS: No differences were found between the groups with respect to age or sex distribution. For the scoliosis and normal groups, boys had greater average vertebral body width and depth for all levels than did girls (p < 0.05). For the scoliosis group, the most common apical vertebra was the eighth thoracic vertebra, the average coronal curve measurement was 55.2 degrees, and the average apical rotation was 17.3 degrees. The average distance from the aortic wall to the vertebral body cortex at the apex of the curve was greater in the patients with scoliosis (4.0 mm) than at similar levels in the normal group (2.5 mm) (p < 0.05). The distance from the posterior aspect of the aorta to the anterior aspect of the spinal canal was less in the scoliosis group (11.1 mm) than in the normal group (19.2 mm) for the fifth to the twelfth thoracic level (p < 0.05). The aorta was positioned more laterally and posteriorly adjacent to the vertebral body at the fifth to the twelfth thoracic level in patients with scoliosis compared with that in normal patients as reflected in a smaller aorta-vertebral angle (p < 0.05). With an increasing coronal Cobb angle in the thoracic curve and apical vertebral rotation, the aorta was positioned more laterally and posteriorly (p < 0.05). CONCLUSION: In patients with right thoracic idiopathic scoliosis, the aorta is positioned more laterally and posteriorly relative to the vertebral body compared with that in patients without spinal deformity.     

Scapular winging: an update

Scapular winging is a rare disorder often caused by neuromuscular imbalance in the scapulothoracic stabilizer muscles. Lesions of the long thoracic nerve and spinal accessory nerves are the most common cause. Numerous underlying etiologies have been described. Patients report diffuse neck, shoulder girdle, and upper back pain, which may be debilitating, associated with abduction and overhead activities. Accurate diagnosis and detection depend on appreciation of the scapulothoracic anatomy and a comprehensive physical examination. Although most cases resolve nonsurgically, surgical treatment of scapular winging has been met with success.     

Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report

The use of nerve transfers (neurotization) in the reconstruction of nerve palsy is not new, but its clinical efficacy is still largely based on reports of successful restoration of elbow flexion and shoulder abduction following brachial plexus avulsion. Although its potential application extends beyond the brachial plexus, little has been written about additional indications or associated postoperative outcomes. The case described in this report illustrates yet another indication for which neurotization may be a useful technique. Medial pectoral nerve transfer to the long thoracic nerve was performed via an 11-cm sural nerve graft to treat scapular winging 4 months following nerve injury caused during axillary node dissection. Neurophysiologic and clinical outcome 18 months postoperatively revealed successful reinnervation of the serratus anterior muscle, decreased scapular winging, and symptomatic improvement from the patient's perspective.     

Multiple vertebral osteotomies in the treatment of rigid adult spine deformities

STUDY DESIGN: Retrospective review of the clinical and radiographic results in adult revision spine deformity surgery using the techniques of osteotomies to effect spine balance and curve correction. OBJECTIVES: To assess the efficacy of multiple vertebral osteotomies in correction of rigid spine deformities in adult patients undergoing revision surgery. METHOD: The records and radiographs of 27 adult patients with idiopathic scoliosis who underwent revision surgery requiring anterior release (discectomy and/or osteotomy) and posterior osteotomy to correct rigid spinal deformities were retrospectively reviewed. RESULTS: All 27 patients were available for follow-up evaluation. Fifteen patients had anterior discectomies followed by posterior osteotomies, whereas 12 had anterior and posterior osteotomies in staged or sequential (same day) fashion. Diagnosis was idiopathic scoliosis for the index operation. At revision, the primary deformity was flatback deformity in 10 patients and pseudarthrosis with progressive deformity in 17 patients. Eleven patients had predominant sagittal decompensation, 11 patients had multiplanar decompensation, and five patients were balanced. The average number of osteotomies performed anteriorly was 4.3 levels (range, 1-8) and the average number of osteotomies posteriorly was 4.6 levels (range, 1-10). There were a total of nine complications in eight patients including three pseudarthroses (11%), five hardware failures (19%), and one transient neurologic deficit (4%). There were no deep wound infections, deep vein thromboses, pulmonary emboli, or deaths. The average scoliosis correction was 40% (range, 5-81%), whereas the average sagittal balance was corrected 6.5 cm (range, -5-29.5 cm), on average, and coronal balance was corrected 2.5 cm (range, 1-6 cm), on average. CONCLUSION: This study demonstrates multiple vertebral osteotomies (anterior and/or posterior) in the management of rigid adult spine deformities and deformity correction with an acceptable complication rate. Use of vertebral osteotomies for patients undergoing revision spine surgery is a safe and reasonable approach to obtain an arthrodesis.     

Two-level motor nerve transfer for the treatment of long thoracic nerve palsy

The authors report a case of long thoracic nerve (LTN) palsy treated with two-level motor nerve transfers of a pectoral fascicle of the middle trunk, and a branch of the thoracodorsal nerve. This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function. A detailed account of the postoperative physical therapy regimen is included, as this critical component of the favorable result cannot be overlooked. This case establishes the two-level motor nerve transfer as a new option for treating LTN palsy, and demonstrates that nerve transfers should be considered in the therapeutic algorithm of an idiopathic mononeuritis.     

Simultaneous anterior-posterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities

BACKGROUND: Congenital kyphosis and acquired kyphoscoliotic deformities are uncommon but are potentially serious because of the risk of progressive deformity and possible paraplegia with growth. Our current approach for the treatment of these deformities is to use a single posterior incision and costotransversectomy to provide access for simultaneous anterior and posterior resection of a hemivertebra or spinal osteotomy, followed by anterior and/or posterior instrumentation and arthrodesis. To our knowledge, this approach has not been reported previously. METHODS: The medical records and radiographs for sixteen patients who had been managed at our institution for the treatment of congenital kyphosis and acquired kyphoscoliosis between 1988 and 2002 were analyzed. The mean age at the time of surgery was twelve years. The diagnosis was congenital kyphosis for fourteen patients and acquired kyphoscoliotic deformities following failed previous surgery for two. The mean preoperative kyphotic deformity was 65 degrees (range, 25 degrees to 160 degrees ), and the mean scoliotic deformity was 47 degrees (range, 7 degrees to 160 degrees ). Fifteen patients were managed with vertebral resection or osteotomy through a single posterior approach and costotransversectomy, anterior and posterior arthrodesis, and posterior segmental spinal instrumentation. The other patient was too small for spinal instrumentation at the time of vertebral resection. A simplified outcome score was created to evaluate the results. RESULTS: The mean duration of follow-up was 60.1 months. The mean correction of the major kyphotic deformity was 31 degrees (range, 0 degrees to 82 degrees ), and the mean correction of the major scoliotic deformity was 25 degrees (range, 0 degrees to 68 degrees ). Complications occurred in four patients; the complications included failure of posterior fixation requiring revision (one patient), lower extremity dysesthesias (one patient), and late progressive pelvic obliquity caudad to the fusion (two patients). The outcome, which was determined with use of a simplified outcomes score on the basis of patient satisfaction, was rated as satisfactory for thirteen patients, fair for two patients, and poor for one patient. CONCLUSIONS: A simultaneous anterior and posterior approach through a costotransversectomy is a challenging but safe, versatile, and effective approach for the treatment of complex kyphotic deformities of the thoracic spine, and it minimizes the risk of neurologic injury. LEVEL OF EVIDENCE: Therapeutic Level IV.