Body casts have a long history in the treatment of spinal deformity. Currently the use of body casts is limited to early onset scoliosis. Here, we aim to provide a brief narrative of the evolution of cast application for the management of spinal deformity.
Methods
A history of cast application is provided with a brief review of the orthopedic literature. The current indications for cast application and the authors’ preferred technique are described.
Results
Serial casting is an effective treatment method for early onset scoliosis. It may be definitive for most idiopathic curves or used to delay surgical intervention in more severe idiopathic, syndromic and even congenital curves.
Conclusions
Surgeons who treat children with early onset scoliosis should familiarize themselves with serial cast application techniques.
Surgical correction of severe and rigid cervical kyphosis with chin-on-chest deformity poses significant challenges to both the patient and surgeon once surgery is considered as the treatment of choice.
Objectives
This article presents the current concepts of corrective surgery for patients with severe and rigid cervical kyphosis.
Material and methods
Narrative review and report of clinical experience.
Results
The treatment of severe cervical kyphosis indicates a dedicated deformity assessment, the analysis of regional and global imbalance, the identification of spinal sagittal plane compensation mechanisms, detailed radiographic and clinical planning of corrective surgery, and the meticulous performance of surgical correction. Most recent large-scale studies serve as evidence for the benefit of surgical correction and outline the complications that need to be targeted during and after surgery.
Conclusion
Surgical correction of severe cervical kyphosis can be a pleasant and life-changing event for the disabled patient.
Degenerative scoliosis is a three-dimensional deformity that can present in some instances with fixed sagittal and coronal imbalance. Pedicle subtraction osteotomy (PSO) is an effective technique that allows correction with a posterior approach. When a combined coronal and sagittal imbalance is present, asymmetric PSOs could be an optimal choice to correct deformity on both planes.
Methods
The asymmetric wedge resected from the vertebral body has to be shorter in the side of coronal imbalance, while a higher side cut has to be performed in the site opposite to the coronal imbalance. This allows to restore both coronal and sagittal alignment after osteotomy closure. An adequate preoperative planning is mandatory to correctly assess the geometry of the wedge to obtain the necessary correction.
Conclusions
The few studies present in literature show good results in terms of correction, even if the difficulty of this technique is certain.
We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent.
Summary of background data
Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual.
Case report
A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped.
Discussion
Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction.
Conclusion
Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.
Evaluation and surgical management for adult spinal deformity (ASD) patients varies between health care providers. The purpose of this study is to identify appropriateness of specific approaches and management strategies for the treatment of ASD.
Methods
From January to July 2015, the AOSpine Knowledge Deformity Forum performed a modified Delphi survey where 53 experienced deformity surgeons from 24 countries, rated the appropriateness of management strategies for multiple ASD clinical scenarios. Four rounds were performed: three surveys and a face-to-face meeting. Consensus was achieved with ≥70% agreement.
Results
Appropriate surgical goals are improvement of function, pain, and neural symptoms. Appropriate preoperative patient evaluation includes recording information on history and comorbidities, and radiographic workup, including long standing films and MRI for all patients. Preoperative pulmonary and cardiac testing and DEXA scan is appropriate for at-risk patients. Intraoperatively, appropriate surgical strategies include long fusions with deformity correction for patients with large deformity and sagittal imbalance, and pelvic fixation for multilevel fusions with large curves, sagittal imbalance, and osteoporosis. Decompression alone is inappropriate in patients with large curves, sagittal imbalance, and progressive deformity. It is inappropriate to fuse to L5 in patients with symptomatic disk degeneration at L5–S1.
Conclusions
These results provide guidance for informed decision-making in the evaluation and management of ASD. Appropriate care for ASD, a very diverse spectrum of disease, must be responsive to patient preference and values, and considerations of the care provider, and the healthcare system. A monolithic approach to care should be avoided.
To identify pelvic rotation and/or distortion in able-bodied and untreated AIS girls with moderate and severe scoliosis and verify association of pelvic morphological changes with Cobb angle increase.
Methods
The 3D coordinates of nine anatomic bony landmarks were identified to estimate pelvic orientation using a Flock of Birds system. The distances between the first sacral vertebral body (S1) and each of the eight iliac spine landmarks in all three planes were calculated to identify pelvic distortion. Analysis of variance was used to assess pelvic orientation and determine pelvic distortion. Pearson coefficients of correlation were used to identify any relationships between Cobb angle and pelvic morphological parameters.
Results
Pelvic orientation was similar in able-bodied and scoliotic girls regardless of the severity of the spinal deformity. Significant differences were observed in pelvic morphology between AIS with severe untreated scoliosis and those with a moderate scoliosis for the right anterosuperior iliac spines (ASIS), the tip of the superior iliac crest (TSIC) and the widest tip of the iliac crest (WTIC) widths from S1. Statistically significant correlations were observed between the Cobb angles and the iliac crest distances measured from S1.
Conclusions
Differences in iliac spine geometries occurred in the transverse plane correlating to Cobb angles which suggest altered bone growth in AIS girls. Such findings could indicate right thoracic spinal deformity as a result of pelvic torsion.
Significant blood loss remains an important concern in terms of the performance of the posterior spinal fusion in adolescent idiopathic scoliosis. Several strategies have been reported to minimize blood loss during surgery. In order to address the need to minimize blood loss without sacrificing the quality of the fusion, in our hospital, we adopted a two-step surgical approach. This surgical approach consist of the exposure and instrumentation of the lumbar region prior to and followed by an extension of the surgical incision to the thoracic region for its subsequent instrumentation. The main purpose of this study was to compare a two-step surgical approach with the one-step (standard) approach.
Methods
This study was a review of all the data on consecutive posterior spinal fusion surgeries performed by a specific two-surgeon team during 2004–2013. Demographics, surgical variables, radiographic findings, and outcomes regarding blood loss, morbidity, and the duration of the procedure were evaluated.
Results
Eighty-five patients underwent the standard surgical exposure, and 41 patients underwent the two-step surgical technique. With the exception of BMI, neither group showed any statistically preoperative variable significant differences. None of the postoperative outcome variables were statistically significant between both surgical approaches.
Conclusions
No differences were detected in terms of using a two-step surgical approach versus the one-step standard surgical approach regarding perioperative blood loss, surgical time, or complications.
In this paper, the authors propose classifying the epiphenomenon of spinal deformity in two different categories: structural deformity, when the main driver of the observed deformity is a fixed and stiff alteration of the spinal segments, and compensatory deformity, which includes cases where the observed deformity is due to focal abnormalities. This last category comprises, but is not limited to, spinal stenosis, spondylolisthesis, disc herniation, infection or tumor, hip disease or neurological disease (such as Parkinson’s disease).
Method
Narrative review article.
Results
We analyzed the focal diseases of the spine that may cause a compensatory deformity inducing adaptation in the unaffected part of the spine.
Conclusion
The compensatory mechanisms involved in adaptive deformity represent an attempt to maintain a global alignment, to escape from pain or to control body posture.
Graphical abstract
These slides can be retrieved under Electronic Supplementary material.
To analyze the clinical and radiographic characteristics, treatment, and outcome of patients with elbow osteoblastoma.
Patients and methods
We present 13 patients (7 males and 6 females; mean age, 28 years) diagnosed and treated for an elbow osteoblastoma from 1975 to 2012. Mean follow-up was 29 months (range 12–60 months). Clinical presentation, imaging, surgical treatment, complications, range of elbow motion, and functional outcome were evaluated. The MSTS, DASH, and OXFORD scores were used.
Results
Main symptom was pain (all patients) accompanied by stiffness (8 patients) and swelling or tumefaction (7 patients), with a median duration of symptoms of 32 months (range 6–96 months). Distal humerus was affected in 10 patients, proximal ulna in 2 patients, and proximal radius in one patient. All patients underwent surgical therapy that consisted of curettage of the lesion (7 patients), curettage and bone allografting (3 patients), wide resection (2 patients; total distal humerus and resection of the radial head), and radiofrequency thermal ablation (1 patient). One patient experienced a recurrence after surgical treatment. The mean MSTS score after treatment was 87% (range 50–100%), which corresponds to excellent results.
Conclusions
Intralesional surgery is successful in tumor control in most patients with osteoblastoma of the elbow. Thermal ablation may be successful for smaller lesions. Most of the patients had a good-to-excellent functional outcome even if they had tumor-related elbow stiffness at diagnosis.
This study aimed to assess the amount of correction and risk of complications of posterior vertebral column resection (PVCR) in the treatment of spinal deformity.
Methods
A comprehensive research was conducted in MEDLINE, EMBASE and Cochrane Database of Systematic Reviews for published articles about PVCR in spinal deformity. Data from these included studies were pooled with the help of the Review Manager software from the Cochrane Collaboration and the R software. The amount of correction of PVCR was indicated with change of coronal and sagittal Cobb angle after operation. Risk of complications was demonstrated with prevalence.
Results
7 studies, a total of 390 patients, were included for analysis. The average operative time for PVCR was 430 min and the estimated blood loss was 2,639 ml. The mean amount of correction by PVCR was 64.1° in scoliosis and 58.9° in kyphosis, accounting a correction rate of 61.2 and 63.1 %, respectively. As to coronal and sagittal imbalance, data were limited. The overall prevalence of complications of PVCR was 32 % (95 % CI 12–54 %). The most common was neurologic complications, estimated to be 8 % (95 % CI 2–16 %). And risk of spinal cord injury was 2 % (95 % CI 0–3 %). The revision rate was 6 % (95 % CI 1–13 %). Incidence of infection was pooled to be 2 % (95 % CI 1–4 %). Complication rate related with implant was 2 % (95 % CI 0–6 %).
Conclusion
PVCR is a powerful surgical procedure for severe spinal deformity. However, it has the risk of excessive blood loss and major complications. Decision of PVCR should be prudent and the procedure should be performed by an experienced surgical team.
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.
Study design
Case report.
Objective
To report a clinical case with adjacent level infection after spinal fusion.
Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.
Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.
Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.
The global appearance of scoliosis in the horizontal plane is not really known. Therefore, the aims of this study were to analyze scoliosis in the horizontal plane using vertebral vectors in two patients classified with the same Lenke group, and to highlight the importance of the information obtained from these vertebral vector-based top-view images in clinical practice.
Methods
Two identical cases of scoliosis were selected, based on preoperative full-body standing anteroposterior and lateral radiographs obtained by the EOS? 2D/3D system. Three-dimensional (3D) surface reconstructions of the spinal curves were performed by using sterEOS? 3D software before and after surgery. In both patients, we also determined the vertebral vectors and horizontal plane coordinates for analyzing the curves mathematically before and after surgery.
Results
Despite the identical appearance of spinal curves in the frontal and sagittal planes, the horizontal views seemed to be significantly different. The vertebral vectors in the horizontal plane provided different types of parameters regarding scoliosis and the impact of surgical treatment: reducing lateral deviations, achieving harmony of the curves in the sagittal plane, and reducing rotations in the horizontal plane.
Conclusions
Vertebral vectors allow the evolution of scoliosis curve projections in the horizontal plane before and after surgical treatment, along with representation of the entire spine. The top view in the horizontal plane is essential to completely evaluate the scoliosis curves, because, despite the similar representations in the frontal and sagittal planes, the occurrence of scoliosis in the horizontal plane can be completely different.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Primary spinal osteosarcoma is quite rare, and the 5-year survival rate is very low. Because of its rarity, successful treatment experience with spinal osteosarcoma is limited. The purpose of this study is to report the effect of therapy of primary osteosarcoma of spine by carbon-ion radiotherapy (CIRT) and long-term follow.
Methods
A 70-year-old with primary spinal osteosarcoma who received CIRT underwent combined anterior artificial vertebral body replacement and posterior lumbar fusion (L1–L5) 3 years later.
Results
According to the surgical resection of tumoral lesion, pathological results showed that the intertrabecular space previously filled with tumor cells on the initial biopsy sample now contained necrotic tissue without tumor cells. This means that primary osteosarcoma of the spine was completely eliminated and achieved local control with CIRT, with a 7-year follow-up after the initial treatment.
Conclusions
Carbon ion beam treatment is an effective local treatment for patients with spinal osteosarcoma for whom surgical resection is not a feasible option, especially for elderly patients. However, more patients need to be evaluated over a longer term to assess the curative effect of CIRT.
Accurate implantation of pedicle screw in spinal deformity correction surgeries is always challenging. We have developed a method of pedicle screw placement in severe and rigid scoliosis with a multi-level 3D printing drill guide template.
Methods
From November 2011 to March 2015, ten patients (4 males and 6 females) with severe and rigid scoliosis (Cobb angle >70° and flexibility <30%)were included. Multi-level template was designed and manufactured according to the part (two or three levels) of the most severe deformity. The drill template was then placed on the corresponding vertebral surface. Then, pedicle screws were carefully inserted along the trajectories. The other screws were placed in free hand. After surgery, the positions of the pedicle screws were evaluated by CT scan and graded for validation.
Results
48 screws were implanted using templates, other 104 screws in free hand, and the accuracies were 93.8 and 78.8%, respectively, with significant difference. The deformity correction ratio was 67.1 and 41.2% in coronal and sagittal plane post-operatively, respectively. The average operation time was 234.0 ± 34.1 min, and average blood loss was 557 ± 67.4 ml.
Conclusions
With the application of multi-level template, the incidence of cortex perforation in severe and rigid scoliosis decreased and this technology is, therefore, potentially applicable in clinical practice.
ACL status varies in the arthritic knee during TKA.
Questions/Purposes
The purpose of this study was to examine clinical features and intraoperative findings associated with stages of ACL degeneration.
Methods
Coronal deformity, ROM, intra-articular degenerative patterns, and ligament releases were assessed for 1656 knees during TKA. Common patterns of deformity and severity of degenerative change were assessed as a function of the severity of ACL deficiency.
Results
Of the 1656 knees assessed, 27% had a normal ACL, 55% exhibited damage, and 18% exhibited complete absence of the ACL. Increased coronal deformity and lower preoperative ROM was associated with ACL deficiency. Increased chondral and meniscal damage and more extensive osteophyte formation were also found. More extensive ligament releases were required in ACL-deficient knees.
Conclusions
The status of the ACL is predictive of the need for increased surgical deformity correction. A better understanding of ACL status is an important consideration during in choosing TKA as opposed to unicompartmental arthroplasty. The status of the ACL should be considered in planning for implant choice in TKA.
Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity with increased risk of osteopenia of unknown etiology. This study examined the dynamic histomorphometry of AIS patients to gain insight into the underlying pathogenesis of bone metabolism changes in AIS.
Methods
Bone histomorphometry of the spinous process of the 12th thoracic vertebra was analyzed in 33 AIS patients and compared to age-matched normative data. Patients were classified into bone turnover subgroups, based on bone formation rate.
Results
Bone volume was subnormal in 67% of AIS patients, but normal in 33%. Bone turnover was high in 76% of the patients, normal in 9%, and low in 15%. Compared to those in the low-turnover group, the high-turnover group patients were taller and had higher TRAP5b values.
Conclusions
Bone histomorphometry indicated that bone fragility and abnormal bone turnover were common in AIS patients. These abnormalities might contribute to the poor bone status and etiology in AIS.
After sacrocolpopexy, intra-abdominal pelvic abscesses are often managed with intravenous antibiotics, excision of the mesh involved, and debridement of compromised tissue.
Methods and results
Three cases of successful management of pelvic abscesses after sacrocolpopexy using long-term antibiotics and percutaneous drainage of intra-abdominal abscesses without removing the mesh are presented.
Conclusions
In selected patients who have undergone sacrocolpopexy, with careful counseling, conservative management of pelvic abscesses with percutaneous drainage and long-term antibiotic treatment without the surgical excision of the mesh may play a role.
Postural deformities in the coronal plane were frequent and disabling complications of PD, which reduces the quality of life of patients. This study aimed to garner greater attention to the Parkinson disease (PD)-related postural trunk deviations in the coronal plane by exploring a method for diagnosis because of the lack of any uniform diagnostic criteria and epidemiological studies. It also aimed to provide correlation data in the Chinese PD patients.
Methods
In this cross-sectional study, 503 consecutive outpatients with PD were enrolled who underwent standardized clinical evaluation. The study recruited 83 PD patients diagnosed with Pisa syndrome (PS). Scoliosis and coronal imbalance were diagnosed accurately by radiographic data. The PD patients were compared based on the Cobb angle and coronal balance for several demographic and clinical variables.
Results
PD patients with PS had a prevalence of 16.5%. The prevalence of coronal imbalance and scoliosis was 10.34 and 7.75%, respectively. PD patients with PS were older and had a more severe disease, significantly longer disease duration and treatment duration, and reduced quality of life. The most important finding was that the different morphology of the spinal level had an effect on the severity of coronal balance or Cobb angle.
Conclusions
The present study indicated that the postural deformities in the coronal plane were related to the morphology of the spinal level, especially the position of the Cobb angle. To benefit the PD patients with PS, the full-length standing spine radiographs should be performed as early as possible.
