Current methods of measuring vertebral rotation by plain radiographs rely on anatomic landmarks that are not present in the postoperative spine or require advanced imaging. Furthermore, there are few studies on the incidence of crankshaft with modern pedicle instrumentation.
Questions/Purposes
We sought to (1) describe and validate a method of vertebral rotation measurement using plain radiographs and (2) measure postoperative rotation in a series of patients treated for adolescent idiopathic scoliosis.
Methods
Patients with adolescent idiopathic scoliosis treated with surgery over a 6-year period were reviewed. Patients with computed tomography (CT) scans and radiographs within 60 days of another were included. Vertebral rotation was calculated by radiographic measurements and measured directly by CT scan. As an internal control, patients with two apical pedicle screws on all radiographs were analyzed. Rotation was measured for all patients with at least 1 year of radiographic follow-up.
Results
Three thousand five hundred fifty-two instrumented spinal levels in 308 consecutive patients were reviewed. Ten patients with 93 screws were analyzed by CT and radiographs. The average discrepancy between computed tomography (CT) and radiographs was 3.3?±?1.9°, with 81.7% (76/93) within 5°. Intra- and inter-rater reliabilities for measured axial rotation were excellent (intra-class correlation coefficient (ICC)?=?0.879 and 0.900, respectively). One hundred swventy-eight patients were eligible with an average follow-up of 2.3?±?1.2 years; 84.8% (151/178) had screw(s) visible on all images at the major curve apex. The average postsurgical rotation was 3.5?±?2.9°; 19.2% (29/151) were measured to have a rotation over 5°, and 4.0% (6/151) demonstrated a rotation over 10°. Only 4.6% (7/151) of patients demonstrated a postoperative Cobb angle change over 10°.
Conclusions
Most major curves have apical pedicle screw instrumentation that can be followed by radiographs alone to measure rotation. Vertebral rotation measurement requires only plain radiographs and is a more sensitive determination for subtle postoperative crankshaft than change in Cobb angle.
To evaluate the radiological and clinical outcomes of the corrective surgery for patients with moderate to severe focal kyphosis in thoracolumbar spine.
Methods
Fifty-seven patients with moderate to severe focal kyphosis of the thoracolumbar spine underwent apical segmental resection osteotomy with dual axial rotation correction at our hospital. There were 30 male and 27 female patients. The mean age was 34.3 years. The kyphosis level radiographs were obtained from each patient before surgery, immediately after surgery and at follow-up. Local kyphosis and scoliosis Cobb angles were measured. Full-spine standing radiographs were obtained before surgery and at follow-up, and the spine sagittal and coronal balance were evaluated. The height of patients, the Frankel grading system for neurological functions, the Oswestry disability index for life quality, the visual analogue score for back pain and the patient satisfactory index for satisfaction to surgery were applied before surgery and at follow-up. The radiological and clinical outcomes were further analyzed in different sub-groups of patients according to etiology, severity of kyphosis, age, level of kyphosis apex, Frankel grade before surgery, and complications.
Results
The average follow-up time of patients was 46.1 months. The average kyphosis angle reduced from 94.6° before surgery to 31.0° immediately after surgery, and remained at 34.4° at follow-up. The sagittal balance of the spine, height of patients, Frankel grading, Oswestry disability index and visual analogue score were improved. The patient satisfactory index (PSI) showed a satisfied rate of 91.2%. The correction rate was significantly higher in patients with kyphosis angle less than 95° and age less than 35 years. The clinical improvement rate was significantly higher in patient with kyphosis apex at lower thoracic spine or thoracolumbar segment, Frankel grade E before surgery and no complication group. The incidence of intra-operative and early stage complications was 38.6%, and the incidence of instrumentation failure was 10.5%. The most severe complication was transient spinal cord injury, and the incidence was 7.0%. All complications got good relief after appropriate intervention.
Conclusions
Apical segmental resection osteotomy with dual axial rotation correction is an effective procedure to treat moderate to severe focal kyphosis, the prevention of serious neurological complications is fundamental to achieve the ideal clinical results.
Torsion has recently become essential in curve evaluation, not only to assess the degree of clinical deformity that can influence decision making, but also to predict curve progression. Since torsion cannot be currently measured using plain X-rays, our aim was to study the relationships between the different torsion-related parameters measured on 2D radiographs that can indirectly guide the clinician about the torsion of a given curve.
Methods
This is a cross-sectional study analyzing prospectively registered data of a consecutive cohort of 113 AIS patients with progressive main thoracic deformity. Demographic data, the Adams test and eight radiographic torsion-related coronal and sagittal deformity parameters [apical vertebral rotation (AVR)—Stokes method, Mehta angle (RVAD), main thoracic Cobb side-bending, T5–T12 kyphosis, T5–T8 kyphosis, T9–T12 kyphosis, kyphotic change and double rib contour sign (rib index)] were correlated between each other and with the main thoracic Cobb angle (MTCobb). Univariate linear regression and multiple linear stepwise regression analyses were performed as well.
Results
The radiographically measurable deformity parameters that best correlated with the MTCobb angle in idiopathic curves were: side-bending, RVAD, AVR and the Adams test. Sagittal variables were correlated the least with MTCobb. Coronal parameters as AVR, RVAD, side-bending and Adam test are highly intercorrelated. Sagittal variables are related between each other but are not directly related to coronal parameters.
Conclusions
There is a strong relationship between the Cobb angle, curve bending, the Mehta angle and the apical vertebral rotation. Together with the clinical Adams test, these are the most important radiographic torsion-related parameters to measure when assessing scoliosis in 2D.
Utilizing 2D measurements, previous studies have found that in AIS, increased thoracic Cobb and decreased thoracic kyphosis contribute to pulmonary dysfunction. Recent technology has improved our ability to measure and understand the true 3D deformity in AIS. The purpose of this study was to evaluate which 3D radiographic measures predict pulmonary dysfunction.
Methods
One hundred and sixty-three surgically treated AIS patients with preoperative PFTs (FEV, FVC, TLC) and EOS® imaging were identified at a single center. Each spine was reconstructed in 3D to obtain the true coronal, sagittal, and apical rotational deformities. These were then correlated with the patient’s preoperative PFT measurements. Regression analysis was performed to determine the relative effect of each radiographic measure.
Results
There were 124 thoracic and 39 lumbar major curves. The range of preoperative thoracic and lumbar 3D coronal angle was 11–115° and 11–98°, respectively. The range of preoperative thoracic 3D kyphosis (T5–T12) and thoracic apical vertebral rotation was ?56 to 44° and 0–29°, respectively. Increasing thoracic 3D Cobb and thoracic vertebral rotation and decreasing thoracic 3D kyphosis most significantly correlated with decreasing pulmonary function, especially FEV. In patients with the largest degree of thoracic deformity (3D Coronal Cobb > 80°, 3D thoracic lordosis >20°, and absolute apical rotation >25°), the majority of patients had moderate to severe pulmonary impairment (≤65 % predicted). 3D thoracic kyphosis was the most consistent predictor of FEV (r2 = 0.087), FVC (r2 = 0.069), and TLC (r2 = 0.098) impairment.
Conclusions
Larger thoracic coronal, sagittal, and axial deformities increase the risk of pulmonary impairment in patients with AIS. Of these, decreasing 3D thoracic kyphosis is the most consistent predictor. This information can guide surgeons in the decision making process for determining which surgical techniques to utilize and which component of the deformity to focus on.
To compare scoliosis progression in quadriplegic spastic cerebral palsy with and without intrathecal baclofen (ITB) pumps.
Methods
A retrospective matched cohort study was conducted. Patients with quadriplegic spastic cerebral palsy, GMFCS level 5, treated with ITB pumps with follow-up >1 year were matched to comparable cases by age and baseline Cobb angle without ITB pumps. Annual and peak coronal curve progression, pelvic obliquity progression and need for spinal fusion were compared.
Results
ITB group: 25 patients (9 female), mean age at pump insertion 9.4 and Risser 0.9. Initial Cobb angle 25.6° and pelvic tilt 3.2°. Follow-up 4.3 (1.0–7.8) years. Cobb angle at follow-up 76.1° and pelvic tilt 18.9°. Non-ITB group: 25 patients (14 female), mean age at baseline 9.2 and Risser 1.0. Initial Cobb angle 29.7° and pelvic tilt 7.1°. Follow-up 3.5 (1.0–7.5) years. Cobb angle at follow-up 69.1° and pelvic tilt 21.0°. The two groups were statistically similar for baseline age, Cobb angle and Risser grade. Mean curve progression was 13.6°/year for the ITB group vs 12.6°/year for the non-ITB group (p = 0.39). Peak curve progression was similar between the groups. Pelvic tilt progression was comparable; ITB group 4.5°/year vs non-ITB 4.6°/year (p = 0.97). During follow-up 5 patients in the ITB group and 9 in the non-ITB group required spinal fusion surgery for curve progression (p = 0.35).
Conclusions
Patients with quadriplegic spastic cerebral palsy with and without ITB pumps showed significant curve progression over time. ITB pumps do not appear to alter the natural history of curve progression in this population.
Primary ciliary dyskinesia (PCD) is a respiratory syndrome in which ‘random’ organ orientation can occur; with approximately 46% of patients developing situs inversus totalis at organogenesis. The aim of this study was to explore the relationship between organ anatomy and curve convexity by studying the prevalence and convexity of idiopathic scoliosis in PCD patients with and without situs inversus.
Methods
Chest radiographs of PCD patients were systematically screened for existence of significant lateral spinal deviation using the Cobb angle. Positive values represented right-sided convexity. Curve convexity and Cobb angles were compared between PCD patients with situs inversus and normal anatomy.
Results
A total of 198 PCD patients were screened. The prevalence of scoliosis (Cobb >10°) and significant spinal asymmetry (Cobb 5–10°) was 8 and 23%, respectively. Curve convexity and Cobb angle were significantly different within both groups between situs inversus patients and patients with normal anatomy (P ≤ 0.009). Moreover, curve convexity correlated significantly with organ orientation (P < 0.001; ? = 0.882): In 16 PCD patients with scoliosis (8 situs inversus and 8 normal anatomy), except for one case, matching of curve convexity and orientation of organ anatomy was observed: convexity of the curve was opposite to organ orientation.
Conclusions
This study supports our hypothesis on the correlation between organ anatomy and curve convexity in scoliosis: the convexity of the thoracic curve is predominantly to the right in PCD patients that were ‘randomized’ to normal organ anatomy and to the left in patients with situs inversus totalis.
Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.
Introduction
Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture.
Methods
We used data from the Fracture Intervention Trial among 3038 women 55–81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD.
Results
Mean baseline kyphosis was 48° (SD?=?12) (range 7–83). At baseline, 962 (32 %) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7° greater average kyphosis (95 % CI 2.8–4.6, p?<?0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10° greater kyphosis was associated with 22 % increase (95 % CI 8–38 %, p?=?0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8 % per 10° kyphosis (95 % CI ?4 to 22 %, p?=?0.18).
Conclusions
While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.
Flattening of rods is known to reduce the correction capability of the instrumentation, but has not been studied in 3D. The aim is to evaluate the rods shape 3D changes during and immediately after instrumentation, and its effect on 3D correction.
Methods
The 5.5 mm CoCr rods of 35 right thoracic adolescent idiopathic scoliosis patients were measured from rod tracings prior to insertion, and reconstructed in 3D from bi-planar radiographs taken intra-operatively after the correction maneuvers and 1 week post-operatively. The rod bending curvature, maximal deflection and orientation of the rod’s plane of maximum curvature (RPMC) were computed at each stage. The relation between rod contour, kyphosis and apical vertebral rotation (AVR) was assessed.
Results
Main thoracic Cobb angle was corrected from 58° ± 10° to 15° ± 8°. Prior to insertion, rods were more bent on the concave side (curvature/deflection: 39° ± 8°/25 ± 6 mm) than the convex side (26° ± 5°/17 ± 3 mm). Only the concave rod shape changed after the correction maneuvers execution (flattening of 21° ± 9°/13 ± 7 mm; p < 0.001) and stayed unchanged post-operatively. After instrumentation, the RPMC was deviated from the sagittal plane (concave side: 27° ± 19°/convex side: 15° ± 12°). There was a significant association between kyphosis change and the relative concave rod to spine contour (rod curvature—pre-operative kyphosis) (R2 = 0.58) and between AVR correction and initial differential concave/convex rods deflection (R2 = 0.28).
Conclusions
Correction maneuvers induce a significant change of the concave rod profile. Both rods end in a plane deviated from the sagittal plane which is representative of the spinal curvature 3D orientation. Differential rod contouring technique has a significant impact on the resulting thoracic kyphosis and transverse plane correction.
This retrospective study evaluated mid-to-long-term outcome of a minimally invasive percutaneous pelvic osteotomy (PPO) approach combined with varus derotational shortening osteotomy (VDRSO) and soft tissue release in children with severe CP.
Methods
A retrospective review was performed of all patients presenting with a diagnosis of CP with hip subluxation or dislocation treated surgically by simultaneous soft tissue release, VDRSO, and PPO between 2002 and 2015. Eligible patients included those with a diagnosis of spastic quadriplegia or CP GMFCS level IV or V with unilateral or bilateral hip subluxation or dislocation and surgical treatment of the deformity by simultaneous soft tissue release, VDRSO and PPO. All anterior–posterior (AP) radiographs of the pelvis were reviewed and Reimers migration percentage (MP) and acetabular angle (AA) were measured.
Results
In total, 54 children and adolescents (34 boys, 20 girls) with CP GMFCS level IV and V were treated during study period: 38 (70.4%) classified GMFCS level IV and 16 (29.6%) classified GMFCS level V. A total of 64 consecutive hips underwent simultaneous PPO associated with VDRSO. Overall, at the time of chart and radiograph review, mean age was 9.1 ± 3.3 years (range 4–16.5) and mean follow-up was 43.9 ± 19.5 months (range 3–72). Mean migration percentage improved from 66.8 ± 19.8% (range 33–100) preoperatively to 8.1 ± 16.5% (range 0–70) at last follow-up. Mean acetabular angle improved from 32.7° ± 7.1° (range 20–50) preoperatively to 14° ± 6.7° (range 0–27) at last follow-up. Only one case of bone graft dislodgment was observed. We did not observe any cases of avascular necrosis of the femoral head. All operated hips were pain free at the time of last follow-up.
Conclusion
PPO through a less invasive surgical approach offers a valuable alternative to standard techniques as it gives similar outcome but with less muscle stripping and less time in surgery.
Recent work has shown the safety and efficacy of halo-gravity traction as an operative adjunct. However, there are no reports specifically looking at halo-gravity traction in patients with skeletal dysplasia. Our purpose was to assess the safety and efficacy of traction in children with skeletal dysplasia who present with severe kyphoscoliosis.
Methods
We retrospectively reviewed eight consecutive children with skeletal dysplasia who were treated with halo-gravity traction preoperatively. Six of the patients had a thoracoscopic anterior release prior to the halo-gravity traction. All patients were ambulatory and presented with severe, rigid kyphoscoliosis.
Results
The mean duration of traction was 32 days. There were no neurologic complications with traction or after posterior spinal instrumentation. The majority of kyphoscoliosis correction was with the halo-gravity traction alone: major curve (MC) Cobb angle improved 41 %; C7–center sacral vertical line, 75 %; C7–MC apex, 21 %; and T2–T12 kyphosis, 35 %. Trunk height increased 37 % and thoracic height 44 %. An additional amount of correction was obtained with posterior spinal instrumentation (±fusion), decreasing MC Cobb angle an additional 23 %; C7–apex, 16 %; and T2–T12 kyphosis, 10 %. There was no additional correction of thoracic height. Two years after posterior spinal instrumentation (±fusion), a mild-to-moderate amount of correction was lost: MC Cobb angle decreased 23 %; compensatory Cobb angle, 28 %; C7–CSVL, 24 %; C7–S1, 22 %; regional kyphosis, 31 %; thoracic kyphosis, 29 %; and trunk height, 27 %.
Conclusions
Among children with skeletal dysplasia and severe kyphosis, halo-gravity traction is well tolerated and safe. Most of the corrections in radiographic parameters were achieved with traction alone. Traction improves coronal balance, apical translation, thoracic height, and kyphosis. In this specific population, the potential for neurologic injury during corrective surgery is high. However, preoperative halo-gravity traction provides slow, progressive correction in a safe manner and avoided neurologic injury in these patients. This study did not compare patients without halo-gravity traction to patients with halo-gravity traction, therefore it cannot be concluded that going straight to instrumentation without traction will give a poorer radiographic result.
Developing fusionless devices to treat pediatric scoliosis necessitates lengthy and expensive animal trials. The objective was to develop and validate a porcine spine numerical model as an alternative platform to assess fusionless devices.
Methods
A parametric finite element model (FEM) of an osseoligamentous porcine spine and rib cage, including the epiphyseal growth plates, was developed. A follower-type load replicated physiological and gravitational loads. Vertebral growth and its modulation were programmed based on the Hueter–Volkmann principle, stipulating growth reduction/promotion due to increased compressive/tensile stresses. Scoliosis induction via a posterior tether and 5-level rib tethering, was simulated over 10 weeks along with its subsequent correction via a contralateral anterior custom tether (20 weeks). Scoliosis induction was also simulated using two experimentally tested compression-based fusionless implants (hemi- and rigid staples) over 12- and 8-weeks growth, respectively. Resulting simulated Cobb and sagittal angles, apical vertebral wedging, and left/right height alterations were compared to reported studies.
Results
Simulated induced Cobb and vertebral wedging were 48.4° and 7.6° and corrected to 21° and 5.4°, respectively, with the contralateral anterior tether. Apical rotation (15.6°) was corrected to 7.4°. With the hemi- and rigid staples, Cobb angle was 11.2° and 11.8°, respectively, with 3.7° and 2.0° vertebral wedging. Sagittal plane was within the published range. Convex/concave-side vertebral height difference was 3.1 mm with the induction posterior tether and reduced to 2.3 with the contralateral anterior tether, with 1.4 and 0.8 for the hemi- and rigid staples.
Conclusions
The FEM represented growth-restraining effects and growth modulation with Cobb and vertebral wedging within 0.6° and 1.9° of experimental animal results, while it was within 5° for the two simulated staples. Ultimately, the model would serve as a time- and cost-effective tool to assess the biomechanics and long-term effect of compression-based fusionless devices prior to animal trials, assisting the transfer towards treating scoliosis in the growing spine.
Aim of this study was to investigate the effectiveness of a new surgical corrective manoeuvre for adolescent idiopathic scoliosis (AIS) by asymmetrically shaped and simultaneously applied rods and in combination with direct vertebral rotation, to control both the triplanar deformity and the kyphosis apex location.
Methods
We retrospectively reviewed 36 patients who undergo surgical treatment using simultaneous translation on two differently contoured rods, in combination with direct vertebral rotation. Patients were divided into three main groups according to the scoliotic curve type.
Results
The average follow-up was 1.8 years (range 1–3 years). Mean thoracic Cobb angle decreased from 64.6° to 17.0 (p?<?0.05). Mean lumbar Cobb angle decreased from 54.9 to 13°. T5–T12 kyphosis values improved from 16.2 to 22.8° (p?<?0.05). Apical vertebral rotation decreased from 25.3 to 9.7°. Mean total SRS-22 score values improved from 2.3 on pre-operative to 3.8 at the last available follow-up. Two major and two minor perioperative complications were recorded. Nor deformity progression or screw pull-out or non-union was recorded at the last available follow-up.
Conclusions
The corrective manoeuvre using two differently contoured rods simultaneously in combination with direct vertebral rotation can provide a good triplanar deformity correction and improve patient’s quality of life and self-image perception in mild-to-moderate AIS. Moreover, the described technique allows the positioning of the desired kyphosis apex at a different level from the scoliosis apex. This procedure allows a better sagittal contour restoration while maintaining a comparable amount of correction on the frontal and axial plane of the already available techniques.
Graphical Abstract
These slides can be retrieved under Electronic Supplementary Material.
The purpose of this study was to compare Cobb angle measurements performed using an Oxford Cobbmeter and digital Cobbmeter in a series of 20 adolescent idiopathic scoliosis (AIS) patients.
Methods
Four observers measured major Cobb angles on 20 standing postero-anterior radiographs of AIS patients with both Oxford Cobbmeter and digital Cobbmeter (iPhone Cobbmeter Application). The measurements were repeated a week after the original measurements.
Results
The mean Cobb angle in this study was 43.6° ± 23.62°. The mean measurement time for an observer to measure the 20 Cobb angles was 24.9 min for the smart phone compared with 25.6 min for the Oxford Cobbmeter. The 95 % confidence interval for differences between smart phone and Oxford Cobbmeter measurements on the same radiograph was ±3.68°. The intra-observer variability of the smart phone is equivalent to the Oxford Cobbmeter. The 95 % confidence intervals for inter-observer error were ±5° and ±5.8° for the smart phone and Oxford Cobbmeter, respectively.
Conclusions
We conclude that the smart phone with integrated Tiltmeter and Cobbmeter application is an equivalent Cobb measurement tool to the Oxford Cobbmeter. The advantages of smart phone are the accuracy of determining the most inclined vertebrae and accordingly more precise Cobb angle measurement. The new smart phones with these integrated applications may be really helpful to the spine surgeons, especially in hospitals where PACS or Oxford Cobbmeter is not available.
Pectus excavatum can negatively impact cardiac function during scoliosis surgery. Several authors reported severe hypotension associated with the prone position during scoliosis surgery in children that had both scoliosis and pectus excavatum. However, we could find no studies that evaluated the change in the thoracic factors, such as sternal tilt angle and Haller index after scoliosis surgery in patients with both scoliosis and pectus excavatum. The purpose of this study is to evaluate the change in thoracic factors after surgical treatment for scoliosis associated with pectus excavatum.
Methods
We performed a retrospective review on 20 patients (10 males and 10 females) who underwent surgical treatment for scoliosis associated with pectus excavatum from August 2004 to April 2014 in our hospital. We investigated the scoliosis diagnosis, preoperative and postoperative Cobb and thoracic kyphosis (TK) angles, the change in TK after surgery and thoracic factors, including the AP and transverse diameters of the chest, the sternal tilt angle, and Haller index.
Results
Patient mean age was 13.2 years old (4–27 years old) at surgery. Types of scoliosis were idiopathic in 8 patients, syndromic in 10, and neuromuscular in 2. The mean Cobb angles were 72.1° preoperatively and 19.0° postoperatively. Curve locations were thoracic in 13 patients, thoracolumbar in 4, and lumbar in 3. Surgical treatment of pectus excavatum was performed in 9 patients (45 %) before scoliosis treatment. Mean sternal tilt angles were 11.5° preoperatively and 11.1° postoperatively. Mean Haller indices were 4.8 preoperatively and 5.3 postoperatively. This was especially true for syndromic or neuromuscular scoliosis and thoracolumbar/lumbar curve type patients in which scoliosis surgery tended to worsen the Haller index.
Conclusion
The Haller index increased postoperatively in 11 of 20 patients, which means sternal depression deteriorated after scoliosis surgery in about 50 % of patients. We suggest that surgeons fully assess the thoracic factors in patients with scoliosis and pectus excavatum prior to performing scoliosis surgery and carefully monitor their patient’s general condition during surgery.
The Gait Deviation Index (GDI) is a score derived from three-dimensional gait analysis (3DGA). The GDI provides a numerical value that expresses overall gait pathology (ranging from 0 to 100, where 100 indicates the absence of gait pathology). The aim of this study was to investigate the association between the GDI and different levels of gross motor function [defined as the Gross Motor Function Classification System (GMFCS)] and to explore if age, height, weight, gender and cerebral palsy (CP) subclass (bilateral and unilateral CP) exert any influence on the GDI in children with unilateral and bilateral spastic CP.
Methods
We calculated the GDI of 109 children [73 % boys, mean age 9.7 years (standard deviation, SD 3.5)] with spastic CP, classified at GMFCS levels I, II and III. Twenty-three normally developing children were used as controls [61 % boys, mean age 9.9 years (SD 2.6)]. Multiple linear regression analysis was performed.
Results
The mean GDI in the control group was 100 (SD 7.5). The mean GDI in the GMFCS level I group was 81 (SD 11), in the GMFCS level II group 71 (SD 11) and in the GMFCS level III group 60 (SD 9). Multiple linear regression analysis showed that gender, age and CP subclass had no significant correlation with the GDI, whereas height and weight had a slight impact.
Conclusion
This study showed a strong correlation between the GDI and GMFCS levels. The present data indicate that calculation of the GDI is a useful tool to characterise walking difficulties in children with spastic CP.
Severe rigid spine deformity with sharp curve can be effectively corrected by posterior vertebral column resection (PVCR). Meanwhile, high risk of this procedure also has been recognized generally. The aim of this study is to review and evaluate the role of preoperative skull-femoral traction prior to PVCR for extremely severe rigid spinal deformity with sharp angular curve >150°.
Methods
Twelve cases with extremely severe rigid deformities and sharp curves were treated by skull-femoral traction before operation. For them, the mean preoperative major scoliotic curve and kyphosis were 153° (110°–168°) and 109° (61°–180°). Continuous skull-femoral traction in supine position was started 4 weeks before operation. In the process of traction, tolerance, neurologic status, deformity changes, etc., were reviewed and documented for analysis. PVCR were performed in all these patients for final and main correction.
Results
The final traction force in the 12 cases was 63 % of body weight. After 4-week traction, the main scoliotic curve and kyphosis were decreased by 34 and 31 %. In 1 week, main scoliotic curve and kyphosis were decreased by 19 and 15 %. In 2 weeks, the major scoliosis curve was decreased by 11 %, but kyphosis was unexpectedly increased by 4 %. Deformity in the last 2 weeks was less significant than the first 2 weeks. After PVCR, the main scoliotic curve and kyphosis were improved 69 and 66 %. No permanent neurological damage occurred.
Conclusion
Preoperative skull-femoral traction effectively mitigates the neurological risks of PVCR for extremely severe rigid spinal deformity with sharp curve. During traction, scoliosis can be improved more significantly and easily than kyphosis.
To investigate incidence, risk factors, and complications of vertebral subluxation (VS) during three-column osteotomy in surgical correction of adult spine deformity.
Methods
Adult spine deformity patients who underwent three-column osteotomies including VCR, PSO, and other modified types from March 2000 to December 2014 in our center were retrospectively reviewed. The following parameters were measured pre- and postoperatively: Cobb angle of main curve, global kyphosis, sagittal vertical axis, and kyphosis flexibility. Radiographic parameters between groups (VCR vs. PSO and subluxation vs. non-subluxation) were compared.
Results
171 ASD patients were recruited, 18 of which (10.5%) developed sagittal vertebral subluxation at the osteotomy site. 5 of 18 patients (27.8%) developed neurological complications after surgery. For these five patients, two patients got partial recovery, and three got complete recovery at 2-year follow-up. 116 patients underwent PSO, 12 of which (10.3%) developed sagittal vertebral subluxation. In 55 patients receiving VCR, 6 (10.9%) developed sagittal vertebral subluxation. No significant difference was noted between the two groups (P > 0.05). The mean age of VS group was larger than that of non-VS group (46.2 vs. 34.2, P < 0.05). VS group had less kyphosis flexibility (11 vs. 23%, P < 0.05). More patients in VS group had preoperative sagittal VS as compared to non-VS group (77.8 vs. 20.9%, P < 0.05). VS group had more neurological complications than non-VS group (25 vs. 5.4%, P < 0.05).
Conclusion
VS occurred in one-tenth of patients receiving three-column osteotomies, one-fourth of which would develop neurological deficits. Older age, rigid kyphosis, and the pre-existence of VS were risk factors for developing VS.
The aim of this retrospective study is to evaluate the efficacy and safety of posterior-only vertebral column resection (PVCR) for the treatment of angular and isolated congenital kyphosis.
Methods
24 patients with isolated angular congenital kyphosis treated by PVCR in our hospital were retrospectively studied. The patients’ radiographs and hospital records were reviewed. Deformity in sagittal planes and global sagittal alignment were analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. The complications and related risk factors were analyzed.
Results
The average age was 13.9 (4–40) years. Three of them were revision surgeries. Two patients have intraspinal anomalies. The mean follow-up is 56.9 (26–129) months. The mean operation time was 293.1 (170–480) min. The averaged blood loss was 993.8 (250–3000) ml. The segmental kyphosis was 87.3° before surgery, 17.6° post surgery and 20.4° at the latest the follow-up. And the sagittal vertical axis was improved from 43.1 mm to 9.2 mm. Mean total score of SRS-22 was 89.3. Complications occurred in 4 patients, including 1 screw pullout due to pseudarthrosis, 1 proximal junctional kyphosis, 1 incomplete spinal cord injury and 1 root injuries.
Conclusion
Posterior-only vertebral column resection is an ideal procedure for severe rigid congenital kyphosis. However, it is still a highly technical demanding procedure. Neurological compromises still remain the biggest challenges. Sufficient height of anterior reconstruction, avoidance sacrifice of bilateral roots in the same level in the thoracic spine, avoidance of the sagittal translation of the upper and lower vertebras, intra-operative neuromonitoring, and preoperative surgical release of diastematomyelia and tethered cord may help to improve the safety.
The treatment of adult scoliosis is a challenge especially in patients over 50 years old with severe, rigid curves in whom the use of vertebral osteotomies may be necessary to correct the deformity. The aim the study was to analyse the perioperative complications related to vertebral osteotomies in elderly treated for spinal deformity.
Methods
We analysed 72 consecutive cases of kyphoscoliosis, we classify them according to Berjano–Lamartina classification. We divided patients into two groups: we only practised SPO and/or PO in patients that composed group A; we practised also PSO in patients that composed group B. We retrospectively analysed the perioperative complications and radiographical results. Average follow-up was 30 months.
Results
We had 50 cases of degenerative segment diseases (DSD) Type III, 13 Type IVa DSD and 9 Type IVb DSD. Mean age was 60.7 years old. Overall complication rate was 22.2 %. In group A, the complication rate was 16.9 % while in group B it was 46.2 %. Mean Cobb primary curve angle was 41.75° with average C7 plumb line (C7PL) of 4.49 cm, residual scoliosis after surgery was 15.41° and average C7PL of 2.08 cm, with statistically significant differences.
Conclusions
Previous studies have shown increased complication rates with vertebral osteotomies in elderly patients, our experience support this evidence. Our study demonstrates a high incidence of intraoperative complication rate in elderly patients underwent a PSO. PSO is a demanding technique to be considered in very selected and motivated patients who must be carefully informed about the risks of the procedure.
