Scoliosis and severe pelvic obliquity in a patient with cerebral palsy: surgical treatment utilizing halo-femoral traction.

STUDY DESIGN: Case report of severe scoliosis and associated pelvic obliquity in a 14-year-old patient with cerebral palsy. OBJECTIVES: To report the presentation of the case, the operative considerations, and the management of this spinal deformity. SUMMARY OF BACKGROUND DATA: Spinal deformity in cerebral palsy may include scoliosis, kyphosis, and hyperlordosis. Pelvic obliquity is a frequent feature associated with neuromuscular scoliosis. The severity of the pelvic obliquity deformity presented here is unusual, and this case study delineates an effective surgical treatment plan for these patients using intraoperative halo-femoral traction. METHODS: A same-day, two-stage surgical reconstruction was performed to effectively correct this spinal deformity. The patient underwent an anterior spinal fusion from T10 to S1 and a posterior spinal fusion from T2 to the pelvis; the posterior procedure was performed with the patient in intraoperative halo-femoral traction. Sacral fixation was obtained using the Galveston technique bilaterally. RESULTS: The patient responded well to surgical intervention, had no complications, and continues to have stable correction of his pelvic obliquity deformity 2 years after surgery. CONCLUSION: It is concluded that scoliosis with associated severe pelvic obliquity deformities can be treated with anterior and posterior spinal fusion and instrumentation with intraoperative halo-femoral traction in the properly selected and prepared patient with cerebral palsy.     

Isolated thoracolumbar and lumbar hyperlordosis in a patient with cerebral palsy

A severe isolated thoracolumbar and lumbar hyperlordosis spinal deformity occurring in a patient with cerebral palsy is rare and has not been reported before. The authors describe the presentation, operative considerations, and treatment of patients with this unusual hyperlordotic spinal deformity, particularly those with cerebral palsy. A multiple-stage surgical reconstruction was required to correct this complex spinal deformity. The patient underwent bilateral femoral extension osteotomies along with spinal extensor myotomies to ensure proper prone positioning for his anticipated spinal surgery. Then he had staged anterior releases and spinal fusion from T8 to the sacrum followed by 2 weeks of "90-90" femoral skeletal traction. Finally, a posterior spinal fusion with instrumentation from T2 to the pelvis definitively corrected his deformity. The patient responded well to surgical intervention without complications and continues to have stable correction of his hyperlordosis deformity 2 years after surgery. Severe lordotic sagittal plane spinal deformities can be treated with anterior and posterior spinal fusion and instrumentation with intervening traction in the properly selected and prepared patient who has cerebral palsy.     

Postoperative complications in adult spinal deformity surgery: An overview of timing,risk factors,and management strategies

Adult spinal deformity (ASD) continues to increase in tandem with a globally aging population. Advances in technology and surgical techniques have significantly improved the efficacy of surgical treatment for ASD. The medical complexity of patients with ASD in combination with the intensive physiologic demands of deformity surgery accentuates the risk of postoperative complications in this patient population. Therefore, this review sequentially outlines postoperative complications in spinal deformity surgery by timing and prevalence, and describes risk factors and management strategies to improve outcomes in patients undergoing surgical treatment for ASD.     

Pain after adult deformity surgery

Adult spinal deformity is a broad spectrum of disorders that are becoming more prevalent with an ageing population. In those with moderate to severe deformity, surgical correction of spinal alignment is an increasingly common treatment and has demonstrated improvement in patients’ quality of life. Whilst continued research in risk stratification, advances in surgical techniques, and preoperative optimization has taken place, rates of adverse outcomes following surgery for adult spinal deformity are still frequent. Pain is a common complaint after spinal deformity correction; however, whether this pain is deemed a ‘normal’ amount, or a ‘pathological’ pain has not been well characterized in the literature. This paper aims to provide a framework for evaluating pain after spinal deformity correction surgery in order to guide clinical decision making.     

Surgical complications of spinal deformity surgery

Spinal column reconstruction for the management of spinal deformity is technically challenging and has been associated with high complication rates. The purpose of this article is to review the major complications associated with spinal deformity. Major complications include pseudarthrosis, proximal junction kyphosis, sagittal decompensation, deep wound infection, and neurovascular injury. The technology and instrumentation used to treat spinal deformity continue to develop, and the complication rates seem to be decreasing. Although only trends can be identified, complications are to be expected when performing this surgery. Awareness of the occurrence of complications can lead to better information and guidance of the surgeon's expectations as well as the patient's.     

Management of adult spine deformity in the elderly

Adult spinal deformity represents a growing problem in the elderly population (age 60 or older). A comprehensive examination, including imaging, is critical for guiding treatment. For most, non-operative management represents the initial treatment modality; however, few studies support its clinical utility. The decision to pursue surgery requires comprehensive preoperative evaluation, given the increased risk of surgical complications seen in elderly patients. Despite the increased risk of complications, patients treated surgically demonstrate significant improvement in clinical and radiographic parameters. This paper will review literature evaluating non-operative and operative management of adult spinal deformity in the elderly patient.     

Sagittal plane deformity: Evaluation and management

Sagittal alignment is a critical component of the evaluation and management of adult spinal deformities. Loss of sagittal alignment may be the result of iatrogenic-induced deformity, metabolic bone problems, progression of idiopathic or neuromuscular deformities, posttraumatic, or de novo. Goals of reconstruction involve restoration of global sagittal balance and lumbopelvic harmony. Treating the deformity often involves long construct fusion to the sacropelvis. Often times, multilevel osteotomies as well as circumferential approaches are needed to adequately address the deformity. Failure to address sagittal plane deformities has been linked to poor patient reported outcomes from surgical management. However, even with correction, postoperative complications are common. These included proximal and distal junctional failure, pseudoarthrosis, and the need for future surgery.     

Value of scoliosis care: Nonsurgical treatment versus surgery

Adult scoliosis is a complex issue, providing unique challenges to both the spine surgeon and the patient. Recently, there has been an interest in examining the quality of life of patients undergoing treatment for adult spinal deformity to compare the value of nonoperative versus operative management. This article reviews the current literature on the treatment of adult spinal deformity, in hopes of drawing conclusions for the best approach to these patients. Quality of life outcome measures and cost-effectiveness are reviewed to better understand the benefits, or lack thereof, of management options. It is crucial for spine surgeons to begin to use the same validated measures when studying this cohort of patients in order to compare treatments and draw appropriate conclusions. There is currently no literature reporting the quality-adjusted life years (QALY) or cost–utility of surgical treatment of adult scoliosis. Only one study analyzing the cost of nonoperative treatment for adult scoliosis was identified. Future prospective studies focusing on the cost-effectiveness of adult scoliosis treatment with an emphasis on improving the quality of life of these patients are needed to confirm the current retrospective literature's assertion that surgery provides better quality of life than nonoperative treatment.     

Intraoperatives Neuromonitoring in der rekonstruktiven Halswirbelsäulenchirurgie

Correction of cervical deformity is associated with a considerable risk of neurological deterioration. The use of intraoperative neuromonitoring (IOM) can, however, significantly increase patient safety. Nonetheless, data on the effectiveness of IOM during reconstructive cervical surgery are very limited. Since the surgical maneuvers in reconstructive cervical surgery represent the same dangers to the spinal cord as in scoliosis correction, the same influence of IOM on the clinical outcome may be assumed. IOM has been shown to decrease the rate of neurological complications in scoliosis surgery. Herein, we discuss the current evidence for the efficacy of IOM during reconstructive cervical surgery as well as during scoliosis surgery.     

The value of preoperative medical assessment for adult spinal deformity surgery: Risk determination,quality, and cost considerations

Adult spinal deformity (ASD) is common and has a significant impact on health-related quality of life. Identification of risk factors for perioperative complications in ASD surgery is a priority for ensuring cost-effectiveness. Preoperative optimization of significant patient risk factors can benefit patient outcome. Establishing benchmarks for expected complications based upon known risk factors is an important goal for future studies on quality of care.     

Double L-rod instrumentation in the treatment of severe kyphosis secondary to Scheuermann's disease

Patients with untreated kyphosis secondary to Scheuermann's disease occasionally develop significant deformities associated with pain in adult life. When these painful deformities do not respond to conservative measures, surgery may be indicated. This report describes a two-stage surgical technique for correction of the deformity. First, an anterior spinal release and fusion is performed and is followed 7-10 days later by a posterior spinal fusion with double L-rod instrumentation. L-rod instrumentation has the advantage that no postoperative immobilization is necessary, which allows the patient to return to a relatively normal life-style in the immediate postoperative period. Excellent maintenance of correction of the deformity in these patients has occurred with no serious complication to date in 24 patients followed from 19 months to 4 years although "transient hyperesthesia" occurred in 16% of patients. A longer follow-up will be necessary to evaluate fully possible late pseudarthrosis and instrumentation failure in this group of patients.     

Minimally invasive spine surgery for the treatment of adult degenerative deformity

The treatment of adult spinal deformity using minimally invasive surgery aims to decrease the morbidity associated with open correction in this traditionally elderly patient population. These techniques are continually evolving and allow decompression, fusion, and instrumentation to be performed with minimal soft tissue disruption, low rates of infection, and reliable surgical correction. Each approach and procedure has its own technical challenges and specific risks. We will provide an overview of multiple minimally invasive approaches for the treatment of adult spinal deformity correction.     

Surgical correction of spinal deformity in patients with congenital muscular dystrophy

Background  

Congenital muscular dystrophy (CMD), among the myopathic disorders is one form of flaccid neuromuscular disorder (NMD). Patients with NMD frequently develop progressive spinal deformity. For NMD patients who have a severe spinal deformity, sitting is often difficult and is accompanied by pain and breakdown of the skin. Spinal deformity surgery in these patients has been highly effective in stabilizing the spine, maintaining upright, comfortable sitting balance, and improving patients’ quality of life. However, many studies have reported significant rates of peri/postoperative complications in these patients. To our knowledge, there has been no study on the results of spinal deformity surgery in patients with CMD. The purpose of this study was to review the clinical and radiological results of spinal deformity surgery in this group of patients with CMD.     

Kyphoscoliosis in Wiedemann-Rautenstrauch-syndrome (neonatal progeroid syndrome)

AIM: The Wiedemann-Rautenstrauch syndrome (neonatal progeroid syndrome, WR syndrome) is a rare autosomal recessive disorder including premature aging already at birth. Most of the patients show an aged face, a craniofacial dysmorphism, decreased subcutaneous fat tissue, a significant developmental delay, and have a short life expectation. We present the second patient described in literature reaching an age of 16 years. Furthermore this patient developed a progressive scoliosis during childhood which to our knowledge has not been reported before among individuals affected by Wiedemann-Rautenstrauch syndrome. The pathogenetic features of the spinal deformity are discussed and the operative management is described. METHOD: The patient underwent a three-stage correction of her spinal deformity (anterior thoracic and lumbar release and posterior release, correction of the deformity with instrumentation and fusion) supported by Halo traction and physiotherapy. RESULTS: At the latest follow-up 12 months postoperatively the patient showed a stable correction from 78 degrees to 38 degrees in the frontal plane with physiologic sagittal alignment both clinically and radiologically. CONCLUSION: The scoliosis of our patient with Wiedemann-Rautenstrauch syndrome showed radiologically and clinically the characteristics of a neuromuscular curve. Since the curve showed a significant progression and high rigidity operative correction and fusion was indicated. We recommend a staged operative management to minimize the high risks of the operations and possible complications from cardiological and respiratory dysfunction associated with WR syndrome.     

Blastomycosis of the lumbar spine: case report and review of the literature, with emphasis on diagnostic laboratory tools and management

We report on the conservative and surgical management of a patient with blastomycosis of the lumbar spine, causing severe and crippling deformity. The diagnosis was made through biopsy. Curative removal, reconstruction and realignment of the spine were achieved. Imaging modalities were highlighted, with a detailed discussion of the histology and conservative and surgical management. We emphasize the importance of early, aggressive treatment of blastomycosis to prevent deformity and disability, and to enable identification of the best management of a destructive lesion with deformity. This case demonstrates that empirical treatment should not be used in cases of unusual sinus and abscess locations. Specific diagnosis and early treatment are indicated to prevent dreadful complications and spinal deformity resulting from blastomycosis. Aggressive antifungal therapy can cure the disease but does not control complications related to deformity. The latter can only be addressed by surgical reconstruction. We review the literature of surgical treatment, focusing on abscess drainage, bone fusion and posterior instrumentation in the absence of addressing the deformity component. Received: 19 November 1997 Revised: 6 February 1998 Accepted: 16 April 1998     

Delayed-onset neurological deficit following correction of severe thoracic kyphotic deformity

There are many potential risks associated with spinal deformity correction procedures including transient and/or permanent neurological deficits. Typically, neurological deficits caused by the surgical correction of spinal kyphosis occur acutely during surgery or immediately after surgery. Delayed postoperative neurological deficits are extremely rare. The authors report a case of delayed neurological deficit that occurred 48 hours after surgical correction of thoracic hyperkyphosis. An 18-year-old man with myotonic dystrophy presented with a 110 degrees T7-L1 kyphosis. The patient underwent an uneventful two-stage correction procedure of the hyperkyphotic deformity. First, anterior discectomies and fusion were performed from T-7 to L-1 using rib autograft, and all segmental vessels were preserved. Subsequently, on the same day, the patient underwent posterior Smith-Petersen osteotomies and T7-L2 pedicle screw fixation. Intact somatosensory and motor evoked potentials were maintained throughout both operations. Postoperatively, he remained neurologically intact without sequelae for nearly 48 hours. On postoperative Day 2, the patient developed delayed monoplegia of the left leg and sensory level loss below T-10. Medical management enabled complete reversal of the patient's monoplegia and sensory loss. At 2-year follow-up, the patient had no adverse neurological sequelae. In this case, a delayed postoperative neurological deficit occurred following spinal hyperkyphosis correction. The authors discuss the possible etiological mechanisms behind this complication and suggest strategies for its management.     

Behandlungsmöglichkeiten bei thorakalen und lumbalen osteoporotischen Problemfrakturen

Most osteoporotic sintering fractures are treated conservatively. However, persistent pain and consecutive spinal deformity may require certain cement-augmenting interventions. These procedures have proven their intermediate-term efficacy in pain reduction, prevention of progressive sintering and improvement of the overall quality of life in the majority of patients. In fractures with relevant spinal stenosis, persisting instability, gross deformity and trauma-associated osteoporotic fractures with or without neurological deficits, the therapeutic options may call for more extensive surgical procedures. In this regard, poor bone quality, age and respective comorbidities of the individual patient must be considered during preoperative planning and management. This article provides an overview of the diverse problem-solving strategies discussed in today's literature. It is generally acknowledged that any decision to perform surgery on an osteoporotic fracture is strongly case-dependent. Treating physicians must therefore master the complete therapeutic spectrum in order to meet this complex orthopedic challenge appropriately.     

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage.Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival.As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.     

Outcomes and cost-effectiveness of adult spinal deformity surgery

Adult spinal deformity is a debilitating disease affecting multiple aspects of patients’ lives including mental and physical well-being and functional ability. Advances in our understanding of the deformities and operative techniques have led to large improvements in patient reported outcomes, even with the associated high rate of complications. As we transition into the era of value-based care, the relatively high cost of deformity surgery has come under increasing scrutiny. Additional investigation of the costs of deformity surgery are required in order to employ effective cost-control measures while continuing to provide high-level care.     

Treatment of Spinal Tuberculosis by Debridement,Interbody Fusion and Internal Fixation via Posterior Approach Only

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three‐column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68‐year‐old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting, and internal fixation can be completed with only one incision and surgical position, and the deformity correction efficiency is higher than anterior surgery.