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.     

Luque-Galveston procedure for correction and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of 68 patients.

Sixty-eight patients with neuromuscular spine deformity were treated by posterior spine fusion with Luque-Galveston instrumentation between 1982 and 1986. The minimum follow-up was 4 years. Diagnoses included cerebral palsy in 34 patients and other neuromuscular diseases in another 34 patients. The average age was 14 years. Twenty patients also had anterior spine fusion without instrumentation. Preoperatively the average scoliosis was 73 degrees and this was corrected to 33 degrees at final follow-up. The subgroup having anterior discectomy and fusion had a more severe scoliosis and pelvic obliquity, but the percent of correction was similar to that of the group with posterior reconstruction only. Twenty-four patients who had an associated significant sagittal plane deformity were corrected to a physiologic curvature. A postoperative thoracolumbosacral orthosis was used in 27 patients, and a molded seating orthosis was used in 18. Although the rate of complications was high (62%), most of them were minor. Instrumentation problems occurred in 14 patients (21%), only 4 of them having broken rods. There were no broken wires. Pseudarthrosis occurred in seven patients (10%). Three patients had minor neurologic deficits, all transient. The "windshield-wiper" sign was defined as any radiolucency of 2 mm or greater. Twenty-six patients had this sign at follow-up, and this group had a higher percentage of complications, but the existence of this sign did not necessarily indicate a problem.     

Vertebral column resection and arthrodesis for complex spinal deformities.

Sixteen patients aged 13 to 55 with severe rigid spine deformities were treated by two-stage anterior and posterior vertebral column resection, fusion, and segmental spinal instrumentation. The purpose of the vertebral column resection was to eliminate pain, prevent progressive deformity, and obtain the maximum correction necessary to achieve spinal balance in the coronal and sagittal plane. The final scoliosis correction averaged 43%. Physiologic sagittal alignment was achieved in all patients. Complications occurred in seven patients (43%). It is our conclusion, based on this series, that the concept of decancellation, radical vertebral column resection, spinal shortening, and segmental instrumentation posteriorly can achieve a balanced correction and significant pain relief for the select patient who presents with severe rigid spine deformity not adequately treatable by more established techniques.     

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.     

Posterior Vertebral Column Resection for VATER/VACTERL Associated Spinal Deformity: A Case Report

The VATER/VACTERL association is a syndrome notable for congenital vertebral malformations, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, and renal or limb malformations. Vertebral malformations may include the entire spectrum of congenital spinal deformities, including kyphosis, as was seen in this case. A 14-year-old girl presented to our institution with severe rigid sagittal deformity in the thoracolumbar spine that had recurred following three prior spinal fusion surgeries: the first posterior only, the second anterior and posterior, and the third a posterior only proximal extension. These surgeries were performed to control progressive kyphosis from a complex failure of segmentation that resulted in a 66° kyphosis from T11 to L3 by the time she was 9 years old. Our evaluation revealed solid arthrodesis from the most recent procedures with resultant sagittal imbalance, and surgical options to restore balance included anterior and posterior revision spinal fusion with osteotomies, multiple posterior extension osteotomies with circumferential spine fusion, and posterior vertebral column resection with circumferential spine fusion. She was advised that multiple posterior extension osteotomies would likely be insufficient to restore sagittal balance in the setting of solid arthrodesis from anterior and posterior surgery, and that the posterior-only vertebral column resection would provide results equivalent to revision anterior and posterior surgery, without the morbidity of the anterior approach. She successfully underwent posterior vertebrectomy and circumferential spinal fusion with instrumentation and is doing well 2 years postoperatively. Severe rigid sagittal deformity can be effectively managed with a posterior-only surgical approach, vertebrectomy, and circumferential spinal fusion with instrumentation. An erratum to this article can be found at     

Cotrel-Dubousset instrumentation in neurofibromatosis spinal problems

Cotrel-Dubousset (CD) instrumentation has been employed in 12 patients with neurofibromatosis with spinal deformity (ten regular scoliosis, one dysplastic kyphoscoliosis, and one multilevel laminectomy). The follow-up period averaged 33 months. In regular scoliosis frontal correction averaged 69%, axial derotation averaged 33%, and sagittal normalcy was produced without immobilization and without pseudoarthrosis. Successful arthrodesis was obtained in a dysplastic patient after initial failure via anterior concave struts and posterior CD instrumentation with immobilization. Stabilization and fusion of one patient with multiple-level thoracic laminectomy was achieved without immobilization. CD instrumentation is effective in the surgical management of neurofibromatous spinal abnormalities.     

Posterior vertebrectomy in kyphosis, scoliosis and kyphoscoliosis due to hemivertebra

Vertebrectomy and instrumentation only via the posterior approach has been increasingly used in sagittal, frontal plane and combined deformities. The aim of this retrospective study is to evaluate the clinical and radiological results of hemivertebrectomy and instrumentation only via the posterior approach in congenital spinal deformities. Between 1998 and 2003, we performed hemivertebrectomy and interbody fusion using posterior instrumentation with titanium mesh cage via the posterior approach in 19 patients (three scoliosis, five kyphosis and 11 kyphoscoliosis). The age of the patients ranged from 2 to 22 years and they all underwent hemivertebrectomy (at thoracic level in six patients, at thoracolumbar level in eight patients and at lumbar level in five patients). A titanium mesh cage was used for anterior column support and interbody fusion in patients who had residual anterior gap preventing bone-to-bone contact. Correction and stabilization were achieved by posterior polyaxial pedicle screws. Follow-up was an average of 4.6 years (range: 2-7 years). We did not confront any loss of correction, pseudoarthrosis, and titanium mesh cage collapse or implant failure. Hemivertebrectomy and instrumentation via the posterior approach is a good one-stage surgical treatment option that can be used to avoid the surgical trauma and morbidity related to anterior surgery. It is a technically demanding surgical procedure, however, requiring extreme care and experience in spine surgery.     

Double-segment total vertebrectomy for the surgical treatment of congenital kyphoscoliosis: a case report

BACKGROUND CONTEXT: Congenital kyphosis or kyphoscoliosis is an uncommon deformity that usually is progressive without surgical intervention. In the lately diagnosed or neglected cases of congenital kyphoscoliosis, the patients may come with shoulder-trunk imbalance anomalies, severe deformity in coronal and sagittal plane, rib cage deformities, pelvic tilt, presence of intramedullary anomalies, neurological deficit, and difficulty in walking and cardiopulmonary problems. PURPOSE: To present a technical note related with double-segment total vertebrectomy for the surgical treatment of a patient who had neglected congenital kyphoscoliosis in lumbar spine. STUDY DESIGN: Case report. METHODS: A 19-year-old girl had submitted to our center with complaints of deformity and pain in her back. Her physical examination revealed scoliosis and gibbosity in lumbar region. Her neurological examination was normal. In the radiological examination, X-ray films showed 42 degrees lumbar scoliosis in frontal plane and 35 degrees kyphotic curvature in the sagittal plane. RESULTS: Three-staged (posterior-anterior-posterior) surgery in the same session (same anesthesia) was performed. CONCLUSION: Total or partial vertebrectomy on the apex of the deformity and the adjacent vertebral bodies along with anterior stabilization by means of a cylindrical cage combined in one operative procedure preceded by temporary posterior instrumentation and followed by posterior instrumentation and fusion may be preferred for the treatment of congenital kyphoscoliosis in neglected cases to provide spinal cord decompression.     

成人退行性脊柱侧凸的研究进展

概述成人退行性脊柱侧凸及其治疗的研究进展。文献资料来自1965—2004年，用“退行性”、“脊柱侧凸”和“治疗”这三个关键词在MEDLINE上搜索，然后查全文。成人退行性脊柱侧凸的治疗根据临床症状和脊柱畸形程度和范围分为保守治疗，单纯椎管减压术，椎管减压＋后路内固定融合术，椎管减压＋后路内固定术＋前后路融合术。脊柱畸形一般包括侧凸、生理前凸的丢失、椎体滑移和脊柱旋转。根据症状和畸形的严重程度来选择合适的治疗方法是至关重要的，全面评价脊柱冠状面和矢状面的畸形程度和了解神经受累情况一样重要，可以指导治疗。生理前凸的丢失、椎体滑移和脊柱旋转的纠正对下肢和腰背疼痛的缓解有很大帮助，然而侧凸的纠正是否有助于缓解下肢和腰背症状仍存争议。畸形中最重要的是生理前凸的丢失，应该尽可能的纠正以达到脊柱矢状面的平衡，从而缓解腰背症状。     

Treatment of symptomatic flatback after spinal fusion

Fifty-five patients who had loss of lumbar lordosis after spinal fusion and subsequently had corrective osteotomies were studied. When they were first seen, fifty-two patients (95 per cent) were unable to stand erect and forty-nine (89 per cent) had back pain. The previous use of distraction instrumentation with a hook placed at the level of the lower lumbar spine or the sacrum was the factor that was most frequently identified as leading to the development of the flatback syndrome. Sixty-six extension osteotomies were performed in these fifty-five patients. Nineteen patients (35 per cent) had an associated anterior spinal fusion. Thirty-three patients (60 per cent) had one or more complications, including pseudarthrosis, a dural tear, failure of hardware, neurapraxia, and urinary tract infection. The results of the operation were evaluated at follow-up by review of clinical records, radiographs, and questionnaires. At an average follow-up of six years (range, two to fourteen years), most patients felt that they had benefited from the corrective osteotomies. However, twenty-six patients (47 per cent) continued to lean forward and twenty patients (36 per cent) continued to have moderate or severe back pain. The failure to restore sagittal plane balance led to a higher rate of pseudarthrosis, which was associated with recurrent deformity. Anterior spinal fusion combined with posterior osteotomy resulted in greater maintenance of correction. The prevention of flatback syndrome is important, since its treatment is difficult. When a spinal fusion must be extended to the level of the lower lumbar spine or the sacrum, the use of distraction instrumentation should be avoided in order to prevent this deformity.     

Surgical treatment of congenital kyphosis

STUDY DESIGN: In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed. OBJECTIVE: To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child. SUMMARY OF BACKGROUND DATA: Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression. METHODS: Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression. RESULTS: In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications. CONCLUSIONS: After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.     

Selective posterior thoracic fusion by means of direct vertebral derotation in adolescent idiopathic scoliosis: effects on the sagittal alignment

The objectives of this retrospective study were to evaluate the effect of direct vertebral derotation on the sagittal alignment of the spine after selective posterior thoracic fusion for Lenke Type I adolescent idiopathic scoliosis (AIS). Preservation of the sagittal alignment has become critical in the management of spinal deformity. Better coronal and rotational corrections in posterior selective thoracic fusion for AIS have been reported with direct vertebral derotation as compared with the simple rod rotation technique. A greater lordogenic effect has been anticipated with direct vertebral derotation; however, data comparing those two techniques in terms of correction in the sagittal plane are still lacking. Standing full-spine PA and standard lateral serial X-rays of a total of 30 consecutive patients with adolescent idiopathic scoliosis treated between 2002 and 2008 at a single institution were evaluated. All the patients had Lenke Type I curves and underwent selective posterior thoracic fusion with pedicle screw instrumentation. Patients who were treated with additional osteotomies and concave or convex thoracoplasty or concomitant anterior releases were excluded. Minimum follow-up period was 24 months. Preoperative and postoperative coronal and sagittal spinal alignments in both the groups were compared. In 13 patients, the correction was achieved by means of a simple rod rotation (SRR). In 17 patients, the technique of direct vertebral derotation (DVD) was used. Scoliosis correction averaged 67 and 69%, respectively, and was similar in both groups (p > 0.05). Thoracic kyphosis and lumbar lordosis remained unchanged in the SRR group (p > 0.1). In the direct vertebral derotation group, a significant decrease of both thoracic kyphosis and lumbar lordosis of 8.1° and 11.8°, respectively, was observed (p < 0.0001). Global sagittal balance remained within normal limits in all the patients at the latest follow-up. Decrease in thoracic kyphosis and lumbar lordosis should be taken into account when using direct vertebral derotation for selective posterior thoracic fusion in AIS. In order to preserve sagittal alignment in these patients, ultra hard rods or maneuvers that pull posteriorly the concave side of the spine, thus avoiding the application of additional flattening forces should be considered.     

One-stage posterior hemivertebra resection and correction using segmental posterior instrumentation

STUDY DESIGN: A retrospective study of 12 patients with congenital kyphoscoliosis caused by a single hemivertebra who underwent one-stage posterior hemivertebra resection and correction by posterior segmental instrumentation. OBJECTIVES: To evaluate the surgical outcomes of 12 patients with hemivertebra treated by hemivertebra resection by single posterior approach and correction with segmental posterior instrumentation. SUMMARY OF BACKGROUND DATA: Congenital scoliosis caused by hemivertebra causes extremely severe curves in some patients. Posterior fusion or posterior and anterior hemi-epiphysiodesis is performed to prevent progression of the deformity. The results of these procedures have been variable and not promising, especially in an adolescent patient with fixed kyphoscoliotic deformity. Hemivertebra resection offers more certain results and better correction of the deformity. To date, hemivertebra resection is performed by anterior and posterior approaches either by one-stage or two-stage operation. Few reports have been published describing a procedure consisting of one-stage posterior hemivertebra resection and correction of the deformity by segmental posterior instrumentation. METHODS: A total of 12 patients with a single hemivertebra between the ages 8-24 years who underwent operative treatment were evaluated for a minimum of 2 years. All patients had a single nonincarcerated hemivertebra [T9 (1 patient), T10 (2), T11 (2), T12 (4), and L1 (3)]. After posterior hemivertebra resection, segmental posterior instrumentation was used for correction of the kyphoscoliotic deformity [CD (4 patients), Kaneda SR (2), and ISOLA (6)]. Radiographic evaluations were conducted on the preoperative, postoperative, and follow-up standing posteroanterior and lateral radiographs. RESULTS: All 12 patients had kyphoscoliotic deformity. Preoperative scoliosis averaging 49 degrees was corrected to 18 degrees (correction rate, 64%). Preoperative kyphosis of 40 degrees was corrected to 17 degrees of kyphosis. Trunk shift of 23 mm was improved to 3 mm. Correction loss was 2 degrees in the frontal plane and 3 degrees in the sagittal plane, and no patients showed more than 5 degrees of correction loss. No intraoperative complications were noted. Solid fusion was obtained in all patients, and no implant failure was verified at the final radiographic evaluations. CONCLUSIONS: This study indicated that correction of kyphoscoliosis caused by a single hemivertebra can be effectively conducted by one-stage posterior hemivertebra resection and correction using segmental posterior instrumentation. The operation was safe, and no associated adverse complications were noted. This procedure is best indicated for adolescent patients with a structural kyphoscoliotic deformity caused by a thoracic or thoracolumbar single hemivertebra.     

Long scoliosis fusion to the sacrum in adults with nonparalytic scoliosis. An improved method

The first 17 adults with nonparalytic scoliosis having long fusion to the sacrum treated with the Luque-Galveston technique were reviewed. There were 3 men and 14 women. Their average age at the time of surgery was 47 years and the mean follow-up period was 42 months. There were no neurologic complications and no patient developed significant loss of lumbar lordosis. Fusion occurred in 88% of patients. Two patients developed pseudarthrosis, neither of whom had anterior fusion at the level of pseudarthrosis. The best results occurred in patients who had two-stage procedures, with initial anterior lumbar fusion to the sacrum without instrumentation followed by posterior segmental instrumentation with the Galveston technique of fixation to the pelvis.     

Posterior instrumentation in scoliosis

Summary The aims of posterior fusion and instrumentation in scoliosis are to achieve and maintain correction of the deformity and balance the spine in three planes, whilst keeping the fusion as short as possible and protecting the spinal cord. Harrington developed the first generation of posterior instrumentation, which considered only frontal plane correction. Since that time there has been an evolution from biplanar correction, addressing the frontal plane and sagittal plane, to triplanar correction, also addressing spinal derotation, and, most recently, to segmental derotation of strategic vertebral bodies.     

Long-term three-dimensional changes of the spine after posterior spinal instrumentation and fusion in adolescent idiopathic scoliosis

This is a prospective study comparing the short- and long-term three-dimensional (3D) changes in shape, length and balance of the spine after spinal instrumentation and fusion in a group of adolescents with idiopathic scoliosis. The objective of the study was to evaluate the stability over time of the postoperative changes of the spine after instrumentation with multi rod, hook and screw instrumentation systems. Thirty adolescents (average age: 14.5 ± 1.6 years) undergoing surgery by a posterior approach had computerized 3D reconstructions of the spine done at an average of 3 days preoperatively (stage I), and 2 months (stage II) and 2,5 years (stage III) after surgery, using a digital multi-planar radiographic technique. Stages I, II and III were compared using various geometrical parameters of spinal length, curve severity, and orientation. Significant improvement of curve magnitude between stages I and II was documented in the frontal plane for thoracic and lumbar curves, as well as in the orientation of the plane of maximum deformity, which was significantly shifted towards the sagittal plane in thoracic curves. However, there was a significant loss of this correction between stages II and III. Slight changes were noted in apical vertebral rotation, in thoracic kyphosis and in lumbar lordosis. Spinal length and height were significantly increased at stage II, but at long-term follow-up spinal length continued to increase while spinal height remained similar. These results indicate that although a significant 3D correction can be obtained after posterior instrumentation and fusion, a significant loss of correction and an increase in spinal length occur in the years following surgery, suggesting that a crankshaft phenomenon may be an important factor altering the long-term 3D correction after posterior instrumentation of the spine for idiopathic scoliosis. Received: 3 March 1998 Revised: 22 August 1998 Accepted: 15 September 1998     

Surgical correction of dystrophic spinal curves in neurofibromatosis. A review of 56 patients

STUDY DESIGN: A presentation of the results from 56 patients with dystrophic spinal deformities caused by neurofibromatosis surgically managed from 1971 to 1992. OBJECTIVES: To focus on the need for combined anterior and posterior fusion in the presence of severe spinal dystrophic changes. SUMMARY OF BACKGROUND DATA: It has been stated that the most effective management for dystrophic curves is early and aggressive surgery. METHODS: The patients were divided into two groups: Type I scoliosis (kyphosis < 50 degrees) and Type II kyphoscoliosis (kyphosis > 50 degrees). Results were evaluated in relation to the type of surgery performed: single posterior instrumented fusion or preplanned combined anterior and posterior fusion. RESULTS: At a mean follow-up period of 15 years (range, 5-22 years), all patients appeared to be stabilized, after a total of 120 surgical interventions. In Group I, the posterior instrumented fusion failed in nine patients (47%), and in Group II it failed in seven patients (63%). The preplanned combined anterior and posterior fusion failed in two patients (33%) in Group I and in four patients (20%) in Group II. The failure incidence of the posterior instrumented fusion alone and of the planned anterior and posterior fusion was 53% (16 patients) and 23% (6 patients), respectively. CONCLUSIONS: The severe dystrophic curve with anterior vertebral scalloping always requires combined anterior and posterior stabilization, particularly in younger patients, even if the sagittal curves have not become pathologic by the time of presentation.     

Spine fusion in cerebral palsy with L-rod segmental spinal instrumentation. A comparison of single and two-stage combined approach with Zielke instrumentation

The benefits of achieving rigid internal fixation and eliminating the need for postoperative external orthotic support with L-rod spinal instrumentation made it desirable for use in the surgical treatment of neuromuscular scoliosis. From May 1981 to May 1985, 31 severely involved cerebral palsy patients with progressive spinal deformity underwent posterior fusion and L-rod instrumentation. All patients except one were nonambulatory. Surgical indications included prevention of curve progression, correction of pelvic obliquity, and achievement of balanced spinal alignment in order to improve sitting balance and tolerance without external spinal orthotic support. Ten patients (Group I), with an average age of 15.2 years, with double major or flexible paralytic C-curves or scoliosis measuring less than 70 degrees, underwent posterior fusion and L-rod instrumentation only. Twenty-one patients (Group II), with an average age of 22.1 years, with thoracolumbar, lumbar, or rigid paralytic C-curves or scoliosis measuring greater than 70 degrees, underwent initial anterior release, bone grafting, and Zielke instrumentation followed by second-stage L-rod instrumentation. In Group I, scoliosis averaged 57 degrees and postoperatively 27 degrees (53% correction). In Group II, scoliosis averaged 88 degrees and postoperatively 36 degrees (63% correction). Fifteen Group II patients had posterior fusion extend into the sacrum using the Galveston technique. Six Group II patients were not fused into the sacrum. Scoliosis and pelvic obliquity were corrected in both groups. Torso decompensation improved to 2.7 cm in the Galveston group, but increased to 5.6 cm at follow-up in the patients not fused into the sacrum.(ABSTRACT TRUNCATED AT 250 WORDS)     

Scoliosis in neurofibromatosis. The natural history with and without operation

We reviewed 47 patients with neurofibromatosis and dystrophic spinal deformities; 32 of these patients had been untreated for an average of 3.6 years and in them the natural history was studied. The commonest pattern of deformity at the time of presentation was a short angular thoracic scoliosis, but with progression the angle of kyphosis also increased. Deterioration during childhood was usual but its rate was variable. Severe dystrophic changes in the apical vertebrae and in particular anterior scalloping have a poor prognosis for deterioration. The dystrophic spinal deformity of neurofibromatosis requires early surgical stabilisation which should be by combined anterior and posterior fusion if there is an abnormal angle of kyphosis or severely dystrophic apical vertebrae. Some carefully selected patients can be treated by posterior fusion and instrumentation alone.     

Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours

This is a retrospective study of 76 children who had had malignant tumours treated with laminectomy or laminoplasty and/or radiation therapy affecting the spine. Spinal tumours in children are extremely rare. However, their treatment can result in progressive spinal deformity. Radiation therapy affecting the growing spine can lead to asymmetric vertebral growth, causing kyphosis and/or scoliosis. These spinal deformities pose one of the most challenging problems for the spine surgeon. The aim of this article is to describe late-onset post-laminectomy/post-radiation spinal deformities and to evaluate the results of their treatment. Seventy-six children, with a mean age of 4 years and 7 months (range, 2 months to 16 years), underwent surgical removal of malignant tumours, between 1961 and 1995. Sixty-seven of them developed post-laminectomy/post-radiation spinal deformity. Conservative treatment consisted of bracing and corrective plaster casts. In 46 cases the deformity was treated surgically. A distraction plaster cast was used as preoperative preparation in the more severe and rigid curves, with or without neurological impairment. Surgery consisted of combined anterior and posterior fusion in 39 cases and posterior fusion in seven cases. Posterior instrumentation was used in 38 cases. The mean follow-up period was 6 years and 7 months (range, 9 months to 20 years and 2 months). Nine children did not develop deformity following the primary tumour treatment. One of them underwent laminectomy with posterolateral fusion and eight had laminoplasty combined with external immobilisation. Forty-six children developed iatrogenic kyphosis and underwent surgical correction from a mean of 75° pre-correction to a mean of 32°. The mean scoliotic angle correction was 66° preoperatively to 34° postoperatively. At follow-up, the mean correction loss was 7° in the sagittal plane and 5° in the coronal plane. Preoperative distraction plaster cast treatment resulted in a correction of 39% in kyphosis and of 58% in scoliosis, and in a partial or complete recovery of neurological deficits in all but one patient. In severe and rigid curves that develop following treatment of paediatric spinal tumours, preoperative application of a distraction plaster cast can reduce deformity and facilitate surgical correction. Furthermore, in the case of pure bony compression of the spinal cord due to the apical vertebra of the deformity, treatment with the distraction plaster can result in recovery from the neurological impairment. The prevention of post-laminectomy/post-radiation spine deformities is emphasised. Rigid external immobilisation for a period of 4 months in the cervical spine and of 6 months in the thoracic spine is recommended after both laminoplasty and laminectomy with posterolateral fusion.The research was carried out at Saint Vincent de Paul Hospital, Department of Pediatric Orthopaedic Surgery, Paris