Adolescent idiopathic scoliosis correction by instrumented vertebral arthrodesis with autologous bone graft from local harvesting without bone substitute use: results with mean 3 year follow-up

Purpose

Bone substitutes’ advantage is enhancing arthrodesis biologic support without further autologous bone graft harvested from other skeleton sites, as from posterior iliac crests; however, in our experience, bone substitutes’ integration is often incomplete.

Methods

From 2012 to 2017, we operated 108 patients by posterior instrumented vertebral arthrodesis in adolescent idiopathic scoliosis (AIS) correction, mean main curve 80° Cobb, and mean age 12 years and 6 months, with all pedicle screws instrumentation in main curve/curves area and hooks at upper tip of implant; bone graft has been harvested only at vertebral level, without bone substitutes or autologous graft from other patient sites or allogenic bone graft. We matched this group with 98 patients previously operated in which we used calcium triphosphate.

Results

At 3 year mean follow-up, all patients in group treated with autologous bone graft only have complete and stable arthrodesis without loss of correction (mean curve 27° Cobb) or instrumentation failure. At 6 year mean follow-up in the group treated with autologous bone graft augmented by calcium triphosphate, 96 patients have stable arthrodesis without loss of correction (mean curve 24°), 1 case has implant break, and 1 case has 8° Cobb loss of correction.

Conclusion

Bone substitutes are a further cost in arthrodesis surgery and suboptimal integration leaves foreign bodies on vertebras. Our experience shows that all pedicle screw instrumentation and bracing after surgery obtain stable correction showing in time a solid arthrodesis with autologous bone only, harvested at local site, without bone substitutes or further bone graft.

Graphical abstract

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Cervical fixation in the pediatric patient: our experience

The surgical management of cervical instability in children is a challenging issue. Although the indications for internal fixation are similar to those for adults, accurate pre-surgery study and sharp surgical techniques are necessary because of the size of such patients’ anatomy, their peculiar tissue biology and the wide spectrum of diseases requiring cervical fusion. Our case study is made up of 31 patients, 15 male and 16 female, with an average age of 7 years and 6 months (2 years and 6 months to 18 years) who underwent cervical fusion for instability. Their physical condition presented various different pathologies ranging from congenital deformity, systemic skeletal disease, tumors, trauma, post-surgery instability. We performed occipito-cervical fusion in 11 cases, 5 of which involved stabilization at the cranium–vertebral junction. We used instrumentation in 13 cases (3 sublaminar wiring, 10 rigid adult instrumentation). We used rigid adult instrumentation in three patients under 10 years of age, treated by rod, occipital screws and sublaminar hook instrumentation in steel C0–C2 (9-year-old male, affected by os odontoideum in Down’s syndrome; male of 7 years and 10 months, affected by os odontoideum in Down’s syndrome; female of 4 years and 6 months with occipito-cervical stenosis and C0–C2 instability in Hurler’s syndrome). We operated on two patients under 3 years of age, using sublaminar wiring with bone precursors and allograft at level C0–C2 (one of these was a 30-month-old male with post-traumatic instability C0–C2, while the other was a 17-month-old male with C0–C2 instability in Larsen’s syndrome). The average follow-up age was 7 years and 1 month (between 1 and 18 years). Cervical fusion was assessed by X-ray examinations at 4th and 12th weeks and at 6th and 12th months after surgery. Where implants could allow, RMN examination was performed at 1st month after surgery. In the other cases, in which implants do not allow RMN to be performed, CT scan and standard X-rays were carried out, and new X-rays were performed every other year. We experienced two cases of sublaminar wiring rupture without impairment of bone fusion. No patient suffered major complications (infection and osteomyelitis, rigid instrumentation mobilization, incomplete fusion with instability, neurologic impairment, insufficient cervical spine range of movement to cope with everyday life activities, cervical pain). Even though most authors still indicate that rigid instrumentation should be performed in cases over 10 years of age and sublaminar wiring in cases over 3 years of age, our findings demonstrate that this age limit can be lowered. We have treated children under 10 years of age by rigid adult instrumentation and under 36 months of age by wiring. The anatomic size of the patient is the most important factor in determining the use of instrument arthrodesis to treat pediatric cervical spine instability. Although not easy, it is possible and preferable in many cases to adapt fixation to child cervical spine even in very young patients.     

Posterior approach lumbar and thoracolumbar hemivertebra resection in congenital scoliosis in children under 10 years of age: results with 3 years mean follow up

Introduction

The authors present 15 cases of congenital scoliosis with lumbar or thoracolumbar hemivertebra in children under 10 years of age (mean age at the time of surgery was 5.5 years). Patients were treated by posterior hemivertebra resection and pedicle screws two levels stabilization or three or more levels stabilization in the case of deformity above or under hemivertebra or for severe curve deformities.

Materials and methods

All operated patients had worsening curves; mean follow up was 40 months. The mean scoliosis curve value was 44° Cobb, and reduced to a mean 11° Cobb after surgery. The mean segmental kyphosis value was 19.7° Cobb, and reduced to a mean −1.8° Cobb after surgery. We did not consider total dorsal kyphosis value as all hemivertebras treated were at lumbar or thoracic lumbar level. No major complications emerged (infections, instrumentation mobilization or failure, neurological or vascular impairment) and only one pedicle fracture occurred.

Results

Our findings show that the hemivertebra resection with posterior approach instrumentation is an effective procedure, which has led to significant advances in congenital deformity control, which include excellent frontal and sagittal correction, excellent stability, short segment arthrodesis, low neurological impairment risk, and no necessity for further anterior surgery.

Conclusion

Surgery should be considered as soon as possible in order to avoid severe deformity and the use of long segment arthrodesis. The youngest patient we treated, with a completed dossier at the end the follow up was 24 months old at the time of surgery; the youngest patient treated by this procedure was 18 months old at the time of surgery.     

Aneurysmal bone cysts: treatment with direct percutaneous Ethibloc injection: long-term results

PURPOSE: To assess the efficacy and long-term results of Ethibloc treatment in aneurysmal bone cysts (ABC). METHODS: Thirteen patients with ABC were treated with direct percutaneous Ethibloc injection. Four patients had only one injection and the other nine patients from two to four injections. No severe complications were observed; in two patients a local leakage of Ethibloc from the cyst into the soft tissues occurred but it was temporary and the consequent inflammation self-healed without residua and sequelae. Imaging follow-up lasted from 6 to 67 months and included conventional radiology (CR) and magnetic resonance imaging (MRI), both used in the presurgical phase. RESULTS AND CONCLUSIONS: All images demonstrated a remarkable shrinkage of the cystic lesion and bone cortex thickening. In all patients, circumscribed areas of lucency persisted at radiography, corresponding to residual cystic areas without fluid-fluid levels at MRI. Pain, which was present in all the patients before treatment, was relieved within a month. According to our experience, direct percutaneous Ethibloc injection is effective in the treatment of ABC and can be recommended as the first-choice treatment. Due to its higher sensitivity MRI must be included either in the pretreatment phase to study the multilocular structure or in the imaging follow-up to evaluate the efficacy of Ethibloc in persistently non-responsive areas.     

Cervical fixation in the pediatric patient: our experience

The surgical management of cervical instability in children is a challenging issue. Although the indications for internal fixation are similar to those for adults, accurate pre-surgery study and sharp surgical techniques are necessary because of the size of such patients’ anatomy, their peculiar tissue biology and the wide spectrum of diseases requiring cervical fusion. Our case study is made up of 31 patients, 15 male and 16 female, with an average age of 7 years and 6 months (2 years and 6 months to 18 years) who underwent cervical fusion for instability. Their physical condition presented various different pathologies ranging from congenital deformity, systemic skeletal disease, tumors, trauma, post-surgery instability. We performed occipito-cervical fusion in 11 cases, 5 of which involved stabilization at the cranium–vertebral junction. We used instrumentation in 13 cases (3 sublaminar wiring, 10 rigid adult instrumentation). We used rigid adult instrumentation in three patients under 10 years of age, treated by rod, occipital screws and sublaminar hook instrumentation in steel C0–C2 (9-year-old male, affected by os odontoideum in Down’s syndrome; male of 7 years and 10 months, affected by os odontoideum in Down’s syndrome; female of 4 years and 6 months with occipito-cervical stenosis and C0–C2 instability in Hurler’s syndrome). We operated on two patients under 3 years of age, using sublaminar wiring with bone precursors and allograft at level C0–C2 (one of these was a 30-month-old male with post-traumatic instability C0–C2, while the other was a 17-month-old male with C0–C2 instability in Larsen’s syndrome). The average follow-up age was 7 years and 1 month (between 1 and 18 years). Cervical fusion was assessed by X-ray examinations at 4th and 12th weeks and at 6th and 12th months after surgery. Where implants could allow, RMN examination was performed at 1st month after surgery. In the other cases, in which implants do not allow RMN to be performed, CT scan and standard X-rays were carried out, and new X-rays were performed every other year. We experienced two cases of sublaminar wiring rupture without impairment of bone fusion. No patient suffered major complications (infection and osteomyelitis, rigid instrumentation mobilization, incomplete fusion with instability, neurologic impairment, insufficient cervical spine range of movement to cope with everyday life activities, cervical pain). Even though most authors still indicate that rigid instrumentation should be performed in cases over 10 years of age and sublaminar wiring in cases over 3 years of age, our findings demonstrate that this age limit can be lowered. We have treated children under 10 years of age by rigid adult instrumentation and under 36 months of age by wiring. The anatomic size of the patient is the most important factor in determining the use of instrument arthrodesis to treat pediatric cervical spine instability. Although not easy, it is possible and preferable in many cases to adapt fixation to child cervical spine even in very young patients.