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Liang Xu, Zhonghui Chen, Yong Qiu, Xi Chen, Song Li, Changzhi Du, Qingshuang Zhou, and Xu Sun

OBJECTIVE

As scoliosis in arthrogryposis multiplex congenita (AMC) is unusual and the number of cases reviewed in previous studies is also relatively small, no previous study exists that has directly compared the results of spinal deformity correction between AMC and adolescent idiopathic scoliosis (AIS) patients. The aim of this study was to compare the radiographic and clinical outcomes of surgical correction of spinal deformity associated with AMC versus AIS.

METHODS

Twenty-four adolescents with AMC were matched with 48 AIS patients in terms of Cobb angle of main curve, curve pattern, sex, age at surgery, Risser grade, and length of follow-up. Patients in both groups underwent posterior-only spinal correction and fusion procedures. The surgical outcomes and complications were analyzed and compared between the 2 groups.

RESULTS

In comparison to the AIS group, the AMC group had a significantly longer mean operation time (5.6 vs 4.4 hours, p = 0.002), more blood loss (1620 ± 250 ml vs 840 ± 260 ml, p < 0.001), and more fusion levels (14.1 ± 2.3 levels vs 12.4 ± 2.5 levels, p = 0.007) as well as a lower correction rate (44.3% ± 11.1% vs 70.8% ± 12.4%, p < 0.001) and a higher rate of loss of correction (5.0% ± 3.1% vs 2.1% ± 1.9%, p < 0.001). Nine patients in the AMC group had preoperative pelvic obliquity, which was corrected from a mean of 14.2° ± 8.4° to a mean of 4.3° ± 3.2° (p < 0.001) after the surgery. The thoracic lordosis and sagittal vertical axis were significantly improved in the AMC group. Notably, however, the AMC group was found to have higher rates of screw malpositioning (15.9% vs 9.5%, p = 0.002) and complications (8/24 [33.3%] vs 4/48 [8.3%], p = 0.016) as compared to the AIS group.

CONCLUSIONS

Correction of AMC-associated scoliosis tends to require a longer operating time and involve more fusion levels but results in less correction, more blood loss, and more complications, in comparison with AIS. In addition, more attention should be paid to pelvic obliquity and sagittal hyperlordosis in AMC patients.

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Liang Xu, Yong Qiu, Zhonghui Chen, Benlong Shi, Xi Chen, Song Li, Changzhi Du, Zezhang Zhu, and Xu Sun

OBJECTIVE

This study aimed to evaluate the correction results of traditional dual growing rods (DGRs) on axial rotation using CT scans and to further explore the relationships between axial and torso deformities in patients with early-onset scoliosis (EOS).

METHODS

Patients with EOS who were treated with traditional DGRs between January 2006 and December 2014 were retrospectively reviewed. Plain radiographs were used to assess the degree of coronal and sagittal deformity. The apical vertebral rotation (AVR) and rib hump (RH) were measured on CT scans at the apical vertebra. Pearson or Spearman rank correlation analyses were used to analyze the associations between spinal and torso deformities.

RESULTS

A total of 27 patients (10 boys and 17 girls, average age 6.5 ± 1.7 years) were enrolled in this study. The average number of lengthenings per patient was 5.0 ± 1.9, with a mean follow-up duration of 52.9 ± 18.2 months. The apical vertebral translation, apical vertebral body–rib ratio (AVB-R), AVR, and RH parameters were significantly decreased after the initial surgery (p < 0.05) but showed notable progression at the latest follow-up evaluation (p < 0.05). The preoperative AVR and its correction after index surgery were significantly correlated with the preoperative values as well as with the corrections of the major Cobb angle, AVB-R, and RH. During the follow-up period, significant correlations were found between the deterioration of AVR and the AVB-R and also between the deterioration of AVR and the RH from the initial surgery to the latest follow-up.

CONCLUSIONS

Significant AVR correction can be achieved by DGR techniques after the initial surgery. However, this technique weakly prevents the deterioration of AVR during the follow-up period.

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Michael Grelat, Chang-Zhi Du, Liang Xu, Xu Sun, and Yong Qiu

OBJECTIVE

Scheuermann kyphosis (SK) could require surgical treatment in certain situations. A posterior reduction is the most widespread treatment so far, although the development of proximal junctional kyphosis (PJK) is one of the possible complications of this procedure. The contour of the proximal part of the rod could influence the occurrence of PJK in SK patients. The objective of this study was to analyze the impact of the proximal rod contour on the occurrence of a PJK complication in SK patients.

METHODS

This retrospective monocentric study was performed in the Nanjing Spine Surgery Department. All eligible patients had undergone posterior correction surgery with pedicle screws only between 2002 and 2017 and had at least 24 months of follow-up. The presence of PJK was quantified on radiographs using the proximal junctional angle (PJA > 10° at the last follow-up). The authors propose a new radiological parameter to measure the angulation of the proximal part of the instrumentation: the proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to the UIV. The patients were analyzed according to the presence or absence of PJK. A t-test, receiver operating characteristic (ROC) curve analysis, and logistic regression analysis were performed for statistical analysis.

RESULTS

Sixty-two patients treated for SK were included in this study. The mean age was 18.6 ± 8.5 years, and the mean follow-up was 42.5 ± 16.4 months. The mean correction rate of global kyphosis was 46.4% ± 13.7%. At the last follow-up, 17 patients (27.4%) presented with PJK. No significant difference was found between the PJK and non-PJK groups in terms of age and other preoperative variables. A significant difference in the postoperative PCRA was found between the PJK and non-PJK groups (8.2° ± 4.9° vs 15.7° ± 6.6°, respectively; p = 0.001). A postoperative PCRA less than 10.1° predicted a significantly higher risk for PJK (p = 0.002, OR 2.431, 95% CI 1.781–4.133).

CONCLUSIONS

Under-contouring of the proximal part of the rods (lower than 10°) is a risk factor for PJK after posterior correction of SK.

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Song Li, Saihu Mao, Changzhi Du, Zezhang Zhu, Benlong Shi, Zhen Liu, Jun Qiao, and Yong Qiu

OBJECTIVE

Dystrophic lumbar scoliosis secondary to neurofibromatosis type 1 (DLS-NF1) may present an atypical, unique curve pattern associated with a high incidence of coronal imbalance and regional kyphosis. Early surgical intervention is complicated and risky but necessary. The present study aimed to assess the unique characteristics associated with the surgical treatment of DLS-NF1.

METHODS

Thirty-nine consecutive patients with DLS-NF1 treated surgically at a mean age of 14.4 ± 3.9 years were retrospectively reviewed. Patients were stratified into three types according to the coronal balance classification: type A (C7 translation < 30 mm), 22 patients; type B (concave C7 translation ≥ 30 mm), 0 patients; and type C (convex C7 translation ≥ 30 mm), 17 patients. Types B and C were considered to be coronal imbalance. The diversity of surgical strategies, the outcomes, and the related complications were analyzed.

RESULTS

The posterior-only approach accounted for 79.5% in total; the remaining 20.5% of patients received either additional anterior supplemental bone grafting (12.8%) to strengthen the fixation or convex growth arrest (7.7%) to reduce growth asymmetry. The lower instrumented vertebra (LIV) being L5 accounted for the largest share (41%), followed by L4 and above (35.9%), the sacrum (15.4%), and the pelvis (7.7%). Type C coronal imbalance was found in 23 patients (59%) postoperatively, and the incidence was significantly higher in the preoperative type C group (14/17 type C vs 9/22 type A, p = 0.020). All the patients with postoperative coronal imbalance showed ameliorative transition to type A at the last visit. The rate of screw malposition was 30.5%, including 9.9% breached medially and 20.6% breached laterally, although no serious neurological impairment occurred. The incidence of rod breakage was 16.1% (5/31) and 0% in patients with the posterior-only and combined approaches, respectively. Four revisions with satellite rods and 1 revision with removal of iliac screw for penetration into the hip joint were performed.

CONCLUSIONS

Surgical strategies for DLS-NF1 were diverse across a range of arthrodesis and surgical approaches, being crucially determined by the location and the severity of dystrophic changes. The LIV being L5 or lower involving the lumbosacral region and pelvis was not rare. Additional posterior satellite rods or supplementary anterior fusion is necessary in cases with insufficient apical screw density. Despite a high incidence of postoperative coronal imbalance, improvement of coronal balance was frequently confirmed during follow-up. Neurological impairment was scarce despite the higher rate of screw malposition.

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Liang Xu, Benlong Shi, Yong Qiu, Zhonghui Chen, Xi Chen, Song Li, Changzhi Du, Qingshuang Zhou, Zezhang Zhu, and Xu Sun

OBJECTIVE

This study aimed to quantify the response of the cervical spine to the surgical correction of Scheuermann’s kyphosis (SK) and to postoperative proximal junctional kyphosis (PJK).

METHODS

Fifty-nine patients (mean age 14.6 ± 2.3 years) were enrolled in the study: 35 patients in a thoracic SK (T-SK) group and 24 in a thoracolumbar SK (TL-SK) group. The mean follow-up period was 47.2 ± 17.6 months. Radiographic data, PJK-related complications, and patient-reported outcomes were compared between groups.

RESULTS

The global kyphosis significantly decreased postoperatively, and similar correction rates were observed between the two groups (mean 47.1% ± 8.6% [T-SK] vs 45.8% ± 9.4% [TL-SK], p = 0.585). The cervical lordosis (CL) in the T-SK group notably decreased from 21.4° ± 13.3° to 13.1° ± 12.4° after surgery and was maintained at 14.9° ± 10.7° at the latest follow-up, whereas in the TL-SK group, CL considerably increased from 7.2° ± 10.7° to 11.7° ± 11.1° after surgery and to 13.8° ± 8.9° at the latest follow-up. PJK was identified in 16 patients (27.1%). Its incidence in the TL-SK group was notably higher than it was in the T-SK group (41.6% [n = 10] vs 17.1% [n = 6], p = 0.037). Compared with non-PJK patients, PJK patients had greater CL and lower pain scores on the Scoliosis Research Society–22 questionnaire (p < 0.05).

CONCLUSIONS

Hyperkyphosis correction eventually resulted in reciprocal changes in the cervical spine, with CL notably decreased in the T-SK group but significantly increased in the TL-SK group. Patients developing PJK have increased CL, which seems to have a negative effect on patients’ health-related quality of life.