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Gregory C. Wiggins, Stephen L. Ondra and Christopher I. Shaffrey

Iatrogenic loss of lordosis is now frequently recognized as a complication following placement of thoracolumbar instrumentation, especially with distraction instrumentation. Flat-back syndrome is characterized by forward inclination of the trunk, inability to stand upright, and back pain. Evaluation of the deformity should include a full-length lateral radiograph obtained with the patient's knees and hips fully extended. The most common cause of the deformity includes the use of distraction instrumentation in the lumbar spine and pseudarthrosis.

Surgical treatment described in the literature includes opening (Smith-Petersen) osteotomy, polysegmental osteotomy, and closing wedge osteotomy. The authors will review the literature, cause, clinical presentation, prevention, and surgical management of flat-back syndrome.

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Gregory C. Wiggins, Christopher I. Shaffrey, Mark F. Abel and Arnold H. Menezes

Pediatric spinal deformity results from multiple conditions including congenital anomalies, neuromuscular disorders, skeletal dysplasia, and developmental disorders (idiopathic). Pediatric spinal deformities can be progressive and cause pulmonary compromise, neurological deficits, and cardiovascular compromise. The classification and treatment of these disorders have evolved since surgical treatment was popularized when Harrington distraction instrumentation was introduced.

The advent of anterior-spine instrumentation systems has challenged the concepts of length of fusion needed to arrest curvature progression. Segmental fixation revolutionized the surgical treatment of these deformities. More recently, pedicle screw–augmented segmental fixation has been introduced and promises once again to shift the standard of surgical therapy. Recent advances in thoracoscopic surgery have made this technique applicable to scoliosis surgery.

Not only has surgical treatment progressed but also the classification of different forms of pediatric deformity continues to evolve. Recently, Lenke and associates proposed a new classification for adolescent idiopathic scoliosis. This classification attempts to address some of the shortcomings of the King classification system.

In this article the authors review the literature on pediatric spinal deformities and highlight recent insights into classification, treatment, and surgery-related complications.

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Michael J. Rauzzino, Christopher I. Shaffrey, Russ P. Nockels, Gregory C. Wiggins, Jack Rock and James Wagner

The authors report their experience with 42 patients in whom anterior lumbar fusion was performed using titanium cages as a versatile adjunct to treat a wide variety of spinal deformity and pathological conditions. These conditions included congenital, degenerative, iatrogenic, infectious, traumatic, and malignant disorders of the thoracolumbar spine. Fusion rates and complications are compared with data previously reported in the literature.

Between July 1996 and July 1999 the senior authors (C.I.S., R.P.N., and M.J.R.) treated 42 patients by means of a transabdominal extraperitoneal (13 cases) or an anterolateral extraperitoneal approach (29 cases), 51 vertebral levels were fused using titanium cages packed with autologous bone. All vertebrectomies (27 cases) were reconstructed using a Miami Moss titanium mesh cage and Kaneda instrumentation. Interbody fusion (15 cases) was performed with either the BAK titanium threaded interbody cage (in 13 patients) or a Miami Moss titanium mesh cage (in two patients). The average follow-up period was 14.3 months. Seventeen patients had sustained a thoracolumbar burst fracture, 12 patients presented with degenerative spinal disorders, six with metastatic tumor, four with spinal deformity (one congenital and three iatrogenic), and three patients presented with spinal infections. In five patients anterior lumbar interbody fusion (ALIF) was supplemented with posterior segmental fixation at the time of the initial procedure. Of the 51 vertebral levels treated, solid arthrodesis was achieved in 49, a 96% fusion rate. One case of pseudarthrosis occurred in the group treated with BAK cages; the diagnosis was made based on the patient's continued mechanical back pain after undergoing L4–5 ALIF. The patient was treated with supplemental posterior fixation, and successful fusion occurred uneventfully with resolution of her back pain. In the group in which vertebrectomy was performed there was one case of fusion failure in a patient with metastatic breast cancer who had undergone an L-3 corpectomy with placement of a mesh cage. Although her back pain was immediately resolved, she died of systemic disease 3 months after surgery and before fusion could occur.

Complications related to the anterior approach included two vascular injuries (two left common iliac vein lacerations); one injury to the sympathetic plexus; one case of superficial phlebitis; two cases of prolonged ileus (greater than 48 hours postoperatively); one anterior femoral cutaneous nerve palsy; and one superficial wound infection. No deaths were directly related to the surgical procedure. There were no cases of dural laceration and no nerve root injury. There were no cases of deep venous thrombosis, pulmonary embolus, retrograde ejaculation, abdominal hernia, bowel or ureteral injury, or deep wound infection. Fusion-related complications included an iliac crest hematoma and prolonged donor-site pain in one patient. There were no complications related to placement or migration of the cages, but there was one case of screw fracture of the Kaneda device that did not require revision.

The authors conclude that anterior lumbar fusion performed using titanium interbody or mesh cages, packed with autologous bone, is an effective, safe method to achieve fusion in a wide variety of pathological conditions of the thoracolumbar spine. The fusion rate of 96% compares favorably with results reported in the literature. The complication rate mirrors the low morbidity rate associated with the anterior approach. A detailed study of clinical outcomes is in progress. Patient selection and strategies for avoiding complication are discussed.

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Christopher I. Shaffrey, Gregory C. Wiggins, Cynthia B. Piccirilli, Jacob N. Young and LaVerne R. Lovell

Object. Multilevel anterior cervical decompressive surgery and fusion effectively treats cervical myeloradiculopathy that is caused by severe cervical spinal stenosis, but degenerative changes at adjacent vertebral levels frequently result in long-term morbidity.

The authors performed a modified open-door laminoplasty procedure in which allograft bone and titanium miniplates were used to treat cervical myeloradiculopathy in younger patients with congenital canal stenosis while maintaining functional cervical motion segments. Pre- and postoperative magnetic resonance imaging and/or computerized tomography myelography were performed to assess changes in cervical spinal canal dimensions. Pre- and postoperative flexion—extension radiographs were compared to determine the residual motion of the targeted operative segments.

Methods. Twenty younger patients (average age 37.7 years) underwent modified open-door laminoplasty for treatment of myelopathy or myeloradiculopathy related to significant cervical spinal stenosis with or without associated central or lateral disc herniation or foraminal stenosis. These surgeries were performed during a 2-year period and follow-up review remains ongoing (average follow-up period 21.6 months). Reconstructive procedures were performed on an average of 4.1 levels (range three—six). Operative time averaged 186 minutes (range 93–229 minutes). Average blood loss was 305 ml (range 100–650 ml). No cases were complicated by neurological deterioration, infection, wound breakdown, graft displacement, or hardware failure. The patients' Nurick Scale grade improved from a preoperative average of 1.8 to a postoperative average of 0.5.

Pre- and postoperative sagittal spinal diameter averaged 11.2 mm (8–14 mm) and 16.6 mm (13–19 mm), respectively. The sagittal compression ratio (sagittal/lateral × 100%) increased from 48% pre- to 72% postoperatively. The spinal canal area increased an average of 55% (range 19–127%). In patients in whom pre- and postoperative flexion—extension radiographs were obtained, 72.7% residual neck motion was maintained. No patient developed increased neck or shoulder pain. Neurological symptoms improved in all patients, with total relief of myelopathy in 50% and partial improvement in 50%.

Conclusions. Modified open-door laminoplasty with allograft bone and titanium miniplates effectively treats neurological deficits in younger patients with congenital and spinal stenosis. Although long-term results are unknown, short-term results are good and there is a low incidence of complications.

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Gregory C. Wiggins, Sohail Mirza, Carlo Bellabarba, G. Alex West, Jens R. Chapman and Christopher I. Shaffrey

Object

Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach–related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure.

To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome.

Methods

Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, pre-operative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups.

Conclusions

Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

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Gregory C. Wiggins, Michael J. Rauzzino, Henry M. Bartkowski, Russ P. Nockels and Christopher I. Shaffrey

Object. The authors sought to analyze prospectively the outcome of surgery for complex spinal deformity in the pediatric and young adult populations.

Methods. The authors evaluate all pediatric and adolescent patients undergoing operative correction of complex spinal deformity from December 1997 through July 1999. No patient was lost to follow-up review (average 21.1 months). There were 27 consecutive pediatric and adolescent patients (3–20 years of age) who underwent 32 operations. Diagnoses included scoliosis (18 idiopathic, five nonidiopathic) and four severe kyphoscoliosis. Operative correction and arthrodesis were achieved via 21 posterior approaches (Cotrel-Dubousset-Horizon), seven anterior approaches (Isola or Kaneda Scoliosis System), and two combined approaches. Operative time averaged 358 minutes (range 115–620 minutes). Blood loss averaged 807 ml (range 100–2000 ml). Levels treated averaged 9.1 (range three–16 levels). There was a 54% average Cobb angle correction (range 6–82%). No case was complicated by the patient's neurological deterioration, loss of somatosensory evoked potential monitoring, cardiopulmonary disease, donor-site complication, or wound breakdown. There was one case of hook failure and one progression of deformity beyond the site of surgical instrumentation that required reoperation. There were 10 minor complications that did not significantly affect patient outcome. No patient received undirected banked blood products. There was a significant improvement in cosmesis, and no patient experienced continued pain postoperatively. All patients have been able to return to their preoperative activities.

Conclusions. Compared with other major neurosurgical operations, segmental instrumentation for pediatric and adolescent spinal deformity is a safe procedure with minimal morbidity and there is a low risk of needing to use allogeneic blood products.

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Gregory C. Wiggins, Michael J. Rauzzino, Christopher I. Shaffrey, Russ P. Nockels, Richard Whitehill, Mark E. Shaffrey, James Wagner and Tord D. Alden

This study was conducted to determine the safety, efficacy, and complication rate associated with the anterior approach in the use of a new titanium mesh interbody fusion cage for the treatment of unstable thoracolumbar burst fractures. The experience with this technique is compared with the senior authors' (C.S., R.W., and M.S.) previously published results in the management of patients with unstable thoracolumbar burst fractures.

Between 1996 and 1999, 21 patients with unstable thoracolumbar (T12-L3) burst fractures underwent an anterolateral decompressive procedure in which a titanium cage and Kaneda device were used. Eleven of the 21 patients had sustained a neurological deficit, and all patients improved at least one Frankel grade (average 1.2 grades). There was improvement in outcome in terms of blood loss, correction of kyphosis, and pain, as measured on the Denis Pain and Work Scale, in our current group of patients treated via an anterior approach when compared with the results in those who underwent a posterior approach.

In our current study the anterior approach was demonstrated to be a safe and effective technique for the management of unstable thoracolumbar burst fractures. It offers superior results compared with the posterior approach. The addition of the new titanium mesh interbody cage to our previous anterior technique allows the patient's own bone to be harvested from the corpectomy site and used as a substrate for fusion, thereby obviating the need for iliac crest harvest. The use of the cage in association with the Kaneda device allows for improved correction of kyphosis and restoration of normal sagittal alignment in addition to improved functional outcomes.