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Joseph C. Noggle, Daniel M. Sciubba, Amer F. Samdani, D. Greg Anderson, Randal R. Betz and Jahangir Asghar

Object

Lumbar spondylolysis occurs in approximately 6% of the population and presents with localized mechanical back pain, often in young athletes. Surgical treatment may involve decompression, lumbar intersegmental fusion, or direct repair of pars defects. Although such open procedures may effectively resolve symptoms, minimal-access approaches may additionally decrease collateral damage to soft tissues, allowing young, active patients to resume athletic activities sooner. In this study, the authors review their experience repairing bilateral lumbar spondylolyses with screw and hook constructs placed via a minimal-access approach.

Methods

Five consecutive pediatric patients with bilateral L-5 spondylolysis were treated. Bilateral incisions (2.5 cm) were made over L-5. Exposure was maintained with bilateral expandable tubular retractor systems. Pedicle screws were placed in the L-5 pedicles and attached to hooks under the L-5 laminae. A direct repair was performed at the pars defect. Clinical characteristics, operative variables, and postoperative outcomes were collected.

Results

All 5 patients underwent surgery; 4 were male (80%) and 1 was female (20%), and the mean age was 15.8 years (range 15–17 years). The mean estimated blood loss and duration of surgery were 37 ml (range 15–75 ml) and 1.94 hours (range 1–3 hours), respectively. Postoperative hospital stays ranged from 1 to 3 days (mean 1.8 days). The only complication occurred in 1 patient who experienced minor superficial wound breakdown. All patients have experienced resolution of symptoms at this preliminary stage, which has continued over an 8-month follow-up period.

Conclusions

Lumbar spondylolysis can be adequately and safely treated via minimal-access surgical repair of the pars interarticularis by using pedicle screws and rod-hook constructs. This approach may decrease the collateral soft tissue damage common to open dissections, and may be ideal for young, active surgical candidates.

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Amer F. Samdani, Ashish Ranade, Henry J. Dolch, Reed Williams, Tricia St. Hilaire, Patrick Cahill and Randal R. Betz

Object

Few options exist for the treatment of severe, early onset scoliosis. Goals of treatment include stabilizing curve progression while allowing for normal spine, chest, and lung growth. The vertical expandable prosthetic titanium rib (VEPTR) is a novel device designed to control the spine deformity while permitting lung and spine growth. In this paper the authors report their experience with using bilateral VEPTRs from the ribs to the pelvis for children with severe, early onset scoliosis.

Methods

Eleven children were identified who had been treated with bilateral VEPTRs from the ribs to the pelvis. The authors conducted a retrospective review and collected the following data: clinical diagnosis, age at surgery, number of lengthening procedures, and complications. In addition, pre- and postoperative radiographs were reviewed to measure maximum Cobb angle (both thoracic and lumbar), thoracic height, total spine height as measured from T-1 to S-1, thoracic kyphosis (T2–12), and lumbar lordosis (L1–S1).

Results

The average patient age at surgery was 71 months; the mean preoperative thoracic Cobb angle was 81.7°. This angle was corrected to 50.6° immediately postoperatively, and this correction was maintained; at the most recent follow-up the curves averaged 58°. Similarly, the preoperative kyphosis (T2–12) angle measured 43° preoperatively, 23° immediately postoperatively, and 37° at the most recent follow-up evaluation. The patients underwent a total of 41 lengthening procedures (average 3.7 lengthening procedures per patient), and overall spine length increased from 23.1 cm preoperatively, to 27.3 cm immediately postoperatively, to 29.4 cm at the final follow-up (an average of 25 months). Four (36.4%) of the 11 patients experienced complications.

Conclusions

The VEPTR offers a viable treatment option for children with severe, early onset scoliosis. It achieves and maintains spinal deformity correction, while allowing for continued spine and chest-wall growth. Complication rates are similar to those reported for other growing systems.

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Jason R. Smith, Amer F. Samdani, Joshua Pahys, Ashish Ranade, Jahangir Asghar, Patrick Cahill and Randal R. Betz

Object

There are few data on treatment results for patients with idiopathic infantile scoliosis (IIS). Thus, the authors have performed a retrospective review of their experience with treating these patients, particularly as newer technologies, such as the vertical expandable prosthetic titanium rib (VEPTR), emerge.

Methods

This retrospective study was conducted to evaluate the methods of treatment used to manage IIS at a single institution. The authors reviewed 31 consecutive patients with a primary diagnosis of IIS. Patients were screened to ensure that there were no confounding congenital anomalies or comorbidities that may have contributed to the spinal deformity. The average age at the time of initial treatment was 25 months. Treatment modalities included bracing, serial body casting, and VEPTR. Pretreatment, posttreatment, and most recent Cobb angles were compared to assess the overall curve correction, and patient charts were reviewed for the occurrence of complications.

Results

Of the 31 patients, 17 were treated with a brace, 9 of whom had curve progression and went on to other forms of treatment. Of the 8 who did respond, there was an overall improvement of 51.2%. The 10 patients who received body casts, who had a mean preoperative Cobb angle of 50.4°, demonstrated an average correction of 59.0%, with only a few skin irritations reported. The 10 patients treated with VEPTR devices demonstrated a mean preoperative Cobb angle of 90.0°, and an average correction of 33.8% was attained. Three of the VEPTR-treated patients (33%) experienced minor problems.

Conclusions

The authors' results suggest that body casting has utility for appropriately selected patients; that is, those with smaller, flexible spinal curves. Bracing had limited utility, with high levels of progression and the need for secondary treatments. The VEPTR device appears to be a viable alternative for large-magnitude curves.

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Amer F. Samdani, Anthony L. Fine, Sukhdeep S. Sagoo, Shailja C. Shah, Patrick J. Cahill, David H. Clements and Randal R. Betz

Object

Tethering of the spinal cord is thought to increase the chance of neurological injury when scoliosis correction is undertaken. All patients with myelomeningocele (MM) are radiographically tethered, and untethering procedures carry significant morbidity risks including worsening neurological function and wound complications. No guidelines exist as regards untethering in patients with MM prior to scoliosis correction surgery. The authors' aim in this study was to evaluate their experience in patients with MM who were not untethered before scoliosis correction.

Methods

Seventeen patients with MM were retrospectively identified and 1) had no evidence of a clinically symptomatic tethered cord, 2) had undergone spinal fusion for scoliosis correction, and 3) had not been untethered for at least 1 year prior to surgery. The minimum follow-up after fusion was 2 years. Charts and radiographs were reviewed for neurological or shunt complications in the perioperative period.

Results

The average age of the patients was 12.4 years, and the following neurological levels were affected: T-12 and above, 7 patients; L-1/L-2, 6 patients; L-3, 2 patients; and L-4, 2 patients. All were radiographically tethered as confirmed on MR imaging. Fourteen of the patients (82%) had a ventriculoperitoneal shunt. The mean Cobb angle was corrected from 82° to 35°, for a 57% correction. All patients underwent neuromonitoring of their upper extremities, and some underwent lower extremity monitoring as well. Postoperatively, no patient experienced a new cranial nerve palsy, shunt malfunction, change in urological function, or upper extremity weakness/sensory loss. One patient had transient lower extremity weakness, which returned to baseline within 1 month of surgery.

Conclusions

The study results suggested that spinal cord untethering may be unnecessary in patients with MM who are undergoing scoliosis corrective surgery and do not present with clinical symptoms of a tethered cord, even though tethering is radiographically demonstrated.

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Steven W. Hwang, Amer F. Samdani, Mark Tantorski, Patrick Cahill, Jason Nydick, Anthony Fine, Randal R. Betz and M. Darryl Antonacci

Object

Several studies have characterized the relationship among postoperative thoracic, lumbar, and pelvic alignment in the sagittal plane. However, little is known of the relationship between postoperative thoracic kyphosis and sagittal cervical alignment in patients with adolescent idiopathic scoliosis (AIS) treated with all pedicle screw constructs. The authors examined this relationship and associated factors.

Methods

A prospective database of pediatric patients with AIS undergoing spinal fusion between 2003 and 2005 was reviewed for those who received predominantly pedicle screw constructs for Lenke Type 1 or Type 2 curves. Parameters analyzed on pre- and postoperative radiographs were the fusion levels; cervical, thoracic, and lumbar sagittal balance; and C-2 and C-7 plumb lines.

Results

Preoperatively, 6 (Group A) of the 22 patients included in the study had frank cervical kyphosis (mean angle 13.0°) with mean associated thoracic kyphosis of 27.2° (range 16°–37°). Postoperatively, cervical kyphosis (13.0°) remained in the patients in Group A along with mean thoracic kyphosis of 17.7° (range 4°–26°, p < 0.05). Preoperatively, the remaining 16 of 22 patients had neutral to lordotic cervical alignment (mean −13.8°) with thoracic kyphosis (mean 45°, range 30°–76°). Postoperatively, 8 (Group B) of these 16 patients demonstrated cervical sagittal decompensation (> 5° kyphosis), with 6 showing frank cervical kyphosis (10.5°, p < 0.05). In Group B, the mean postoperative thoracic kyphosis was 25.6° (range 7°–49°, p < 0.05). The other 8 patients (Group C) had mean postoperative thoracic kyphosis of 44.1° (range 32°–65°), and there was no cervical decompensation (p < 0.05).

Conclusions

The sagittal profile of the thoracic spine is related to that of the cervical spine. The surgical treatment of Lenke Type 1 and 2 curves by using all pedicle screw constructs has a significant hypokyphotic effect on thoracic sagittal plane alignment (19 [86%] of 22 patients). If postoperative thoracic kyphosis is excessively decreased (mean 25.6°, p < 0.05), the cervical spine may decompensate into significant kyphosis.

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Steven W. Hwang, Amer F. Samdani, Baron S. Lonner, Michelle C. Marks, Tracey P. Bastrom, Randal R. Betz and Patrick J. Cahill

Object

In the surgical management of adolescent idiopathic scoliosis (AIS), patients are often preoperatively informed that they will gain height as a result of their surgery. However, current estimations conflict significantly and do not have any clinical correlation. The authors developed a formula that would predict postoperative gains in height after deformity correction in AIS.

Methods

A large, multicenter, prospective database was retrospectively queried for AIS patients with Lenke Type 1, 2, or 3 curves having undergone posterior spinal fusion alone. A univariate and multivariate analysis was performed to identify which factors contributed significantly to changes in height.

Results

Four hundred forty-seven patients were included in the series. Factors correlating with changes in postoperative height included: upper thoracic curve magnitude, main thoracic curve magnitude, lumbar curve magnitude, T2–12 kyphosis, T5–12 kyphosis, curve flexibility, number of levels fused, presence of Ponte osteotomies, total preoperative coronal Cobb angle, change in coronal curve magnitude, total preoperative sagittal curvature, change in sagittal curvature, and thoracic curve correction.

When combined in a multivariate regression analysis the following variables remained significant: thoracic curve magnitude (p < 0.01), number of levels fused (p < 0.01), change in total sagittal curvature (p < 0.01), and the presence of osteotomies (p = 0.03). The contribution from the thoracic curve magnitude was significantly greater than any of the other parameters identified (R2 = 0.140). Change in height (in cm) = ([thoracic curve magnitude × 0.039] + [number of levels fused × 0.193] − [change in sagittal curvature × 0.033] + [x × 0.375]) − 1.858, where x = 1 if 1 or more osteotomies were performed and x = 0 if no osteotomy was performed.

Conclusions

The authors' results suggest that changes in the coronal plane contribute more significantly to height changes than those in the sagittal plane and approximately 0.39 cm of height gain can be expected for each 10° of coronal curve preoperatively. Unfortunately, a significant fraction of the postoperative height changes cannot be predicted by currently measured parameters.

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Charles E. Mackel, Patrick J. Cahill, Marie Roguski, Amer F. Samdani, Patrick A. Sugrue, Noriaki Kawakami, Peter F. Sturm, Joshua M. Pahys, Randal R. Betz, Ron El-Hawary and Steven W. Hwang

OBJECTIVE

The authors performed a study to identify clinical characteristics of pediatric patients diagnosed with Chiari I malformation and scoliosis associated with a need for spinal fusion after posterior fossa decompression when managing the scoliotic curve.

METHODS

The authors conducted a multicenter retrospective review of 44 patients, aged 18 years or younger, diagnosed with Chiari I malformation and scoliosis who underwent posterior fossa decompression from 2000 to 2010. The outcome of interest was the need for spinal fusion after decompression.

RESULTS

Overall, 18 patients (40%) underwent posterior fossa decompression alone, and 26 patients (60%) required a spinal fusion after the decompression. The mean Cobb angle at presentation and the proportion of patients with curves > 35° differed between the decompression-only and fusion cohorts (30.7° ± 11.8° vs 52.1° ± 26.3°, p = 0.002; 5 of 18 vs 17 of 26, p = 0.031). An odds ratio of 1.0625 favoring a need for fusion was established for each 1° of increase in Cobb angle (p = 0.012, OR 1.0625, 95% CI 1.0135–1.1138). Among the 14 patients older than 10 years of age with a primary Cobb angle exceeding 35°, 13 (93%) ultimately required fusion. Patients with at least 1 year of follow-up whose curves progressed more 10° after decompression were younger than those without curve progression (6.1 ± 3.0 years vs 13.7 ± 3.2 years, p = 0.001, Mann-Whitney U-test). Left apical thoracic curves constituted a higher proportion of curves in the decompression-only group (8 of 16 vs 1 of 21, p = 0.002).

CONCLUSIONS

The need for fusion after posterior fossa decompression reflected the curve severity at clinical presentation. Patients presenting with curves measuring > 35°, as well as those greater than 10 years of age, may be at greater risk for requiring fusion after posterior fossa decompression, while patients less than 10 years of age may require routine monitoring for curve progression. Left apical thoracic curves may have a better response to Chiari malformation decompression.