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Yizhar Floman, Ron El-Hawary, Michael A. Millgram, Baron S. Lonner and Randal R. Betz

OBJECTIVE

A posterior dynamic deformity correction (PDDC) system was used to correct adolescent idiopathic scoliosis (AIS) without fusion. The preliminary outcomes of bridging only 3–4 discs in patients with variable curve severity have previously been reported. This paper examines a subgroup of patients with the authors’ proposed current indications for this device who were also treated with a longer construct.

METHODS

Inclusion criteria included a single AIS structural curve between 40° and 60°, curve flexibility ≤ 30°, PDDC spanning 5–6 levels, and minimum 2-year follow-up. A retrospective review was conducted and demographic and radiographic data were recorded. A successful outcome was defined as a curve magnitude of ≤ 30° at final follow-up. Any serious adverse events and reoperations were recorded.

RESULTS

Twenty-two patients who met the inclusion criteria were operated on with the PDDC in 5 medical centers. There were 19 girls and 3 boys, aged 13–17 years, with Risser grades ≥ 2. Thirteen had Lenke type 1 curves and 9 had type 5 curves. The mean preoperative curve was 47° (range 40°–55°). At a minimum of 2 years’ follow-up, the mean major curve measured 25° (46% correction, p < 0.05). In 18 (82%) of 22 patients, the mean final Cobb angle measured ≤ 30° (range 15°–30°). Trunk shift was corrected by 1.5 cm (range 0.4–4.3 cm). The mean minor curve was reduced from 27° to 17° at final follow-up (35% correction, p < 0.05). For Lenke type 1 patterns, the mean 2D thoracic kyphosis was 24° preoperatively versus 27° at final follow-up (p < 0.05), and for Lenke type 5 curves, mean lumbar lordosis was 47° preoperatively versus 42° at final follow-up (p < 0.05). The mean preoperative Scoliosis Research Society-22 questionnaire score improved from 2.74 ± 0.3 at baseline to 4.31 ± 0.4 at 2 years after surgery (p < 0.0001). The mean preoperative self-image score and satisfaction scores improved from preoperative values, while other domain scores did not change significantly. Four patients (18%) underwent revision surgery because of nut loosening (n = 2), pedicle screw backup (n = 1), and ratchet malfunction (n = 1).

CONCLUSIONS

In AIS patients with a single flexible major curve up to 60°, the fusionless PDDC device achieved a satisfactory result as 82% had residual curves ≤ 30°. These findings suggest that the PDDC device may serve as an alternative to spinal fusion in select patients.

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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.