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PubMed2000

Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis.

STUDY DESIGN: Prospective study. OBJECTIVES: To prospectively evaluate sequential pulmonary function tests (PFTs) at a minimum 2-year follow-up after an open anterior spinal fusion (ASF) with instrumentation for thoracic AIS. SUMMARY OF BACKGROUND DATA: Anterior spinal fusion with instrumentation is currently undergoing evaluation as an alternative to posterior spinal fusion (PSF) for thoracic adolescent idiopathic scoliosis (AIS). However, the effect of an open thoracotomy on pulmonary function in these patients is unknown. METHODS: Fifty-one patients with thoracic AIS with an average age of 15+0 (range 11+2 to 20+5) had PFTs consisting of volume (FVC), flow (FEV-1), and total lung capacity (TLC). Parameters were obtained preoperatively, and at 3 months, 1 year, and a minimum 2-year follow-up. All patients had a single or double open thoracotomy with the diaphragm kept intact. Fusion levels ranged from T4 (most proximal) to L1 (most distal). The average preoperative thoracic coronal Cobb measurement was 53 degrees (range 38 degrees to 80 degrees ), and the average postoperative coronal measurement was 24 degrees (range 7 degrees to 49 degrees ). The average preoperative thoracic sagittal kyphosis (T5-T12) averaged 22 degrees (range 10 degrees to 58 degrees ), and the average postoperative sagittal kyphosis measured 29 degrees (range 7 degrees to 67 degrees ). RESULTS: There was a significant decline (P< or =0.05) in PFT absolute values (L) of 19%-FVC, 15%-FEV-1, and 11%-TLC at 3 months postoperatively with subsequent improvement and no statistical difference between preoperative and 2-year postoperative values. When evaluating percent predicted values, there was a statistical decline (P< or =0.05) at 3 months postoperatively averaging 19% FVC, 14% FEV-1, and 12% TLC. These values returned to within 94% to 96% of baseline by the 2-year follow-up visit, but were still statistically less than the preoperative values (P</=0.05). CONCLUSIONS: Pulmonary function following thoracotomy with ASF with instrumentation demonstrated a significant decline of 3-month postoperative PFT values, but returned to preoperative baseline absolute values (L) by the 2-year follow-up visit. The percent predicted values returned to within 95% of baseline 2 years postoperatively. Scoliosis surgeons should be aware of these findings when deciding upon the approach (anterior versus posterior) utilized for thoracic AIS.

Adolescent↗
PubMed2000

Results of brace treatment of scoliosis in Marfan syndrome.

STUDY DESIGN: Retrospective review of a defined Marfan population with traditional indications for bracing. OBJECTIVES: To determine the success rate of brace treatment in keeping curves from progressing by more than 5 degrees or exceeding 45 degrees. SUMMARY OF BACKGROUND DATA: Few studies exist regarding brace treatment of Marfan syndrome, and they include many patients with curves of more than 45 degrees, as well as some who are near maturity. All of the prior studies risk the possibility of some selection bias. METHODS: Patients were selected from support groups and several institutions. Inclusion criteria were: Definite diagnosis of Marfan syndrome, curve of 45 degrees or less, Risser sign 2, 1, or 0 at inception of bracing, recommended wear of 18 hours or more per day, and follow-up until maturity or surgery (minimum, 2 years). Success was defined as curve progression of 5 degrees or less and final curve remaining 45 degrees or less. Failure was a final curve of more than 45 degrees. Twenty-four patients met the criteria. There were 15 girls and 9 boys. Twenty-two patients wore a brace as recommended. Two additional patients were unable to tolerate it. RESULTS: Mean age at inception of bracing was 8.7 years (range, 4-12 years). There were 14 double major, 6 thoracic, and 4 thoracolumbar curves with a mean size of 29 degrees at the beginning of bracing. The stated wearing time averaged 21 hours per day. Five patients had significant pain over bony prominences. Although correction of the curve in brace was good (45%), only 4 of the patients had success, and in 20 of the 24 treatment was considered a failure. Mean progression was 6 degrees +/- 8 degrees per year, for a final mean curve of 49 degrees. Sixteen of the patients had, or were advised to have, surgical correction. The difference in age and degree of curvature were not statistically significant between the success and nonsuccess groups. CONCLUSIONS: The success rate for brace treatment of Marfan scoliosis is 17%, which is lower than that reported for idiopathic scoliosis. Possible reasons include increased progressive forces, altered transmission of corrective pressure to the spine, and younger age at inception of bracing. Because there was no control group, it is unknown whether bracing slowed curve progression. Physicians should understand that most patients with Marfan syndrome who have a curve of more than 25 degrees and a Risser sign of 2 or less will reach the surgical range, even with brace treatment.

Braces↗
PubMed2000

Further development and validation of the Scoliosis Research Society (SRS) outcomes instrument.

STUDY DESIGN: Outcome study to determine response distribution, internal consistency, and validity of a Modified SRS Outcomes Instrument (MSRSI). OBJECTIVES: Refinement and validation of the SRS Outcomes Instrument for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Experience with the SRS Outcomes Instrument suggested several refinements and the need for validation. METHODS: Following experience-based modification, the Modified SRS Outcomes Instrument and Short Form 36 (SF-36) questionnaires were administered to 35 previously surveyed postoperative idiopathic scoliosis patients. RESULTS: Thirty (86%) patients with an average age of 25 years returned the questionnaires at an average of 10 years postoperative. Distribution of scores was acceptable. Internal consistency utilizing Cronbach's alpha was 0.80, 0.81, 0.77, 0.89, and 0.88 for pain, self-image/appearance, function/activity, mental health, and satisfaction with surgery, respectively. Validity, determined by Pearson correlation coefficients with comparable SF-36 domains, was 0.70 or greater for 13 of the 14 relevant domains between SF-36 and MSRSI (P < 0.001). CONCLUSION: The SRS Outcomes Instrument is simple and internally consistent. Based on experience, a number of modifications have been made that improve the instruments scope and internal consistency. Finally, the instrument is valid in comparison to SF-36.

Adult↗
PubMed2001

Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective evaluation of radiographs in patients undergoing anterior spinal fusion or posterior spinal fusion for adolescent idiopathic scoliosis. OBJECTIVE: To determine the most effective preoperative radiographic method for evaluating coronal plane flexibility by comparing preoperative and postoperative correction. SUMMARY OF BACKGROUND DATA: Curve flexibility is traditionally evaluated with side-bending radiographs. Recently, the fulcrum-bending radiograph was shown to provide better correction of thoracic curves undergoing posterior spinal fusion but was not evaluated in thoracolumbar/lumbar curves or in patients undergoing anterior spinal fusion. METHODS: Preoperative coronal radiographs of 46 consecutive patients undergoing spinal fusion for adolescent idiopathic scoliosis obtained while standing, lying supine, side-bending (maximally bending while supine), push-prone (padded bolsters applied to chest wall while prone), and fulcrum-bending (curve apex suspended over a radiolucent fulcrum while lateral) were compared with standing postoperative radiographs. Cobb angles were determined and evaluated for statistical significance. RESULTS: The fulcrum-bending radiograph demonstrated statistically better correction than other preoperative methods for main thoracic curves (P < 0.01) but fell short of demonstrating the correction obtained surgically. There was no statistical difference between side-bending, fulcrum-bending, or postoperative correction for thoracolumbar/lumbar curves (all P values > 0.07). The left side-bending was the most effective method for reducing upper thoracic curves (P < 0.001). There was no difference in the results obtained for curves corrected by anterior spinal fusion or anterior spinal fusion. CONCLUSION: To achieve maximal preoperative correction, thoracic fulcrum-bending radiographs should be obtained for evaluating main thoracic curves, whereas side-bending radiographs should continue to be used for evaluating both upper thoracic and thoracolumbar/lumbar curves.

Adolescent↗
PubMed2001

Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals.

STUDY DESIGN: This study is a follow-up investigation for a consecutive series of patients with adolescent idiopathic scoliosis treated between 1968 and 1977. In this series, 156 patients underwent surgery with distraction and fusion using Harrington rods, and 127 were treated with brace. OBJECTIVES: To determine the long-term outcome in terms of radiologic findings and curve progression at least 20 years after completion of the treatment. SUMMARY OF BACKGROUND DATA: Radiologic appearance is important in comparing the outcome of different treatment options and in evaluating clinical results. Earlier studies have shown a slight increase of the Cobb angle in brace-treated patients with time, but not in fused patients. METHODS: Of 283 patients, 252 attended a clinical and radiologic follow-up assessment by an unbiased observer (91% of the surgically treated and 87% of the brace-treated patients). This evaluation included chart reviews, validated questionnaires, clinical examination, and full-length standing frontal and lateral roentgenographs. Curve size was measured by the Cobb method on anteroposterior roentgenograms as well as by sagittal contour and balance on lateral films. The occurrence of any degenerative changes or other complications was noted. An age- and gender-matched control group of 100 individuals was randomly selected and subjected to the same examinations. RESULTS: The mean follow-up times were 23 years for surgically treated group and 22 years for brace-treated group. The deterioration of the curves was 3.5 degrees for all the surgically treated curves and 7.9 degrees for all the brace-treated curves (P < 0.001). Five patients, all brace-treated, had a curve increase of 20 degrees or more. The overall complication rate after surgery was low: Pseudarthrosis occurred in three patients, and flat back syndrome developed in four patients. Eight of the patients treated with fusion (5.1%) had undergone some additional curve-related surgical procedure. The lumbar lordosis was less in the surgically treated than in the brace-treated patients or the control group (mean, 33 degrees vs 45 degrees and 44 degrees, respectively). Both surgically treated and brace-treated patients had more degenerative disc changes than the control participants (P < 0.001), but no significant differences were found between the scoliosis groups. No statistically significant difference in terms of radiographically detectable degenerative changes in the unfused lumbar discs was found between patients fused below L3 or those fused to L3 and above (P = 0.22). A study on intra- and interobserver measurements of kyphosis, lordosis, and sagittal vertical axis on two films for each patient demonstrated that the repeatability of measuring sagittal plumbline on two different lateral radiographs, with patients moving between radiograms, was unreliable for comparison. CONCLUSIONS: Although more than 20 years had passed since completion of the treatment, most of the curves did not increase. The surgical complication rate was low. Degenerative disc changes were more common in both patient groups than in the control group.

Adolescent↗
PubMed2001

Intervertebral disc composition in neuromuscular scoliosis: changes in cell density and glycosaminoglycan concentration at the curve apex.

STUDY DESIGN: An analysis of the variation in glycosaminoglycan, water content, and cell density with disc level in patients with neuromuscular scoliosis. OBJECTIVES: To determine whether the composition of the apical disc differed from that of adjacent discs in the same spine. SUMMARY OF BACKGROUND DATA: Compositional differences between the convex and concave sides of scoliotic discs have been noted and are thought to be secondary to altered loading. However, there is little information on changes relative to the apex. METHODS: Intact wedges of disc obtained during anterior fusion procedures were taken from 23 discs of 6 patients with neuromuscular scoliosis. Radial profiles of glycosaminoglycan, water content, and cell density were measured. Concentrations were compared at a standard distance (5 mm) into the disc and plotted versus spinal level. RESULTS: Glycosaminoglycan and water content were lowest in the outer annulus and increased steadily toward the disc center, whereas the cell density was highest in the outer 2 mm, fell steeply and then remained constant. At 5 mm from the annulus edge, cell density was lowest in apical discs and, in most cases, was noticeably higher in adjacent discs of the same spine. At the same point, there was no consistent change in glycosaminoglycan/dry weight from disc to disc, indicating no significant proteoglycan loss. However, glycosaminoglycan/tissue water, and therefore swelling pressure, was highest in the apical discs, suggesting that these discs were the most heavily loaded. CONCLUSIONS: The loss of cells from the disc at the curve apex probably arose because this disc experiences greater mechanical stress or is more deformed than its neighbors. The decrease in cell density was not associated with major changes in tissue composition, possibly because rates of degradation and of synthesis were reduced, leaving the matrix largely unchanged.

Adolescent↗
PubMed2001

Anterior versus posterior instrumentation for the correction of thoracic idiopathic scoliosis.

Traditionally, thoracic idiopathic scoliosis has been treated by posterior instrumentation and fusion, which is still the gold standard. However, anterior instrumentation and fusion became a viable option for these patients during the 1990s and are gaining acceptance. Currently, controversy still exists regarding the indications for the anterior approach, and the benefits of the anterior versus posterior approach remain unsettled. Therefore, this topic was considered ideal for noted experts on both sides to present their opinions, with Dr. Harry Shufflebarger promoting posterior instrumentation and Dr. Randy Betz encouraging anterior instrumentation. The efforts of these two outstanding and dedicated scoliosis specialists to educate the readers of Spine regarding their viewpoints are appreciated.

Humans↗
PubMed2001

Functional classification of patients with idiopathic scoliosis assessed by the Quantec system: a discriminant functional analysis to determine patient curve magnitude.

STUDY DESIGN: A stepwise discriminant analysis was used to define a spinal deformity score based on three-dimensional measurements by the Quantec spinal image system (raster stereophotograph). OBJECTIVE: To provide functional classification of spinal deformity in patients with mild idiopathic scoliosis without using radiographs. SUMMARY OF BACKGROUND DATA: Most studies classify the degree of spinal deformity in terms of coronal plane radiograph without analyzing transverse rotation. To the authors' knowledge, no studies investigating classification of spinal deformity in idiopathic scoliosis using Quantec system measurements have been documented. METHODS: In this study, 129 patients with a single curve and 119 patients with a double curve were divided into three groups according to Cobb angle: Group 1 (less than 10 degrees ), Group 2 (10-20 degrees ), and Group 3 (greater than 20 degrees ). RESULTS: The patients were assigned to the group with the highest scores after application of a stepwise discriminant analysis. The accuracy of the classification system by functional scores for the patients with a single curve was 85% for Group 1, 63.5% for Group 2, and 71.7% for Group 3. The accuracy of classification by functional scores for the patients with a double curve was 87.1% for Group 2 and 76.1% for Group 3. CONCLUSION: The back surface image study is a method for providing a quantitative assessment of mild spinal deformity, allowing evaluation of patients by integrated three-dimensional parameters with no reference to radiographs.

Adolescent↗
PubMed2001

Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis.

STUDY DESIGN: A prospective review of patients undergoing epidural catheter placement after anterior spinal fusion and instrumentation for adolescent scoliosis was performed. Data were collected using visual analog pain scores reflecting the patients' perception of their pain control. OBJECTIVES: To present the authors' technique for epidural catheter placement and dosing protocol, and to demonstrate the results from postoperative pain control after anterior spinal instrumented fusion for 10 consecutive patients. SUMMARY OF BACKGROUND DATA: The literature regarding the benefits of epidural catheters after spinal surgery is contradictory, even with controlled studies comparing epidural catheters with intravenous morphine patient-controlled anesthesia. The authors believe that this lack of consensus stems from varied epidural dosing protocols and techniques in catheter placement, which they have witnessed anecdotally at their own institution. This prompted the authors to develop and refine a standardized dosing and catheter placement protocol for pain control after spinal surgery. METHODS: Epidural catheters were placed intraoperatively before wound closure, then removed on postoperative Day 5. Dosing consisted of fentanyl (1 microg/kg) and hydromorphone (5 microg/kg) diluted in preservative-free saline (0.2 mL/kg). After surgery, dosing consisted of 0.1% ropivacaine and hydromorphone (10 microg/ml) continuously infused at 0.2 mL/kg/hour. Postoperative pain control was assessed on each postoperative day using a visual analog pain scale with choices ranging from 0 to 10. RESULTS: The arithmetic mean of the median pain scores after surgery was 2.1. The mean of the maximum pain scores for the 5 days was 4.1. Three patients required an epidural bolus and a 20% increase in the epidural infusion rate. One patient was judged to be excessively sleepy, so the epidural infusion rate was decreased by 20%. Pruritus requiring diphenhydramine developed in three patients. No other adverse effects related to epidural analgesia were noted. No catheters were accidentally pulled out or disconnected. CONCLUSION: By following the dosing protocol described, epidural catheters can be used safely and effectively to control postoperative pain after anterior instrumentation and spinal fusion for adolescent scoliosis.

Adolescent↗
PubMed2001

Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited.

OBJECTIVE: To determine the incidence of delayed infections in idiopathic scoliosis treated with TSRH instrumentation, proper wound management after instrumentation removal, and whether the previously identified bacterial trend remains consistent. METHODS: All patients with idiopathic scoliosis > or =2 years after surgery with posterior TSRH instrumentation were included. Those cases with delayed infections were retrospectively reviewed. Time of presentation (infection) from index operation, clinical picture, sedimentation rate, presence of pseudarthrosis, organisms grown on culture, type of wound closure, and duration of antibiotics were examined. RESULTS: A total of 489 patients were identified > or =2 years postoperation; 23 had delayed infections (4.7%). Time of presentation averaged 27 months after initial surgery. Spontaneous drainage occurred in 15 patients, fluctuance in 6, and neither in the remaining 2 (pain and fever). Sedimentation rate averaged 48 mm/hr. All patients had instrumentation removed. Primary closure (1 stage) was performed in 14 patients, and delayed primary closure (> or =2 stages) was performed in nine patients. All wounds healed uneventfully. Cultures at the time of instrumentation removal grew Propionibacterium acnes in 12 patients, Staphylococcus epidermidis (or Staphylococcus coagulase-negative) in 4, Micrococcus varians in 1, and Staphylococcus aureus in 1. Five patients had negative cultures. After removal, patients received parenteral antibiotics; in 21 of these patients this was followed by oral antibiotics. CONCLUSIONS: Low-virulent skin organisms are primarily responsible for delayed infections. Intraoperative seeding followed by subclinical quiescent periods appears to be the method by which infection occurs. The increased bulk and modularity of modern instrumentation systems can lead to inflammation and bursa formation, thus contributing significantly to the activation of these infections. Primary wound closure results in successful wound healing. Delayed closure after 48 hours is unnecessary. Short-term postoperative parenteral antibiotics (2-5 days) followed by short-term oral antibiotics (7-14 days) is recommended.

Adolescent↗
PubMed2002

Is Cobb angle progression a good indicator in adolescent idiopathic scoliosis?

STUDY DESIGN: A retrospective follow-up study of spine geometry after posterior instrumentation and fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVES: To evaluate 1) if Cobb angle progression is a reliable indicator of the crankshaft phenomenon; 2) if significant growth of the spine can occur after surgery without the development of a crankshaft phenomenon? SUMMARY OF BACKGROUND DATA: Anterior fusion of the spine is often recommended for skeletally immature scoliotic patients to avoid the risk of a crankshaft phenomenon, a long-term loss of curve correction caused by residual growth of the spine combined with the constraints of a posterior fusion. The crankshaft phenomenon is usually assessed indirectly by documenting progression of the Cobb angle on frontal radiographs. Thus far, no study has directly measured the three-dimensional growth of the spine after surgery in AIS. METHODS: Cobb angle, spine length and spine height were obtained from three-dimensional radiographic reconstructions of the spine in 48 adolescent scoliotic patients undergoing posterior instrumentation and fusion. Measurements were done before surgery, after surgery and at skeletal maturity. A significant growth of the spine was defined as a > or = 10 mm increase in spine length, while a significant curve progression was defined as a > or = 10 degrees increase in Cobb angle at skeletal maturity. RESULTS: In the majority of patients (56%), there was no significant change in spinal length or in Cobb angle measurements at an average 2.4 years post surgery. A crankshaft phenomenon was detected in 6 patients (12%) for which significant increases both in spinal length and Cobb angle measurement were found. Significant curve progression without any change in spine length was noted in 9 patients (19%) while an increase in spine length with no evidence of curve progression was present in 6 patients at last follow-up. CONCLUSION: Spinal growth as indicated by an increase in spinal length can be measured in a significant proportion of adolescents with idiopathic scoliosis after posterior instrumentation and fusion. Some of these study participants will develop a crankshaft phenomenon but Cobb angle progression is not a reliable indicator of this complication, since it may occur without any detectable growth of the spine.

Adolescent↗
PubMed2002

Biomechanical analysis of anterior scoliosis instrumentation: differences between single and dual rod systems with and without interbody structural support.

STUDY DESIGN: Nondestructive biomechanical testing was performed on bovine lumbar spines instrumented with multilevel scoliosis type anterior spine constructs. OBJECTIVE: To determine the biomechanical effects from the number of anterior rods (1 vs 2) and the effects of interbody structural support on construct stiffness after anterior multisegmental instrumentation. SUMMARY OF BACKGROUND DATA: Corrective surgery using anterior instrumentation for thoracolumbar and lumbar scoliosis has been performed with single rod and, more recently, with dual rod constructs. The biomechanical effect of one- or two-rod anterior instrumentation systems on construct stiffness and the addition or absence of interbody structural support have not been defined adequately in the literature. METHODS: Eight bovine lumbar spines each underwent instrumentation using four different constructs: one rod without interbody support; one rod with titanium mesh interbody support at the L2-L3, L3-L4, and L4-L5 disc spaces; two rods alone; and two rods with interbody support. Nondestructive cyclic testing in flexion-extension (+/-5 Nm), lateral bending (+/-5 Nm), and torsion (+/-2 Nm) were performed. The construct stiffness (Nm/ degrees ) of the four implant configurations was compared. RESULTS: With the addition of a second rod, the construct was significantly stiffer than a single rod construct in flexion (P = 0.006), extension (P = 0.02), and torsion (P = 0.01), but not in lateral bending. The addition of interbody structural support to the rod systems resulted in significantly stiffer constructs than those without cages in flexion (P = 0.03), but not in the other loading conditions (extension, lateral bending, torsion). CONCLUSIONS: Dual rod constructs were stiffer in torsion and flexion-extension loading than single rod constructs. Neither the number of rods nor the use of structural mesh interbody support had any effect on lateral bending stiffness. However, in a single rod system, the addition of interbody support increased stiffness in flexion. The use of structural support in dual rod constructs may be helpful in "setting" the desired lordosis, but adds little to construct stiffness.

Animals↗
PubMed2002

Platelet calmodulin levels in adolescent idiopathic scoliosis: do the levels correlate with curve progression and severity?

STUDY DESIGN: This ongoing longitudinal study evaluates simultaneous radiographic and platelet calmodulin determinations for patients with idiopathic scoliosis who are skeletally immature. OBJECTIVES: To determine whether platelet calmodulin levels correlate with curve progression and severity. SUMMARY OF BACKGROUND DATA: A previous study based on a single calmodulin determination and a single radiograph identified higher calmodulin levels in progressive curves and in higher magnitude curves. A longitudinal study was needed to demonstrate the relation of calmodulin to curve changes for individual patients over time during the growth period. METHODS: In this study, 55 patients with idiopathic scoliosis of varying types and severity were followed longitudinally with serial radiographs and platelet calmodulin determinations. A Risser sign was recorded for each radiograph at each visit. RESULTS: Calmodulin levels increased in all the patients with progressive curves (13/13), remained stable in 73% of the patients with nonprogressive curves (11/15), and were higher generally in curves greater than 30 degrees and double structural curves. Calmodulin levels usually decreased in patients undergoing brace treatment (14/17) or spine fusion (9/10). CONCLUSIONS: It appears that platelet calmodulin levels correlate closely with curve progression and stabilization by bracing or spine fusion. Correlation with nonprogressive curves was not as consistent, with 27% noncorrelation. Longer follow-up evaluation and enrollment of additional patients will be necessary to determine whether calmodulin may serve as a biochemical marker of curve progression and to help identify stable and progressive curves.

Adolescent↗
PubMed2002

Desmoid tumor of the spinal canal causing scoliosis and paralysis.

STUDY DESIGN: This report describes a case of successful surgical excision of an intrathoracic paraspinal desmoid tumor with an intraspinous extension causing scoliosis and paralysis in a 12-year-old girl. OBJECTIVES: The purpose of this report is to illustrate the potential spectrum of disease of a desmoid tumor and to make physicians aware of the rare possibility of an intraspinal extension of a paraspinal desmoid tumor. SUMMARY OF BACKGROUND DATA: Surgical excision of desmoid tumors in the pediatric population is the standard of care for initial treatment. There have been no clinical reports in the spine literature of a desmoid tumor causing scoliosis or of a desmoid tumor with an intraspinous extension causing paralysis. METHODS: The tumor was decompressed from a posterior approach followed by an anterior resection and an anterior spinal fusion. Two weeks later a posterior spinal fusion was performed to correct the spinal deformity. The patient also received radiation therapy after surgery for 5 weeks. RESULTS: The patient tolerated the procedure well, has been free of recurrence for 9 years, and is currently doing well. CONCLUSION: This case report should help expand the understanding of the spectrum of this uncommon tumor.

Child↗
PubMed2002

Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. OBJECTIVES: To correlate radiographic and clinical features of shoulder balance and the proximal thoracic curve with patient satisfaction outcomes at a minimum 2-year follow-up. SUMMARY OF BACKGROUND DATA: Traditionally, radiographic features of a structural proximal thoracic curve have been T1 tilt, proximal thoracic Cobb angle, and proximal thoracic side-bending Cobb; however, these do not always correlate with clinical shoulder balance. METHODS: A total of 112 patients (single surgeon) with adolescent idiopathic scoliosis and a proximal thoracic curve >or=20 degrees (average 32 degrees, range 20-78 degrees) were evaluated in terms of shoulder balance and curve flexibility/correction. Four groups were analyzed: Group 1, posterior spinal fusion to T2 (proximal thoracic curve included, n = 24); Group 2, posterior spinal fusion to T3 (proximal thoracic curve partially included, n = 23); Group 3, posterior spinal fusion to T4 or T5 (proximal thoracic curve not included, n = 21); and Group 4, anterior spinal fusion to T4 or below (proximal thoracic not included, n = 44). Proximal thoracic, main thoracic, and thoracolumbar-lumbar upright coronal, side-bending, and sagittal Cobb measurements were assessed before surgery, 1 week after surgery, and at a minimum 2-year postoperative follow-up (average 3.8 years, range 2.0-7.6 years). In addition to T1 tilt, clavicle angle (intersection of a horizontal line and the tangential line connecting the highest two points of each clavicle), coracoid height difference, trapezius length (horizontal distance of the T2 pedicle to second rib-clavicle intersection), first rib-clavicle height difference (vertical distance of first rib apex to superior clavicle), and proximal thoracic, main thoracic, and thoracolumbar-lumbar apical vertical translation were determined. Shoulder asymmetry as measured by the radiographic soft tissue shadow was graded as balanced (<1 cm), slight (1-2 cm), moderate (2-3 cm), or significant (>3 cm). A postoperative patient questionnaire addressed shoulder balance and overall appearance at most recent follow-up. RESULTS: The four groups were found to be statistically equivalent in terms of preoperative proximal thoracic curve (P = 0.4146), proximal thoracic side-bending Cobb (P = 0.2199), main thoracic curve (P = 0.6999), and main thoracic side-bending curves (P = 0.7307). Radiographic: Preoperative proximal thoracic measurements correlating with postoperative shoulder balance (P < 0.05) included the clavicle angle (three of four groups with a trend toward statistical significance in the fourth group, P = 0.07) and coracoid height (two of four groups). No other measurement, including T1 tilt and proximal thoracic side-bending Cobb, correlated in more than one group. Proximal thoracic curve correction was greatest in Group 1 (posterior spinal fusion to T2; average 12 degrees) and Group 4 (anterior spinal fusion to T4 or below; average 12 degrees). Clinical: Shoulder balance improved in all four groups (range 0.38-1.00 grades). There was no difference in shoulder balance between groups (P = 0.2723). Patient assessment: All four groups also reported improvement in self-perceived shoulder balance (63% up to one grade, 37% over two-grade improvement), whereas no patient reported worsening of shoulder balance. There was no significant difference in patient outcomes between the four groups (P = 0.3654). CONCLUSION: The clavicle angle, not T1 tilt, upright proximal thoracic, or side-bending proximal thoracic Cobb, provided the best preoperative radiographic prediction of postoperative shoulder balance. In each of the four groups, postoperative shoulder balance and clinical appearance also improved and correlated with patient postoperative assessments.

Adolescent↗
PubMed2002

Patient-based outcomes analysis of patients with single torsion thoracolumbar-lumbar scoliosis treated with anterior or posterior instrumentation: an average 5- to 9-year follow-up study.

INTRODUCTION: Since the advent of single, stiff rod anterior instrumentation, and now dual rod anterior instrumentation, most thoracolumbar-lumbar scoliosis is treated with an anterior approach. We have previously reported a retrospective comparison of patients with single torsion thoracolumbar-lumbar scoliosis treated with either anterior or posterior instrumented fusion. The purpose of this study is to examine the patient-based outcomes in this cohort of patients at an average of 5 years (anterior instrumentation) and 9 years (posterior instrumentation). MATERIALS AND METHODS: Inclusion criteria were as follows: 1) single torsion thoracolumbar or lumbar curve of <or=70 degrees; 2) thoracic curve bends to <or=20 degrees on nonstressed supine bends; and 3) thoracic kyphosis of <or=60 degrees. Fourteen patients were treated with posterior transpedicular instrumented fusion from 1989 to 1993 (none treated with anterior discectomy). Fourteen patients were treated with anterior, single, solid rod instrumented fusion from 1993 to 1996. SRS 22 was performed after surgery in 12 of 14 patients from the posterior group (average 9.2 years) and in 14 of 14 patients from the anterior group (average 5.1 years). RESULTS: Posterior: The average age was 14.8 years (range 12-17.8 years). Curve correction at average 6.5 years (range 4.0-10.9 years) was 75%. The average lower instrumented vertebra was L3.1. There were no complications. Twelve of 14 patients completed SRS 22 at an average of 9.2 years (range 6.2-10.9 years). Domain scores for Pain, Self-Image, Function, Mental Health, Satisfaction, and Total were 3.8, 4.1, 4.0, 3.8, 4.5, and 4.1, respectively. Anterior: The mean age was 14.5 years (range 12.5-16.5 years). Curve correction at average 4.8 years (range 2.3-7.6 years) was 63% (instrumented segment 89%). The average lower instrumented vertebra was L2.6. Complications included one intercostal neuritis that resolved with suture removal, one broken inferior screw that healed with some loss of correction, and one pseudarthrosis treated successfully with posterior fusion. Fourteen of 14 patients completed SRS 22 at an average of 5.3 years (range 2.0-7.6 years). Domain scores for Pain, Self-Image, Function, Mental Health, Satisfaction, and Total were 4.1, 4.3, 4.4, 4.0, 4.5, and 4.3, respectively. There were no statistically significant differences in any of the domains or the Total score, although there was a trend toward improved function in the patients treated anteriorly. The follow-up was statistically longer in the posterior group. CONCLUSION: At an average of 9 years of follow-up, patients treated with posterior transpedicular instrumentation have equivalent patient-based outcomes to patients treated with anterior single solid rod instrumentation at an average of 5 years of follow-up.

Adolescent↗
PubMed2002

Identifying sources of variability in scoliosis classification using a rule-based automated algorithm.

STUDY DESIGN: Use of a rule-based automated algorithm to determine sources of variability in radiographic classification. OBJECTIVES: To determine whether unambiguous rules encoded in a computer program would ensure reliable classification. SUMMARY OF BACKGROUND DATA: Reliability problems have been identified in classifications used in surgical planning for patients with thoracic idiopathic scoliosis, but the sources of unreliability are not understood. METHODS: Objective classification methodology was tested on the King et al (1983) scheme. There were two novel components: 1) positions of the corners of vertebrae in radiographs were digitized relative to a defined axis system and used in automated evaluation of spinal shape parameters required for classification; and 2) the assignment of a classification was done with a rule-based algorithm. The algorithm was implemented after some ambiguities and absence of precise definitions in the King et al classification scheme had been resolved. The algorithm was tested with radiographs of patients having adolescent idiopathic scoliosis. RESULTS: The automated procedure could encounter reliability problems in cases in which a lumbar curve was very close to crossing the midline, thoracic and lumbar curves were of approximately equal value, when the apex level in the thoracolumbar region was ambiguous, when a Cobb angle was close to 10 degrees, or when the flexibility index was close to unity. CONCLUSION: Objective measurements and rule-based algorithms can eliminate some sources of interobserver and intraobserver errors in classification of spinal deformity. When classification parameters fall close to the boundaries for classification, reliability problems will persist.

Algorithms↗
PubMed2000

Congenital scoliosis.

Congenital scoliosis is a deformity of the developing spine that results from defects in vertebral development. The developmental etiologies may be classified as either a failure of formation, a failure of segmentation, or a mixture of these two modes of maldevelopment. Early detection and close surveillance of congenital scoliosis is critical, as a rapidly progressive curve may lead to significant deformity, pulmonary restriction, and neurologic problems if not treated. Early surgical treatment is often necessary for rapidly progressive curves.

Cervical Vertebrae↗