Lawrence G Lenke

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (391)837.92 Total impact

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    ABSTRACT: Study Design. Retrospective review of prospective database.Objective. To investigate the long-term results following extension of previous long spine fusions to the sacrum.Summary of Background Data. Long spine fusions not involving the sacrum may be complicated by distal degeneration and require subsequent extension to the sacrum. The clinical and radiographic outcomes following such revision remain unknown.Methods. Patients who had extension of a long fusion (≥ 5 levels with a thoracic level at the cranial end) to the sacrum between 2002-2007 at a single institution were analyzed. ODI and SRS scores and/or radiographic parameters were assessed at baseline, 6 weeks and 1, 2, 3 and/or 5 years postoperatively (PO) and complications were recorded.Results. There were 74 patients included with an average age of 49yrs (range: 19-76yrs) and average clinical follow-up of 4.5yrs (range 3mos to 10yrs, 82% >2yrs PO). All had degeneration distal to prior fusions and 72% (n = 53) had fixed sagittal imbalance. Sagittal alignment improved at all PO time points from baseline (mean 78mm), but worsened between 1yr (mean 21mm) and 5yrs PO (mean 44mm, p = 0.01). Major surgical complications occurred in 30% (n = 22) and there were 17 major reoperations in 15 patients (20%). Significant improvements (p<0.05) in ODI and all SRS domain scores were found at each PO time point with no deterioration from 1 to 5yrs PO. Mean outcome scores at 5yrs PO were similar in groups with major surgical complications vs. without and with major reoperation vs. without.Conclusion. Extension of long fusions to the sacrum resulted in significant and sustained improvements in ODI and SRS scores and alignment over 5yrs PO compared to baseline. Major surgical complications occurred in 30% and reoperations were performed in 20%, but outcome scores following treatment were similar to those without complications or reoperations.
    Spine 04/2014; · 2.16 Impact Factor
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    ABSTRACT: The role of preoperative narcotic use and its influence on outcomes following spinal deformity surgery is unknown. It is important to determine what patient factors and co-morbidities can affect the success of spinal deformity surgery, a challenging surgery with high rates of complications at baseline. Evaluate if preoperative narcotic use persists following spinal deformity surgery, and whether the outcomes are adversely affected by preoperative narcotic use. Retrospective evaluation of prospectively collected data PATIENT SAMPLE: 253 adult patients (230 females/23 males) undergoing primary spinal deformity surgery were enrolled from 2000 to 2009. Pre-operative and post-operative narcotic use. Changes in Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) pain and SRS total score. Preoperative, 2-year postoperative and latest follow-up pain medication use were collected along with ODI, SRS pain and SRS scores. Preoperative insurance status, surgical and hospitalization demographics and complications were collected. All patients had a minimum 2-year follow-up (average, 47.4 months). 168 patients (NoNarc) were taking no pain meds/NSAIDs only preoperative. 85 patients (Narc) were taking mild/moderate/heavy narcotics prior to surgery. The average age was 48.2 for the NoNarc versus 53.6 for the Narc group (p<0.005). There were significantly more patients with degenerative than adult scoliosis in the Narc group (47 vs. 28, p<0.001; mild 19 vs. 24, p<0.02; moderate 6 vs. 14, p<0.0003; heavy 3 vs. 10, p<0.0002). Insurance status (private/Medicare/Medicaid) was similar between the groups (p=0.39). At latest follow-up, 137/156 (88%) prior NoNarc patients were still not taking narcotics while 48/79 (61%) prior Narc patients were now off narcotics (p<0.001). Significant postoperative improvements were seen in Narc versus NoNarc with regard to ODI (26-15 vs. 44-30.3, p<0.001), SRS pain (3.36-3.9 vs. 2.3-3.38, p<0.001) and overall SRS outcomes scores (3.36-4 vs. 2.78-3.68, p<0.001). A comparison of change in outcomes scores between the two groups showed a higher improvement in SRS pain scores for the Narc versus NoNarc group (p<0.001). In adults with degenerative scoliosis taking narcotics a significant decrease in pain medication use was noted following surgery. All outcome scores significantly improved postoperative in both groups. However, the Narc group had significantly greater improvements in SRS pain scores versus the NoNarc group.
    The spine journal: official journal of the North American Spine Society 04/2014; · 2.90 Impact Factor
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    ABSTRACT: A previous biomechanical study using adult thoracic vertebrae (both normal and osteoporotic bone density) demonstrated the deleterious effect of the pedicle screw hubbing technique. Pedicle screw "hubbing" involves seating and engaging the ventral aspect of the screw head onto the dorsal lamina cortex. This technique is postulated to provide a load-sharing effect by improving pullout resistance, as well as decreasing cephalocaudad toggling and implant loosening. We hypothesized the elastic properties of immature bone may mitigate, and perhaps enhance the purported benefits of the hubbing technique. We set out to evaluate pullout strength of fixed-head pedicle screws after hubbing versus standard insertion in the immature thoracic calf spine. Twenty-two (n=22) single-level disarticulated fresh-frozen immature calf thoracic vertebra specimens (ranging from T2 to T13) were prepared. Twelve specimens were instrumented with pedicle screws in group I (nonhubbed) and group II (hubbed) in the opposite pedicle. Cyclic loading in a cephalocaudad direction was applied for 2000 cycles at a rate of 1 Hz. Pullout testing was performed in-line with the midline of the vertebra and peak pullout strength was measured in Newtons. Ten different specimens underwent micro-computed tomography evaluation to assess for trabecular architecture and incidence of iatrogenic microfractures. Hubbed screws resulted in significantly lower pullout strength (747±197 vs. 922±112 N, P=0.01). With the hubbing technique, the dorsal cortex demonstrated plastic deformation and conformed to the screw head in 83% of cases compared with no visible plastic deformation in the control group. Micro-computed tomography demonstrated microfractures of the dorsal cortex in 10/10 for the hubbed group compared with 1/10 for the control group. This is the largest study ever performed on immature thoracic vertebra to evaluate this topic. Hubbed pedicle screws have significantly decreased pullout strength and frequently cause iatrogenic microfractures of the dorsal cortex. The unique ability of immature bone to exhibit plastic deformation did not provide a protective effect on immediate fixation strength, and the increased insertional torque during the hubbing technique should not give a false sense of added fixation. This study, along with our adult study, provides critical information to the surgeon to avoid this common misunderstanding with screw insertion technique. In vitro fresh-frozen immature calf spine study.
    Journal of pediatric orthopedics 03/2014; · 1.23 Impact Factor
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    ABSTRACT: Retrospective review of prospective database. To investigate long-term results after 3-column osteotomies (3-CO). Short-term studies have noted improved outcomes and alignment after 3-CO, but there is a paucity of long-term studies with a large group of patients. An analysis of 126 patients who underwent a 3-CO (pedicle subtraction osteotomy [N = 101]/vertebral column resection [N = 25]) with minimum 5-year follow-up was performed at a single institution. The mean age was 48 years (range, 8-79 yr) and average follow-up was for 7 years (range, 5-14 yr). Oswestry Disability Index and Scoliosis Research Society (SRS) scores and radiographical parameters were assessed at baseline, 6 weeks, and 1, 2, 3, and/or 5 years postoperatively and complications were recorded. Sagittal alignment improved at all postoperative time points from baseline (mean, 117 mm), but diminished from 6 weeks (mean, 24 mm) to 5 years (mean, 41 mm; P = 0.03). Average coronal alignment was improved from baseline (27 mm) at 6 weeks (18 mm; P = 0.003) and 5 years postoperatively (19 mm; P = 0.007), with no deterioration between 6 weeks and 5 years postoperatively (P = 0.9). Major surgical complications occurred in 36% (n = 45) and major repeat surgery was performed in 28% (n = 35). Significant improvements (P < 0.05) in Oswestry Disability Index and all SRS domain scores were found at each time point. All mean outcome scores at 5 years postoperatively exceeded minimal clinically important difference thresholds except the SRS function domain. Improvement in outcomes at 5 years postoperatively was similar in groups with major surgical complications versus those without and in those with reoperation versus those without. This study of 126 patients undergoing 3-CO found significant and sustained improvements in Oswestry Disability Index and SRS scores and sagittal alignment at a minimum 5 years postoperatively. This demonstrates the durability of these complex spinal reconstructions, even surprisingly in those patients having a major complication and/or revision surgery.Level of Evidence: 4.
    Spine 03/2014; 39(5):424-32. · 2.16 Impact Factor
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    ABSTRACT: Study Design. Prospectively enrolled, retrospectively analyzed case series.Objective. Evaluate a large series of pediatric/adult spinal deformity patients undergoing surgery with posterior column osteotomies (PCO).Summary of Background Data. Osteotomies of the posterior column (Smith-Petersen or Ponté) are utilized to reduce kyphosis, increase lordosis or increase spinal flexibility. However, little focused evidence exists regarding the efficacy and safety of this technique.Methods. 128 consecutive patients underwent posterior spinal instrumented fusion (PSF) with PCOs with minimum 2-year follow-up. 75 were primary surgeries; 53 were revisions. Data were collected from hospital charts, clinic notes, radiographs and standardized questionnaires [Scoliosis Research Society-30 (SRS-30) and Oswestry Disability Index (ODI)].Results. 128 patients aged 37.6±21 years underwent 518 PCOs (mean, 4.0±2.2) with 14.4±3 mean instrumentation levels, with 3-year (range, 2-6.8) average follow-up. PCOs were used for kyphosis correction in 49%, scoliosis correction at the apex of a curve in 13%, and both in 38%. 106 patients had complete radiographic data available for evaluation. Mean kyphosis correction per PCO was 8.8°±7.2, varying with patient age (10.2° for <21 vs. 7.7° for ≥21, P<0.0001) and region of the spine: Thoracolumbar (TL, T10-L2) 11.6° > lumbar (L, L2-S1) 9.4° > mid-thoracic (MT, T6-10) 7.2° > proximal thoracic (PT, T1-T6) 3.6°. With PCOs at the apex of a curve, max coronal Cobb decreased from 66°±21 to 31°±14 (P<0.0001). Average estimated blood loss (EBL) was 1419±887mL, correlating with greater age (P<0.0001) and more instrumented levels (P<0.0001), but not with number of PCOs (P = 0.32). Complications occurred in 31 (24.2%) patients, including 4 radiculopathies (none attributable to PCOs). Complications did not correlate with number of PCOs (P = 0.5). Six (4.7%) patients had loss of spinal cord monitoring or a failed wake-up test that could be attributed to overcorrection with PCOs, but none had postoperative deficits. ODI scores improved (34.4±17 to 23.6±18, P<0.0001), as did normalized SRS-30 scores (63.7±13 to 76.4±15, P<0.0001).Conclusion. Patients in this series undergoing PSF with PCOs achieved overall favorable outcomes for spinal deformity correction. The number of PCOs did not correlate with increased EBL or complications. The main technical concern was overcorrection, but neurologic consequences associated with overcorrection were identified by intraoperative SCM and wake-up tests, and no patients suffered permanent neurologic deficits related to PCOs.
    Spine 02/2014; · 2.16 Impact Factor
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    ABSTRACT: Object Chiari malformation Type I (CM-I) is a developmental abnormality often associated with a spinal syrinx. Patients with syringomyelia are known to have an increased risk of scoliosis, yet the influence of specific radiographically demonstrated features on the prevalence of scoliosis remains unclear. The primary objective of the present study was to investigate the relationship of maximum syrinx diameter and tonsillar descent to the presence of scoliosis in patients with CM-I-associated syringomyelia. A secondary objective was to explore the role of craniovertebral junction (CVJ) characteristics as additional risk factors for scoliosis. Methods The authors conducted a retrospective review of pediatric patients evaluated for CM-I with syringomyelia at a single institution in the period from 2000 to 2012. Syrinx morphology and CVJ parameters were evaluated with MRI, whereas the presence of scoliosis was determined using standard radiographic criteria. Multiple logistic regression was used to analyze radiological features that were independently associated with scoliosis. Results Ninety-two patients with CM-I and syringomyelia were identified. The mean age was 10.5 ± 5 years. Thirty-five (38%) of 92 patients had spine deformity; 23 (66%) of these 35 patients were referred primarily for deformity, and 12 (34%) were diagnosed with deformity during workup for other symptoms. Multiple regression analysis revealed maximum syrinx diameter > 6 mm (OR 12.1, 95% CI 3.63-40.57, p < 0.001) and moderate (5-12 mm) rather than severe (> 12 mm) tonsillar herniation (OR 7.64, 95% CI 2.3-25.31, p = 0.001) as significant predictors of spine deformity when controlling for age, sex, and syrinx location. Conclusions The current study further elucidates the association between CM-I and spinal deformity by defining specific radiographic characteristics associated with the presence of scoliosis. Specifically, patients presenting with larger maximum syrinx diameters (> 6 mm) have an increased risk of scoliosis.
    Journal of Neurosurgery Pediatrics 02/2014; · 1.63 Impact Factor
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    ABSTRACT: Study Design. Case Control StudyObjective. To evaluate risk factors in patients in 3 groups, those without PJK (N), with PJK but not requiring revision (P) and then those with PJK requiring revision surgery (S).Summary of Background Data. It is becoming clear that some patients maintain stable PJK angles, while others progress and develop severe PJK necessitating revision surgery.Methods. 206 pts at a single institution from 2002-2007 with adult scoliosis with 2 yr min f/u (avg. 3.5 yrs) were analyzed. Inclusion criteria were age > 18, primary fusions >5 levels from any thoracic UIV to any LIV. Revisions were excluded. Radiographic assessment included Cobb measurements in the coronal/sagittal plane and measurements of the PJK angle at post-operative timepoints: 1-2 months, 2 yrs and final f/u. PJK was defined as an angle >10°.Results. The prevalence of PJK was 34%. The average age in N was 49.9 vs. 51.3 in P and 60.1 in S. Gender, Body Mass index (BMI), smoking status were not significantly different between groups. Fusions extending to the pelvis were 74%, 85% and 91% of the cases in Groups N, P and S. Instrumentation type was significantly different between groups N and S with a higher number of UIV hooks in group N. Radiographic parameters demonstrated a higher postop LL and a larger sagittal balance (SVA) change with surgery in those with PJK requiring revision surgery. SRS post-op pain scores were inferior in group N vs. P and S and ODI scores were similar between all groups.Conclusion. PJK patients requiring revision were older, had higher postop LL and larger SVA corrections than patients without PJK. Based on this data, it appears as though older patients with large corrections in their LL and SVA were at risk for developing PJK requiring revision surgery.
    Spine 01/2014; · 2.16 Impact Factor
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    ABSTRACT: Study Design. Retrospective review of prospectively collected databases.Objective. To compare two approaches for assessment of mortality associated with spine surgery.Summary of Background Data. The Scoliosis Research Society (SRS) collects morbidity and mortality (M&M) data from its members. Previously this included details for all spine cases and all complications. To reduce time burden and improve compliance, collection was changed to focus on a few major complications (death, neurologic deficit, and blindness) for specific deformity diagnoses (scoliosis, spondylolisthesis, and kyphosis) and only for cases with complications.Methods. Data were extracted from the SRS from 2004-2007 (detailed system) and 2009-2011 (simplified system). As an anchor for comparison, mortality rates were compared between the systems.Results. Between 2009-2011, 87,162 deformity cases were reported, with 131 deaths (1.50/1,000 cases). Of these 131 patients, mean age was 50, mean ASA grade was 2.8, 10% were smokers, and 18% had diabetes. Rates of death (per 1,000 cases) were: idiopathic scoliosis (0.4), congenital scoliosis (1.3), neuromuscular scoliosis (3.6), other scoliosis (3.1), spondylolisthesis (0.6), and kyphosis (4.7). Common causes of mortality included respiratory (48), cardiac (32), sepsis (12), organ failure (9), and blood loss (7). Compared with the detailed system, the simplified system had greater surgeon compliance (79% versus 62%, p<0.001), greater number of deformity cases/reporting surgeon/year (139 versus 90, p<0.001) and had modestly but significantly lower mortality rates (1.50 versus 1.80/1,000 cases; p<0.001). Causes of death were comparable between the two systems.Conclusion. Based on the simplified collection system, the rate of mortality for spinal deformity surgery was 1.50/1,000 cases. Compared with the detailed system, the simplified system had significantly improved compliance and similar mortality rates. Although the simplified system is limited by less data collected, it achieves better compliance and may prove effective, especially if supplemented with focused data collection modules.
    Spine 01/2014; · 2.16 Impact Factor
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    ABSTRACT: Global sagittal malalignment is significantly correlated with health-related quality-of-life scores in the setting of spinal deformity. In order to address rigid deformity patterns, the use of spinal osteotomies has seen a substantial increase. Unfortunately, variations of established techniques and hybrid combinations of osteotomies have made comparisons of outcomes difficult. To propose a classification system of anatomically-based spinal osteotomies and provide a common language among spine specialists. The proposed classification system is based on 6 anatomic grades of resection (1 through 6) corresponding to the extent of bone resection and increasing degree of destabilizing potential. In addition, a surgical approach modifier is added (posterior approach or combined anterior and posterior approaches). Reliability of the classification system was evaluated by an analysis of 16 clinical cases, rated 2 times by 8 different readers, and calculation of Fleiss kappa coefficients. Intraobserver reliability was classified as "almost perfect"; Fleiss kappa coefficient averaged 0.96 (range, 0.92-1.0) for resection type and 0.90 (0.71-1.0) for the approach modifier. Results from the interobserver reliability for the classification were 0.96 for resection type and 0.88 for the approach modifier. This proposed anatomically based classification system provides a consistent description of the various osteotomies performed in spinal deformity correction surgery. The reliability study confirmed that the classification is simple and consistent. Further development of its use will provide a common frame for osteotomy assessment and permit comparative analysis of different treatments. P, posterior approachA/P, combined anterior and posterior approachesPSO, pedicle subtraction osteotomy.
    Neurosurgery 01/2014; 74(1):112-20. · 2.53 Impact Factor
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    ABSTRACT: Background Context The role of preoperative narcotic use and its influence on outcomes following spinal deformity surgery is unknown. It is important to determine what patient factors and co-morbidities can affect the success of spinal deformity surgery, a challenging surgery with high rates of complications at baseline. Purpose Evaluate if preoperative narcotic use persists following spinal deformity surgery, and whether the outcomes are adversely affected by preoperative narcotic use. Study Design/Setting Retrospective evaluation of prospectively collected data Patient Sample 253 adult patients (230 females/23 males) undergoing primary spinal deformity surgery were enrolled from 2000 to 2009. Outcome Measures Pre-operative and post-operative narcotic use. Changes in Oswestry Disability Index (ODI), Scoliosis Research Society (SRS) pain and SRS total score. Methods Preoperative, 2-year postoperative and latest follow-up pain medication use were collected along with ODI, SRS pain and SRS scores. Preoperative insurance status, surgical and hospitalization demographics and complications were collected. All patients had a minimum 2-year follow-up (average, 47.4 months). Results 168 patients (NoNarc) were taking no pain meds/NSAIDs only preoperative. 85 patients (Narc) were taking mild/moderate/heavy narcotics prior to surgery. The average age was 48.2 for the NoNarc versus 53.6 for the Narc group (p<0.005). There were significantly more patients with degenerative than adult scoliosis in the Narc group (47 vs. 28, p<0.001; mild 19 vs. 24, p<0.02; moderate 6 vs. 14, p<0.0003; heavy 3 vs. 10, p<0.0002). Insurance status (private/Medicare/Medicaid) was similar between the groups (p=0.39). At latest follow-up, 137/156 (88%) prior NoNarc patients were still not taking narcotics while 48/79 (61%) prior Narc patients were now off narcotics (p<0.001). Significant postoperative improvements were seen in Narc versus NoNarc with regard to ODI (26-15 vs. 44-30.3, p<0.001), SRS pain (3.36-3.9 vs. 2.3-3.38, p<0.001) and overall SRS outcomes scores (3.36-4 vs. 2.78-3.68, p<0.001). A comparison of change in outcomes scores between the two groups showed a higher improvement in SRS pain scores for the Narc versus NoNarc group (p<0.001). Conclusion In adults with degenerative scoliosis taking narcotics a significant decrease in pain medication use was noted following surgery. All outcome scores significantly improved postoperative in both groups. However, the Narc group had significantly greater improvements in SRS pain scores versus the NoNarc group.
    The Spine Journal. 01/2014;
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    ABSTRACT: Study Design. Retrospective review of prospectively-accrued cohorts.Objective. We hypothesized that posterior-only vertebral column resection (PVCR) would result in improved postoperative pulmonary function, avoiding pulmonary insults from combined anterior/posterior (A/P) approaches.Summary of Background Data. Pulmonary function after PVCR for severe spinal deformity has not been previously studied. Previous studies have demonstrated impaired pulmonary performance after combined A/P fusions.Methods. Serial pulmonary function testing (PFTs) in 49 patients (27 pediatric, 22 adult) who underwent PVCR at a single institution were reviewed. Mean age at surgery was 28.7 years (range, 8-74 years), and mean follow-up was 32 months (range, 23-64 months). Thoracic PVCRs (T5-T11) were performed in 31 patients and thoracolumbar PVCRs (T12-L5) in 18 patients.Results. Pediatric PVCR patients experienced both increased mean forced vital capacity (FVC) (2.10 to 2.43L, p = 0.0005) and forced expiratory volume in 1 second (FEV1) (1.71 to 1.98L, p = 0.001). There were no significant differences in percent-predicted values (%PV) for FVC (69% to 66%, p = 0.51) or FEV1 (64% to 63%, p = 0.77). In adult patients, there were no significant changes in FVC (2.73 to 2.61L, p = 0.35) or FEV1 (2.22 to 2.07L, p = 0.51) after PVCR; also, changes in adult%PV for FVC (79% to 76%, p = 0.47) and FEV1 (78% to 74%, p = 0.40) were not significant. In pediatric PVCR patients, improved PFTs were correlated with younger age (p = 0.02), diagnosis of angular kyphosis (p≤0.0001), no previous spine surgery (p = 0.04), and preoperative halo traction (p = 0.02). Comparison of PFT changes between PVCR patients and a control group who underwent combined A/P approaches revealed no significant differences.Conclusion. In pediatric patients, PVCR resulted in small but significant improvements in postoperative FVC and FEV1. In adult patients, no significant increases in PFTs were found. Patients who have the greatest potential for lung and thoracic cage growth after spinal correction are most likely to have improved pulmonary function after PVCR.
    Spine 12/2013; · 2.16 Impact Factor
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    ABSTRACT: With the increasing popularity of thoracic pedicle screws, the freehand technique has been espoused to be safe and effective. However, there is currently no objective, definable landmark to assist with freehand insertion of pedicle screws in the thoracic spine. With our own increasing surgical experience, we have noted a reproducible and unique anatomic structure known as the ventral lamina. We set out to define the morphologic relationship of the ventral lamina to the superior articular facet (SAF) and pedicle, and describe an optimal medial-lateral pedicle screw starting point in the thoracic spine. We conducted an in vitro fresh-frozen human cadaveric study. One hundred fifteen thoracic spine vertebral levels were evaluated. After the vertebral body was removed, Kirschner wires were inserted retrograde along the four boundaries of the pedicle. Using digital calipers, we measured width of the SAF and pedicle at the isthmus, and from the borders of the SAF to the boundaries of the pedicle. We calculated the morphologic relationship of the ventral lamina and the center of the pedicle (COP) to the SAF. Two hundred twenty-nine pedicles were measured, with one pedicle excluded because of fracture of the SAF during disarticulation. The ventral lamina was clearly identifiable at all levels, forming the roof of the spinal canal and confluent with the medial pedicle wall (MPW). The mean distance from the SAF midline to the MPW was 1.36±1.23 mm medial. The MPW was lateral to SAF midline in 34 pedicles (14.85%) and, on average, was a distance of 0.52±0.51 mm lateral. The mean distance from the SAF midline to the COP was 2.17±1.38 mm lateral. The COP was medial to SAF midline in only 11 pedicles (4.80%). The ventral lamina is an anatomically reproducible structure located consistently medial to the SAF midline (85%). We also found the COP consistently lateral to the SAF midline (95%). Based on these morphologic findings, the medial-lateral starting point for thoracic pedicle screws should be 2 to 3 mm lateral to the SAF midline (superior facet rule), allowing screw placement in the COP and avoiding penetration into the spinal canal.
    The spine journal: official journal of the North American Spine Society 11/2013; · 2.90 Impact Factor
  • Daniel G Kang, Ronald A Lehman, Lawrence G Lenke
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    ABSTRACT: Phan P, Mezghani N, Wai EK, et al. Artificial neural networks assessing adolescent idiopathic scoliosis: comparison with Lenke classification. Spine J 2013;13:1527-33 (in this issue).
    The spine journal: official journal of the North American Spine Society 11/2013; 13(11):1534-7. · 2.90 Impact Factor
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    ABSTRACT: There are no guidelines for when surgeons should allow patients to return to sports and athletic activities after spinal fusion for adolescent idiopathic scoliosis (AIS). Current recommendations are based on anecdotal reports and a survey performed more than a decade ago in the era of first/second-generation posterior implants. To identify current recommendations for return to sports and athletic activities after surgery for AIS. Questionnaire-based survey. Adolescent idiopathic scoliosis after corrective surgery. Type and time to return to sports. A survey was administered to members of the Spinal Deformity Study Group. The survey consisted of surgeon demographic information, six clinical case scenarios, three different construct types (hooks, pedicle screws, hybrid), and questions regarding the influence of lowest instrumented vertebra (LIV) and postoperative physical therapy. Twenty-three surgeons completed the survey, and respondents were all experienced expert deformity surgeons. Pedicle screw instrumentation allows earlier return to noncontact and contact sports, with most patients allowed to return to running by 3 months, both noncontact and contact sports by 6 months, and collision sports by 12 months postoperatively. For all construct types, approximately 20% never allow return to collision sports, whereas all surgeons allow eventual return to contact and noncontact sports regardless of construct type. In addition to construct type, we found progressively distal LIV resulted in more surgeons never allowing return to collision sports, with 12% for selective thoracic fusion to T12/L1 versus 33% for posterior spinal fusion to L4. Most respondents also did not recommend formal postoperative physical therapy (78%). Of all surgeons surveyed, there was only one reported instrumentation failure/pullout without neurologic deficit after a patient went snowboarding 2 weeks postoperatively. Modern posterior instrumentation allows surgeons to recommend earlier return to sports after fusion for AIS, with the majority allowing running by 3 months, noncontact and contact sports by 6 months, and collision sports by 12 months.
    The spine journal: official journal of the North American Spine Society 10/2013; · 2.90 Impact Factor
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    ABSTRACT: The Shilla growth guidance technique has been developed to treat spinal deformities without the necessity of repeated operative lengthenings. The dual stainless steel rods are fixed to the corrected apex of the curve by pedicle screws with limited fusion about the apex. Vertebral growth occurs in a cephalad and caudad direction through extraperiosteally placed sliding pedicle screws. A retrospective review of patients treated with the Shilla growth guidance technique for early-onset spinal deformity was performed to study patients with >2-year follow-up and describe outcome parameters. From a cohort of 38 patients, 10 patients with a mean age of 7+6 years were identified as qualifying for 2-year follow-up inclusion. The average preoperative curve of 70.5 degrees was corrected to 27 degrees at 6 weeks follow-up and maintained at 2-year follow-up. The space available for lung improved an average of 13%. Truncal height (C7 to S1) increased an average of 12%. One patient required rod revision, 1 required rod change to a smaller size rod, and 1 required rod replacement. Two patients required wound debridement for low-grade infection in the early-postoperative period for a total of 5 procedures beyond the index correction. No patient had changes neurologically as a result of surgery. Patients were braced for the first 3 months postoperatively while the fusion was incorporating then not thereafter. At 2-year follow-up, the Shilla procedure has allowed children correction of their spinal deformity with an acceptable complication rate and ability to grow brace free without repeated trips to the operating room for lengthenings. These patients would have had 49 scheduled lengthening procedures after their initial correction if treated by conventional distraction growing rod methods. IV case series of therapeutic study investigating results of treatment.
    Journal of pediatric orthopedics 08/2013; · 1.23 Impact Factor
  • Michael P Kelly, Ronald A Lehman, Lawrence G Lenke
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    ABSTRACT: Hamzaoglu A, Ozturk C, Enercan M, Alanay A. Traction X-ray under general anesthesia helps to save motion segment in treatment of Lenke type 3C and 6C curves. Spine J 2013;13:845-52 (in this issue).
    The spine journal: official journal of the North American Spine Society 08/2013; 13(8):853-5. · 2.90 Impact Factor
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    ABSTRACT: Study Design: Retrospective case series.Objective: The aim of this study was to determine the repeat revision rates for all revision SD surgeries performed at a single center and to investigate the changes in measures of HRQL in these patients.Summary of Background Data: Reported revision rates for primary adult spinal fusion surgeries have ranged from 9% to 45%, but to our knowledge, the repeat revision rate following revision spinal deformity (SD) surgery has not been reported. The reported improvements in health-related quality of life (HRQL) measures following revision SD surgery have also been quite modest.Methods: 455 consecutive adult revision SD surgeries (1995-2008) were identified and the records were reviewed to determine the reason for and timing to any additional operation(s). SRS Outcomes scores were recorded at the first visit and at planned followup visits.Results: 94/455 patients underwent further surgeries for a repeat revision rate of 21%. 2-year followup was available for 74 (78%) of these patients (mean followup, 6.0 years, range 2.4-12.6, gender: F = 61, M = 13; mean age 53 years, range 21-78). The most common causes of repeat revision surgery were pseudarthrosis (N = 23, 31%), implant prominence/pain (N = 15, 20%), adjacent segment disease (N = 14, 19%), and infection (N = 10, 14%). Twenty five (27%) patients underwent more than one revision procedure. SRS Outcomes scores were available for 50 (68%) patients, at an average followup of 4.9 years (range 2-11.4). The mean improvements in the SRS outcomes measures were Pain: 0.74 (p<0.001), Self-Image: 0.8 (p<0.001), Function: 0.5 (p<0.001), Satisfaction: 1.2 (p<0.001) and Mental Health: 0.3 (p = 0.012).Conclusion: The rate of repeat revision following revision spinal deformity surgery was 21%, most commonly due to pseudarthrosis, adjacent segment disease, infection and implant prominence/pain. However, significant improvements in SRS outcome scores were still observed in those patients requiring additional revision procedures.
    Spine 06/2013; · 2.16 Impact Factor
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    ABSTRACT: Study DesignMulticenter matched case analysis.Objective Compare patients with Lenke 5C scoliosis surgically treated with anterior spinal fusion with dual rod instrumentation and anterior column support versus posterior release and pedicle screw instrumentation.Summary of Background DataTreatment of single, structural, lumbar and thoracolumbar curves in patients with adolescent idiopathic scoliosis (AIS) has been the subject of some debate. Previous papers directly comparing these approaches are problematic because of heterogeneity of the groups, nonrandomized protocols, and surgeon bias and variation of instrumentation (upper instrumented vertebrae and lower instrumented vertebrae) in relation to the defined Cobb angle (upper end vertebra and lower end vertebrae). This report sought to remedy these flaws by analyzing a database of Lenke 5C AIS and performing matched cases.Methods We analyzed 96 patients with Lenke 5C AIS curves based on radiographic and clinical data at 3 institutions, surgically treated between 2001 and 2005 with minimum 2-year follow-up. Case matched criteria (age within 1 year, sex, curve within 5°, lower end vertebrae, and lower instrumented vertebrae) yielded 21 matched patient pairs. We evaluated and compared multiple clinical and radiographic parameters.ResultsWe observed no significant statistical differences between groups in any preoperative clinical or radiographic parameters. At final follow-up, the major curve measured 8° (83%) in the posterior spinal fusion group, compared with 13° (72%) in the anterior spinal fusion group (p = .002). Estimated blood loss was similar in both groups. Hospital stay was significantly shorter in the posterior spinal fusion group. There were no differences in radiographic complications, such as proximal junctional kyphosis.Conclusions At a minimum of 2 years' follow-up in a multicenter, matched case analysis, adolescents with Lenke 5C curves demonstrated statistically significantly better curve correction and shorter hospital stays when treated with a posterior release with pedicle screw instrumented fusion compared with an anterior instrumented fusion with dual rods for similar patient populations.
    Spine Deformity. 05/2013; 1(3):217–222.
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    ABSTRACT: Study Design. Multicenter retrospective analysis of prospectively collected data.Objective. Evaluate radiographic and clinical characteristics of patients undergoing an STF for Lenke 1C curves.Summary of Background Data. Selective thoracic fusion (STF) of adolescent idiopathic scoliosis (AIS) has been advocated for the so-called "false double major" curve (Lenke 1C/King Type II). Despite these recommendations, many surgeons continue to perform non-selective fusions (NSF) for this curve type. It is unknown to what extent other factors influence the surgeon's fusion level selection.Methods. A prospective multicenter database included 264 patients with surgically treated Lenke 1C curves and were divided into two groups. The STF group included patients with the lowest instrumented vertebra (LIV) at or cephalad to L1, while the NSF group included patients with the LIV at or caudal to L3. Preoperative radiographic, clinical (scoliometer), Scoliosis Appearance Questionnaire (SAQ), and Scoliosis Research Society (SRS) questionnaires were analyzed and compared.Results. Only 138/264 patients (49%) underwent an STF. Gender ratio (90% vs. 86% female), average age (14.7 vs. 14.8 years), and preoperative main thoracic (MT) Cobb angles (56.0°±9.9 vs. 55.3°±11.4) were not significantly different (STF vs. NSF). However, the average thoracolumbar/lumbar (TL/L) preoperative Cobb angle was significantly smaller in the STF group (42.1°±8.6 vs. 47.0°±9.0; p<0.001) while the MT:TL/L Cobb ratio (1.35±0.20 vs. 1.18±0.15; p<0.001), apical vertebral translation and rotation (1.82±0.59 vs. 1.31±0.53; p<0.001), (1.16 vs. 0.98; p<0.001) were significantly greater in the STF group. Preoperative coronal balance, sagittal Cobb angles (including T10-L2 kyphosis) and Risser Grade were not significantly different. Preoperative TL/L scoliometer measures were significantly less in the STF group (8.1°±3.7 vs. 10.3°±5.4; p = 0.001). On the SAQ, the STF group had less desire for an appearance change.Conclusion. Despite the recommendation to fuse only the structural thoracic curve in a 1C curve, only 49% of patients were treated with an STF. An STF resulted in smaller TL/L Cobb angles, less TL/L clinical deformity, larger MT:TL/L ratios, and less desire for an appearance change.
    Spine 04/2013; · 2.16 Impact Factor
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    ABSTRACT: STUDY DESIGN.: Retrospective study with prospectively collected outcomes data. OBJECTIVE.: Determine the significance of coronal balance on spinal deformity surgery outcomes. SUMMARY OF BACKGROUND DATA.: Sagittal balance has been confirmed as an important radiographic parameter correlating with adult deformity treatment outcomes. The significance of coronal balance on functional outcomes is less clear. METHODS.: Eighty-five patients with more than 4 cm of coronal imbalance who underwent reconstructive spinal surgery were evaluated to determine the significance of coronal balance on functional outcomes as measured with the Oswestry Disability Index (ODI) and Scoliosis Research Society outcomes questionnaires. Sixty-two patients had combined coronal (>4 cm) and sagittal imbalance (>5 cm), while 23 patients had coronal imbalance alone. RESULTS.: Postoperatively, 85% of patients demonstrated improved coronal balance. The mean improvement in the coronal C7 plumb line was 26 mm for a mean correction of 42%. The mean preoperative sagittal C7 plumb line in patients with combined coronal and sagittal imbalance was 118 mm (range, 50-310 mm) and improved to a mean 49 mm. The mean preoperative and postoperative ODI scores were 42 (range, 0-90) and 27 (range, 0-78), for a mean improvement of 15 (36%) (P = 0.00001; 95% CI, 12-20). The mean Scoliosis Research Society scores improved by 17 points (29%) (P = 0.00). Younger age (P = 0.008) and improvement in sagittal balance (P = 0.014) were positive predictors for improved ODI scores. Improvement in sagittal balance (P = 0.010) was a positive predictor for improved Scoliosis Research Society scores. In patients with combined coronal and sagittal imbalance, improvement in sagittal balance was the most significant predictor for improved ODI scores (P = 0.009). In patients with preoperative coronal imbalance alone, improvement in coronal balance trended toward, but was not a significant predictor for improved ODI (P = 0.092). CONCLUSION.: Sagittal balance improvement is the strongest predictor of improved outcomes in patients with combined coronal and sagittal imbalance. In patients with coronal imbalance alone, improvement in coronal balance was not a factor for predicting improved functional outcomes.
    Spine 03/2013; 38(6):476-483. · 2.16 Impact Factor

Publication Stats

8k Citations
837.92 Total Impact Points

Institutions

  • 1992–2014
    • Washington University in St. Louis
      • • Department of Orthopaedic Surgery
      • • Department of Anesthesiology
      San Luis, Missouri, United States
  • 2006–2013
    • University of Utah
      Salt Lake City, Utah, United States
    • The University of Tokyo
      • Department of Surgical Sciences
      Tokyo, Tokyo-to, Japan
  • 1995–2013
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
  • 2012
    • University of California, Los Angeles
      • Department of Orthopaedic Surgery
      Los Angeles, CA, United States
    • Harvard Medical School
      Boston, Massachusetts, United States
    • Miami Children's Hospital
      Miami, Florida, United States
  • 2002–2012
    • Walter Reed National Military Medical Center
      • • Division of Orthopaedic Surgery
      • • Department of Orthopaedics and Rehabilitation
      Washington, Washington, D.C., United States
    • Madigan Army Medical Center
      Tacoma, Washington, United States
    • University of Missouri
      • Department of Orthopaedic Surgery
      Columbia, MO, United States
  • 2011
    • Uniformed Services University of the Health Sciences
      • Department of Surgery
      Bethesda, MD, United States
    • Kyushu University
      Hukuoka, Fukuoka, Japan
    • Johns Hopkins University
      • Department of Orthopaedic Surgery
      Baltimore, MD, United States
    • Chinese PLA General Hospital (301 Hospital)
      • Department of Orthopaedics
      Beijing, Beijing Shi, China
    • St.Mary's Hospital (Fukuoka - Japan)
      Hukuoka, Fukuoka, Japan
  • 2009–2011
    • Shriners Hospitals for Children
      Tampa, Florida, United States
    • Keio University
      Edo, Tōkyō, Japan
    • Rady Children's Hospital
      San Diego, California, United States
    • Meijo University
      Nagoya, Aichi, Japan
  • 2010
    • Stanford University
      • Department of Orthopaedic Surgery
      Stanford, CA, United States
  • 2005–2009
    • Inha University
      • Department of Orthopaedic Surgery
      Seoul, Seoul, South Korea
    • California State University, Sacramento
      Sacramento, California, United States
  • 2008
    • Seoul Veterans Hospital
      Sŏul, Seoul, South Korea
    • Niigata University
      Niahi-niigata, Niigata, Japan
    • Texas Scottish Rite Hospital for Children
      Texas City, Texas, United States
    • St. Luke's Hospital (MO, USA)
      Saint Louis, Michigan, United States
    • Chungnam National University
      • Department of Orthopaedic Surgery
      Daiden, Daejeon, South Korea
    • Duke University Medical Center
      • Department of Orthopaedic Surgery
      Durham, NC, United States
  • 2005–2008
    • University of California, San Diego
      • Department of Orthopaedic Surgery
      San Diego, CA, United States
  • 2007
    • Wooridul Spine Hospital Group
      Sŏul, Seoul, South Korea
  • 2000
    • Children's Hospital of Richmond
      Richmond, Virginia, United States
  • 1993–2000
    • Johns Hopkins Medicine
      • • Department of Orthopaedic Surgery
      • • Department of Neurology
      Baltimore, MD, United States
  • 1998
    • The Ohio State University
      Columbus, Ohio, United States
  • 1990–1991
    • University of Washington Seattle
      • Department of Surgery
      Seattle, WA, United States