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ABSTRACT: A retrospective review of data prospectively entered into a multicenter database.
To evaluate the adherence to classification-specific surgical treatment recommendations for adolescent idiopathic scoliosis (AIS) before and after the Lenke classification system introduction in 2001.
The Lenke classification system of AIS was developed in 2001 to provide a comprehensive and reliable means to categorize and guide treatment. The treatment recommendations of the system state that major and structural minor curves are included in the instrumentation and fusion and the nonstructural minor curves are excluded.
Surgical AIS cases for each Lenke classification (curve types 1-6) were queried for "Rule-breakers," in which the treatment performed did not follow the recommendations of the Lenke classification system. Each "Rule-breaker" case was individually evaluated to ensure correct Lenke classification and radiographic image verification was performed. "Rule-breaker" patients were expressed as a percentage of the total number of patients for each curve type. The presence of "Rule-breakers" before and after the introduction of the Lenke classification system in 2001 was evaluated for statistical difference using a chi-square analysis.
The data for 1310 AIS patients who underwent surgical correction for their deformity were included in this analysis. Overall, treatment of 191 patients did not follow the classification recommendations; the rules are broken 15% of the time. The proportion of "Rule-breakers" (18%) was significantly greater prior to the introduction of the Lenke classification system than it was after (12%) (P=0.001).
The introduction of this system has led to a reduction in the variation of treatment approaches; however, our data suggest that 6% to 29% of the time, depending on the curve pattern, there are other aspects of the clinical and radiographic deformity that suggest deviation from the recommendations of the classification system. The outcome of adherence to this system remains yet to be evaluated.
Spine 02/2011; 36(14):1142-5. · 2.08 Impact Factor
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Christine Baldus,
Keith Bridwell,
John Harrast,
Christopher Shaffrey,
Stephen Ondra, Lawrence Lenke,
Frank Schwab,
Steven Mardjetko,
Steven Glassman,
Charles Edwards,
Thomas Lowe,
William Horton,
David Polly
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ABSTRACT: Prospective, cross-sectional study.
To determine Scoliosis Research Society (SRS)-30 health-related quality of life (HRQOL) reference values by age and gender in an adult population unaffected by scoliosis thereby allowing clinicians and investigators to compare individual and/or groups of spinal deformity patients to their generational peers.
Normative data are collected to establish means and standard deviations of health-related quality of life outcomes representative of a population. The SRS HRQOL questionnaire has become the standard for determining and comparing treatment outcomes in spinal deformity practices. With the establishment of adult SRS-30 HRQOL population values, clinicians, and investigators now have a reference for interpretation of individual scores and/or the scores of subgroups of adult patients with spinal deformities.
The SRS-30 HRQOL was issued prospectively to 1346 adult volunteers recruited from across the United States. Volunteers self-reported no history of scoliosis or prior spine surgery. Domain medians, means, confidence intervals, percentiles, and minimum/maximum values were calculated for six generational age-gender groups: male/female; 20-39, 40-59, and 60-80 years of age.
Median and mean domain values ranged from 4.1 to 4.6 for all age-gender groups. The older the age-gender group, the lower (worse) the reported domain median and mean scores. The only exception was the mental health domain scores in the female groups which improved slightly. Males reported higher (better) scores than females but only the younger males were significantly higher in all domains than their female counterparts. In addition, all male groups reported higher Mental Health domain scores than their female counterparts (P=0.003).
This study reports population medians, means, standard deviations, percentiles, and confidence intervals for the domains of the SRS-30 HRQOL instrument. Clinicians must be mindful of age-gender differences when assessing deformity populations. Generational decreases noted in the older adult volunteer scores may provide a basis for future investigators to interpret observed score decreases in patient cohorts at long-term follow-up.
Spine 02/2011; 36(14):1154-62. · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN.: Multicenter, prospective clinical series. OBJECTIVE.: To investigate the effect of preoperative bracing on postoperative outcome of posterior spine fusion with instrumentation for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA.: Bracing is the standard of care for adolescent idiopathic scoliosis between 25° and 45°, yet the efficacy of bracing is questionable. It is important to evaluate the effect of bracing on outcomes in the adolescent idiopathic scoliosis population. METHODS.: We reviewed the outcomes of 281 before surgery braced and 328 before surgery nonbraced patients who underwent posterior spine fusion with instrumentation for adolescent idiopathic scoliosis before operation and at 2 years after operation using the Scoliosis Research Society instrument (SRS-30) and the Spinal Appearance Questionnaire. RESULTS.: At 2 years after operation, nonbraced patients demonstrated a greater improvement in the SRS-30 Pain domain score (0.23 vs. 0.08, P < 0.001), more improvement in back pain at rest (26.7% vs. 20.5%, P = 0.0009), and more improvement in back pain in the past 6 months (42.4% vs. 32.6%, P = 0.039) compared to braced patients. Also at 2 years after operation, nonbraced patients reported higher SRS-30 Activity domain scores (4.38 vs. 4.32, P = 0.031), Satisfaction domain scores (4.53 vs. 4.42, P = 0.007), and Total scores (4.27 vs. 4.35, P = 0.036) compared with braced patients. The 2-year Spinal Appearance Questionnaire scores showed that nonbraced patients reported a greater "decrease in importance" than braced patients in having "more even shoulders" (79.4% vs. 70.5%, P = 0.03), "more even hips" (74.6% vs. 71.6%, P = 0.042), and "more even ribs in back" (78.4% vs. 69.5%, P = 0.05). CONCLUSION.: Before surgery braced patients have more pain, lower activity levels, lower satisfaction, and lower total SRS-30 scores at 2 years after operation. Braced patients also have more "spine-specific" appearance concerns compared to nonbraced patients. These results suggest a negative impact of preoperative bracing on outcomes after posterior spinal fusion for adolescent idiopathic scoliosis. This "brace signature" should be taken into account when brace treatment is being considered.
Spine 09/2010; 35(20):1876-9. · 2.08 Impact Factor
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ABSTRACT: The ability to treat severe pediatric and adult spinal deformities through an all-posterior vertebral column resection (VCR) has obviated the need for a circumferential approach in primary and revision surgery, but there is limited literature evaluating this new approach. Our purpose was therefore to provide further support of this technique. We reviewed 43 patients who underwent a posterior-only VCR using pedicle screws, anteriorly positioned cages, and intraoperative spinal cord monitoring between 2002 and 2006. Diagnoses included severe scoliosis, global kyphosis, angular kyphosis, or kyphoscoliosis. Forty (93%) procedures were performed at L1 or cephalad in the spinal cord (SC) territory. Seven patients (18%) lost intraoperative neurogenic monitoring evoked potentials (NMEPs) data during correction with data returning to baseline after prompt surgical intervention. All patients after surgery were at their baseline or showed improved SC function, whereas no one worsened. Two patients had nerve root palsies postoperatively, which resolved spontaneously at 6 months and 2 weeks. Spinal cord monitoring (specifically NMEP) is mandatory to prevent neurologic complications. Although technically challenging, a single-stage approach offers dramatic correction in both primary and revision surgery of severe spinal deformities. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 10/2009; 468(3):687-99. · 2.53 Impact Factor
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ABSTRACT: A retrospective review of scores from the Scoliosis Research Society outcomes instrument (SRS-24 questionnaire).
To quantify the isolated effects of spinal fusion and deformity magnitude on quality of life in patients with adolescent idiopathic scoliosis (AIS).
Significant improvements in 2-year postoperative SRS-24 questionnaire scores have been reported despite the loss of spinal motion due to instrumentation and arthrodesis. As deformity reduction may influence patient perception, it has been difficult to isolate the effect of spinal fusion on quality of life after scoliosis surgery.
SRS-24 scores were compared between 3 cohorts of AIS patients (preoperative, postoperative, and nonoperative) using an ANOVA (P < 0.05) to determine the isolated effects of spinal fusion and deformity magnitude. Preoperative SRS-24 scores were collected from a group of patients with preoperative major Cobb angles greater than 40 degrees (n = 194). Postoperative SRS-24 scores were collected from patients with preoperative major Cobb angles greater than 40 degrees and 2-year postoperative major Cobb angles between 20 degrees and 40 degrees (n = 196). Finally, SRS-24 scores were collected from a nonoperative group of patients with major Cobb angles between 20 degrees and 40 degrees (n = 112).
Spinal fusion was found to have a negative isolated effect on the Activity domain (-0.3) and on the Total score (-0.2) (P = 0.001) of the SRS-24 questionnaire (score range: 1-5). A smaller deformity magnitude, on the other hand, was found to have a significantly positive isolated effect on all 4 preoperative domains (P < 0.001) and on the Total score (P < 0.001). The combined effect of surgery (spinal fusion and deformity correction) was found to be significantly positive for the Total score (P < 0.001) and for the domains of Pain, Self-Image, and Function (P < 0.001).
Spinal fusion has an isolated negative effect on AIS patients' quality of life (Total score) mostly due to a decrease in scores of the Activity domain. The overall positive effect of surgery depends on the individual effects of spinal fusion (slight reduction in quality of life) and deformity reduction (modest improvement in quality of life).
Spine 09/2009; 34(18):E653-8. · 2.08 Impact Factor
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ABSTRACT: Multicenter analysis of 2 groups of patients surgically treated for Lenke 5C adolescent idiopathic scoliosis (AIS).
Compare patients with Lenke 5C scoliosis surgically treated with anterior spinal fusion with dual rod instrumentation and anterior column support with patients surgically treated with posterior release and pedicle screw instrumentation.
Treatment of single, structural, lumbar, and thoracolumbar curves in patients with AIS has been the subject of some debate. Advocates of the anterior approach assert that their technique spares posterior musculature and may save distal fusion levels, and that with dual rods and anterior column support the issues with nonunion and kyphosis have been obviated. Advocates of the posterior approach assert that with the change to posterior pedicle screw based instrumentation that correction and levels are equivalent, and the posterior approach avoids the issues with nonunion and kyphosis. This report directly compares the results of posterior versus anterior instrumented fusions in the operative treatment of adolescent idiopathic Lenke 5C curves.
We analyzed 62 patients with Lenke 5C based on radiographic and clinical data at 2 institutions: 31 patients treated with posterior, pedicle-screw instrumented fusions at 1 institution (group PSF); and 31 patients with anterior, dual-rod instrumented fusions at another institution (group ASF). Multiple clinical and radiographic parameters were evaluated and compared.
The mean age, preoperative major curve magnitude, and preoperative lowest instrumented vertebral (LIV) tilt were similar in both groups (age: PSF = 15.5 years, ASF = 15.6 years; curve size: PSF = 50.3 degrees +/- 7.0 degrees , ASF = 49.0 degrees +/- 6.6 degrees ; LIV tilt: PSF = 27.5 degrees +/- 6.5 degrees , ASF = 27.8 degrees +/- 6.2 degrees ). After surgery, the major curve corrected to an average of 6.3 degrees +/- 3.2 degrees (87.6% +/- 5.8%) in the PSF group, compared with 12.1 degrees +/- 7.4 degrees (75.7% +/- 14.8%) in the ASF group (P < 0.01). At final follow-up, the major curve measured 8.0 degrees +/- 3.0 degrees (84.2% +/- 5.8% correction) in the PSF group, compared with 15.9 degrees +/- 9.0 degrees (66.6% +/- 17.9%) in the ASF group (P = 0.01). This represented a loss of correction of 1.7 degrees +/- 1.9 degrees (3.4% +/- 3.7%) in the PSF group, and 3.8 degrees +/- 4.2 degrees (9.4% +/- 10.7%) in the ASF group (P = 0.028). The LIV tilt decreased to 4.1 degrees +/- 3.4 degrees after surgery in the PSF group, and 4.5 degrees +/- 3.7 degrees in the ASF group. At final follow-up, the LIV tilt was 5.1 degrees +/- 3.5 degrees in the PSF group, and 4.5 degrees +/- 3.7 degrees in the ASF group. EBL was identical in both groups, and length of hospital stay was significantly (P < 0.01) shorter in the PSF group (4.8 vs. 6.1 days). There were no complications in either group which extended hospital stay or required an unplanned second surgery.
At a minimum of 2-year follow-up, adolescents with Lenke 5C curves demonstrated statistically significantly better curve correction, less loss of correction over time, 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 09/2009; 34(18):1942-51. · 2.08 Impact Factor
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Lawrence Lenke
Spine 09/2009; · 2.08 Impact Factor
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ABSTRACT: Retrospective review with matched-cohort analysis performed at a single institution.
To determine risk factors and outcomes for acute fractures at the proximal aspect of long pedicle screw constructs.
Acute fractures at the top of long segmental pedicle screw constructs (FPSC) can be catastrophic. Substantial surgical increase in lordosis may precipitate this problem. In relation to a matched cohort, we postulated that age, body mass index (BMI), and significant correction of lumbar lordosis would increase risk of FPSC and patients with FPSC would have lesser improvements in outcomes.
Thirteen patients who sustained FPSC between 2000 and 2007 were evaluated. During this time, 264 patients aged 40 or older had a spinal fusion from the thoracic spine to the sacrum using an all-pedicle screw construct. A cohort of 31 of these patients without FPSC but with all pedicle screw constructs was matched for diagnosis of positive sagittal imbalance, gender, preoperative C7 sagittal plumb, and number of levels fused.
There was a significant difference in age (P = 0.02) and BMI (P = 0.006) between the matched groups. There was no significant difference in preoperative/postoperative C7 plumb or change in lumbar lordosis between groups. Acute neurological deficit developed in 2 patients; both patients improved substantially after revision surgery. Nine patients underwent proximal extension of the fusion. For 7 of the 13 FPSC patients with bone mineral density data (BMD) available, average T score was-1.73; -0.58 for the matched group (10/31 with bone mineral density data) (P = 0.02).
Factors that increased the risk of FPSC included obesity and older age. Osteopenia increased the risk as evidenced by BMD (based on 17 patients) and the older age of these patients. There was no statistical difference in clinical improvement between groups based on ODI, but the FPSC group did demonstrate a smaller improvement in ODI score than the matched cohort.
Spine 09/2009; 34(20):2134-9. · 2.08 Impact Factor
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ABSTRACT: It is often difficult to predict postoperative radiographic curve magnitude and balance parameters while performing intraoperative correction during scoliosis surgery. We asked whether there was a radiographic correlation between intraoperative long-cassette scoliosis film and postoperative standing radiographs of adolescent idiopathic scoliosis with pedicle screw instrumentation. We retrospectively reviewed 44 patients with adolescent idiopathic scoliosis who underwent posterior instrumentation with pedicle screws. We made preoperative, intraoperative (after instrumentation and correction), and standing postoperative radiographic measurements (eg, curve magnitudes, coronal and sagittal balance, disc angles) and compared those for the intra- and postoperative radiographs. The intraoperative long-cassette scoliosis film correlated with the immediate postoperative standing film for all curve correction and balance parameters. The routine use of a long-cassette intraoperative scoliosis film provides the surgeon with a valuable tool to guide intraoperative decision-making and foreshadows the correction and balance obtained on the immediate postoperative film. LEVEL OF EVIDENCE: Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 06/2009; 468(3):679-86. · 2.53 Impact Factor
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ABSTRACT: Retrospective review.
To compare the results of spinal fusion in patients with open triradiate cartilages (OTRC) and closed triradiate cartilages (CTRC).
Patients with OTRC at the time of spinal fusion may be at increased risk of developing postoperative changes related to growth.
From a database of patients with adolescent idiopathic scoliosis, we identified 44 patients with OTRC (mean age, 11.6 years) and 450 patients with CTRC (mean age, 15.6 years) and a minimum follow-up of 2 years. Patients in both groups were treated with anterior-only, posterior-only, or combined anterior and posterior spinal fusion; none had all-pedicle screw posterior instrumentation.
In the OTRC group, anterior or posterior instrumentation, but not the combined approach, resulted in a significant mean late increase in the main curve (4.4 degrees and 7.3 degrees vs. 0 degrees , respectively; P = 0.002), an approach-related difference not seen in the CTRC group. Significantly more OTRC patients had proximal levels added on after surgery than did CTRC patients (18% vs. 8%, respectively; P = 0.02), and there was a trend toward this phenomenon distally (29% vs. 19%, respectively; P = 0.10). Proximal and distal junctional kyphosis was not significantly different between the 2 groups. Reoperation rate was 11% and 7% for OTRC and CTRC patients, respectively. For the selectively fused Lenke 1C curves in OTRC and CTRC patients, there was a trend in the uninstrumented lumbar curve toward a smaller lumbar curve before surgery (36 degrees and 41 degrees , respectively; P = 0.07) and a larger curve after surgery (27 degrees and 24 degrees , respectively; P = 0.07).
Patients with scoliosis and OTRC have a greater risk of adding-on proximally and of loss of correction with anterior-only instrumentation; they may also have less predictable lumbar correction from selective thoracic fusion. However, after combined surgery, they have results similar to those of more skeletally mature patients.
Spine 04/2009; 34(8):827-31. · 2.08 Impact Factor
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ABSTRACT: Multicenter analysis of 3 groups of patients who underwent surgical treatment for adolescent idiopathic scoliosis (AIS). OBJECTIVE.: To evaluate 3 surgical approaches to determine the modality that has the greatest influence on improving thoracic kyphosis.
AIS is characterized by thoracic hypokyphosis which may be restored to normal to varying degrees with surgery.
A multicenter retrospective AIS surgical database was reviewed. Patients with only a structural main thoracic curve (Lenke 1, 2, or 3), and instrumentation of only the main thoracic curve were included. Lateral radiographs were analyzed to determine sagittal plane measurements before surgery, after surgery at 6 to 8 weeks, 1 year, and 2 years. The 3 groups were compared and statistical significance was defined as P < 0.05.
Three groups were analyzed: (1) ASF group (n = 135), Anterior spinal fusion and instrumentation, (2) PSF-Hybrid group (n = 86), PSF with proximal hooks, +/- apical wires and distal pedicle screws, and 3) PSF-Hooks group (n = 132), PSF with only hooks. All groups had similar preoperative coronal main thoracic curve magnitudes (ASF: 50.6 degrees , PSF-Hybrid: 49.1 degrees , PSF-Hooks: 52.0 degrees ) and thoracic kyphosis (ASF: 23.7 degrees , PSF-Hybrid: 19.3 degrees , PSF-Hooks: 21.9 degrees ). After surgery, the T5-T12 kyphosis was greater in the ASF group (25.1 degrees ) compared with PSF-Hooks (19.0 degrees ) and PSF-Hybrid (18.5 degrees (P < 0.05). At 1 year, thoracic kyphosis (T5-T12) remained greater in the ASF group (28.8 degrees ) compared with PSF-Hooks (22.6 degrees ) and PSF-Hybrid (20.2 degrees ) (P < 0.05), and was also greater at 2 years (29.9 degrees vs. 23.8.8 degrees and 19.7 degrees ) (P < 0.05). Kyphosis at the thoracolumbar junction was not seen in the PSF-Hybrid group. Lumbar lordosis increased only in the ASF group in response to the increase in thoracic kyphosis.
ASFI is the best method to restore thoracic kyphosis when compared with posterior approaches using only hooks or a hybrid construct in the treatment of thoracic adolescent idiopathic scoliosis.
Spine 11/2008; 33(24):2630-6. · 2.08 Impact Factor
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Baron S Lonner,
Peter Newton,
Randy Betz,
Carrie Scharf,
Michael O'Brien,
Paul Sponseller, Lawrence Lenke,
Alvin Crawford,
Tom Lowe,
Lynn Letko,
Jurgen Harms,
Harry Shufflebarger
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ABSTRACT: A retrospective multicenter review of 78 patients with Scheuermann's kyphosis treated operatively was conducted.
The purpose of this study was to evaluate correction of sagittal alignment, maintenance of correction, and occurrence of, and etiologic factors associated with, junctional kyphosis in patients managed operatively for Scheuermann's kyphosis.
There is a paucity of literature regarding the surgical treatment of Scheuermann's kyphosis using current implant systems and operative techniques. Junctional kyphosis has been shown to occur in up to one third of patients. Factors causing junctional kyphosis have not been clearly elucidated. Loss of correction has been variable based on the technique used. No clear-cut advantages or disadvantages have been shown for the use of anterior release.
Kyphosis, lordosis, C7 sagittal plumbline, apical translation, junctional sagittal alignment, and pelvic incidence were assessed among other radiographic parameters from a centralized database. The incidence of junctional kyphosis and its association to the above parameters and to fusion levels were assessed. Complication rates and differences between patients undergoing combined anteroposterior surgery and those having posterior surgery alone were evaluated.
Of the 78 patients, 42 underwent combined anteroposterior procedures (Group 1) and 36 had posterior surgery only (Group 2). Mean age was 16.7 years. Overall, the greatest Cobb kyphosis of 78.8 degrees was corrected to 51.4 degrees at follow-up. Preoperative kyphosis was 82.6 degrees and 74.4 degrees for Groups 1 and 2, respectively (P < 0.001) and 55.8 degrees and 46.2 degrees at follow-up (P = 0.000). Loss of correction was 3.2 degrees (not significant) and 6.4 degrees (P = 0.000), respectively. Lordosis corrected from -65.5 degrees to -51.7 degrees . Proximal and distal junctional kyphosis of >or=10 degrees occurred in 25 (32.1%) and 4 (5.1%), respectively. The development of a proximal junctional kyphosis correlated directly with kyphosis at follow-up and indirectly with percent correction. Among patients with proximal junctional kyphosis, the magnitude of junctional kyphosis correlated directly with the degree of pelvic incidence. Pelvic incidence correlated directly with lumbar lordosis but not kyphosis. Twelve complications occurred in 12 patients, including posterior wound infection (1), distal (2), and proximal (1) junctional kyphosis, and pseudarthrosis (1), those requiring reoperation.
This is one of the largest reported series of Scheuermann's kyphosis treated operatively to our knowledge. A high rate of junctional kyphosis, especially at the proximal end, is associated with surgery for Scheuermann's kyphosis using current techniques. Proximal junctional kyphosis is associated with higher magnitude of kyphosis at follow-up, less percent correction; its magnitude correlated directly with pelvic incidence. Loss of correction is less in patients undergoing combined anteroposterior surgery. Pelvic incidence correlates directly with lordosis but not kyphosis, suggesting that these parameters are not causative of Scheuermann's kyphosis.
Spine 11/2007; 32(24):2644-52. · 2.08 Impact Factor
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ABSTRACT: Tricenter retrospective cohort study of 72 patients who underwent posterior correction of Lenke 1 adolescent idiopathic scoliosis (AIS). Each center represented a single surgeon using only one type of construct.
Compare the initial postoperative and 2-year follow-up correction of Lenke 1 AIS curves, after accounting for the preoperative flexibility of the curves.
There are multiple reports in literature of the enhanced posterior corrective ability of the pedicle screw in the treatment of AIS. Unfortunately, none of these reports took into account the preoperative flexibility of the curve. It stands to reason that rigid curves will not correct as much as flexible curves irrespective of the nature of the construct.
Groups were as follows: Group 1 (proximal and distal hooks and segmental intraspinous collar button wires), 24 patients; Group 2 (proximal hooks, distal screws, and apical sublaminar wires), 23 patients; and Group 3 (pedicle screws only), 25 patients. The postoperative correction percentage was expressed as a ratio of the preoperative flexibility and was termed Cincinnati correction index (CCI). Mathematically speaking the CCI equals (postoperative correction/preoperative erect Cobb angle) divided by (supine bending preoperative correction/preoperative erect Cobb angle). The postoperative sagittal correction was also measured.
CCI 2 (at 2-year follow-up) for Group 1 was 1.71, for Group 2 was 1.34, and for Group 3 was 1.41. The differences were not statistically significant. Within Group 1, however, there was a statistically significant difference between CCI (1.95) and CCI 2 (1.71), indicating a statistically significant loss of correction over 2 years. However, in terms of absolute values, there was only a 4 degree (average) difference between the initial and the 2-year postoperative Cobb measurement, rendering the loss off correction clinically insignificant. No such statistically or clinically significant differences were noted within Groups 2 and 3. Group 1 and Group 3 constructs further lordosed the curve by 8 degrees and 11 degrees, respectively, whereas the Group 2 construct retained or marginally increased the preoperative kyphosis.
The Group 3 (pedicle screw only) construct did not give an enhanced correction of Lenke 1 AIS, when the preoperative flexibility of the curve was considered. Also, contrary to popular belief, the pedicle screw construct has a lordosing effect on the thoracic spine. Therefore, we think that there is no significant advantage in using a relatively expensive pedicle screw construct in the correction of Lenke 1 AIS.
Spine 09/2007; 32(17):1869-74. · 2.08 Impact Factor
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ABSTRACT: This is a retrospective multicenter analysis of a subset of 375 patients with thoracic adolescent idiopathic scoliosis (AIS) treated with either anterior (238) or posterior (137) fusion with preoperative or postoperative distal junctional kyphosis (DJK) >or=10 degrees .
To determine the incidence of DJK before and after surgery in patients with AIS undergoing either anterior or posterior thoracic fusion, and provide recommendations for prevention.
DJK following surgical treatment for AIS may result in pain, imbalance, and unacceptable deformity. The true incidence of DJK following selective anterior or posterior instrumentation and fusion is unknown, as are "risk factors" for its development.
Mean age at surgery was 14.4 years (range 9.1-20.9) in the anterior group and 14.7 years (range 10.2-20.7) in the posterior. Analysis included the Cobb and instrumented levels of the thoracic curves, and sagittal measurements, all on preoperative and 2-year follow-up standing 36-in radiographs.
In the anterior group, the incidence of preoperative DJK was 4.2%, and postoperative DJK was 7.1%. In the posterior group, the incidence of preoperative DJK was 5.0% and 14.6% after surgery. When postoperative DJK developed in the posterior group, mean postoperative T10-L2 was +17 degrees kyphosis compared to +2 degrees in the posterior group without DJK (P < 0.001). When postoperative DJK developed in the anterior group, mean postoperative T10-L2 was +12 degrees kyphosis compared to +2 degrees for the anterior group without DJK (P = 0.006). DJK was significantly more likely to occur in the posterior group if the Cobb was instrumented to less than Cobb +1 (P < 0.001).
It appears that both posterior and anterior instrumentation for thoracic curves must include the junctional level to prevent postoperative DJK when postoperative DJK is present. The presence of increased kyphosis after surgery in the T10-L2 region seen in both anterior and posterior groups that had postoperative DJK develop constitutes a "risk factor" for the development of DJK.
Spine 02/2006; 31(3):299-302. · 2.08 Impact Factor
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ABSTRACT: A retrospective analysis of patients that underwent perioperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis.
To review the clinical and radiographic results of perioperative halo-gravity traction in several time periods.
Few reports to our knowledge review the use of perioperative and intraoperative halo-gravity traction in this patient population.
A total of 33 patients with severe operative scoliosis, kyphoscoliosis, or kyphosis were studied based on hospital records, standing pretreatment, traction (before anterior/posterior fusion), postoperative (each stage), and final radiographs. Patients were analyzed by age at date of examination (range, 2-20 years; mean, 13.8 years), gender (18 male, 15 female), major coronal curve magnitude (range, 22 degrees-158 degrees; average, 84 degrees), major compensatory coronal curve magnitude (range, 8 degrees-123 degrees; average, 51 degrees), major sagittal curve magnitude (range, 13 degrees-143 degrees; average, 78 degrees), traction protocol, and procedure type. Halo-traction-related, short- and long-term complications were noted in each case.
The major coronal curve reduced 38 degrees or 46% after posterior spinal fusion compared to pretreatment radiographs. At an average of 44 months radiographic follow-up (range, 24-107 months), the loss of correction averaged 7 degrees for major coronal curves and 4 degrees of thoracic kyphosis. Clinical complications were noted in the perioperative and long-term time periods.
The treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods, especially if there is a significant kyphosis or a history of intraspinal pathology. Halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize postoperative correction in this difficult population. There were no permanent neurologic deficits in this series.
Spine 03/2005; 30(4):475-82. · 2.08 Impact Factor
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ABSTRACT: Study Design. A retrospective analysis of patients that underwent perioperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis.
Objective. To review the clinical and radiographic results of perioperative halo-gravity traction in several time periods.
Summary of Background Data. Few reports to our knowledge review the use of perioperative and intraoperative halo-gravity traction in this patient population.
Methods. A total of 33 patients with severe operative scoliosis, kyphoscoliosis, or kyphosis were studied based on hospital records, standing pretreatment, traction (before anterior/posterior fusion), postoperative (each stage), and final radiographs. Patients were analyzed by age at date of examination (range, 2–20 years; mean, 13.8 years), gender (18 male, 15 female), major coronal curve magnitude (range, 22°–158°; average, 84°), major compensatory coronal curve magnitude (range, 8°–123°; average, 51°), major sagittal curve magnitude (range, 13°–143°; average, 78°), traction protocol, and procedure type. Halo-traction-related, short- and long-term complications were noted in each case.
Results. The major coronal curve reduced 38° or 46% after posterior spinal fusion compared to pretreatment radiographs. At an average of 44 months radiographic follow-up (range, 24–107 months), the loss of correction averaged 7° for major coronal curves and 4° of thoracic kyphosis. Clinical complications were noted in the perioperative and long-term time periods.
Conclusions. The treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods, especially if there is a significant kyphosis or a history of intraspinal pathology. Halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize postoperative correction in this difficult population. There were no permanent neurologic deficits in this series.
Spine 02/2005; 30(4):475-482. · 2.08 Impact Factor
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Neurology India. 01/2005;
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ABSTRACT: A prospective, cross-sectional analysis of patients with operative idiopathic scoliosis comparing Scoliosis Research Society's Outcomes Instrument (SRS-24) scores from both parents and patients obtained separately on the same day along with pertinent radiographic data.
To determine the correlation of parents' and patients' perspectives of the patients' preoperative and postoperative experience using the SRS-24 questionnaire emphasizing parent-patient disparities.
No report to our knowledge has addressed the association between parent assessments of their child's presurgical and postsurgical outcome as verified by SRS-24 questionnaire data.
A total of 101 patients with operative idiopathic scoliosis were analyzed based on paired parent-patient SRS-24 data and radiographs performed on the same day. Patients were analyzed by age at date of examination (9-23 years, mean 17 +/- 5 years), gender (16 male, 85 female), major curve magnitude (41-126 degrees ), procedure type [preoperative (22 pairs), anterior spinal fusion (49 pairs), anterior spinal fusion/posterior spinal fusion (19 pairs), posterior spinal fusion (46 pairs)], and time from surgery (preoperative, postoperative 1-93 months, mean 24 months). All questionnaire scores were classified based on domains of pain, self-image, function, overall satisfaction, and total score.
In overall time periods, parents consistently scored higher than their children in the self-image (P = 0.0001), satisfaction (P = 0.0001), and total score (P = 0.04), but not pain or function. Before surgery, parents overestimated patients' scores in self-image (P = 0.002) by 7.5% but not other domains. Satisfaction differences (P = 0.04) improved with increasing age of the patient, but not other domains. There were no significant differences with gender or preoperative/postoperative major curve magnitudes.
Based on SRS-24 data, parents typically scored higher than their children in the operative treatment of idiopathic scoliosis in total score, self-image, and overall satisfaction. Some parent-patient scores correlated better with increasing age of the patient, and later in the postoperative period.
Spine 03/2004; 29(3):303-10. · 2.08 Impact Factor
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ABSTRACT: STUDY DESIGN A retrospective analysis of primary cases of adult idiopathic scoliosis treated with long instrumented fusions from the thoracic spine proximally to segments that range from T11 to L4 distally.
To analyze whether patients requiring revision surgery had lower postoperative SRS-24 scores; age >or=40 years correlated with higher rates of revision surgery; disc degeneration below the fusion occurred more commonly with a more distal lowest instrumented vertebra or older patient age (>or=40 years); and whether smokers had higher rates of major complications or revision surgery.
Few reports describe complications related to primary long fusions using modern 2+ rods, hook/pedicle screw instrumentation methods in the treatment of adult idiopathic scoliosis.
Sixty-seven patients were analyzed with an average age of 38.8 years (range 21-61 years). The average clinical follow-up was 7.8 years (range 2-16 years): 42 patients had >5 years follow-up, including 23 patients with >10 years follow-up. Patients were categorized by age (< or >or=40 years) and level of the lowest instrumented vertebra (T11-L2 vs. L3-L4). Upright radiographs and postoperative SRS-24 questionnaires from the latest follow-up date were analyzed.
Patients requiring revision surgery had lower total score (average 72.0) than those that did not (total score = 94.2; P = 0.01). More specifically, patients with pseudarthrosis had lower total scores (average 74.7) than those without (average total score = 93.5; P = 0.02). When analyzing age, there were similar rates of pseudarthrosis, but higher rates of transition syndrome (2) and sagittal/coronal imbalance (1 each) in patients >or=40 years. Subsequent distal disc degeneration did not correlate significantly with more distal lowest instrumented vertebra or older patient age. Smokers did not have higher rates of major complications or revision surgery than nonsmokers.
Patients with adult idiopathic scoliosis and long fusions had similar pseudarthrosis rates, but higher rates of transition syndrome when lowest instrumented vertebra was L3-L4 relative to levels T11-L2. When categorized by age, complication rates were similar in each group. Patients with pseudarthroses or other diagnoses requiring revision surgery had lower SRS-24 total scores than those without (P = 0.02 and P = 0.01, respectively).
Spine 02/2004; 29(3):318-25. · 2.08 Impact Factor
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ABSTRACT: To evaluate the ability of single-rod anterior instrumentation to save or preserve fusion levels and improve thoracic hypokyphosis in patients with adolescent idiopathic thoracic, thoracolumbar, or lumbar scoliosis.
To provide indications for single anterior rod instrumentation for the treatment of adolescent idiopathic scoliosis and demonstrate effectiveness in properly selected cases.
Posterior multisegmented dual rod instrumentation is the most commonly used instrumentation for the surgical treatment of adolescent idiopathic scoliosis. The issue of longer fusion levels and inability to correct hypokyphosis with posterior instrumentation continues to be debated in the literature. Anterior instrumentation has the ability in certain curve patterns to preserve distal and proximal levels as well as correct thoracic hypokyphosis.
A brief discussion of the Lenke adolescent idiopathic scoliosis classification system is presented. Surgical treatment options for each of the curve types are discussed in detail.
Single-rod anterior instrumentation for adolescent idiopathic scoliosis will predictably save levels in Type I curves without hyperkyphosis as well as Type 5 curves; however, it is usually contraindicated in Type 2, Type 4, and Type 6 curves. Single-rod anterior instrumentation can occasionally be utilized in Type 3 curves if the magnitude of the lumbar curve is significantly less than the thoracic curve and the flexibility of the lumbar curve approaches 25 degrees on the side-bending radiograph.
Single-rod anterior instrumentation will often saved one to three distal fusion levels when treating isolated major thoracic, thoracolumbar, or lumbar curves. Fusion levels should include upper to lower Cobb levels. Additionally, anterior single-rod instrumentation because its kyphogenic nature will predictably correct hypokyphosis of the thoracic spine.
Spine 11/2003; 28(20):S208-16. · 2.08 Impact Factor
