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ABSTRACT: BACKGROUND CONTEXT: Congenital kyphoscoliosis is a disorder that often requires surgical treatment. Although many methods of surgical treatment exist, posterior-only vertebral column resection with instrumentation and fusion seem to have become the gold standard for very severe and very rigid curves. Multiple chevron and concave rib osteotomies have been previously reported to be effective in the treatment of neglected severe idiopathic curves. We hypothesized that this method may also be used successfully in the treatment of congenital kyphoscoliosis. PURPOSE: To evaluate the effectiveness and safety of multiple chevron osteotomies combined with concave rib osteotomy and posterior pedicle screw instrumentation. STUDY DESIGN: Retrospective chart review in the spine service of a large university hospital. PATIENT SAMPLE: Adolescent patients undergoing a specific surgical treatment for the indication of rigid congenital kyphoscoliotic deformity. OUTCOME MEASURES: Radiographic images were used for the measurement of deformity correction. The Turkish version of the Scoliosis Research Society 22 (SRS-22) Patient Questionnaire has been used as a clinical outcome measure in the patient population. METHODS: A retrospective chart review was performed. Patients admitted to Hacettepe Hospital Spine Center during the period of 2005 to 2009 were included. Criteria for inclusion were as follows: adolescent age group (10-16 years); congenital kyphoscoliosis; formation and/or segmentation defect of at least two vertebral motion segments; surgical treatment of deformity by posterior all-pedicle screw instrumentation, multiple chevron osteotomies, and multiple concave rib osteotomies; follow-up of at least 24 months; and a complete set of preoperative, postoperative, and follow-up standing posteroanterior and lateral full spinal radiographs. The patients' hospital records and X-rays were reviewed. Duration of surgery, intraoperative blood loss, postoperative transfusion requirements, postoperative stay in postanesthesia care unit (PACU), time of hospitalization, and complications were recorded. Deformity in both coronal and sagittal planes was analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. Patients' health-related quality of life was assessed using the SRS-22 questionnaire at the final follow-up. RESULTS: Eighteen patients met the inclusion criteria. Their average age was 13.6 years (range, 11-16 years). Chevron osteotomies were performed at apical segments (three to seven levels) and concave rib osteotomies at Cobb-to-Cobb (five to eight levels). No patient had preoperative cord compression because of the sharply angulated deformity or neurologic deficit. The average preoperative scoliosis was 66.0° (range, 31°-116°), 52.4° (range, 22°-85°) on flexibility X-rays, and became 24.9° (range, 12°-52°) postoperatively. The average preoperative global kyphosis (T2-T12) of 75.9° (range, 50°-106°) became 49.5° (range, 18°-66°). The average preoperative local kyphosis of 71.9° (range, 35°-114°) became 31.4° (range, -44° to 64°). The average intraoperative bleeding was 989 cc, surgical time was 292 minutes, and intraoperative transfusion was 2.3 units. The maximum PACU stay was overnight. There were no neurologic complications except one pneumothorax and one pneumonia. The average follow-up was 34.3 months. At follow-up, average scoliosis was 27.5° (range, 10°-50°), global kyphosis was 50.3° (range, 28°-73°), and local kyphosis was 36.9°(range, -36° to 58°). Performed on the last follow-up, the average scores for the five domains of SRS-22 were 4.3, 4.4, 4.2, 4.1, and 4.8 for function, pain, self-image, mental health, satisfaction, and total, respectively. CONCLUSIONS: Multiple chevron and concave rib osteotomies with posterior instrumentation provide an acceptable rate of deformity correction and maintenance of correction at 2 years with acceptable intraoperative bleeding, surgical time, postoperative morbidity, and rate of complications. It can be considered as an alternative in the treatment of rigid congenital curves involving more than three levels or multiple curves separated by at least two segments that would otherwise require multiple vertebral resections.
The spine journal: official journal of the North American Spine Society 12/2012; · 2.90 Impact Factor
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ABSTRACT: Osteotomies may be life saving procedures for patients with rigid severe spinal deformity. Several different types of osteotomies have been defined by several authors. To correct and provide a balanced spine with reasonable amount of correction is the ultimate goal in deformity correction by osteotomies. Selection of osteotomy is decided by careful preoperative assessment of the patient and deformity and the amount of correction needed to have a balanced spine. Patient's general medical status and surgeon's experience levels are the other factors for determining the ideal osteotomy type. There are different osteotomy options for correcting deformities, including the Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR) providing correction of the sagittal and multiplanar deformity. SPO refers to a posterior column osteotomy in which the posterior ligaments and facet joints are removed and a mobile anterior disc is required for correction. PSO is performed by removing the posterior elements and both pedicles, decancellating vertebral body, and closure of the osteotomy by hinging on the anterior cortex. BDBO is an osteotomy that aims to resect the disc with its adjacent endplate(s) in deformities with the disc space as the apex or center of rotational axis (CORA). VCR provides the greatest amount of correction among other osteotomy types with complete resection of one or more vertebral segments with posterior elements and entire vertebral body including adjacent discs. It is also important to understand sagittal imbalance and the surgeon must consider global spino-pelvic alignment for satisfactory long-term results. Vertebral osteotomies are technically challenging but effective procedures for the correction of severe adult deformity and should be performed by experienced surgeons to prevent catastrophic complications.
European Spine Journal 05/2012; · 1.97 Impact Factor
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ABSTRACT: Retrospective review, case series.
Determination of whether growing rod treatment with routine lengthening every 6 months causes growth stimulation of individual vertebrae within instrumentation levels (WIL).
The Hueter-Volkmann law states that distractive forces exerted upon growing physes stimulate growth and vice versa, a principle that has been in clinical use for decades. In previous studies, it has been shown that vertebral endplates might respond in a similar manner to distraction. It has been proven that fusionless instrumentation, which is the mainstay of treatment after failure of conservative measures for early-onset scoliosis, allows near-normal vertebral growth but the issue of how individual vertebrae respond to distraction has not yet been analyzed.
This institution's database, including the radiographic data for growing rod patients, was analyzed retrospectively. Vertebral level heights within and outside instrumentation levels were measured in postindex and postfinal follow-up x-rays, and the amount of growth that has taken place in a minimum follow-up period of 2 years was calculated and then compared for statistical significance.
Twenty patients (6 M, 14 F, average age, 71.0 mo) met the inclusion criteria. The average follow-up was 49 months (range, 26 to 72 mo). Lengthenings were performed every 6 months regularly. The average height of vertebrae WIL was 15.9 mm (range, 10.0 to 21.1 mm) in postindex and 22.9 mm (range, 15.0 to 32.9 mm) in the final follow-up; vertebrae outside instrumentation levels was 18.1 mm (range, 13.5 to 22.1 mm) postindex and 23.3 mm (range, 14.8 to 28.8 mm) in the final follow-up. The average growth was 5.2±3.4 mm in outside instrumentation levels and 7.0±2.9 mm in WIL. These values were significantly different statistically (P<0.01).
Growing rod treatment performed with regular lengthenings every 6 months appears to stimulate growth in individual vertebral bodies WIL.
Level IV.
Journal of pediatric orthopedics 03/2012; 32(2):184-9. · 1.23 Impact Factor
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ABSTRACT: Review article.
To review the indications, technical details, and complications of lateral mass and transfacet mass fixation methods.
Potential advantages of rigid fixation in subaxial cervical spine have been defined as early mobilization, faster healing and fusion, and increased fusion rates. Lateral mass screw fixation has been the most popular fixation technique for posterior instrumentation. Transfacet screw fixation, on the other hand, is an alternative method less commonly used.
Narrative and review of the literature.
Several different techniques aiming for the most safe and secure lateral mass screw fixation have been described by several different authors. Lateral mass screws provide rigid fixation and high fusion rates in patients with healthy bone. Complications are rare when patients' anatomy is well documented and proper technique is used. Transfacet screw fixation is another method less commonly used and with better biomechanical stability.
Lateral mass screw provides excellent 3-dimensional fixations from C3 to C7, and currently it is also the most commonly performed posterior fixation method.
Spine 01/2012; 37(5):E335-41. · 2.08 Impact Factor
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ABSTRACT: Retrospective case series.
To analyze the efficacy and safety of posterior vertebral column resection performed on a consecutive series of patients with severe congenital spinal deformity.
The treatment of severe congenital spinal deformities is a demanding and difficult surgical challenge. Conventional procedures, such as posterior and anterior instrumentation or combined anteroposterior instrumentation provide limited correction in rigid neglected or maltreated (fused) deformities.
Forty-four patients with severe deformity and managed by posterior vertebral column resection between years 1997 and 2007 having more than 2 years of follow-up were included. Mean age was 8 (range, 2-28) years at the time of operation. The hospital charts were reviewed for demographic data and etiology of deformity. Measurements of curve magnitude and balance were made on 36-in. standing anteroposterior and lateral radiographs obtained before surgery and at most recent follow-up to assess deformity correction, spinal balance, complications related to the instrumentation, and any evidence of pseudarthrosis.
Preoperative coronal plane major curve of 106° (range, 90°-132°) with flexibility of less than 30% was corrected to 41.4° (range, 20°-72°), showing a 61% scoliosis correction at the final follow-up. Coronal imbalance was improved by 79% at the most recent follow-up assessment. Preoperative thoracic kyphosis of 87° (range, 67°-103°) in patients with kyphosis was corrected to 36° (range, 25°-48°) at the most recent follow-up evaluation. Lumbar lordosis of 27° (range, 8°-35°) in patients with hypolordotic deformity was corrected to 45°. Complications included postoperative infection in 2 patients, dural laceration in 2 patients, and hemopneumothorax in 1 patient.
Posterior vertebral column resection is an effective technique providing a successful correction of stiff complex congenital deformities. However, it is a technically demanding procedure, with possible risks for major complications.
Spine 10/2011; 37(12):1054-7. · 2.08 Impact Factor
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Spine 03/2011; 36(5):E340-4. · 2.08 Impact Factor
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ABSTRACT: Patients with spinal cord injury without radiographic abnormality (SCIWORA) are prone to develop spinal deformities. The purpose of this study is to report on the clinical and radiological features of post-SCIWORA spinal deformities.
Four patients with SCIWORA and spinal deformities requiring surgery were analyzed clinically and radiographically.
All four SCIWORA patients developed progressive neuromuscular scoliosis. There were 2 males and 2 females. The mean age at spinal cord injury was 3.9 years (range 6 months to 7 years). Spinal deformity was first noticed at a mean of 17 months after their initial injury (range 9 months to 2 years), and surgical intervention was performed at a mean of 6.5 years following their injury (range 4-11 years). The mean preoperative curve was 54° (range 50-62°). The mean postoperative curve was 9.5° (range 5-16°). The level of injury was T5 in two patients, and T10 and L2 in one patient each. All but the lumbar level injury patient had complete paraplegia. One patient with complete injury (T10) and another with incomplete injury (L2) improved neurologically and were able to walk with the aid of orthoses and crutches. Pelvic obliquity improved in all patients following spinal reconstruction surgery, and none of the patients required additional surgery for spinal deformity. The mean postoperative follow-up was 51.75 months (range 24-93 months).
Long scoliotic curves extending to the pelvis should be expected in SCIWORA. Early intervention may prevent severe deformities. Modern instrumentation techniques employing pedicle screws provided satisfactory correction, improved hip subluxation, and did not adversely affect the ambulatory ability or functional level of the patients in this series.
Journal of Children s Orthopaedics 02/2011; 5(1):27-33.
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ABSTRACT: Retrospective case series.
To evaluate the safety and efficacy of prophylactic inferior vena cava filter (IVCF) to prevent pulmonary embolism (PE) in high risk patients undergoing major complex spinal surgery.
PE has been reported to be the major cause of death after spinal reconstructive surgery. Mechanical prophylaxis alone is often not sufficient whereas anticoagulation therapy carries a significant risk of bleeding complications. Prophylactic IVCF placement is advocated in high-risk patients.
A total of 129 high-risk patients undergoing complex spine surgery, having prophylactic IVCF were compared to a matched cohort of age, diagnosis, and risk factors of 193 patients for whom only mechanical prophylaxis was used. Patients were observed for potential complications related to the IVCF and also for clinical signs and symptoms of PE.
Eight cases (4.2%) of symptomatic PE were detected in the matched cohort control group (5 cases having combined anterior + posterior surgery and 3 patients having only posterior surgery). One of them died due to massive PE (0.5%). Symptomatic PE was detected in only 2 patients (1.5%), having combined anterior + posterior surgery due to lumbar spinal stenosis in IVCF group who responded well to medical treatment (P < 0.05). No complications were associated with filter insertion.
Prophylactic IVCF is effective and safe in prevention of pulmonary embolism in patients with risk factors for PE.
Spine 09/2010; 35(20):1893-6. · 2.08 Impact Factor
