Posterior all-pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies in the treatment of adolescent congenital kyphoscoliosis
Department of Orthopaedics and Traumatology, Hacettepe University, Hacettepe Hastaneleri, 06100 Sihhiye, Ankara, Turkey.The spine journal: official journal of the North American Spine Society (Impact Factor: 2.43). 12/2012; 14(1). DOI: 10.1016/j.spinee.2012.10.016
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.
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ABSTRACT: Spinal cord injury (SCI) in the pediatric population is an infrequent but clinically important disease to scoliosis surgeons. Spinal deformity after SCI is extremely common and almost uniformly develops in patients being injured before the growth spurt. Most treatment paradigms extrapolate management from both the adult literature as well as adolescent idiopathic scoliosis data. Since these patient populations are different in many respects, we sought out to investigate the rates of loss of correction over time as well as the factors associated with loss of correction in pediatric patients undergoing pedicle screw fixation for treatment of SCI-related scoliosis. All consecutive pediatric patients with spinal cord injury and paralytic scoliosis managed with pedicle screw constructs were identified at a single institution. Clinical and radiographic parameters were reviewed and analyzed with specific focus on parameters associated with loss of correction at an average follow-up of 2 years. Approximately 15 % of patients had a loss of correction of greater than 10° of Cobb angle. Postoperative sagittal imbalance was found to be significantly greater in patients who lost greater than 10° of correction compared to patients who did not lose correction (53.6 ± 39.9 vs 4.3 ± 41.3 mm, p = 0.02). Correction of patients with paralytic associated scoliosis should aim for a neutral sagittal balance in order to prevent postoperative loss of correction. Further study is needed on this subgroup of patients with scoliosis given the differences in strategies needed to correct and maintain their deformity correction.
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ABSTRACT: Study Design. Biomechanical cadaver studyObjective. To evaluate the relative effectiveness of Ponte osteotomies for spinal release in deformity correctionSummary of Background Data. Controversy exists as to the role of Ponte osteotomy in deformity correction surgery. Very little has been written about the biomechanical effects of Ponte osteotomy. Past biomechanical studies have been limited to application of forces through endplates, single functional units, or lack of comparison with anterior release.Methods. 12 fresh-frozen human full thoracic spinal units were tested for motion in axial rotation, flexion/extension, and lateral bending in a custom designed robotic environment. Testing was repeated after sequential facetectomy and Ponte osteotomy (6 specimens) and compared to partial and full discectomy(6 specimens).Results. Motion in axial rotation is increased 21% by Ponte osteotomy compared to 35% for full discectomy. Anterior displacement of the spinal column, creating lordosis, was increased 15% by Ponte and 40% by full discectomy. Posterior displacement of the spinal column, creating kyphosis, was increased 23% by Ponte and 89% by full discectomy. Finally, in coronal force application the Ponte osteotomy had virtually no effect (2%) compared to 40% increased motion by full discectomy.Conclusions. Posterior Ponte releases produced more motion than facetectomy alone in axial rotation and sagittal correction maneuvers, but had no effect on coronal correction. Anterior discectomy release destabilized spinal column significantly more than posterior releases in all force applications. Despite ample clinic experience demonstrating the effectiveness of posterior only surgery, the biomechanical effect of Ponte osteotomies is modest.
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ABSTRACT: Purpose The aim of this retrospective study is to evaluate the efficacy and safety of posterior-only vertebral column resection (PVCR) for the treatment of angular and isolated congenital kyphosis. Methods 24 patients with isolated angular congenital kyphosis treated by PVCR in our hospital were retrospectively studied. The patients’ radiographs and hospital records were reviewed. Deformity in sagittal planes and global sagittal alignment were analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. The complications and related risk factors were analyzed. Results The average age was 13.9 (4–40) years. Three of them were revision surgeries. Two patients have intraspinal anomalies. The mean follow-up is 56.9 (26–129) months. The mean operation time was 293.1 (170–480) min. The averaged blood loss was 993.8 (250–3000) ml. The segmental kyphosis was 87.3° before surgery, 17.6° post surgery and 20.4° at the latest the follow-up. And the sagittal vertical axis was improved from 43.1 mm to 9.2 mm. Mean total score of SRS-22 was 89.3. Complications occurred in 4 patients, including 1 screw pullout due to pseudarthrosis, 1 proximal junctional kyphosis, 1 incomplete spinal cord injury and 1 root injuries. Conclusion Posterior-only vertebral column resection is an ideal procedure for severe rigid congenital kyphosis. However, it is still a highly technical demanding procedure. Neurological compromises still remain the biggest challenges. Sufficient height of anterior reconstruction, avoidance sacrifice of bilateral roots in the same level in the thoracic spine, avoidance of the sagittal translation of the upper and lower vertebras, intra-operative neuromonitoring, and preoperative surgical release of diastematomyelia and tethered cord may help to improve the safety.
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