Non-fusion and growing instrumentation in the correction of congenital spinal deformity associated with split spinal cord malformation: an early follow-up outcome

Halo Gravity Traction for the Correction of Spinal Deformities in the Pediatric Population: A Systematic Review and Meta-Analysis

OBJECTIVE

Halo gravity traction (HGT) is an effective way of managing pediatric spinal deformities in the preoperative period. This study comprehensively reviews the existing literature and evaluates the effect of HGT on various radiographic parameters regarding spinal correction and, secondarily, evaluates the improvement in pulmonary function as well as nutritional status.

METHODS

In accordance with PRISMA guidelines, a comprehensive search was conducted for articles on HGT in the treatment of spinal deformity. Spinal deformity after traction and surgery, change of pulmonary function, nutritional status, and prevalence of complications were the main outcome measurements. All meta-analyses were conducted using random models according to the between-study heterogeneity, estimated with I².

RESULTS

A total of 694 patients from 24 studies were included in this review. Compared with pretraction values, the average coronal Cobb angle reduction after traction was 27.66° (95% confidence interval [CI], 23.41-31.90; P < 0.001) and 47.43° (95% CI, 39.32-55.54; P < 0.001) after surgery. The sagittal Cobb angle reduction after HGT and surgery was 27.23° (95% CI, 22.83-31.62; P <0.001) and 36.77° (95% CI, 16.90-56.65; P < 0.001), respectively. There was a statistically significant improvement in the overall pulmonary function, as evident by an increase in a forced vital capacity of 8.44% (95% CI, -5.68 to -11.20; P < 0.001), and an increase in nutritional status, with a percentage correction of body mass index by 1.58 kg/m² (95% CI, -2.14 to -1.02; P < 0.001) after HGT application.

CONCLUSIONS

HGT has been shown to significantly improve coronal deformities, sagittal deformities, nutritional status, and pulmonary function in the preoperative period.

Decompression Using Minimally Invasive Surgery for Lumbar Spinal Stenosis Associated with Degenerative Spondylolisthesis: A Review

Lumbar spinal stenosis (LSS), which often occurs concurrently with degenerative spondylolisthesis (DS), is a common disease in the elderly population, affecting the quality of life of aged people significantly. Notwithstanding the frequently good effect of conservative therapy on LSS, a minority of the patients ultimately require surgery. Surgery for LSS aims to decompress the narrowed spinal canals with preservation of spinal stability. Traditional open surgery, either pure decompression or decompression with fusion, was considered effective for the treatment of LSS with or without DS. However, the long-term clinical outcomes of traditional open surgery are still unclear. Moreover, the disadvantages of conventional open surgery are extensive, examples including tissue injuries or secondary instability, with limited outcomes and significant reoperation rates. With the development and improvement of surgical tools, various minimally invasive spine surgery (MISS) methods, including indirect decompression techniques of interspinous process devices (IPDs) and direct decompression techniques such as microscopic spine surgery or endoscopic spine surgery (ESS), have been updated with enhancement. IPDs, such as Superion devices, were reported to behave with comparable physical function, disability, and symptoms outcomes to laminectomy decompression. As an emerging technique of MISS, ESS has beneficial hallmarks including minimal tissue injuries, reduced complication rates, and shortened recovery periods, thus gaining popularity in recent years. ESS can be classified in terms of endoscopic hallmarks and approaches. Predictably, with the continuous development and gradual maturity, MISS is expected to replace traditional open surgery widely in the surgical treatment of LSS associated with DS in the future.

Similar surgical outcomes of the growing rod technique for treatment of early-onset scoliosis with versus without untreated intraspinal anomalies

OBJECTIVE

The aim of this study was to compare the radiological and clinical outcomes of early-onset scoliosis (EOS) patients with or without intraspinal anomalies (IAs) managed with growing rods (GRs), and to evaluate the safety of the GR technique in EOS patients with untreated IAs.

METHODS

EOS patients undergoing GR placement between August 2008 and July 2017 were retrospectively reviewed. Patients with untreated IAs were classified into the EOS+IA group, and those without IAs into the EOS-IA group. The radiographic parameters including Cobb angle of the major curve, T1-S1 height, and apical vertebral translation were measured, and a detailed assessment of the neurological status was performed at each visit.

RESULTS

Seventy-six patients with EOS (32 boys, 44 girls) with an average age of 6.5 ± 2.3 years at initial surgery satisfied the inclusion and exclusion criteria, including 28 patients in the EOS+IA group and 48 patients in the EOS-IA group. The radiographic measurements were comparable between groups preoperatively, postoperatively, and at the latest follow-up. One patient in the EOS+IA group experienced sensory deficit in a unilateral lower extremity after initial surgery, and an intraoperative neurophysiological monitoring event was observed in a patient in the EOS-IA group. No permanent neurological deficit was observed in either group.

CONCLUSIONS

EOS patients with and those without IAs had comparable clinical and radiological outcomes of the GR technique. Repeated lengthening procedures may be safe for EOS patients with untreated IAs.

Perioperative Halo-Gravity Traction in the Treatment of Scoliosis with Intraspinal Anomalies

OBJECTIVE

To investigate the efficacy and safety of preoperative halo-gravity traction and 1-stage posterior surgery for the treatment of scoliosis with intramedullary anomalies.

METHODS

A total of 11 patients with scoliosis with intramedullary anomalies were evaluated. All patients were treated with preoperative halo-gravity traction and 1-stage posterior surgery. The average age was 11.4 years (range, 7-21 years). All patients were followed-up for at least 2 years (mean, 3.5 years; range, 2-5 years). Their radiologic presentations and complications were reviewed.

RESULTS

The operating time was 7.9 hours, and the intraoperative bleeding amount was 1890 mL. Both the Cobb angle of scoliosis and kyphosis were significantly improved after halo-gravity traction and the operation (P < 0.05). Tethered cords were released, and intraspinal masses (neurofibromatosis and lipoma) were excised. Syringomyelia and split spinal cord malformations were left untreated. None of the patients experienced deterioration in their neurologic status after surgery. No severe complications, such as infection, cerebrospinal fluid leakage, failed internal fixation, or fractured pedicle screws or rods occurred after the operation. There was no deterioration of neurologic function, delayed infection, or pseudoarthrosis during the follow-up visits.

CONCLUSIONS

Preoperative halo-gravity traction and 1-stage posterior surgery provided patients who had scoliosis and intramedullary anomalies an effective and safe treatment option with few complications.

A comprehensive review of the diagnosis and management of congenital scoliosis

PURPOSE

To provide the reader with a comprehensive but concise understanding of congenital scoliosis METHODS: We have undertaken to summarize available literature on the pathophysiology, epidemiology, and management of congenital scoliosis.

RESULTS

Congenital scoliosis represents 10% of pediatric spine deformity and is a developmental error in segmentation, formation, or a combination of both leading to curvature of the spine. Treatment options are complicated by balancing growth potential with curve severity. Often associated abnormalities of cardiac, genitourinary, or intraspinal systems are concurrent and should be evaluated as part of the diagnostic work-up. Management balances the risk of progression, growth potential, lung development/function, and associated risks. Surgical treatment options involve growth-permitting systems or fusions.

CONCLUSION

Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.

Halo-gravity traction in the treatment of severe spinal deformity: a systematic review and meta-analysis

PURPOSE

Halo-gravity traction has been reported to successfully assist in managing severe spinal deformity. This is a systematic review of all studies on halo-gravity traction in the treatment of spinal deformity to provide information for clinical practice.

METHODS

A comprehensive search was conducted for articles on halo-gravity traction in the treatment of spinal deformity according to the PRISMA guidelines. Appropriate studies would be included and analyzed. Preoperative correction rate of spinal deformity, change of pulmonary function and prevalence of complications were the main measurements.

RESULTS

Sixteen studies, a total of 351 patients, were included in this review. Generally, the initial Cobb angle was 101.1° in the coronal plane and 80.5° in the sagittal plane, and it was corrected to 49.4° and 56.0° after final spinal fusion. The preoperative correction due to traction alone was 24.1 and 19.3%, respectively. With traction, the flexibility improved 6.1% but postoperatively the patients did not have better correction. Less aggressive procedures and improved pulmonary function were observed in patients with traction. The prevalence of traction-related complications was 22% and three cases of neurologic complication related to traction were noted. The prevalence of total complications related to surgery was 32% and that of neurologic complications was 1%.

CONCLUSION

Partial correction could be achieved preoperatively with halo-gravity traction, and it may help decrease aggressive procedures, improve preoperative pulmonary function, and reduce neurologic complications. However, traction could not increase preoperative flexibility or final correction. Traction-related complications, although usually not severe, were not rare.

Perioperative Neurologic Injury Associated With Rib-Based Distraction Surgery

STUDY DESIGN

Retrospective, comparative case series from the study group database.

OBJECTIVES

The primary objective was to report the neurologic injury rate for rib-based distraction surgery and determine whether preoperative diagnosis affects this rate. The secondary objective was to describe these injuries and outcome.

SUMMARY OF BACKGROUND DATA

Posterior distraction-based systems are commonly used to treat early-onset scoliosis. General complication rates for these surgeries are high; however, there are few reports in the literature on neurologic injury after rib-based distraction surgery.

METHODS

This was a retrospective review of the Children's Spine Study Group database from 2004 to 2013. The researchers used the chi-square test to compare the distributions of proportions between diagnoses.

RESULTS

A total of 524 patients were identified and treated with rib-based distraction surgery. The preoperative diagnoses consisted of 222 congenital/structural, 163 neuromuscular, 63 syndromic, 67 idiopathic, and 9 unknown. There were 9 neurologic injuries (7 clinical and 2 neuromonitoring alerts) for a neurologic injury rate of 1.7%. Using the Classification for Early-Onset Scoliosis, 8 patients were classified as congenital and 1 as neuromuscular. The neurologic injury rate in the congenital curves group was 3.6% and was 0.34% in non-congenital curves (p = .005). The proportion of injured patients with an additional secondary diagnosis was 3.82%, compared with 0.82% patients with only a primary diagnosis (p = .01). Eight injuries occurred at initial implantation and 1 at revision surgery. Most were brachial plexus (n = 5) with no complete spinal cord injuries. Four patients required return to surgery and 1 needed intraoperative intervention. At 4.2 years' follow-up, 7 of 9 patients had full resolution of symptoms and 2 patients had residual upper extremity weakness.

CONCLUSIONS

The rate of neurologic injury for patients treated with rib-based distraction surgery was 1.7%. Most injuries occurred with congenital diagnoses and they were more likely in patients with additional secondary diagnoses. These injuries were predominantly to the brachial plexus and generally resolved.

[Treatment of juvenile scoliosis: Increasing the lengthening interval with the growing rod technique should not necessarily compromise thoracic growth]

OBJECTIVE

Serial lengthening with growing rods is recommended every six months for the treatment of early onset scoliosis. The objective of this study was to evaluate the longitudinal growth of the thorax and control of the deformity in a series of patients with juvenile scoliosis when time intervals were increased between lengthenings.

MATERIAL AND METHODS

Retrospective study of eight patients. The following variables were measured: the Cobb angle, the apical vertebral translation, the coronal balance, thoracic T1-L1 length, thoracic T5-T12 kyphosis, the proximal junctional kyphosis (PJK) angle, and the lumbar lordosis. Complications were recorded.

RESULTS

Five idiopathic and three syndromic scoliosis cases (mean age 9.4 ± 1.5 years) were evaluated. The initial surgery was followed by with an average of two distractions per patient. The mean time between distractions was 15.7 months. The final coronal main curve correction was 58%. Apical translation and coronal balance were improved and maintained after the surgeries. The thoracic (T1-L1) preoperative length was 20.8 cm, the postoperative length was 24.4 cm, and the final length was 26 cm. At the end of follow-up, the average growth of the thorax was 5.2 cm. The preoperative (T5-T12) kyphosis was 33.5°, and final 32.1°. The change in the PJK angle was 2.5° at the end of follow-up. Most complications were related to instrumentation. Two superficial wound infections were encountered.

CONCLUSION

For less severe juvenile scoliosis patients treated with growing rods, spacing out lengthenings over more than a year can decrease the number of surgeries, while still controlling the deformity and allowing longitudinal thoracic growth.