Treatment of congenital thoracic scoliosis with associated rib fusions using VEPTR expansion thoracostomy: a surgical technique

Evaluation of the efficacy of posterior hemivertebrectomy combined with two or more segments fusion

BACKGROUND

Although early hemivertebra (HV) resection and short fusion (within 4 segments) have been successful in treating congenital HV, there is limited research comparing the outcomes of the shortest-segment fusion (2 segments) versus 3 or 4 segments, particularly in young children. To evaluate the efficacy of posterior hemivertebrectomy combined with two or more segments fusion in children under the age of 10 years with a solitary simple lower thoracic or lumbar HV (T8-L5).

METHODS

This retrospective study included patients under the age of 10 with lower thoracic or lumbar solitary simple HV who underwent hemivertebra resection (HVR) and transpedicular short fusion and were divided into HV ± 1 group (2 segment fusion) and HV ± 2 group (3 or 4-segment fusion). The study recorded preoperative, postoperative (1 week), and the latest follow-up radiographic parameters and complications. The results of the coronal and sagittal planes were analyzed, and the main curve, segmental scoliosis curve, compensatory scoliosis curve, segmental kyphosis curve, and trunk shift were compared.

RESULTS

The study included 35 patients (15 in the HV ± 1 group and 20 in the HV ± 2 group) with a mean age of 5.26 ± 2.31 years and a mean follow-up of 22.54 months (12-68). The mean preoperative Cobb angle was 32.66° ± 7.339° (HV ± 1) and 29.31°±6.642° (HV ± 2). The final Cobb angle was 10.99°± 7.837° (HV ± 1) and 8.22° ± 4.295° (HV ± 2). The main curve corrected by 72% (HV ± 1), 75% (HV ± 2) postoperatively and 67% (HV ± 1), 72% (HV ± 2) at the final follow-up (P > 0.05). There were no significant differences in the correction of the segmental scoliosis curve, compensatory scoliosis curve, segmental kyphosis curve, and trunk shift between the HV ± 1 and HV ± 2 groups (P > 0.05). The unplanned reoperation rate for HV in the thoracolumbar region (T11-L2) is significantly higher (P = 0.038).

CONCLUSION

In the context of solitary simple lower thoracic or lumbar HV (T8-L5), HV ± 1 segment fusion suffices and yields comparable correction outcomes in the midterm period when compared to HV ± 2. The reoperation rate exhibited a statistically significant increase in the thoracolumbar region.

Spondylocostal dysostosis with type II split cord malformation: A report of a rare case and brief review of the literature

Spondylocostal dysostosis (Jarcho Levin syndrome) is a rare costovertebral malformation syndrome that will result in restrictive pulmonary physiology. It manifests its major components at birth. Split cord malformation, together with spondylocostal dysostosis, is even rarer. We hereby report our experience with diagnosing 1 infant with spondylocostal dysostosis and type II split cord malformation using computed tomography and magnetic resonance imaging. We also present a concise summary of previously published case reports and case series involving patients with concurrent spondylocostal dysostosis and split cord malformations.

Biomechanical effects of different instrumented segments and trunk shifts on distal adjacent segments after congenital scoliosis posterior hemivertebrectomy: Preliminary results of a single case

Objective

The present study aims to discuss the biomechanical effects of the sagittal vertical axis and different instrumented segments on distal adjacent segments after congenital scoliosis posterior hemivertebrectomy.

Method

A case of congenital scoliosis caused by hemivertebra was selected for the reconstruction of the preoperative and postoperative 3D computed tomography data of the full spine. A finite element model of different fusion lengths and postoperative trunk shift (TS) values was established using the finite element method to compare the biomechanical effects of different models on the distal adjacent segment.

Result

In the L1-L3 and T12-L1-L3-L4 fusion modes, the horizontal shift of the 1st vertebra below the lowest instrumented vertebra (LIV) increased with the trunk shift (TS) expansion after operation, and the imbalance between the left and right vertical stress of the 1st intervertebral disc below the LIV increased. With the decrease in fused segments in cases of TS = 10 mm and TS = 5 mm, the 1st vertebra below the LIV was subjected to a greater unbalanced force in the horizontal direction, and the 1st intervertebral disc below the LIV was subjected to a smaller imbalance between the left and right vertical stress after operation.

Conclusion

When treating congenital scoliosis with hemivertebrectomy and pedicle screw fixation, fused segments can be properly extended and the postoperative TS shortened with a view of reducing the imbalance between the left and right stress of the 1st intervertebral disc below the LIV as well as the horizontal shift of the 1st vertebra below the LIV.

Effects of spinal deformities on lung development in children: a review

Scoliosis before the age of 5 years is referred to as early-onset scoliosis (EOS). While causes may vary, EOS can potentially affect respiratory function and lung development as children grow. Moreover, scoliosis can lead to thoracic insufficiency syndrome when aggravated or left untreated. Therefore, spinal thoracic deformities often require intervention in early childhood, and solving these problems requires new methods that include the means for both deformity correction and growth maintenance. Therapeutic strategies for preserving the growing spine and thorax include growth rods, vertically expandable titanium artificial ribs, MAGEC rods, braces and casts. The goals of any growth-promoting surgical strategy are to alter the natural history of cardiorespiratory development, limit the progression of underlying spondylarthrosis deformities and minimize negative changes in spondylothorax biomechanics due to the instrumental action of the implant. This review further elucidates EOS in terms of its aetiology, pathogenesis, pathology and treatment.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.

Posterior thoracolumbar hemivertebra resection and short-segment fusion in congenital scoliosis: surgical outcomes and complications with more than 5-year follow-up

Background

Treatment of congenital hemivertebra is challenging and data on long-term follow-up (≥ 5 years) are lacking. This study evaluated the surgical outcomes of posterior thoracolumbar hemivertebra resection and short-segment fusion with pedicle screw fixation for treatment of congenital scoliosis with over 5-year follow-up.

Methods

This study evaluated 27 consecutive patients with congenital scoliosis who underwent posterior thoracolumbar hemivertebra resection and short-segment fusion from January 2007 to January 2015. Segmental scoliosis, total main scoliosis, compensatory cranial curve, compensatory caudal curve, trunk shift, shoulder balance, segmental kyphosis, and sagittal balance were measured on radiographs. Radiographic outcomes and all intraoperative and postoperative complications were recorded.

Results

The segmental main curve was 40.35° preoperatively, 11.94° postoperatively, and 13.24° at final follow-up, with an average correction of 65.9%. The total main curve was 43.39° preoperatively, 14.13° postoperatively, and 16.06° at final follow-up, with an average correction of 60.2%. The caudal and cranial compensatory curves were corrected from 15.78° and 13.21° to 3.57° and 6.83° postoperatively and 4.38° and 7.65° at final follow-up, with an average correction of 69.2% and 30.3%, respectively. The segmental kyphosis was corrected from 34.30° to 15.88° postoperatively and 15.12° at final follow-up, with an average correction of 61.9%. A significant correction (p < 0.001) in segmental scoliosis, total main curve, caudal compensatory curves and segmental kyphosis was observed from preoperative to the final follow-up. The correction in the compensatory cranial curve was significant between preoperative and postoperative and 2-year follow-up (p < 0.001), but a statistically significant difference was not observed between the preoperative and final follow-up (p > 0.001). There were two implant migrations, two postoperative curve progressions, five cases of proximal junctional kyphosis, and four cases of adding-on phenomena.

Conclusion

Posterior thoracolumbar hemivertebra resection after short-segment fusion with pedicle screw fixation in congenital scoliosis is a safe and effective method for treatment and can achieve rigid fixation and deformity correction.

A review of the hemivertebrae and hemivertebra resection

Hemivertebra (HV) is a congenital spinal abnormality. Most hemivertebrae have normal growth plates so create a progressive deformity with growth leading to asymmetric loads on adjacent vertebrae which also show an asymmetric growth. We review the condition and its treatment.

Functional outcomes in bilateral upper limb Amelia patient with scoliosis post vertical expandable prosthetic titanium rib (VEPTR) application: A case report

INTRODUCTION

Congenital upper limb Amelia is one of the extremely rare conditions in the world. Defined as complete absence of a limb which may present as isolated defect or as a part of syndrome with associated anomalies.

PRESENTATION OF THE CASE

We report a case of a medically free 6-year-old boy with bilateral upper limb Amelia associated with right thoracolumbar idiopathic Scoliosis.

DISCUSSION

Treatment for early onset scoliosis includes either posterior spinal fusion and instrumentation, or Vertical Expandable Prosthetic Titanium Rib (VEPTR). The choice of care for our patient was decided to be VEPTR alone as definitive management. Up to our knowledge, there are very scanty articles published regarding treatment for such cases.

CONCLUSION

Patient underwent vertical expandable prosthetic titanium rib (VEPTR) application for his large 45-degree curve as a definitive treatment and still have his preoperative physical functions, in terms of using lower limbs in daily living activities.

COSTAL MALFORMATION RELATED TO THORACOLUMBAR SCOLIOSIS IN ADOLESCENTS - CASE REPORT

ABSTRACT Congenital scoliosis associated with costal malformation is well known. However, there are no reports of idiopathic scoliosis associated with the fusion of the costal arcs in the literature. This report describes a case of idiopathic scoliosis with fusion of the 1st and 2nd costal arches in a female patient and reports changes in the deformity due to scoliosis because of the treatment. The analysis was performed from a morphological and clinical point of view, and by complementary tests. Radiographs and CT scans were obtained and evaluated from the first consultation in 2012 and during the period in which the patient was followed in a private clinic, until the stabilization of the condition, in 2014. The evolution was favorable with the use of a Milwaukee vest and there was improvement of the clinical picture after the skeletal maturity, and the angle of lateral curvature, measured by the Cobb method, initially of 20 degrees, was reduced and stabilized in nine degrees, measure which is currently maintained. The analysis showed concomitant pathologies, and the fusion of costal arches did not influence the spine deformity, since there was regression with the clinical treatment. This evolution leads us to conclude that adolescent idiopathic scoliosis should be imputed as the sole responsible for the clinical picture of the patient, and that the fusion of the costal arches does not interfere with the biomechanics of the spine. Level of Evidence: IV. Type of study: Case series.

The Effect of Concomitant Rib Deformity in Congenital Scoliosis on Spinal Curve Correction After Segmental Pedicle Screw Instrumentation

STUDY DESIGN

A single-center, prospective study.

OBJECTIVE

To investigate the effect of rib anomaly on surgical curve correction outcome in congenital scoliosis.

SUMMARY OF BACKGROUND DATA

The presence of rib anomalies may complicate surgical correction of congenital scoliosis. The outcome of surgical correction, however, has not been documented in scoliotic patients with and without rib deformity.

METHODS

Percent Cobb angle decrease (CAD) after operation was calculated in 94 patients with congenital scoliosis. Posterior segmental pedicle screw instrumentation (posterior approach) with or without previous anterior spinal release and fusion (anterior approach) was the method of correction. The impact of vertebral anomaly and rib deformity on CAD was examined.

RESULTS

Although the type of vertebral anomaly had no significant effect on the mean CAD, it was significantly lower in 56 patients with rib deformity compared with that in the remaining patients without rib deformity (35.14%±15.83% vs. 51.54%±17.82%, P<0.001); particularly in those with complex, unilateral rib abnormalities, and in those with same-level vertebral and rib deformities. Patients' sex and age at the time of operation, rib number abnormality, and the type of operation (ie, posterior-only approach vs. anterior and posterior approach) did not contribute significantly to Cobb angle change after operation.

CONCLUSIONS

Concomitant rib deformities, particularly of complex and unilateral types, significantly compromise operative curve correction outcome in congenital scoliosis.

Posterior hemivertebrectomy and short segment fixation-long term results

OBJECTIVES

The objectives of this study were to study the long-term results of one-stage single and multiple level posterior hemivertebrectomies and to find out the safety and efficacy of the procedure.

METHOD

Twenty patients (9 male and 11 female) with mean age of 9.2 years (2 years 4 months-14 years 10 months) with congenital scoliosis (hemivertebrae) were treated with posterior hemivertebrectomy with intraoperative neuromonitoring. Posterior exposure and transpedicular fixation of the adjoining vertebrae was done. The hemivertebra was approached from the convex side, and transpedicular decancellation followed by complete excision was done. Controlled compression at the convexity was done after a cantilever manoeuvre was done for rod capturing on the convexity to achieve the reduction.

RESULTS

Average number of hemivertebra removed was 1.46 (1-3). Mean pre-op and post-op coronal Cobb angle was 48.8° (range 22 to 80) and 24.2° (range 7 to 41), respectively (p < 0.001). Mean pre-op and post-op sagittal Cobb angle was 32.1° (range 7 to 76) and 13.6° (range 0 to 23) respectively, (p < 0.005). Mean coronal and sagittal Cobb correction percentage achieved was 50.2 and 51.8%, respectively. Mean follow-up was 62.4 months (range 24-73 months). Mean loss of coronal and sagittal correction at final follow-up was 2.26° (0-8) and 1.55° (0-5), respectively. Maximum correction in both coronal (p = 0.167) and sagittal (p = 0.095) planes was achieved in thoracolumbar vertebrae. Maximum correction was achieved in 3 level hemivertebrae in sagittal (p = 0.9) and 2 level hemivertebrae in coronal plane (p = 0.740).

CONCLUSIONS

Posterior hemivertebrectomy is a safe and effective procedure for congenital scoliosis. Not only single but up to 3 level hemivertebrae can be safely removed with good correction of deformity. Long-term follow-up reveals good maintenance of correction.

Biomechanical Evaluation of a Growth-Friendly Rod Construct

BACKGROUND

Distraction-type rods mechanically stabilize the thorax and improve lung growth and function by applying distraction forces at the rib, spine, pelvis, or a combination of locations. However, the amount of stability the rods provide and the amount the thorax needs is unknown.

METHODS

Five freshly frozen and thawed cadaveric thoracic spine specimens were tested for lateral bending, flexion/extension, and axial rotation in displacement control (1°/sec) to a load limit of ±5 Nm for five cycles after which a growth-friendly unilateral rod was placed in a simulated rib-to-lumbar attachment along the right side. The specimens were tested again in the same modes of bending. From the seven Optotrak Orthopedic Research Pin markers (Northern Digital Inc., Waterloo, Ontario, Canada) inserted into the top potting to denote T1, and the right pedicles at T2, T4, T5, T8, T9, and T11 and the Standard Needle Tip Pressure Transducers (Gaeltech, Isle of Skye, Scotland) inserted into the T4/T5 and T8/T9 discs, motion, stiffness, and pressure data were calculated. Parameters from the third cycle of the intact case and the construct case were compared using two-tailed paired t tests with 0.05 as the level of significance.

RESULTS

With the construct attached, the T1-T4 segment showed a 30% increase in neutral zone stiffness during extension (p = .001); the T8-T12 segment experienced a 63% reduction in the in-plane range of motion during flexion (p = .04); and the T8/T9 spinal motion unit had a significant decrease of 24% in elastic zone stiffness during left axial rotation (p = .04).

CONCLUSIONS

It is clear the device as tested here does not produce large biomechanical changes, but the balance between providing desired changes while preventing complications remains difficult.

The effect of vertical expandable prosthetic titanium rib on growth in congenital scoliosis

Aims:

In the treatment of thoracic insufficiency syndrome, the main aim is to maintain spinal and thoracic growth in order to continue respiratory functions. Vertical expandable prosthetic titanium rib (VEPTR) device application is a method of choice especially in the congenital cases with a thoracic deformity. In our study, we evaluated the effect of VEPTR on growth in congenital scoliosis.

Materials and Methods:

Four female patients in whom VEPTR was applied were retrospectively evaluated. Anteroposterior (AP) and lateral Cobb angles that were measured preoperatively and during the last control, space available for lung (SAL), T1-S1 and T1-T12 distances, coronal and sagittal balances were compared.

Results:

Four female patients in whom VEPTR was applied were retrospectively evaluated. AP and lateral Cobb angles that were measured preoperatively and during the last control, SAL, T1-S1, and T1-T12 distances, coronal and sagittal balances were compared.

Conclusions:

VEPTR may provide a good correction, and we observed a growth in the spine height and SAL following the treatment of congenital deformities. Long-term, multicenter, prospective studies that compare the spinal height, respiratory functions, the severity of the deformity, and the spinal balance are required in order to evaluate the efficacy of VEPTR.