Anterior release may not be necessary for idiopathic scoliosis with a large curve of more than 75° and a flexibility of less than 25

The Comparison of Posterior Intervertebral Release Combined with Posterior Column Osteotomy and Posterior Column Osteotomy Alone for the Treatment of Moderate-to-Severe Rigid Scoliosis: A Prospective Controlled Study

OBJECTIVES

There is no consensus on the treatment of moderate-to-severe rigid scoliosis. Anterior release and three-column osteotomy are excessively traumatic, whereas posterior column osteotomy (PCO) alone results in poor outcomes. An emerging surgical technique, posterior intervertebral release (PR), can release the rigid spine from the posterior approach. This study was performed to compare the multi-segment apical convex PR combined with PCO and PCO alone in patients with moderate-to-severe rigid scoliosis.

METHODS

From June 2021 to June 2022, this prospective study of moderate-to-severe (Cobb: 70-90°) rigid scoliosis (flexibility of main curve <25%) involved two groups defined by surgical procedure: the PR group, the patients undergoing PR combined with PCO; and the PCO group, the patients undergoing PCO alone. Follow-up was at least 12 months. Radiographic results mainly included main curve Cobb, correction of per PR/PCO segment, apical vertebra rotation (AVR) and apical vertebra translation (AVT). Demographics, surgical data, complications were also recorded. Student's independent samples t test and Pearson's chi-square test were used to compare the differences between groups.

RESULTS

Forty patients with an average age of 16.65 years were included (PR group, n = 20; PCO group, n = 20). The main curves averaged 77.56° ± 5.86° versus 78.02° ± 5.72° preoperatively and 20.07° ± 6.73° versus 33.58° ± 5.76° (p < 0.001) at the last follow-up in the PR and PCO groups, respectively. The mean correction rates were 74.30% and 56.84%, respectively (p < 0.001). The average coronal curve correction was 13.49° per release segment, which was significantly higher than the PCO correction of 6.20° (p < 0.001). The correction of apical vertebra rotation and translation in the main thoracic curve was significantly better in the PR group than in the PCO group (p < 0.05). Several minor complications in the two groups improved after conservative treatment.

CONCLUSION

The multi-segment apical convex PR combined with PCO offers more advantages than PCO alone in the treatment of patients with moderate-to-severe rigid scoliosis. Owing to its excellent corrective effect and few complications, this is a high benefit-risk ratio surgical strategy for rigid scoliosis.

The effectiveness of pre-contoured titanium alloy rods in inducing thoracic kyphosis after sequential spinal releases in an in vitro biomechanical model

Purpose

Evaluate the ability of pre-contoured rods to induce thoracic kyphosis (TK) in human cadaveric spines and determine the effectiveness of sequential surgical adolescent idiopathic scoliosis (AIS) release procedures.

Methods

Six thoracolumbar (T3-L2) spine specimens were instrumented with pedicle screws bilaterally (T4-T12). Over correction using pre-contoured rods was performed for intact condition and Cobb angle was measured. Rod radius of curvature (RoC) was measured pre- and post-reduction. The process was repeated following sequential release procedures of (1) interspinous and supraspinous ligaments (ISL); (2) ligamentum flavum; (3) Ponte osteotomy; (4) posterior longitudinal ligament (PLL); and (5) transforaminal discectomy. Cobb measurements determined the effective contribution of release on TK and RoC data displayed effects of reduction to the rods.

Results

The intact TK (T4-12) was 38.0° and increased to 51.7° with rod reduction and over correction. Each release resulted in 5°-7°of additional kyphosis; the largest releases were ISL and PLL. All releases resulted in significant increases in kyphosis compared to intact with rod reduction and over correction. Regionally, kyphosis increased ∼2° for each region following successive releases. Comparing RoC before and after reduction showed significant 6° loss in rod curvature independent of release type.

Conclusion

Kyphosis increased in the thoracic spine using pre-contoured and over corrected rods. Subsequent posterior releases provided a substantial, meaningful clinical change in the ability to induce additional kyphosis. Regardless of the number of releases, the ability of the rods to induce and over correct kyphosis was reduced following reduction.

Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis

The aim of this meta-analysis was to analyze the results of one-stage all-posterior spinal fusion for severe adolescent idiopathic scoliosis (AIS). A systematic search of articles about one-stage posterior spinal fusion for severe AIS was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about population, pre-and postoperative radiographical data, surgical procedure details, and complications were extracted. Meta-analyses were performed when possible. Fourteen studies (640 patients) were included. The mean Cobb angle of the major curve varied from 80.0 ± 7.3 to 110.8 ± 12.1. The meta analysis showed a comprehensive coronal correction rate of the major curve of 58.6%, a comprehensive operative time of 274.5 min, and a comprehensive estimated intraoperative blood loss of 866.5 mL (95% confidence interval: 659.3-1073.6, I 2 ≈ 0%). A total of 48 complications (5.4%) were reported. Overall, the meta-analysis showed a major complication rate of 4%. In seven cases, revision surgery was needed. Posterior-only approach is effective enough to correct severe curves and can spare the patient possible adverse events due to anterior approach. However, when choosing this approach for severe AIS, screw density needs to be high and posterior column osteotomies may need to be planned to mobilize the spine and maximize correction.

Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost compared to non-severe scoliosis

PURPOSE

To compare the perioperative outcome and operative cost of posterior spinal fusion (PSF) surgery between severe and non-severe Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients.

METHODS

A total of 509 AIS patients who underwent single-staged PSF between 2013 and 2020 were reviewed. Fifty-four severe scoliosis patients (Cobb angle ≥ 90°) were categorized into Gp1, and 455 non-severe scoliosis (Cobb angle < 90°) patients into Gp2. Propensity score matching (PSM) analysis using one-to-one nearest neighbor matching and match tolerance of 0.001 were performed. Outcome measures were operative time, intraoperative blood loss (IBL), allogeneic transfusion rate, perioperative complication, length of stay, fusion level, number of screws used, postoperative Cobb angle, correction rate (CR), side bending correction index (SBCI) and operative cost.

RESULTS

From the PSM analysis, 35 patients from each group were matched. The operative time was 155.9 ± 41.4 and 130.0 ± 30.3 min for Gp1 and Gp2, respectively (p = 0.004). The IBL was 1349.2 ± 1019.0 and 781.9 ± 325.1 mLs for Gp1 and Gp2, respectively (p = 0.003). Fusion level (12.5 ± 0.8 vs. 11.2 ± 1.3, p < 0.001) and number of screws used (16.4 ± 1.6 vs. 14.6 ± 1.4, p < 0.001) were higher in Gp1. Four perioperative complications were observed in Gp1 compared to none in Gp2 (p < 0.039). Gp1 had larger postoperative Cobb angle (p < 0.001), lower CR (p = 0.005) and higher SBCI (p < 0.001). The operative cost was higher in Gp1 (p < 0.001).

CONCLUSIONS

Severe Lenke 1 and 2 AIS patients had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost than non-severe AIS.

Intraoperative halo-femoral traction during posterior spinal arthrodesis for adolescent idiopathic scoliosis curves between 70° and 100°: a randomized controlled trial

OBJECTIVE

Surgical management of scoliosis curves between 70° and 100° remains controversial. The authors designed this randomized controlled trial to validate the efficacy of intraoperative halo-femoral traction (IOHFT) in patients with adolescent idiopathic scoliosis (AIS), Cobb angles between 70° and 100°, and flexibility < 35%.

METHODS

The authors prospectively recruited and randomized 29 patients with severe AIS scheduled for posterior surgery into a traction group or control (nontraction) group. The primary outcome measures were operative time, blood loss, and length of hospital stay. Secondary outcomes included degree of spine deformity correction, traction-related complications, and health-related quality of life.

RESULTS

In the traction group, the average preoperative Cobb angle was 83.2°, with an average 20.6% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.3° at the final follow-up. In the control group, the average preoperative major curve was 80.3° with 22.8% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.1° at the final follow-up. The operative duration was 325.7 minutes for the traction group and 385.4 minutes for the control group (p = 0.018). Compared with the control group, the traction group had a 29.5% reduction in intraoperative blood loss and a significantly lower rate of blood transfusion (13.3% vs 50.0%, p = 0.033). There were no neurological complications in either group. One patient in the traction group had a superficial infection at the traction site.

CONCLUSIONS

Use of IOHFT contributed to significant reductions in operative time and blood transfusion requirements, with no added morbidity. It is an effective and safe method to assist correction of AIS curves between 70° and 100° and flexibility < 35%.

A novel posterior multiple screws distraction reducer system versus anterior release, posterior internal distraction, and subsequent spinal fusion for severe scoliosis

Purpose

We previously reported anterior release, posterior internal distraction, and subsequent spinal fusion (ARPIDF) for the correction of severe scoliosis with a satisfactory correction rate. However, surgical procedures were completed in 2–3 stages. Here we compare Cobb angle of ≥90° in scoliosis correction between a novel posterior multiple screws distraction reducer (MSDR) system and ARPIDF.

Methods

Thirty-six patients with severe scoliosis treated by MSDR or ARPIDF (n = 18 in both groups). We retrospectively analyzed and compared outcome measures between the two groups over a minimum follow-up duration of 2 years. The following variables were compared between the two groups: age at surgery, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, operation time, estimated blood loss, hospitalization time, follow-up duration, various radiological parameters, complication rate, and Scoliosis Research Society-30 score.

Results

There were no significant between-group differences with respect to age, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, and follow-up duration. Further, there was no significant difference in terms of preoperative, postoperative, and final follow-up findings of the radiographic data. However, the ARPIDF group had longer operation and hospitalization times and greater blood loss. In the ARPIDF group, 4 patient developed complications (infection, intraoperative neuromonitoring changes, transient dyspnea); none of these events occurred in the MSDR group.

Conclusion

The use of MSDR helped achieve greater scoliosis correction with a shorter operation time, lower blood loss, and lower complication rate than the use of ARPIDF. MSDR facilitates safer and easier correction of severe scoliosis without increasing surgical risk.

Pioneering Experience of Uniportal Video-Assisted Thoracoscopic Surgery for Anterior Release of Severe Thoracic Scoliosis

The optimal way to treat severe thoracic scoliosis remains controversial. Compared with conventional procedures, the uniportal video-assisted thoracoscopic surgery (UniVATS) rises in popularity in thoracic surgery because of less pain and faster recovery. This retrospective study aimed to apply UniVATS to treat severe thoracic scoliosis. Between October 2013 and March 2018, eight scoliotic patients with extremely large Cobb angle and profoundly limited flexibility underwent UniVATS for anterior release, followed by posterior instrumentation and fusion. The mean age at the time of surgery was 14.8 ± 2.4 years and the mean follow-up was 2.2 ± 1.3 years. The average levels of anterior thoracic discectomy and posterior fusion were 3.6 ± 0.7 and 11.5 ± 1.2, respectively. The mean coronal and sagittal correction rates were 70 ± 19% and 71 ± 23%, respectively. UniVATS contributed to minor access trauma (3-cm incision) with minimal blood loss, shorter operation time (75 ± 13 mins), less requirement of stay in the intensive care unit (0.3 ± 0.5 day) or chest tube placement (0.3 ± 0.7 day), speedier and narcotic-free recovery, and earlier ambulation within one day. This is the first study to assess the safety and efficacy of UniVATS in the treatment of severely stiff thoracic scoliosis, providing comparable surgical outcomes, less pain, faster recovery and superior cosmetic results without significant complications.

Comparison of Complications and Surgical Outcomes of Adolescent Idiopathic Scoliosis Between Junior Attending Surgeons and Senior Attending Surgeons

BACKGROUND

To our knowledge, few studies have compared complications and surgical outcomes of adolescent idiopathic scoliosis (AIS) between junior attending surgeons and senior attending surgeons.

OBJECTIVES

To compare surgical strategies, complications, and outcomes of posterior corrective surgery for AIS between junior attending surgeons and senior attending surgeons.

METHODS

According to experience level of operation surgeons, the patients were assigned to 2 groups. Group A was the "junior surgeon" group. Group B was the "senior surgeon" group. The following parameters were compared between the 2 groups: age, sex, diagnosis, hospital of record, surgeon experience level, type of instrumentation, type of screws, estimated blood loss, duration of surgery, length of fusion, correction techniques, main curve correction, and thoracic kyphosis correction.

RESULTS

A total of 132 patients with AIS were included in group A, whereas 207 were in group B. The translational technique was used more often in group A (P < 0.05). whereas the derotation technique was used more often in group B (P < 0.05). Senior surgeons used more monoaxial screws than junior surgeons (P < 0.05). The junior group had significantly greater estimated blood loss than the senior group (P < 0.05). The senior group had significant better correction rates of severe main curve (>70°) and thoracic kyphosis than the junior group (P < 0.05).

CONCLUSIONS

Senior attending surgeons outperformed junior surgeons in blood loss control, thoracic kyphosis correction, and correction of severe curves.