Congenital scoliosis treated with posterior vertebral column resection in patients younger than 18 years: longer than 10-year follow-up

Spinopelvic morphology impacts on postoperative proximal junctional kyphosis in congenital scoliosis with thoracolumbar hemivertebrae

PURPOSE

It aims to investigate the lumbar and pelvic morphology in congenital scoliosis with thoracolumbar hemivertebrae and its impact on proximal junctional kyphosis (PJK) incidence after hemivertebra resection and short fusion.

METHODS

23 congenital scoliosis patients with thoracolumbar hemivertebra aged between 10 and 18 years were enrolled in the retrospective study. Spinopelvic sagittal parameters were analyzed on whole-spine standing lateral radiographs preoperatively, one-week postoperatively and at the final follow-up. Pearson correlations were calculated for local kyphosis (LK), lumbar and pelvic morphology parameters. Binary logistic regression and receiver operating characteristics (ROC) curve analysis were performed to identify the risk factors for PJK.

RESULTS

Thoracolumbar hemivertebra caused LK of 29.2° ± 17.3°, an increased lumbar lordosis (LL) (-64.7° ± 16.3°), lower LL apex (52.2% at L5), and small pelvic incidence (PI) (36.8° ± 6.6°). LK was correlated with lumbar morphology parameters, including LL (r = - 0.837), upper arc of LL (LLUA) (r = - 0.879), thoracolumbar kyphosis (TLK) (r = 0.933), thoracic kyphosis (TK) (r = 0.762) and TK apex (TKA) (r = - 0.749). Surgical treatment improved the lumbar morphology, but not pelvic morphology. At the final follow-up, LL had returned to its preoperative value (p = 0.158). PJK occurred in 30.4% of cases as a compensatory mechanism. Preoperatively, significant differences of parameters between non-PJK and PJK groups were observed in LK and TLK. Binary logistic regression identified three independent risk factors for PJK: preoperative LLA (OR = 0.005, 95%CI = 0.000-0.287, p = 0.011), preoperative TLK (OR = 1.134, 95%CI = 1.001-1.286, p = 0.048), and preoperative lumbar lordosis morphology type (OR = 5.507, 95%CI = 1.202-25.227, p = 0.028). However, residual LK after surgery was not correlated with PJK incidence. ROC curve analysis verified that preoperative TLK > 22.59° was associated with increased PJK incidence after surgery.

CONCLUSIONS

Lumbar morphology changes as a compensatory mechanism beneath the thoracolumbar hemivertebra. However, a stable pelvis tends to allow the LL to return to its preoperative value. PJK occurred as a cranial compensatory mechanism for increasing LL and corrected TLK. A larger TLK (> 22.59°) was an independent risk factor for PJK incidence in patients with type 2 and 3A lumbar lordosis morphology.

Clinical outcomes and spinal growth after posterior hemivertebra resection and short segment fusion in children

To evaluate the corrective effect of posterior hemivertebra resection and short-segment fusion surgery on pediatric patients and to assess the impact of short-segment fixation surgery on vertebral development during follow-up, a retrospective analysis was performed on 28 pediatric patients who underwent posterior hemivertebra resection surgery. The corrective effect was evaluated by comparing indicators such as segmental scoliosis Cobb angle, upper and lower compensatory curves and trunk balance at different time points. Meanwhile, the vertebral and spinal canal diameters of instrumented vertebrae and adjacent noninstrumented vertebrae were measured and compared to assess vertebral and spinal canal development. The correction rate of segmental scoliosis was 72.2%. The estimated mean vertebral volume of the instrumented vertebra was slightly lower than that of the unfused segment at the final follow-up, but the difference was not statistically significant. The growth rate of the spinal canal during follow-up was much smaller than that of the vertebral body. In summary, internal fixation at a young age shows no significant inhibitory effects on spinal development within the fusion segment. Posterior hemivertebra resection and short-segment fusion surgery are safe and effective.

Congenital Cervical Scoliosis Treated with Concave Side Distraction with Three-Dimensional Printed Titanium Cage

STUDY DESIGN

Single-center, retrospective study.

OBJECTIVE

Hemivertebra resection is the only treatment option for congenital cervical scoliosis (CCS). However, this procedure is complex and technically demanding. It often requires a considerably long operation, and there is substantial intraoperative bleeding. Therefore, we have attempted to treat CCS with a concave side distraction comprising a three-dimensional (3D) printed titanium cage. The purpose of this study is to evaluate the safety and efficacy of this technique for the treatment of patients with CCS.

METHODS

A series of 22 patients with CCS who underwent a concave side distraction technique between 2019 and 2021 were retrospectively reviewed and analyzed. Radiological measurements included the Cobb angle of the distraction segments, the kyphosis angle, the range of movement, and the distraction correction angle. Student's t-test and Spearman correlation analysis were used for statistical analysis. p < 0.05 was considered statistically significant.

RESULTS

The study included 12 males and 10 females whose ages ranged from 6 to 14 years old (9.8 ± 2.1 years old). Follow-up times ranged from 15 to 30 months (25.8 ± 3.6 months). Among 22 patients, two patients developed a postoperative C5 nerve root palsy and recovered after being treated with conservative treatment for 6 months. The duration of surgery ranged from 229 to 756 min (389 ± 112 min), and the estimated volume of blood loss ranged from 100 to 600mL (235 ± 121 mL). The coronal Cobb angle (p < 0.001), kyphosis angle (p < 0.05), and range of movement (p < 0.001) between the last follow-up and preoperative period were significantly different. A total of 28 segments were distracted, and the Cobb angle of the distraction segment ranged from 2.4 to 14.1° (8.5 ± 3.0°). There were six upper cervical spines (8.9 ± 1.9°) and 22 lower cervical spines (8.4 ± 3.2°) with no significant difference between them (p = 0.130). In addition, there was no correlation between the angle of the concave side distraction and patients' age (r = 0.018, p = 0.315). The fusion was solid between the bone and the customized 3D-printed pore metal cage at the final follow-up.

CONCLUSION

The concave side distraction comprising a customized 3D-printed titanium cage implantation can provide satisfactory correction results and is a safe and reliable procedure for treating CCS.

The Efficacy of Single-Stage Correction by Posterior Approach for Neglected Congenital Scoliosis: Comparative Analysis According to the Age of Surgical Intervention

Background: A single-stage correction for congenital scoliosis through a posterior-only approach is a commonly used surgical technique. However, there are few studies on the surgical treatment effect of posterior single-stage correction in patients with neglected congenital scoliosis. Methods: Patients who underwent a single-stage posterior correction for congenital scoliosis with a minimum follow-up of 2 years were divided into three groups based on age: Group A (7−11 years), B (12−18 years) and C (>18 years). A comparison of surgical, radiological, and clinical outcomes was performed for three groups. Results: The Cobb angle changed form 75 ± 18° to 37 ± 18° with a correction rate of 53%. Group A showed a significantly higher correction rate than Group B and C (all p < 0.001). The amount of blood loss in Groups B and C was significantly larger than that of Group A (p = 0.015). Pulmonary complications were significantly higher in Group C (p = 0.007). Conclusions: A single-stage correction with pedicle screws through a posterior-only approach achieved a significant correction with improved outcomes, even in neglected cases. However, the early correction for younger patients was still more beneficial in terms of bleeding loss, complications, and flexible curve correction.

Developments in Congenital Scoliosis and Related Research from 1992 to 2021: A Thirty-Year Bibliometric Analysis

BACKGROUND

Many studies, mainly original articles and reviews, have been reported on congenital scoliosis (CS), but there is a lack of bibliometric analyses. This study aimed to systematically analyze the developments and focuses in CS and related research fields.

METHODS

Data were retrieved from the Web of Science Core Collection database, and the top 100 most-cited studies were analyzed emphatically. The Web of Science Results Analysis and Citation Report was used to analyze different aspects of the literature. CiteSpace was used to analyze the cooperation network, reference co-citation, burst keywords, and burst citations.

RESULTS

The final analysis included 749 studies. CS and related research has been rapidly expanding. Several journals have published relevant studies and most-cited studies on this topic. Cooperation was noted among authors, institutions, and countries/regions in multiple instances. Surgical techniques (hemivertebra resection/posterior vertebral column resection/vertical expandable prosthetic titanium rib/double approach/grade 4 osteotomy) was one of the most common research focuses. In addition, research on genetics and molecular biology related to CS has become an emerging trend as a result of advances in basic science.

CONCLUSIONS

Over time, research on CS and in related fields has gained greater attention and has been expanding continuously, showing a trend toward globalization. We recommend that researchers focus on the progress of surgical techniques, advances in molecular biology and genetics, and characteristics of CS. The top clusters, most-cited articles, and references with the strongest burst citations should be studied further.

L5 Vertebral Column Resection for Correction of Severe Lumbar Hyperlordosis and Pelvic Anteversion in an Adolescent With Prior Myelomeningocele Repair and Lumbar Fusion: Case Report

BACKGROUND AND IMPORTANCE

Lumbar hyperlordosis in ambulatory children is an uncommon but potentially problematic spinal deformity, and the operative management has not been comprehensively described.

CLINICAL PRESENTATION

We report the case of a 14-yr-old girl presenting with severe progressive lumbar hyperlordosis (-122°) and sagittal imbalance (-6 cm). She had multiple prior surgeries, including myelomeningocele repair at 10 d old, midlumbar meningioma resection at 8 mo old, and posterior lumbar instrumented spinal fusion at 5 yr old. She presented with progressive lumbosacral back pain and intermittent numbness in her left lower extremity, and severe skin contractures over her prior posterior incisions. From an all posterior approach, prior implants and dural scar were removed and then an L5 vertebral column resection (VCR) was performed to disarticulate her lumbar spine from her anteverted pelvis, allowing for slow distraction forces to correct her lumbar hyperlordosis. This was followed by a T7-sacrum fusion using pedicle screws and iliac screws, with autologous bone graft and plastic surgery wound closure. Postoperatively, lumbar lordosis was corrected to -55° and sagittal balance reduced to -0.5 cm. At 10-wk and 14-mo follow-ups, the patient reported resolution of her back pain with no limitations in physical activities. Dramatic improvement was seen in both her preoperative to 14-mo postoperative Oswestry Disability Index (ODI) (54 to 12) and Scoliosis Research Society Scoliosis Research Society (SRS)-22r (54 to 93) scores.

CONCLUSION

This case highlights a rare presentation of severe progressive lumbar hyperlordosis in an ambulatory adolescent after myelomeningocele repair, meningioma resection, and posterior lumbar instrumented spinal fusion with subsequent surgical treatment incorporating important components of both spinal and plastic surgery involvement.

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.

Congenital Scoliosis of the Pediatric Cervical Spine: Characterization of a 17-Patient Operative Cohort

BACKGROUND

Congenital cervical scoliosis is rare, and there is a paucity of literature describing surgical outcomes. We report surgical outcomes in a 17-patient cohort with surgical correction for congenital cervical scoliosis and identify risk factors associated with complications.

METHODS

Data were retrospectively collected from a single-center cohort of 17 consecutive patients (9 boys, 8 girls) receiving surgical deformity correction for congenital cervical scoliosis. The mean age at surgery was 7.1±3.4 years with an average follow-up of 3.6±1.1 years.

RESULTS

There were 24 operations performed on 17 patients, and 4 complications (17%) were reported in the series, including one each of pressure ulcer, asystole, vertebral artery injury, and pseudarthrosis. The mean preoperative major curve angle was 36±20 degrees, which improved to 24±14 degrees (P=0.02). The mean operative time was 8±2 hours with a mean estimated blood loss of 298±690 mL. Halo-gravity traction was used in 5 patients and 6 cases were staged with anterior/posterior procedures.

CONCLUSIONS

Congenital scoliosis of the cervical spine is a complex process. The spinal deformity of this nature can be managed successfully with carefully planned and executed surgical correction.

LEVEL OF EVIDENCE

Level IV-retrospective review.

Risk factors for blood transfusion in adolescent patients with scoliosis undergoing scoliosis surgery: a study of 722 cases in a single center

Background

To assess the risk factors for blood transfusion in a great number of adolescent cases with different types of scoliosis who received scoliosis surgery.

Methods

Data of patients who were diagnosed as scoliosis and received one-stage posterior correction and spinal fusion from January 2014 to December 2017 were prospectively collected and retrospectively analyzed. Patients’ demographic characteristics, segments of spinal fusion, Cobb angle of the major curve,osteotomy pattern, preoperative and postoperative levels of hemoglobin, and allogeneic blood transfusion (ABT) were recorded and analyzed.

Results

In this study, 722 cases with adolescent scoliosis were included, of whom 32.8% (237/722) received ABT. Risk factors included diagnosis: neurofibromatosis (OR = 5.592), syndromic (OR = 3.029),osteotomy: Ponte osteotomy (OR = 5.997), hemivertebrae resection (OR = 29.171), pedicle subtraction osteotomy (PSO)(OR = 8.712), vertebral column resection (VCR)(OR = 32.265);fusion segments (OR = 1.224) and intraoperative blood loss (OR = 1.004). In the subgroup analysis of cases with idiopathic scoliosis, Ponte osteotomy (OR = 6.086), length of segments of spinal fusion (OR = 1.293), and intraoperative blood loss (OR = 1.001) were found as risk factors for ABT. Results of receiver operating characteristic (ROC) curve analysis revealed that length of segments of spinal fusion equal to 11.5 vertebrae was the best cutoff value for cases with idiopathic scoliosis who did not receive osteotomy in both ABT group and non-ABT group. In the subgroup analysis of congenital scoliosis, Ponte osteotomy (OR = 5.087), hemivertebra resection (OR = 5.457), PSO (OR = 4.055), VCR (OR = 6.940), and intraoperative blood loss (OR = 1.004) were risk factors for ABT.

Conclusions

Method of diagnosis, osteotomy pattern, segments of spinal fusion, and intraoperative blood loss were risk factors for ABT in cases with adolescent scoliosis. In cases with idiopathic scoliosis, Ponte osteotomy and segments of spinal fusion longer than 11.5 vertebrae were risk factors for ABT. In cases with congenital scoliosis, osteotomy pattern was the main risk factor for ABT.

Level of evidence

Level III.

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.

Posterior vertebral column resection with short-segment fusion for the patients with congenital kyphoscoliosis

The purpose of this study was to assess the surgical outcomes of posterior vertebral column resection (PVCR) with short-segment fusion for pediatric patients with congenital kyphoscoliosis (CKS). The medical records of 12 consecutive pediatric patients with CKS due to hemivertebrae located in thoracolumbar and lumbar area that had undergone PVCR and presented for follow-up at a minimum of 2 years were retrospectively reviewed. The mean follow-up period was 56.2 months, and the mean age at the surgery was 9.2 years. We evaluated radiographic parameters using plain radiographs, and evaluated segmental correction using computed tomography imaging. The mean values of the preoperative Cobb angle (cranial curve, main curve, and caudal curve) were 16.0°, 41.3°, and 25.0°, respectively. The main curve was reduced 5.4° after surgery and was maintained at 6.3° at the time of the most recent follow-up. The overall correction rate of main curve was 86.6%. Spontaneous correction rate in the cranial curve and caudal curve were calculated as 55.9 and 80.8%, respectively. The mean segmental scoliosis in the osteotomized segments and fused segments at preoperative/postoperative/final follow-up (FFU) were 40.8°/7.8°/9.2° and 34.3°/3.9°/5.1°, respectively. The mean segmental kyphosis in the osteotomized segments and fused segments at the preoperative/postoperative/FFU were 36.0°/3.8°/4.0° and 27.5°/-1.3°/0.7°, respectively. Our data indicate that PVCR with short-segment fusion for CKS can provide good correction in the main curve and spontaneous correction in the compensatory curves after a minimum 2-year follow-up. Further investigation over the long term is mandatory for pediatric patients.

Clinical and radiological outcomes of hemivertebra resection for congenital scoliosis in children under age 10 years: More than 5-year follow-up

The surgical treatment of congenital scoliosis under 10 years is difficult as it involves resecting vertebrae. Moreover, patient follow-up after surgery is extremely important because the patient is a child whose growth has not been completed. However, there are very few long-term follow-up studies after surgical treatment of congenital scoliosis. Therefore, this study is designed to evaluate surgical outcomes after posterior hemivertebra resection in children under 10 years and its long-term effects.Twenty-one patients with congenital scoliosis who were younger than 10 years at the time of the surgery and received posterior hemivertebra resection and fusion using pedicle screw fixation were included in this study.There were significant improvements in the main curve, coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis after surgery (P < .001, .021, .047, .043, .006, respectively). Coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis remained within the normal range during the follow-up period; however, main curve deteriorated significantly (P = .005). Trunk appearance of perception scale improved significantly after surgery (P = .031) and was maintained during the follow-up period (P = .078).In conclusion, posterior hemivertebra resection and fusion using pedicle screw fixation in patients under 10 years old with congenital scoliosis is a safe and effective procedure that can achieve rigid fixation and deformity correction. Complete resection of the hemivertebra is important for deformity correction and prevention of curve progression, and careful long-term follow-up is necessary.

Correlation between Age and Surgical Approach for Thoracic and Lumbar Hemivertebra

Objective Hemivertebra (HV) is a congenital defect of the formation of the spinal vertebra, which can result in scoliosis or kyphosis along with the related symptomatology of spine deformity. More often than not, it is linked to other abnormalities and requires attention. Its management is surgical and it is of great importance for the physician to choose the right approach at the right time, due to its deteriorative prognosis.

Methods Due to the interest of the subject, the authors investigated the world literature between 1990 and 2018 and found 45 articles, reporting thoracic, thoracolumbar, and lumbar HV in children and its postsurgical outcome, aiming to show whether the approaches are equal in terms of the final outcome.

Results The chosen surgical method depends much on the level of the pathology. Despite this fact, after analyzing the included data, we found that the surgical techniques are unequal with regard to the purpose of achieving improvement. Age, caudal and cranial curves, segmental kyphosis, and scoliosis are factors playing a major role in this.

Conclusion If not treated, HV leads to deterioration and dysfunction. The most optimal result, however, is achieved only when the surgical approach is applied according to age and rest of the accompanying factors, which should be considered in future management planning.

[Comparison of radiological changes after Halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity]

Objective

To compare the changes of scoliosis and kyphosis angles after Halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity.

Methods

A clinical data of 28 patients with severe rigid spinal deformity between January 2015 and November 2017 was retrospectively analyzed. Sixteen patients were treated by Halo-pelvic traction with posterior spinal osteotomy (group A) and 12 patients were treated with posterior spinal osteotomy only (group B). There was no significant difference between the two groups ( P>0.05) in gender, age, body mass index, and preoperative pulmonary function, coronal and sagittal Cobb angles, and flexibility. The operation time, intraoperative blood loss, and complications were recorded. The coronal and sagittal Cobb angles were measured on X-ray films before operation (before traction in group A), at 10 days after operation, at last follow-up in the two groups and after traction in group A. The improvement rate of deformity after traction in group A, the correction rate of deformity after operation, and the loss rate of correction at last follow-up were calculated.

Results

All patients were followed up 24-30 months (mean, 26.5 months). The operation time and intraoperative blood loss were significantly less in group A than in group B ( t=7.629, P=0.000; t=8.773, P=0.000). In group A, 1 patient occurred transient numbness of both legs during continuous traction and 2 patients needed ventilator support for more than 12 hours. In group B, 7 patients needed ventilator support for more than 12 hours, including 1 patient with deep incision infection. The incidence of complications was 18.75% (3/16) in group A and 58.33% (7/12) in group B, and the difference between the two groups was significant ( χ ²=4.680, P=0.031). The coronal and sagittal improvement rates of deformity after traction in group A were 40.47%±3.60% and 40.70%±4.20%, respectively. There was no significant difference between the two groups ( P>0.05) in the coronal and sagittal Cobb angles at 10 days after operation and at last follow-up, in the correction rate of deformity after operation, and in the loss rate of correction at last follow-up.

Conclusion

For the severe rigid spinal deformity, Halo-pelvic traction with posterior spinal osteotomy and simple posterior spinal osteotomy can obtain the same orthopedic effect and postoperative deformity correction. However, the Halo-pelvic traction can shorten operation time, reduce blood loss and incidence of perioperative complications.

The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon's experience with 197 cases

BACKGROUND CONTEXT

Three-column osteotomy (3CO) is used to correct rigid adult spinal deformity. It presents risk of complications because it involves extensive osseous resection and spinal destabilization.

PURPOSE

Our purpose was to characterize the learning curve for performing 3CO in adult spinal deformity patients.

DESIGN

Retrospective review.

PATIENT SAMPLE

A surgical registry at a tertiary care center was used to identify 238 cases of 3CO for correction of adult spinal deformity by 1 surgeon between 2005 and 2014. Patients with at least 1 year of clinical and radiographic follow-up were included (n=197; mean duration of follow-up, 43 months; range, 12-121).

OUTCOME MEASURES

We quantified associations between surgeon experience and (1) estimated blood loss per vertebral level fused (EBL/VLF), (2) incidence of new neurologic deficits, (3) incidence of reoperation for instrumentation failure, (4) operative time in minutes, and (5) magnitude of correction at the level of the osteotomy.

METHODS

The learning curve for binary outcomes was demonstrated using a LOWESS smoother plot of the probability of occurrence. Change in risk was calculated using a generalized linear model with link identity and binomial family. The learning curve for continuous variables was demonstrated using a scatter plot and a line of best fit based on linear regression analysis. Alpha=0.05.

RESULTS

EBL/VLF decreased by a mean of 19.7 mL (95% confidence interval [CI]: 11.3-28.1) with each 10 cases (decrease of 388 mL/level fused by the end of the study period). The risk of a neurologic deficit declined by 7.98% (95% CI: 7.98%, 7.99%) with every 100 cases. The risk of reoperation declined by 1.99% (95% CI: 0.83%, 3.17%) with every 10 cases until the 100th case. After that point, there was no significant change in the probability of reoperation (p>.05). The magnitude of correction and operative time did not change with increasing surgeon experience (p>.05).

CONCLUSION

Incidence of reoperation for instrumentation failure, incidence of new neurologic deficits, and estimated blood loss improved with increasing surgeon experience at performing 3CO. Most outcomes, except the risk of reoperation, improved through the last case.

Coronal Imbalance After Three-Column Osteotomy in Thoracolumbar Congenital Kyphoscoliosis: Incidence and Risk Factors

STUDY DESIGN

Retrospective radiographical clinical study.

OBJECTIVE

To investigate the incidence and risk factors of coronal imbalance (CI) after three-column osteotomy (3-CO) in patients with thoracolumbar congenital kyphoscoliosis (CKS).

SUMMARY OF BACKGROUND DATA

The incidence and risk factors of postoperative CI have been reported in adolescent idiopathic and degenerative lumbar scoliosis. However, limited data exists for patients with CKS after 3-CO.

METHODS

We reviewed a consecutive series of patients with CKS who underwent posterior-only 3-CO. Coronal curve patterns were classified according to absolute C7 translation values into: Type A, C7 translation is less than 30 mm; Type B, C7 translation more than or equal to 30 mm and C7 plumb line (C7PL) shifted to the concave side of the main curve; and Type C, C7 translation more than or equal to 30 mm and C7PL shifted to the convex side. CI was defined as C7 translation on either side more than or equal to 30 mm. According to C7 translation at the latest follow-up, patients was subdivided into an imbalanced group and a balanced group.

RESULTS

One-hundred-thirty patients (mean age, 17.7 ± 5.2 yr) were recruited. The mean follow-up was 41.3 ± 18.5 months. Twenty-six patients (20%) were identified as having CI at the latest follow-up. Compared with the balanced group, the imbalanced group had a larger proportion of preoperative Type C pattern, higher main curve correction, and greater lowest instrumented vertebra (LIV) tilt before and after surgery. Multiple logistic regression showed that risk factors for CI were preoperative type C pattern, preoperative LIV tilt more than or equal to 23.5° and immediate postoperative LIV tilt more than or equal to 12.3°.

CONCLUSION

The incidence of CI in patients with CKS after 3-CO was 20%. A preoperative type C pattern, preoperative LIV tilt more than or equal to 23.5°, and immediate postoperative LIV tilt more than or equal to 12.3° were found to be associated with CI at the latest follow-up.

LEVEL OF EVIDENCE

3.

Fractional curve progression with maintenance of fusion mass in congenital scoliosis: An 18-year follow-up of a case report

RATIONALE

The management of congenital scoliosis concentrates on early diagnosis and proper surgical treatment before the development of severe deformities. Decision making regarding the appropriate fusion levels, proper surgical treatment, and reduction amount of kyphoscoliosis is very important but difficult in the treatment of congenital scoliosis, especially in young children.

PATIENT CONCERNS

We report an 11-year follow-up of revision surgery for fractional curve progression after combined anterior and posterior fusion without hemivertebra resection using pedicle screw fixation (PSF) in congenital kyphoscoliosis at age 4 years (a total 18-year follow-up). A T12 hemivertebra was documented in a 4-year-old girl and was treated by combined anterior and posterior fusion in two stages with PSF. The fusion mass was maintained but the distal compensatory curve progressed during the follow-up period. The patient underwent a posterior vertebral column resection (PVCR) with extended posterior fusion at the age of 11, 7 years after initial surgery.

OUTCOMES

Eleven years after the revision surgery with PVCR, the patient showed satisfactory results and her spine was well balanced.

LESSONS

The cause of revision surgery for the curve progression may include inappropriate fusion level, incomplete hemivertebra resection, or failure of anterior and posterior fusion. Especially, inappropriate fusion level may result in deterioration of the compensatory curve even without progression of the fusion mass.

CONCLUSION

Appropriate selection of fusion levels, complete resection of hemivertebra, and satisfactory reduction of scoliosis and kyphosis are important factors for deformity correction and prevention of progression of both main and compensatory curves (adding-on of structural curve or progression of compensatory curve) as well as reducing the influence of adjacent vertebral growth using as short a fusion as possible.

Radiologic comparison of posterior release, internal distraction, final PSO and spinal fusion with one-stage posterior vertebral column resection for multi-level severe congenital scoliosis

Background

To compare radiologic results of posterior release, internal distraction, and final pedicle subtraction osteotomy (PSO) and spinal fusionwith one-stage posterior vertebral column resection (PVCR) in treating multi-level severe congenital scoliosis.

Methods

Forty-onesevere congenital scoliosis patients were used in the study. Group A comprised 24 patients who underwent one-stage PVCR. Group B comprised 17 patients who underwent posterior release with internal distraction, followed by final posterior fusion and instrumentation. The average preoperative main curve was 110.4° (95–130°) in group A and 109.4° (range 90°–126°) in group B. Postoperative follow-up time was ≥2 years (2.0–4.5 years) to analyze the radiographic and clinical outcomes.

Results

A comparison of posterior release, internal distraction, and final spinal fusion with PVCR showed no significant differences in postoperative main curve and compensatory caudal curve correction, coronal and sagittal imbalance. However, significant differences were found between the 2 groups in compensatory cranial curve correction.

Conclusions

Posterior release, internal distraction, and final spinal fusion produce better corrective results in compensatory cranial curve correction than PVCR in treating severe multi-level congenital scoliosis.

Selective hemivertebrae resection in a congenital scoliosis patient with multiple hemivertebrae deformities

PURPOSE

To report the surgical experience of selective hemivertebrae resection for a case of congenital scoliosis with multiple hemivertebrae deformities.

METHODS

A 14-year-old male presented with progressive rib hump, tilted torso and spine deformity was admitted in our department. No abnormalities were detected in neurological examination and the comprehensive imaging study demonstrated congenital scoliosis of multiple hemivertebrae in T5, T10, L1 and L3. Treatment of the patient commenced with a 10-day skin traction therapy prior to the surgery. Selective resection of hemivertebrae in T5 and L1 was performed with segmental fusion from T3 to L2.

RESULTS

After surgical procedure, the patient achieved a good coronal and sagittal balance along with a good correction of the curve. 18-month postoperative follow-up showed no evidence of significant loss of correction. No device-related complication such as implant loosening or failure or neurologic complication occurred during the follow-up. Besides, patient's shoulder balance was further improved and coronal balance was maintained in a normal range.

CONCLUSION

Many factors have to be considered in the clinical decision-making of congenital scoliosis with multiple hemivertebrae deformities patients. Much emphasis in this regard is laid on the type and location of the hemivertebrae as well as the patient's age. Selective hemivertebrae resection may be more suitable for such patients.

Revision surgery for curve progression after implant removal following posterior fusion only at a young age in the treatment of congenital scoliosis: A case report

RATIONALE

Congenital scoliosis due to a hemivertebra creates a wedge-shaped deformity, which progresses and causes severe spinal deformities as an individual grows. The treatment of congenital scoliosis focuses on early diagnosis and appropriate surgical management before the development of severe deformity.

PATIENT CONCERNS

We report the case of a 4-year-old male child with a left thoracolumbar scoliosis of 27° (T10-T12) due to a T11 hemivertebra who was treated by posterior fusion and pedicle screw fixation at the age of 4 years. The implant was removed due to pain secondary to implant prominence after 4 years without definitive revision surgery, which led to significant progression of the scoliosis, to 50°. The indication for posterior vertebral column resection (PVCR) is a congenital spinal deformity with a curve magnitude greater than 30° with fast progression. This includes documented progression of the curve by more than 5° in a 6- month period, failure of conservative treatment, or both.

OUTCOMES

The patient underwent PVCR of the T11 hemivertebra. Nine years after the revision surgery with PVCR, the patient showed satisfactory results and his spine was well balanced.

LESSONS

This case shows that removal of an implant that was not the only cause of curve progression at a young age may lead to progression of scoliosis and, therefore, should be avoided unless it is absolutely necessary.

CONCLUSION

Congenital scoliosis due to a hemivertebra at a young age could be treated by hemivertebra resection or anterior and posterior epiphysiodesis as definitive surgical treatment. The patient was eventually treated with PVCR, which achieved satisfactory correction without curve progression in a long-term follow-up.

Congenital Kyphoscoliosis in Monozygotic Twins: Ten-Year Follow-up Treated by Posterior Vertebral Column Resection (PVCR): A Case Report

The etiology of congenital scoliosis and its development remains unclear and has not yet been fully identified, even there are theories that congenital scoliosis could be derived from the failure of formation or failure of segmentation, which are etiologically heterogeneous with genetic, epigenetic, and environmental factors contributing to their occurrence. We reported a case of long-term follow-up after posterior vertebral column resection (PVCR) in both identical twins with similar congenital kyphoscoliosis at thoracolumbar levels. Twin I had been noticed by his parents to have asymmetry of his back at age 5 years, but no treatment was given. Twin II was first noticed to have a spinal problem at 11 years of age by his parents. Overtime, spine of both twins became further deviated to the left with kyphosis and was referred to our hospital. Both monozygotic twins were treated by PVCR and satisfactory results were demonstrated at 10-year follow-up.This case is the first report on the surgical treatment with PVCR, almost simultaneously, in both identical twins who had similar congenital vertebral anomalies causing kyphoscoliosis. Both identical twins with congenital kyphoscoliosis had undergone surgical correction by PVCR, anterior support with a mesh cage and posterior fusion using pedicle screws at the age of 14 years and achieved a satisfactory correction and a stable spine without curve progression with 10-year follow-up.