The relationship between physical activity, structural deformity, and spinal mobility in adolescent idiopathic scoliosis patients

PURPOSE

Adolescent idiopathic scoliosis (AIS) patients experience structural spinal deformity, but the impact of AIS on physical activity is not widely studied. Reports of physical activity levels between children with AIS and their peers are mixed. This study sought to characterize the relationship between spinal deformity, spinal range of motion, and self-reported physical activity in AIS patients.

METHODS

Patients aged 11-21 completed self-reported measures of physical activity using the HSS Pedi-FABS and PROMIS Physical Activity questionnaires. Radiographic measures were obtained from standing biplanar radiographic imaging. Surface topographic (ST) imaging data was obtained using a whole-body ST scanning system. Hierarchical linear regression models analyzed the relationship between physical activity, ST, and radiographic deformity while controlling for age and BMI.

RESULTS

149 patients with AIS (mean age 14.5 ± 2.0 years, mean Cobb angle 39.7° ± 18.9°) were included. In the hierarchical regression predicting physical activity from Cobb angle, no factors were significant predictors of physical activity. When predicting physical activity from ST ROM measurements, age and BMI served as covariates. No covariates or ST ROM measurements were significant predictors of physical activity levels for either activity measure.

CONCLUSIONS

Physical activity levels of patients with AIS were not predicted by levels of radiographic deformity or surface topographic range of motion. Although patients may experience severe structural deformity and range of motion limitations, these factors do not appear to be associated with decreased physical activity level utilizing validated patient activity questionnaires.

LEVEL OF EVIDENCE

Level II.

Scoliosis with Chiari I malformation without associated syringomyelia

PURPOSE

Many patients with presumed idiopathic scoliosis are found to have Chiari I malformation (CM-I) on MRI. The objective of this study is to report on scoliosis progression in CM-I with no syringomyelia.

METHODS

A retrospective review of patients with scoliosis and CM-I was conducted from 1997 to 2015. Patients with syringomyelia and/or non-idiopathic scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation and latest follow-up. CM-I was defined as the cerebellar tonsil extending 5 mm or more below the foramen magnum on MRI.

RESULTS

Thirty-two patients (72% female) with a mean age of 11 years (range 1-16) at scoliosis diagnosis were included. The average initial curve was 30.3° ± SD 16.3. The mean initial Chiari size was 9.6 mm SD ± 4.0. Fifteen (46.9%) experienced Chiari-related symptoms, and three (9%) patients underwent Posterior Fossa Decompression (PFD) to treat these symptoms. 10 (31%) patients went on to fusion, progressing on average 13.6° (95% CI 1.6-25.6°). No association was detected between decompression and either curve progression or fusion (p = 0.46, 0.60). For those who did not undergo fusion, curve magnitude progressed on average 1.0° (95% CI - 4.0 to 5.9°). There was no association between age, Chiari size, presence of symptoms, initial curve shape, or bracing treatment and fusion.

CONCLUSION

Patients with CM-I and scoliosis may not require surgical treatment, including PFD and fusion. Scoliosis curvature stabilized in the non-surgical population at an average progression of 1.0°. These results suggest that CM-I with no syringomyelia has minimal effect on scoliosis progression.

Bracing for infantile scoliosis: no sedation needed

Mehta casting technique applied under anesthesia is standard treatment for infantile scoliosis (IIS). However, concern has been raised about frequent anesthesia in children less than three years. The development of a customized thoracolumbar sacral orthosis (TLSO) could avoid the risks of Mehta casting. To develop a bracing technique for IIS that achieves patient compliance and scoliosis correction. Nine patients with ISS were offered a custom TLSO as an alternative to Mehta casting. One patient declined due to an insurance issue. No anesthesia was required for measurement or fitting of the TLSO. A temperature sensitive monitor recorded wear time. Brace success was determined by radiographic correction and adherence to prescription of greater than 18 hours per day. Eight patients had brace treatment with mean(range): age 19(12-44) months, curve magnitude 34° (22-44°), rib vertebral angle of greater than 20° with follow-up 17(3-28) months. In brace correction was less than 15 degrees in 6 of 8 patients. Compliance monitor recorded wear: 4 patients ≥ 18 hours, 2 patients 16-18 hours, 1 had 14 hours, and 1 monitor malfunctioned and could not be read. Brace design evolved to maximize ipsilateral abdominal relief away from the lateral apical shift of the design. Foam lining was added to prevent skin irritation through the relief opening. Average number of braces per year =2.2. A customized TLSO can achieve in brace correction comparable to Mehta casting with acceptable compliance and without the need for general anesthesia, while allowing bathing and skin care.

Variability in Antibiotic Treatment of Pediatric Surgical Site Infection After Spinal Fusion at A Single Institution

BACKGROUND

Recent focus on surgical site infections (SSIs) after posterior spine fusion (PSF) has lowered infection rates by standardizing perioperative antibiotic prophylaxis. However, efforts have neglected to detail antibiotic treatment of SSIs. Our aim was to document variability in antibiotic regimens prescribed for acute and latent SSIs following PSF in children with idiopathic, neuromuscular, and syndromic scoliosis.

METHODS

This study included patients who developed a SSI after PSF for scoliosis at a pediatric tertiary care hospital between 2004 and 2019. Patients had to be 21 years or younger at surgery. Exclusion criteria included growing rods, staged surgery, and revision or removal before SSI diagnosis. Infection was classified as acute (within 90 d) or latent. Clinical resolution of SSI was measured by return to normal lab values. Each antibiotic was categorized as empiric or tailored.

RESULTS

Eighty subjects were identified. The average age at fusion was 14.7 years and 40% of the cohort was male. Most diagnoses were neuromuscular (53%) or idiopathic (41%).Sixty-three percent of patients had an acute infection and 88% had a deep infection. The majority (54%) of subjects began on tailored antibiotic therapy versus empiric (46%). Patients with a neuromuscular diagnosis had 4.0 times the odds of receiving initial empiric treatment compared with patients with an idiopathic diagnosis, controlling for infection type and time (P=0.01). Ninety-two percent of patients with acute SSI retained implants at the time of infection and 76% retained them as of August 2020. In the latent cohort, 27% retained implants at infection and 17% retained them as of August 2020.

CONCLUSIONS

Patients with acute infections were on antibiotics longer than patients with latent infections. Those with retained implants were on antibiotics longer than those who underwent removal. By providing averages of antibiotic duration and lab normalization, we hope to standardize regimens moving forward and develop SSI-reducing pathways encompassing low-risk patients.

LEVEL OF EVIDENCE

Level III.

Chiari I malformations with syringomyelia: long-term results of neurosurgical decompression

STUDY DESIGN

Retrospective case series.

OBJECTIVES

The objective was to assess the long-term outcomes on scoliosis following Chiari-I (CM-I) decompression in patients with CM-I and syringomyelia (SM). A secondary objective was to identify risk factors of scoliosis progression.

BACKGROUND

The association between CM-I with SM and scoliosis is recognized, but it remains unclear if CM-I decompression alters the long-term evolution of scoliosis in patients with associated syringomyelia.

METHODS

A retrospective review of children with scoliosis, CM-I, and SM during 1997-2015 was performed. Congenital, syndromic, and neuromuscular scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation, pre-decompression, after 1-year, and latest follow-up. A scale to measure syringomyelia area on MRI was used to evaluate SM changes post-decompression.

RESULTS

65 children with CM-I, SM, and scoliosis and a mean age of 8.9 years (range 0.7-15.8) were identified. Mean follow-up was 6.9 years (range 2.0-20.4). Atypical curves were present in 28 (43%) children. Thirty-eight patients (58%) underwent decompression before 10 years. Syringomyelia size reduced a mean of 70% after decompression (p < 0.001). Scoliosis improved in 26 (40%), stabilized in 17 (26%), and progressed in 22 (34%) cases. Early spinal fusion was required in 7 (11%) patients after a mean of 0.5 ± 0.37 years and delayed fusion in 16 (25%) patients after 6.0 ± 3.24 years. The remaining 42 (65%) patients were followed for a median of 6.1 years (range 2.0-12.3) without spine instrumentation or fusion. Fusion patients experienced less improvement in curve magnitude 1-year post-decompression (p < 0.001) and had larger curves at presentation (43° vs. 34°; p = 0.004).

CONCLUSIONS

Syringomyelia size decreased by 70% after CM-I decompression and scoliosis stabilized or improved in two-thirds of patients. Greater curve improvement within the first year post-decompression and smaller curves at presentation decreased the risk of spinal fusion. Neurosurgical decompression is recommended in children with CM-I, SM, and scoliosis with the potential to treat all three conditions.

LEVEL OF EVIDENCE

Level IV.

Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions

OBJECTIVE

Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion.

METHODS

A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms.

RESULTS

A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07).

CONCLUSIONS

An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.

Restoration of normal pelvic balance from surgical reduction in high-grade spondylolisthesis

PURPOSE

To investigate the effectiveness of surgical reduction in high-grade spondylolisthesis in maintaining or restoring a normal pelvic balance, as related to the QoL.

METHODS

It is a retrospective analysis of prospectively collected data of 60 patients (17 males, 43 females) aged 15 ± 3.1 years who underwent surgery for high-grade spondylolisthesis and were followed for a minimum of 2 years after surgery. Patients with a residual high-grade slip following surgery were referred to the postoperative high-grade (PHG) group, while patients with a residual low-grade slip were referred to the postoperative low-grade (PLG) group. Pelvic balance was assessed from pelvic tilt and sacral slope, in order to identify patients with a balanced pelvis or unbalanced pelvis. The SRS-22 questionnaire was completed before surgery and at last follow-up.

RESULTS

Postoperatively, there were 36 patients with a balanced pelvis and 24 patients with an unbalanced pelvis. The improvement in QoL was better in patients with a postoperative balanced pelvis. There were 14 patients in the PHG group and 46 patients in the PLG group. Four of seven patients (57%) in the PHG group and 21 of 26 patients (81%) in the PLG group with a preoperative balanced pelvis maintained a balanced pelvis postoperatively (P = 0.1). None of the patients in the PHG group and 11 of 20 patients (55%) in the PLG group improved from an unbalanced to a balanced pelvis postoperatively (P < 0.05).

CONCLUSIONS

Surgical reduction in high- to low-grade slip is more effective in maintaining and restoring a normal pelvic balance postoperatively. These slides can be retrieved under Electronic Supplementary Material.

Correction to: The "Risser+" grade: a new grading system to classify skeletal maturity in idiopathic scoliosis

Unfortunately, the affiliation of the author Negrini S has been incorrectly published in the original version. The complete correct affiliation of this author should read as follows.

Sagittal plane parameters in growing rod patients following final fusion

Almost half of growing rod (GR) patients that undergo final fusion (FF) have an extension of instrumented levels. The purpose of this study was to review sagittal plane radiographic parameters of patients with distal extension of instrumented levels at FF to those whose levels remained the same. Radiographs were assessed preoperatively, after GR insertion/first lengthening, following GR treatment before FFs, and after FF. Measurements included sagittal balance, lumbar lordosis, thoracic kyphosis, and distal junction angle (DJA). Twenty-one patients were included. There was no change in sagittal balance. There was a significant decrease in lordosis and kyphosis following initial GR implantation. Kyphosis and lordosis increased during the GR period, but remained unchanged at time of FF. DJA increased 8° on average. Seven patients had distal extension of instrumented levels at time of FF (average 2 levels, range: 1-4). Indication for distal extension was sagittal plane decompensation in four cases. When comparing patients who had distal extension at the time of FF to those whose levels remained the same, there was no difference in the change in sagittal balance, lordosis, or kyphosis. Final DJA was significantly smaller in those patients with distal extension. Most GR patients that undergo FF demonstrate acceptable correction of sagittal plane radiographic parameters. A small cohort of patients requires distal extension at FF due to sagittal plane decompensation.

LEVEL OF EVIDENCE

Level IV, Therapeutic.

Allograft Bone Use in Pediatric Subaxial Cervical Spine Fusions

BACKGROUND

The use of freeze-dried allograft as a bone graft substitute for pediatric spine surgery is safe and efficacious in the thoracic and lumbar spines. Allograft bone use in segmental instrumented fusions in the subaxial cervical spine has not been well reported in the literature. We sought to describe our experience with allograft bone in this patient cohort, and to compare union rates to patients treated with autograft.

METHODS

Medical records were queried over a 10-year time period (2004 to 2014). Inclusion criteria were all pediatric patients (18 y old and below) who underwent subaxial cervical spine fusion with minimum follow-up of 24 months. Variables queried included demographics, type of graft material used, diagnosis, approach (anterior, posterior, combined), levels instrumented, placement of postoperative halo, surgical-related complications, and achievement of fusion.

RESULTS

A total of 26 patients qualified for inclusion (18 allograft, 8 autograft). No differences existed between the 2 groups regarding age, sex, or number of fused levels. In the allograft cohort, average age at initial surgery was 13.3 years (range, 5 to 18 y). The most common reasons for surgery included trauma (6), tumor (3), and syndrome-associated kyphosis (3). The average number of instrumented levels was 4 (range, 2 to 13). Four patients (22%) developed a postoperative surgical complication. There were 2 asymptomatic pseudarthroses not requiring revision. At a minimum of 24-month follow-up (average, 45 mo; range, 24 to 121 mo), the allograft group demonstrated a fusion rate of 88%, which was comparable with a fusion rate of 87% in the autograft group.

CONCLUSIONS

The use of allograft bone for pediatric subaxial instrumented cervical spine fusions is safe in a variety of conditions, with the same rate of fusion as autograft. Rates of complications are acceptable. To avoid donor-site morbidity from autogenous graft harvest, we recommend considering allograft bone in subaxial cervical spine fusions with modern segmental instrumentation.

LEVEL OF EVIDENCE

Level IV-case series; therapeutic.

Scoliosis Research Society members attitudes towards physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis

Background

Attitudes regarding non-operative treatment for adolescent idiopathic scoliosis (AIS) may be changing with the publication of BRAiST. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are used to treat AIS, but high-quality evidence is limited. The purpose of this study is to assess the attitudes of members of the Scoliosis Research Society towards PSSE.

Methods

A survey was sent to all SRS members with questions on use of Physical Therapy (PT) and PSSE for AIS.

Results

The majority of the 263 respondents were from North America (175, 67 %), followed by Asia (37, 14 %) and Europe (36, 14 %). The majority of respondents (166, 63 %) prescribed neither PT nor PSSE, 28 (11 %) prescribed both PT and PSSE, 39 (15 %) prescribe PT only and 30 (11 %) prescribe PSSE only. PT was prescribed by 67 respondents, as an adjunct to bracing (39) and in small curves (32); with goals to improve aesthetics (27) and post-operative outcomes (25). Of the 196 who do not prescribe PT, the main reasons were lack of evidence (149) and the perception that PT had no value (112).

PSSE was prescribed by 58 respondents. The most common indication was as an adjunct to bracing (49) or small curves (41); with goals to improve aesthetics (36), prevent curve progression (35) and improve quality of life (31). Of the respondents who do not prescribe PSSE, the main reasons were lack of supporting research (149), a perception that PSSE had no value (108), and lack of access (63). Most respondents state that evidence of efficacy may increase the role of PSSE, with 85 % (223 of 263) favoring funding PSSE studies by the SRS.

Conclusion

The results show that 22 % of the respondents use PSSE for AIS, skepticism remains regarding the benefit of PSSE for AIS. Support for SRS funded research suggests belief that there is potential benefit from PSSE and the best way to assess that potential is through evidence development.

Bracing for scoliosis in 2014: state of the art

Bracing is currently the primary method for treating moderate idiopathic scoliosis (IS) during the developmental phase of growth. Following a lengthy debate, during which researchers and authors questioned the role of bracing in the treatment of IS due to inconsistent evidence, the Bracing in Adolescent Idiopathic Scoliosis Trial study have provided a high level of evidence to the value of bracing and may have convinced most of those who were skeptic. However, although some guidelines have been published, there remains no standard for constructing scoliosis orthoses and no standard treatment protocol. The Scoliosis Research Society criteria were established to provide a framework by which to research bracing and adolescent idiopathic scoliosis, and the Society on Scoliosis Orthopedic and Rehabilitation Treatment criteria were published to guarantee a minimum level of expertise for MDs and CPOs involved in the brace treatment. However, very few contemporary papers follow both sets of criteria, and the extensive variety of braces makes it difficult to determine if one is superior to another. The aim of this paper is to provide an overview of state-of-the-art brace treatment, highlighting commonly used braces and their history, biomechanical concept, and results, as reported in published literature. Specific focus is placed on European (i.e., Chêneau and derivatives, Dynamic Derotating, Lyon, PASB, Sforzesco, TLI, TriaC) and North American (i.e. Boston, Charleston, Milwaukee, Providence, Rosenberger, SpineCor, Wilmington) designs. Details about different building techniques are also reported, along with recently developed tools that are designed to monitor compliance.

Complications of plate fixation of femoral shaft fractures in children and adolescents

PURPOSE

This study aims to critically analyze the major and minor complications that may be associated with plate fixation of pediatric diaphyseal femur fractures.

METHODS

The medical records of skeletally immature patients (6-15 years of age) who underwent plate fixation of a diaphyseal femur fracture at a tertiary-care level-1 pediatric trauma center between 1/2003 and 12/2010 were reviewed. Demographic and clinical information regarding the mechanism of injury, fracture type, and surgical technique were recorded. Radiographic evaluation of bony healing, hardware position, and deformity was performed throughout the study period. All intraoperative and postoperative complications were recorded. Complication incidence and time from surgery to complication were described. Multivariate logistic regression and multivariate Cox regression models were used to assess the association between different variables and the occurrence of a complication. Kaplan-Meier survivorship curves were used to evaluate the freedom from a complication with longer follow-up.

RESULTS

Over an 8-year period, 85 skeletally immature patients (83 % males, mean age 10.2 years) underwent plate fixation for diaphyseal femur fractures. Overall, complications were identified in 11 patients (13 %). Major complications, defined as those resulting in unplanned reoperation (excluding elective removal of asymptomatic plate/screws), occurred in five patients (6 %) and included two patients (2 %) with wound infections requiring irrigation and debridement, two patients (2 %) with distal femoral valgus deformity (DFVD) leading to osteotomy and hardware removal, respectively, and one patient (1 %) with a 3-cm leg length discrepancy (LLD) requiring epiphysiodesis. Minor complications, defined as those not requiring unplanned operative intervention, occurred in six patients (7 %) and included two patients (2 %) with delayed union, two patients (2 %) with symptomatic screw prominence, one patient (1 %) with a superficial wound infection effectively treated with oral antibiotics, and one patient (1 %) with valgus malunion, which was asymptomatic at early follow-up. There were no intraoperative complications and no reports of postoperative knee stiffness, shortening, or reoperations to address fracture stability. Fifty-two patients (61 %) underwent routine elective removal of hardware without related complications following fracture union. Overall, complications occurred postoperatively at a mean time of 20 months (range 0-65 months), though major complications occurred at a later time point (mean 29.1 months, range 0-65 months) than minor complications (mean 12.5 months, range 0-40.1 months). Longer follow-up was associated with higher occurrence of a complication [p = 0.0012, odds ratio = 1.05, 95 % confidence interval (CI): 1.02-1.08].

CONCLUSIONS

The plating of pediatric femur fractures is associated with 6 and 7 % rates of major and minor complications, respectively. There were minimal long-term sequelae associated with the complications noted. This complication rate compares favorably with the published rate of complications (10-62 %) associated with titanium elastic nail fixation of similar fracture types. Most complications occurred >4 months postoperatively, with major complications occurring at a later time point than minor complications. Long-term follow-up of these patients is recommended to ensure that complications do not go undetected.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures

BACKGROUND

This study investigated the frequency and potential risk factors associated with the development of distal femoral valgus deformity following plate fixation of diaphyseal femoral fractures in children.

METHODS

Records of eighty-five skeletally immature patients who underwent plate fixation of a diaphyseal femoral fracture at a tertiary-care pediatric center from January 2003 to December 2010 were reviewed. Demographic data and clinical information were analyzed. Radiographic measurement of the distance from the distal plate edge to the distal femoral physis and of the anatomic lateral distal femoral angle was performed. Development of distal femoral valgus deformity was defined as a change in the anatomic lateral distal femoral angle of ≥5° in the valgus direction. Logistic regression analysis and contingency tables were used to relate the development of distal femoral valgus deformity with retention of hardware, patient age, fracture site, plate-to-physis distance, and the location of a bend in the plate at fixation.

RESULTS

Midshaft fractures (45%) were more common than proximal or distal diaphyseal fractures. Intraoperatively, the plate was bent proximally or distally, or both, in 80% of the patients. Distal femoral valgus deformity of ≥5° was seen in ten patients, eight of whom had distal diaphyseal fractures. Three of the ten patients developed symptoms as a result of the distal femoral valgus deformity that required at least one unplanned additional surgical procedure. On the basis of the statistical analysis, patients with a plate-to-physis distance of ≤20 mm (relative risk= 12.77, p = 0.005) and a distal fracture (relative risk = 11.0, p < 0.001) were at a significantly higher risk of developing distal femoral valgus deformity. Although not clearly an independent factor, a distal bend was also found to be associated with distal femoral valgus deformity (p = 0.004) but was not predictive of the pathology.

CONCLUSIONS

Distal femoral valgus deformity occurred in 30% of patients with distal diaphyseal fractures and in 12% overall. We advocate long-term monitoring of patients with femoral plate fixation, particularly those in whom the plate is placed ≤20 mm from the distal femoral physis.

Classification of high-grade spondylolistheses based on pelvic version and spine balance: possible rationale for reduction

STUDY DESIGN

Retrospective review of a radiographic database of high-grade spondylolisthesis patients in comparison with asymptomatic controls.

OBJECTIVE

To analyze the sagittal spinopelvic alignment in high-grade spondylolisthesis patients and identify subgroups that may require reduction to restore sagittal balance.

SUMMARY OF BACKGROUND DATA

High-grade spondylolisthesis is associated with an abnormally high pelvic incidence (PI); however, the spatial orientation of the pelvis, determined by sacral slope (SS) and pelvic tilt (PT), is not known. We hypothesized that sagittal spinal alignment would vary with the pelvic orientation.

METHODS

Digitized sagittal radiographs of 133 high-grade spondylolisthesis patients (mean age, 17 years) were measured to determined sagittal alignment. K-means cluster analysis identified 2 groups based on the PT and SS, which were compared by paired t test. Comparisons were made to asymptomatic controls matched for PI.

RESULTS

High-grade spondylolisthesis patients had a mean PI of 78.9 degrees +/- 12.1 degrees . Cluster analysis identified a retroverted, unbalanced pelvis group with high PT (36.5 degrees +/- 8.0 degrees )/low SS (40.3 degrees +/- 9.0 degrees ) and a balanced pelvic group with low PT (mean 21.3 degrees +/- 8.2 degrees )/high SS (59.9 degrees +/- 11.2 degrees ). The retroverted pelvis group had significantly greater L5 incidence and lumbosacral angle with less thoracic kyphosis than the balanced pelvic group. A total of 83% of controls had a "balanced pelvis" based on the categorization by SS and PT.

CONCLUSION

Analysis of sagittal alignment of high-grade spondylolisthesis patients revealed distinct groups termed "balanced" and "unbalanced" pelvis. The PT and SS were similar in controls and balanced pelvis patients. Unbalanced pelvis patients had a sagittal spinal alignment that differed from the balanced pelvis and control groups. Treatment strategies for high-grade spondylolisthesis should reflect the different mechanical strain on the spinopelvic junction in each group; reduction techniques might be considered in patients with an unbalanced pelvis high-grade spondylolisthesis.

A comparison of methods for measuring spinal motion in female patients with adolescent idiopathic scoliosis

Noninvasive surface measures of spine motion are validated in adult patients but are infrequently used in adolescent scoliosis patients. The agreement between surface and radiographic measurements of spinal motion is not known. We performed a comparative prospective analysis of 3 methods to measure spinal motion in female patients with adolescent idiopathic scoliosis (AIS) to establish normative data of spinal motion in AIS patients and evaluate the relationship between surface and radiographic measurements of spine motion. Measurements were obtained using a cloth tape measure, dual inclinometers, and a 3-dimensional electrogoniometer in 37 female patients with AIS. Radiographic parameters of the deformity were correlated with the spine motion. Differences between methods were evaluated by paired t tests. The Bland-Altman method was applied to evaluate agreement in measuring flexion. The average spinal flexion was 5.7 +/- 2.2 cm by the modified Schober method, 49 +/- 11 degrees by the dual inclinometers method, and 64 +/- 10 degrees by the 3-dimensional electrogoniometer. Spinal motion did not vary with magnitude of the scoliosis. In addition, surface measurements of spinal motion did not correlate with radiographic measurements of scoliosis flexibility. In this study, the amount of spinal motion varied, depending on the method of measurement. Surface measurements of motion cannot predict the magnitude or flexibility of the scoliosis.

Surgical treatment of congenital kyphosis

STUDY DESIGN

In this study, 26 cases of congenital kyphosis and kyphoscoliosis treated surgically were retrospectively reviewed.

OBJECTIVE

To assess the clinical outcomes and surgical indications for posterior only versus anteroposterior surgery in the child.

SUMMARY OF BACKGROUND DATA

Congenital kyphosis usually is progressive without surgical intervention. Current recommended treatment includes posterior arthrodesis for deformities of less than 50 degrees to 60 degrees, and anterior release or decompression, anterior fusion, and posterior instrumented arthrodesis for large deformities and cord compression.

METHODS

Cases involving myelodysplasia, spinal dysgenesis, and skeletal dysplasia were excluded from the study. Kyphoscoliosis was included if the kyphotic deformity was greater than the scoliotic deformity. Patients were grouped by age and surgical technique. The patients in group P1 underwent posterior arthrodesis at an age younger than 3 years, and those in group P2 underwent the procedure at an age older than 3 years. The patients in group AP1 underwent anterior and posterior procedures at an age younger than 3 years, and those in group AP2 underwent the procedures at an age older than 3 years. The preoperative deformity, complications, and postoperative deformity correction were analyzed. There were nine Type 1 (failure of formation), nine Type 2 (failure of segmentation), and eight Type 3 (mixed) deformities. Four patients had associated spinal dysraphism. Three patients with Type 1 deformities had clinical or radiographic evidence of cord compression.

RESULTS

In Group P1, five patients at an average age of 16 months underwent posterior arthrodesis alone for an average kyphotic deformity of 49 degrees. The immediate postoperative correction improved over a period of 6 years and 9 months by an additional 10 degrees, resulting in a final deformity of 26 degrees. Pseudarthrosis developed in two patients, requiring fusion mass augmentation or anterior arthrodesis. Neither patient was instrumented. In Group P2, five patients at an average age of 13 years and 7 months underwent posterior arthrodesis with instrumentation for kyphotic deformity of 59 degrees. Approximately 30 degrees of intraoperative correction was achieved safely using compression instrumentation and positioning. No further correction occurred with growth. The final residual kyphotic deformity was 29 degrees after a follow-up period of 4 years and 5 months. In Group AP1, seven patients underwent anterior release or vertebra resection for deformity correction and posterior arthrodesis for an average kyphotic deformity of 48 degrees at the age of 16 months. There were no iatrogenic neurologic injuries. The final residual kyphotic deformity was 22 degrees after a follow-up period of 6 years and 3 months. In Group AP2, nine patients underwent anterior release or decompression with posterior arthrodesis for kyphotic deformity of 77 degrees at the age of 11 years and 6 months. The deformity was corrected to 37 degrees, with no significant loss over a follow-up period of 5 years and 2 months. There were two postoperative neurologic complications.

CONCLUSIONS

After reviewing their experience, the authors made the following observations: 1) The pseudarthrosis rate was low even without routine augmentation of fusion mass if instrumentation was used; 2) gradual correction of kyphosis may occur with growth in patients younger than 3 years with Types 2 and 3 deformities after posterior fusion, but appears to be unpredictable; 3) the risk of neurologic injury with anterior and posterior fusion for kyphotic deformity was associated with greater age, more severe deformity, and preexisting spinal cord compromise.

Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis

We performed a retrospective analysis of 212 patients (299 hips) with slipped capital femoral epiphysis (SCFE) over a 9-year period to assess the incidence of osteonecrosis of the femoral head. Risk factors for the occurrence of osteonecrosis and the influence of treatment on the development of osteonecrosis were determined. Osteonecrosis occurred in 4 hips with unstable SCFE (4/27) and did not occur in hips with stable SCFE (0/272). The proportion of hips in which osteonecrosis developed was significantly higher among the unstable hips (4/27 vs. 0/272, p < 0.0001). Among those with an unstable hip, younger age at presentation was a predictor of a poorer outcome. Magnitude of the slip, magnitude of reduction, and chronicity of the slip were not predictive of a poorer outcome in the unstable group. In situ fixation of the minimally or moderately displaced "unstable" SCFE demonstrated a favorable outcome. We have identified the hip at risk as an unstable SCFE. The classification of hips as unstable if the epiphysis is displaced from the metaphysis or if the patient is unable to walk is most useful in predicting a hip at risk for osteonecrosis.

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.

Extrapleural thoracoscopic anterior spinal fusion: a modified video-assisted thoracoscopic surgery approach to the pediatric spine

Video assisted thoracoscopic surgery (VATS) has recently been developed as an alternative to thoracotomy for anterior spinal surgery. We report a case in which an extrapleural dissection was combined with VATS to further improve this approach.

Comparison of single- and dual-rod techniques for posterior spinal instrumentation in the treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Two groups of patients undergoing posterior spinal instrumentation and arthrodesis for treatment of adolescent idiopathic scoliosis were reviewed retrospectively.

OBJECTIVE

To compare intraoperative concerns (operative time and blood loss), complications, and outcome in patients undergoing single or double posterior rod instrumentation for treatment of adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The current treatment of idiopathic scoliosis includes posterior spinal instrumentation and arthrodesis. The standard configuration is a rectangular construct of dual rods connected by cross-links. Use of a single rod with multiple fixation points has been proposed as an alternative method to decrease operative time and blood loss, and to avoid late deep infections.

METHODS

In this study, 21 patients underwent posterior instrumentation using a standard dual-rod construct, and 25 patients underwent posterior instrumentation using a solitary rod with multiple fixation points. Patients were assessed after a minimum 2-year follow-up period.

RESULTS

No significant differences were found in blood loss, operative time, or overall frequency of long-term complications. Although not statistically significant, the trend was toward implant prominence in the double-rod group and implant failure in the single-rod group. Implant failure occurred only in instrumentations extending into the lumbar spine. There was no statistical difference in curve progression.

CONCLUSIONS

Single-rod instrumentation and dual-rod constructs offered similar curve correction, blood loss, and operative time. However, single-rod instrumentation may be more prone to implant failure when extended into the lumbar spine.

Occipitocervical fusions in children. Retrospective analysis and technical considerations

This report presents a retrospective analysis of the authors' experience with occipitocervical fusions in children and adolescents during the last 2 decades. A description of an operative technique devised by the senior author (JEH), and a comparison of the results using this and other methods of fusion are given. Twenty-three patients underwent occipitocervical fusion. Fifteen of the patients were operated on using the authors' technique. To achieve stable fixation of the distal cervical vertebra a threaded Kirschner wire was passed transversely through the spinous process; occipital fixation was achieved by the traditional method of wiring corticocancellous bone graft to the skull through burr holes. The occipital wires then were wrapped around the Kirschner wire and the graft was cradled in the resulting nest. Halo immobilization was used in 10 patients for an average of 12.5 weeks (range, 6-24 weeks). Twenty-two patients achieved successful fusion at an average followup of 5.8 years (range, 1-14.33 years). Several complications, including transient quadriplegia in one patient, pseudarthrosis in two (one of which persists), hardware fixation failure in one, unintended distal extension of the fusion, pneumonia, wound infection, halo pin infection, skin breakdown under the halo vest, hydrocephalus, cerebrospinal fluid leak, and traumatic fusion fracture were encountered. Results using the technique described herein are comparable with or better than the results reported in the previous literature, and the results of the patients in this series in whom the technique was not used.

Lumbosacral fusion in children and adolescents using the modified sacral bar technique

Between 1986 and 1995 10 patients who were 9 to 18 years of age underwent posterior spinal fusion and instrumentation to the pelvis for correction of spinal deformity using the modified sacral bar technique at the authors' institution. Etiologies of the spinal deformity included congenital scoliosis, cerebral palsy, myelomeningocele, neurofibromatosis, and postlaminectomy kyphosis. Indications for pelvic instrumentation were progressive scoliosis of the lower lumbar spine, pelvic obliquity greater than 15 degrees, and dysraphic posterior elements. Five of the patients had prior spinal surgery. Five patients had a prior or a planned pelvic osteotomy. Nine of the patients achieved lumbosacral fusion without an additional procedure. Major complications included loss of pelvic fixation in two patients, and a dural leak and a wound infection in another patient with myelomeningocele. Mean scoliotic curve correction was from 71.9 degrees to 34.5 degrees at final followup. Lumbar lordosis essentially was unchanged. Pelvic obliquity was corrected from a mean of 20.5 degrees preoperatively to a mean of 7.6 degrees at final followup. The modified sacral bar technique was selected for fusion to the sacrum because of planned or prior pelvic osteotomies, prior posterior spinal fusion and instrumentation, sacral dysraphism, or local anatomic anomalies. The modified sacral bar technique proved to be an effective technique in these patients.

Excision of the radial head in patients younger than 18 years

We evaluated the results of an excision of the radial head in 25 patients (27 operated-on elbows) younger than 18 years with stiff painful radiocapitellar joints. The mean age was 14.2 years (range, 4.6-17.8 years) with average follow-up of 7.8 years. Analysis of the results with a postoperative elbow score revealed excellent or good results in 19 of the 27 elbows of patients. Skeletal maturity of the patient did not alter the results based on the rating scale. Revision surgery to remove appositional bone growth was needed in six of the 12 posttraumatic cases and one of 15 developmental elbows. Cubitus valgus, wrist pain, and ulnar neuropathy were not clinical problems at follow-up examination. Excision of the radial head was beneficial for 70% of patients younger than 18 years with stiff, painful radiocapitellar joints. Results were not improved in patients who had reached skeletal maturity.

MRI demonstration of occult purely chondral fractures of the tibia: a potential mimic of meniscal tears

We report the case of a 12-year-old boy with bilateral, purely chondral fractures of the tibia. The patient had Crohn's disease treated with systemic corticosteroids. MR images of the knee were initially interpreted to show a bucket-handle tear of the lateral meniscus. However, arthroscopic evaluation revealed purely chondral fractures of the tibial plateau without meniscal damage. Re-evaluation of the MR study identified the chondral fracture of the lateral tibial articular cartilage detected arthroscopically. This purely chondral fracture of the tibial plateau represented a rare finding in the symptomatic knee that mimicked a meniscal tear by history, physical exam, and MR imaging.

Segmental spinal dysgenesis: early neurologic deterioration and treatment

Segmental spinal dysgenesis is a rare congenital condition of the lumbar or thoracolumbar spine that can be associated with significant progressive or permanent neurologic defects, including paraplegia. In the past, both bracing and surgery have been recommended. Of the seven children we have seen with this problem, three have lost motor function between presentation and the time of surgery. Our experience suggests that to prevent catastrophic neurologic deterioration, surgery is indicated once the diagnosis is made.

Patellar sleeve fracture: demonstration with MR imaging

PURPOSE

To demonstrate the magnetic resonance (MR) imaging characteristics of patellar sleeve fracture, a cartilaginous avulsion from the lower pole of the patella occurring during forceful contraction of the quadriceps muscle against a partially flexed knee.

MATERIALS AND METHODS

The authors evaluated radiographs and MR images from three children with suspected sleeve fractures.

RESULTS

Radiographs showed small bone fragments avulsed from the lower patella in two children and no bone abnormality in one. MR imaging demonstrated separation of most of the cartilaginous lower patella in all children, definite intraarticular extension in one, and possible intraarticular extension in another.

CONCLUSION

MR imaging can help determine the need for surgery by depicting the extent of cartilaginous injury and displacement of fracture fragments.

Burst fractures of the fifth lumbar vertebra

Eleven patients with burst fractures of the fifth lumbar vertebra were reviewed. The results of nonoperative treatment were compared with that of immediate surgery and stabilization with pedicle screw fixation. Five patients were treated nonoperatively and six patients underwent pedicle screw instrumentation and spinal fusion. Five patients had neurologic injury associated with their L5 burst fracture. Nonoperative treatment yielded excellent results in young patients with minimal canal compromise. Neurologic deficits responded more predictably to surgical decompression than to conservative treatment and internal fixation with pedicle screws restores spinal stability and allows early mobilization.

Hip disease in adults with Down syndrome

The life expectancy of patients with Down syndrome has increased significantly in recent years. Hip abnormalities occur in children with this syndrome but little is known about their natural history in later life. In 65 adults with Down syndrome we found hip abnormalities in 28%, and this was statistically correlated with walking ability. A subgroup of 18 patients was followed by serial examination; this showed that hip instability occurred in adulthood and became worse with time. In some patients, hip instability started after skeletal maturity.

Latent psoas abscess after anterior spinal fusion

This case is presented to emphasize that late infection should be considered in all postoperative patients as a cause of pain. A psoas abscess may remain dormant for many years after an anterior spinal procedure. It should be considered in the differential diagnosis of back pain and lumbar radiculopathy after anterior spinal fusion. The lumbar nerve plexus lies within the psoas muscle, and referred pain patterns may occur in the lumbar nerve distribution. In this case, dysesthesias occurred in the distribution of the genitofemoral nerve. The diagnosis and treatment of a psoas abscess has been greatly aided by use of CT and ultrasound. Either of these modalities may be used for directed percutaneous drainage of the abscess. The presence of metal fixation devices necessitates removal of the hardware in order to ensure eradication of the infection.

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Unicameral bone cyst in the scapula of an adolescent

Unicameral bone cysts of the scapula have been reported mainly in adult patients. The atypical location of the unicameral bone cyst in a 12-year-old girl presented a diagnostic dilemma. Curettage proved to be an effective method for both diagnosis and treatment of this benign lesion.