Analysis of duration of different stages of surgery in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients: comparison between severe versus non-severe AIS

PURPOSE

Prolonged surgical duration in severe adolescent idiopathic scoliosis (AIS) patients is associated with increased blood loss and perioperative complications. The aim of this study was to compare the duration of each stage of posterior spinal fusion (PSF) in severe AIS (Cobb angle ≥ 90°) with non-severe AIS patients. This analysis will identify the most time-consuming stage of PSF and help surgeons formulate strategies to shorten operative time.

METHODS

Retrospective study whereby 90 AIS patients (Lenke type 2, 3, 4, and 6) who underwent PSF from 2019 to 2023 were recruited. Twenty-five severe AIS patients were categorized in Gp1 and 65 non-severe AIS patients in Gp2. Propensity score matching (PSM) with one-to-one with nearest neighbor matching (match tolerance 0.05) was performed. Outcomes measured via operation duration of each stage of surgery, blood loss, number of screws, fusion levels and screw density.

RESULTS

Twenty-five patients from each group were matched. Total operative time was significantly higher in Gp1 (168.2 ± 30.8 vs. 133.3 ± 24.0 min, p < 0.001). The lengthiest stage was screw insertion which took 58.5 ± 13.4 min in Gp1 and 44.7 ± 13.7 min in Gp2 (p = 0.001). Screw insertion contributed 39.5% of the overall increased surgical duration in Gp1. Intraoperative blood loss (1022.2 ± 412.5 vs. 714.2 ± 206.7 mL, p = 0.002), number of screws (17.1 ± 1.5 vs. 15.5 ± 1.1, p < 0.001) and fusion level (13.1 ± 0.9 vs. 12.5 ± 1.0, p = 0.026) were significantly higher in Gp1.

CONCLUSION

Screw insertion was the most time-consuming stage of PSF and was significantly longer in severe AIS. Adjunct technologies such as CT-guided navigation and robotic-assisted navigation should be considered to reduce screw insertion time in severe AIS.

Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND

There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision.

METHODS

A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients.

RESULTS

Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused.

CONCLUSION

There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Frontal correction assessment in severe adolescent idiopathic scoliosis surgery using halo gravity traction before to posterior vertebral arthrodesis: a multicenter retrospective observational study

PURPOSE

Preoperative preparation with halo gravity traction (HGT) has several advantages but is still controversial. A multicenter, observational, retrospective study was conducted to determine whether HGT provides better frontal correction in surgery for adolescent idiopathic scoliosis (AIS).

METHODS

Between 2010 and 2020, all patients who underwent posterior spinal fusion (PSF) AIS with a Cobb angle greater than 80° were included. The included patients who underwent HGT were compared (complications rate and radiographic parameters) to patients who did not undergo traction (noHGT). For patients who underwent HGT, a spinal front X-ray at the end of the traction procedure was performed.

RESULTS

Sixty-four in noHGT and forty-seven in HGT group were analyzed with a 31-month mean follow-up. The mean ratio of Cobb angle correction was 58.8% in noHGT and 63.6% in HGT group (p = 0.023). In HGT, this ratio reached 9% if the traction lasted longer than 30 days (p = 0.009). The complication rate was 11.7% with a rate of 6.2% in noHGT and 19.1% in HGT group (p = 0.07). In patient whose preoperative Cobb angle was greater than 90°, the mean ratio of Cobb angle correction increases to 6.7% (p = 0.035) and the complications rate increased to 14% in the no HGT group and decreased to 13% in the HGT group (p = 0.9).

CONCLUSION

HGT preparation in the management of correction of AIS with a Cobb angle greater than 90° is a technique providing a greater frontal correction gain with similar complication rate than PSF correction alone. We recommend a minimum halo duration of 4 weeks.

A comparison of three- and two-rod constructs in the correction of severe pediatric scoliosis

Purpose

Managing severe scoliosis is challenging and risky with a significant complication rate regardless of treatment strategy. In this retrospective comparative study, we report our results using a three-rod compared to two-rod construct in the surgical treatment of severe spine deformities to investigate which technique is safer, and which provides superior radiological outcomes.

Methods

Forty-six consecutive patients undergoing posterior spine fusion for scoliosis between 2006 and 2017 were identified in our institutional records. Inclusion criteria were minimum coronal deformity of 90°, age < 18 years at the time of surgery and a minimum 2 years of follow-up. Radiographic and clinical parameters, as well as post-operative complications were compared between the two groups.

Results

There were 21 patients in the three-rod group and 25 in the two-rod group. The mean preoperative major coronal deformity was 100°± 9 and 102°± 10 in the three-rod and two-rod, respectively (p = 0.6). The average major curve correction was 51% and 59% in three-rod and two-rod groups, respectively (p = 0.03). The post-operative thoracic kyphosis was 30°± 11 and 21°± 12 in the three-rod and the two-rod groups, respectively (p = 0.01). The surgical time was 476 ± 52 and 387 ± 84 min in three-rod and two-rod, respectively (p < 0.01). One patient in the two-rod cohort showed permanent post-operative sensory deficit. There were three unplanned returns to operating theater in the two-rod group.

Conclusions

Coronal correction was better with two-rod, whereas sagittal balance was superior with three-rod. Both techniques achieved balanced spine treating severe scoliosis. The two-rod technique was associated with a higher likelihood of requiring revision surgery.

Level of evidence

level 3.

Halo-pelvic traction in the treatment of severe scoliosis: a meta-analysis

PURPOSE

To provide better evidence of the efficacy and safety of preoperative halo-pelvic traction on the improvements of deformity and pulmonary functions in patients with severe scoliosis.

METHODS

Electronic database searches were conducted including the Cochrane Library, PubMed, Web of Science and Embase. All studies of halo-pelvic traction for the management of severe spinal deformity were included. We referred to a list of four criteria developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the quality of included studies. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

Based on the study selection criteria, a total of eight articles consisting of a total of 210 patients were included. Statistically significant differences were found in coronal Cobb angle (P < 0.001), sagittal Cobb angle (P < 0.001) and height (P < 0.001) between pre- and post-traction. Sensitivity analysis was conducted, and there were substantial changes in heterogeneity with preoperative thoracoplasty subgroup in coronal Cobb angle (P < 0.001). Three trials including 74 subjects reported FVC and FEV1 predicted value between pre- and post-traction. There were statistically significant differences in FVC, FVC%, FEV1 and FEV1% (P < 0.001). The complication rate was 6.6-26.7%, and symptoms disappeared after reasonable traction strategy and intensive care.

CONCLUSIONS

Preoperative halo-pelvic traction achieved significant improvements in spinal deformity and pulmonary functions, with minor and curable complications. Thus, it is an effective and safe solution before surgery and may be the optimal choice for severe scoliosis. In light of the heterogeneity and limitations, future researches are needed to better determine the long-term efficacy on comprehensive assessment and to explore the appropriate traction system.

Temporary internal distraction for severe scoliosis: two-year minimum follow-up

PURPOSE

Temporary internal distraction (TID) is a surgical technique used to correct severe scoliosis. We sought to evaluate the long-term outcomes associated with temporary internal distraction (TID) for severe scoliosis.

METHODS

Scoliosis patients who underwent TID from 2006 to 2019 at a single institution were identified. Patients with coronal Cobb angles ≥ 90° or congenital scoliosis, and ≥ 2-year follow-up were included. Clinical and imaging data were reviewed for patient and operative characteristics and complications. Patient-reported outcomes were also analyzed.

RESULTS

51 patients (37 female) were included. Mean age at surgery was 14.3 ± 3.5 years. Mean follow-up was 5.8 ± 3.0 years. Eighteen (35%) curves were idiopathic, 24 (47%) were cerebral palsy (CP) related, and 9 (18%) were congenital. Mean Cobb angle was 103° preoperatively and 20° at final follow-up, with an intermediate angle of 55º in staged procedures. Intraoperative neuromonitoring changes occurred in 13 (25.4%) cases, but all returned to baseline with immediate lessening of distraction. Overall, three (5.8%) cases of wound dehiscence, five (9.7%) cases of deep infections, one (2%) case of screw protrusion, and one (2%) case of delayed extremity weakness occurred. Patient-reported outcomes significantly improved at final follow-up.

CONCLUSION

Our findings suggest that TID is a valuable adjunct for correcting severe scoliosis. The mean Cobb reduction achieved (81%) was higher than that reported for halo-traction and was sustained over long-term follow-up. TID also allowed a shorter a hospital stay. While intraoperative neuromonitoring changes were not uncommon, they were reversible. However, care must always be exercised as major corrections may rarely result in delayed neurologic deficits despite intact neuromonitoring.

LEVEL OF EVIDENCE

Therapeutic-Level III.

Ultrasound-guided nusinersen administration for spinal muscular atrophy patients with severe scoliosis: an observational study

BACKGROUND

This observational study describes our experience delivering nusinersen through lumbar puncture with real-time ultrasound guidance in spinal muscular atrophy (SMA) patients with severe scoliosis.

RESULTS

Intrathecal nusinersen via real-time ultrasound-guided lumbar puncture was given to three patients who had severe thoracic and lumbar scoliosis: a 34-year-old female with type 3a SMA, a 28-year-old male with type 2a SMA, and a 14-year-old girl with type 3a SMA. Lumbar puncture was performed without sedation under ultrasound guidance using a 22G echogenic needle in the interlaminar aspect of the L4-L5 or L5-S1 interspace and a full dose of nusinersen (12 mg/5 mL) was injected after visualizing free cerebrospinal fluid flow. Patients completed their four loading doses and one maintenance dose of nusinersen. All 15 procedures were successful and well tolerated.

CONCLUSIONS

Real-time ultrasound-guided lumbar puncture is an effective and radiation-free technique to administer intrathecal nusinersen in SMA patients with severe scoliosis when done by practitioners with expertise in this procedure.

Preoperative skull tongs-femoral traction versus cotrel longitudinal traction for rigid and severe scoliosis: Cohort study

Background

To compare two methods of preoperative traction (Cotrel traction exercises and skull tongs femoral traction) in severe scoliosis treatment.

Methods

We collected retrospective data of severe (>80°) and rigid scoliosis patients who underwent preoperative traction before correction surgery from 2016 to 2018. The first group consisted of patients who underwent Cotrel traction exercises and second group underwent continuous-progressively increasing Skull Tongs Femoral Traction (STFT) traction. Posterior fusion was performed in all patients. Intraoperative parameters (blood loss, operation time and level instrumented) and radiologic change (initial, post-traction and postoperative Cobb Angle) was evaluated and analyzed.

Results

Thirty consecutive case of severe and rigid scoliosis were included (15 in each group). Despite Cotrel group having larger initial Cobb angle, the amount of post traction correction was statistically similar in both groups (16.4° and 11.8°, in STFT and Cotrel group respectively). Mean traction duration was 14.0 days for Cotrel group and 12 days for STFT. There were also no significant differences in postoperative curve correction rate between two groups, although STFT group had a slightly higher correction rate (69.3° vs 55.0°). No major/neurologic complication were found in our series.

Conclusions

Both preoperative traction methods were found safe and beneficial to reduce preoperative curve degree before definitive scoliosis correction surgery. Although, no statistical difference were found between two methods, STFT may provide better correction rate.

Level of evidence

3.

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Compare two preoperative traction methods in severe scoliosis.

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Preoperative traction were safe and beneficial to reduce preoperative curve degree.

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Skull Tongs Femoral Traction may provide better correction rate.

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.

Predictive factors for correction rate in severe idiopathic scoliosis (Cobb angle ≥ 90°): an analysis of 128 patients

PURPOSE

Knowledge on the factors affecting the correction rate (CR) aids in the surgical planning among severe idiopathic scoliosis (IS) patients. This study aimed to investigate the independent factors affecting CR among patients with severe IS (Cobb angle ≥ 90°) who underwent single-staged posterior spinal fusion (PSF).

METHODS

We retrospectively reviewed 128 severe IS patients who underwent single-staged PSF. Factors including age, height, weight, body mass index, Risser sign, Lenke subtypes, preoperative major Cobb angle, side bending major Cobb angle, side bending flexibility (SBF), motion segments of the major curve, AR curve, number of levels fused, screw density, operative time and postoperative major Cobb angle were analysed using linear regression analysis.

RESULTS

The mean age was 15.5 ± 4.5 years with mean Risser sign of 3.1 ± 1.6. The mean preoperative Cobb, SBF, postoperative Cobb and CR were 102.8 ± 12.3°, 37.5 ± 13.7%, 44.4 ± 13.5° and 57.2 ± 10.8%, respectively. From stepwise multiple linear regression analysis, SBF, Risser sign and AR curve were the independent predictive factors for CR, with R² value of 0.345 (p < 0.001). CR can be predicted using the formula: 47.21 + (0.34 × SBF)-(1.47 × Risser sign) + (3.69 × AR), where AR = 1 and non-AR = 0.

CONCLUSION

The flexibility of the major curve, Risser sign and AR curve were the most important predictors for CR in a single-staged PSF among patients with severe IS.

A posterior-only approach for treatment of severe adolescent idiopathic scoliosis with pedicle screw fixation: A case series

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Mean major coronal correction rate was 67%.

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Pedicle screws provide three-dimensional deformity correction.

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Posterior spinal fusion alone (PSF) obtains a good and stable correction for severe scoliosis.

Introduction

Adolescent idiopathic scoliosis (AIS) can lead to severe deformity. However, early detection and treatment can prevent its progression. Surgical instrumentation for scoliosis treatment has evolved from Harrington instrumentation to pedicle screws. However, there are still some concerns about the efficacy and long-term effects of pedicle screw fixation, and the clinical and radiographic outcomes of surgical treatment for severe AIS (>90°) by posterior spinal fusion alone need to be established.

Presentation of case

Eight patients with severe and rigid idiopathic scoliosis were recruited for this study. All surgeries were performed by one senior spine surgeon between 2015 and 2018. Free hand technique, intraoperative neurophysiologic monitoring (IONM), and intraoperative fluoroscopy to assess the screw position was performed.

Discussion

Severe scoliosis results in a complex three-dimensional spinal deformity that often requires correction in multiple planes. Mean major coronal correction rate was 67% (45–80%). No major complications occurred during the perioperative period and after one year follow up.

Conclusion

Pedicle screws provide three-dimensional deformity correction. There were no complications other than the low-grade late implant-associated infections. Posterior spinal fusion with pedicle screw-only instrumentation obtains a good and stable correction for severe scoliosis.

One stage or two? A cohort analysis of anterior-posterior spinal fusions for severe pediatric scoliosis

STUDY DESIGN

Retrospective case-series study of prospectively collected data.

OBJECTIVE

We sought to identify the differences in outcomes between one-stage (single surgical episode) and two-stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases.

BACKGROUND

Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days.

METHODS

A retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21 years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders.

RESULTS

There were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1  ± 54.7 months. In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52-229 min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3-14.1 days, p = 0.007) increased hospital length of stay. In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108 ml increase in crystalloid use (95% confidence interval: 834-3381 ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0-6.5 days, p < 0.001). There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups.

CONCLUSION

Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior-posterior scoliosis surgery may be preferable to two-stage surgery.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Intrathecal administration of nusinersen for spinal muscular atrophy: report of three cases with severe spinal deformity

Background

Spinal muscular atrophy (SMA) is a genetic disease characterized by degeneration of the spinal cord, resulting in progressive muscle atrophy. Recently, nusinersen has been approved for treating SMA, which should be administered intrathecally.

Case presentation

Patient 1 was a 36-year-old woman with SMA type 2. Patients 2 and 3 were 10- and 17-year-old girls with SMA type 1. In patients 1 and 2, the needle was inserted into the spinal column, but outflow of cerebrospinal fluid was unable to be confirmed. CT revealed that the dural sac terminated at the L5 level in patients 1 and 3 and at the L5/S1 level in patient 2.

Conclusions

Patients with SMA often present with high-grade scoliosis, making intrathecal administration difficult. In addition, the dural sac may terminate at a level higher than normal. To ensure intrathecal administration, the level of dural sac termination must be confirmed by CT before puncture.

Is VCR necessary to correct very severe deformity? case report and review of literature

Background: Management of severe scoliotic deformities is challenging. Deformity correction may need three column osteotomies that may be associated with significant morbidity. Staged procedure and use of Halo gravity traction is a useful strategy in such cases.Case Description: A thirty-year-old woman presented with complaint of progressive deformity over the back for the past few years. She was very frail as per the adult spine deformity frailty index (ASD-FI), and her BMI was less than 18. Her Cobb angle measured 180 degrees of main thoracic curve. Her pulmonary function was compromised and had dyspnea on exertion. Management options in these deformities are limited and fraught with risk of major complications. To correct these deformities, a 2-3 level vertebral column resection (VCR) is required using an all-posterior approach. This patient was treated by anterior release followed by halo-gravity traction (HGT) for two weeks, which was then followed by posterior release and correction. The Cobb angle was reduced from 180° to 55° at final follow up of 2 years.Conclusion: Anterior release and traction can help in obviating the vertebral column resection in these severe rigid U-shaped deformities.

A Novel Posterior Rod-Link-Reducer System Provides Safer, Easier, and Better Correction of Severe Scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVES

To compare the Cobb >75° scoliosis correction obtained using a novel Rod-Link-Reducer (RLR) system versus traditional corrective techniques (TCT) in patients with severe adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Current implant strategies provide for good correction, especially for moderate curves; however, severe scoliosis continues to be challenging to obtain correction in a safe and effective manner.

METHODS

A novel correction device was developed so that two provisional rods are placed on the convex side of the scoliosis proximally and distally, which are then linked to an external reduction device termed the RLR. A retrospective analysis was performed to compare the RLR versus the TCT in patients with curve >75° with the diagnosis of AIS with respect to the radiographic outcomes, operative time, intraoperative blood loss, complications, and SRS-30 scores of a minimum 2-year follow-up.

RESULTS

A total of 36 patients were evaluated (RLR-18, TCT-18). The data sets were similar for age, gender, coronal Cobb, curve flexibility, and follow-up period. The mean preoperative Cobb for the RLR group was 91.7° (76°-113°) and 91.8° (78°-108°) for the TCT group. The mean coronal Cobb correction rate was significantly greater for the RLR group (73.1% vs. 56.6%, p < .0001). The mean operative time was 74.8 minutes shorter in the RLR group (316.6 minutes vs. 391.4 minutes, p = .03). There were 2 late-developing infections and 3 intraoperative neuro-monitoring changes during the correction maneuvers in the TCT group compared with none in the RLR group (p = .02).

CONCLUSION

In a matched cohort, the use of the RLR exhibited greater coronal Cobb correction, shorter operative time, and was less likely to have critical neuro-monitoring changes compared with the TCT group. The RLR provides safer and improved correction for severe curves without adding surgical risk.

LEVEL OF EVIDENCE

Level III.

Ventilation/perfusion SPECT/CT in patients with severe and rigid scoliosis: An evaluation by relationship to spinal deformity and lung function

OBJECTIVE

Structural changes of the spine and chest wall associated with SRS result in poor cardiopulmonary function. Comprehensive assessment of pulmonary function is extremely important for patients with SRS before a correction operation. We explore the changes of distribution of lung ventilation and perfusion function in patients with SRS using SPECT/CT and describe the relation between these changes with Cobb angle and FVC%.

PATIENTS AND METHODS

From March 2015 to August 2016, 16 consecutive SRS patients with a mean age of 20.1 years(range 11-36 years) were included in the study. Scoliotic parameters on radiographs were analyzed. FVC% were obtained by spirometry test. Lungs ventilation/perfusion single photon emission computed tomography scans was performed preoperatively in all patients to explore pulmonary ventilation and perfusion function changes. These changes were measured as the deviation form the normal perfusion and ventilation function distribution in right and left lung and correlated with the Cobb angle of main curve and FVC%.

RESULTS

The regional lung ventilation and perfusion function defects were not found in all SRS patients. Ventilation function deviation was a mean 5.7%(range, -3.6% to 10.1%), significantly less than perfusion function deviation of 8.2%(range, -0.3% to 22.2%) (P = 0.015, t = -2.732). Lung ventilation and/or perfusion function deviation did not correlated with Cobb angle and FVC%, respectively. There was significant correlation between lungs ventilation and perfusion function deviation(P = 0.001, r = 0.753).

CONCLUSION

The ventilation and perfusion function distribution were favourable in convex and concave side lung of SRS. Deformity bring about greater lungs perfusion function changes than ventilation function. The measurement of lung ventilation and perfusion function changes may represents an additional functional feature to assess pulmonary function of SRS more comprehensively.

Posterior-only surgery with preoperative skeletal traction for management of severe scoliosis

PURPOSE

The surgical treatment of severe adolescent spinal deformities is challenging and carries substantial risks of mortality and morbidity. To mitigate this risk, surgeons have employed various methods as this study designed to evaluate the safety and effectiveness of preoperative halo-femoral or halo gravity traction (HGT) followed by posterior-only surgery in the management of severe scoliosis.

METHOD

A total number of 23 patients with severe scoliosis treated by preoperative skeletal traction (halo gravity or halo femoral) followed by posterior fusion and instrumentation in one stage. All patients were followed for a minimum of 2 years after surgery.

RESULTS

The average age of the patients was 12.7 years at the time of surgery. Mean of the Cobb angle improved from 99.9° ± 8.2° preoperatively to 75.3° ± 8° post-traction and 49.5° ± 7.7° postoperatively. Kyphosis angle corrected from 56.4° ± 9.5° to 38.6° ± 5.8°. The preop-FVC% was 41 ± 6.1% and after 1 year follow-up FVC% was 45.7 ± 7.7%. No patients required an anterior release due to amount of their deformity.

DISCUSSION

Despite the benefits of modern instrumentation procedures, the treatment of severe scoliosis can be very competing. We think that by applying preoperative halo femoral traction and halo-gravity traction, managing severe scoliosis will be in safe and easy manner and can lead to better deformity correction and less neurological complications and facilitate to avoid anterior operation for severe scoliosis and its related complications.

Neuromonitoring Changes Are Common and Reversible With Temporary Internal Distraction for Severe Scoliosis

STUDY DESIGN

Retrospective review of consecutive cases.

OBJECTIVE

To examine the neurologic implications of applying intraoperative distraction to large curves.

SUMMARY OF BACKGROUND DATA

Temporary rods provide internal distraction during correction of severe scoliosis and may be an alternative to prolonged halo traction or vertebral column resection.

METHODS

A single surgeon's consecutive experience with posterior-only spinal fusion with temporary distraction rods was reviewed retrospectively. Inclusion criteria were long posterior-only spinal fusion (10 or more levels) for severe scoliosis (major Cobb angle 80° or greater), treated with temporary internal distraction. Records were reviewed for age, gender, diagnosis, intraoperative course, and complications. Radiographs were reviewed for Cobb angles, T1-S1 length, and space available for each lung.

RESULTS

Twenty-two patients with a mean age of 14 years and a mean of 15 levels fused (range, 10-18 levels) were included. The mean preoperative coronal Cobb angle was 113° (range, 83°-144°), and a mean correction of 62° (54%) was achieved. There was a mean T1-S1 increase of 8.4 cm (range, 2.4-14 cm). Nine patients had 2-stage procedures separated by a mean of 7 days. Thirteen patients had a single procedure. Of 22 patients, 9 (41%) had intraoperative neuromonitoring changes. All neuromonitoring changes were reversed after releasing distraction on the temporary rod, except in 1 case. No patient had a clinical neurologic deficit.

CONCLUSIONS

Use of temporary distraction rods for severe scoliosis produces curve correction while providing a mean increase in T1-S1 height of 8 cm. Most steps in this surgery are reversible. Neuromonitoring changes are common, but they are reversible with release of some distraction. Neuromonitoring changes did not affect the final magnitude of correction, and there were no clinical neurologic deficits. We recommend that this procedure be performed only with good neuromonitoring.