Spine deformity最新文献

Purpose: The insertion of ilio-sacral (IS) screws for distal anchoring in the instrumentation of pediatric neuromuscular scoliosis (NS) presents a significant challenge, often leading to elevated rates of complications. Utilizing computed tomography (CT) navigation and preoperative planning technology is proposed as a potential solution to mitigate these challenges. This study aims to assess the precision of IS screw placement through CT-graphic measurements, both with and without preoperative planning, followed by navigated IS screw insertion, in pediatric neuromuscular scoliosis.

Methods: Thirty-two treated patients were grouped based on surgical procedure: planned (P): 19 patients (n = 38 screws) and non-planned (NP): 13 patients (n = 26 screws). All screw placements (P and NP) took place under CT navigation. IS screw trajectories of P-group were drawn preoperatively on CT images with the cranial trajectory planning program and fused with the intraoperative CT images. There are several important anatomical structures that should be avoided when placing the IS screw (L5 root, spinal canal, L5S1 facet, SI joint, neurovascular structures anteriorly to the sacrum, S1 root in the S1 foramen and the intestines). Each trajectory was evaluated based on seven radiographical parameters whom we have enlisted partially based on the essentials of a good trajectory described by Miladi et al. (1: Ilium; 2: SI joint; 3: Promontorium; 4: Sacral plate; 5: Anterior sacral cortex; 6: S1 foramen; 7: Spinal canal). An independent sample T test was executed to compare both groups.

Results: The trajectories in the P group showed a significantly (P < 0.05) higher overall similarity and optimality (12.1 ± 2.1 vs 9.1 ± 2.2 points) compared to the non-planned trajectory.

Conclusions: Preoperative planning and navigated placement of IS screws on fusion images with intraoperative CT, results in a better trajectory of the ilio-sacral screws.

Purpose: The study aimed to evaluate the validity and reliability of the pediatric adaptation of the Japanese Orthopedic Association (mJOA) scale in pediatric patients with various cervical spine pathologies.

Methods: Initial assessments were performed by a neurosurgeon, followed by an independent evaluation by a neurologist within 1-2 days to test inter-rater reliability. The same clinician assessed the same group of children using the adapted mJOA scale at different point in time (between 1 month and 1 year after the initial assessment) to test intra-rater reliability. For known-groups validity, the pediatric mJOA scale assessments were compared between two groups of pathologies with different prognosis. Concurrent validity was assessed against the McCormick scale, and convergent validity was tested by reassessing patients using the adult mJOA scale two or more years after the initial assessment by pediatric one.

Results: A cohort of 169 pediatric patients aged 6 months to 18 years (mean age: 10 ± 4.6 years) with various cervical spine pathologies was recruited. Pathologies included atlanto-axial rotatory fixation (AARF), Chiari type I anomaly, congenital cervical spine scoliosis, atlanto-axial dislocation (AAD) and instability (AAI), cervical spine stenosis and trauma, and congenital cervicothoracic dislocations. The majority of patients underwent cervical spine surgery and were followed up for an average of 6.9 ± 2.97 years. The pediatric mJOA scale demonstrated high inter-rater reliability (r = 0.99, p < 0.0001) and strong intra-rater reliability (r = 0.82, p < 0.0001). Significant differences in pediatric mJOA scores were observed between patients with expected-intact neurological status and those with expected-pathological neurological status (p < 0.0001). The pediatric mJOA scale showed a strong correlation with the McCormick grading system (r = 0.97, p < 0.001) and good correlation with the adult mJOA scale during long-term follow-up (r = 0.82, p < 0.0001).

Conclusions: The pediatric version of the mJOA scale is a reliable and valid tool for assessing pediatric patients with cervical spine disorders. Its high reliability and validity support its use in both clinical practice and research.

Purpose: Using patient-reported outcome measures (PROMs), this study was undertaken to determine how well patients with early onset scoliosis (EOS) fare in adulthood.

Methods: Among eight healthcare centers, 272 patients (≥ 18 years) surgically managed for EOS (≥ 5 years) completed the Scoliosis Research Society (SRS)-22r, Functional Assessment of Chronic Illness Therapy-10 (FACIT-Dyspnea-10), and Short Form (SF)-12. Functional and demographic data were collected.

Results: The response rate was 40% (108/272). EOS etiologies were congenital (45%), neuromuscular (20%), idiopathic (20%) syndromic (11%), and unknown (4%). All patients scored within normal limits on the FACIT-Dyspnea-10 pulmonary (no breathing aids, 78%; no oxygen, 92%). SF-12 physical health scores and most SRS-22r domains were significantly decreased (p < 0.05 and p < 0.001, respectively) compared with normative values. SF-12 and SRS-22r mental health scores (MHS) were lower than normative values (p < 0.05 and p < 0.02, respectively). Physical health PROMs varied between etiologies. Treatment varied by etiology. Patients with congenital EOS were half as likely to undergo definitive fusion. There was no difference between EOS etiologies in SF-12 MHS, with t scores being slightly lower than normative peers.

Conclusion: Good long-term physical and social function and patient-reported quality of life were noted in surgically managed patients. Patients with idiopathic EOS physically outperformed those with other etiologies in objective and PROM categories but had similar MHS PROMs. Compared to normative values, EOS patients demonstrated decreased long-term physical capacity, slightly lower MHS, and preserved cardiopulmonary function.

Level of evidence: Level IV Case Series.

Purpose: This study calculated the rates of Unplanned Return to the Operating Room (UPROR) in early-onset scoliosis patients who had no previous spine surgery and underwent Magnetically Controlled Growing Rod (MCGR) implantation.

Methods: We reviewed surgical, radiographic, and UPROR outcomes for EOS patients treated with the MCGR implant < 12 years + 11 months of age, had complete preop/postop major curve measurements, and had complete MCGR details.

Results: 376 patients underwent MCGR implantation at a mean age of 7.7 years (1.8-12.9). Diagnoses included 106 (28%) idiopathic, 84 (22%) syndromic, 153 (41%) neuromuscular, and 33 (9%) congenital. The mean preop-cobb was 76.7° (9-145°), and an immediate postop correction was 41% (0-84%). We found that 38% (142/376) of patients experienced an UPROR prior to the maximal actuator length being achieved. UPROR occurred at mean 2 years (3 days-5 years) after initial implantation. Of the 142 patients who experienced UPROR there were 148 complications that lead to an UPROR. The most common reason for UPROR was anchor (55/148: 37%) or MCGR implant related (33/148: 22%). Wound related (22/148:15%), Neuro related 4/148: 3%), and other (34/148: 23%) accounted for the remaining UPROR occurrences.

Conclusion: In conclusion, the MCGR UPROR rate was 142/376 (38%) after an average of 2 years post implantation. At 2-year follow-up, only 20% of MCGR patients had experienced an UPROR. However, between 2 and 5 years, the development of an UPROR increased precipitously with only 39% of MCGR patients remaining UPROR free at 5 years post MCGR implantation. The most common reason for UPROR was related to anchor or MCGR implant-related complications. This information can be utilized to set realistic expectations about the need and timing of future surgical procedures with patients and their families.

Introduction: Previous studies have shown that T1 tilt is positively correlated with post-operative shoulder balance (SB). The aim of this study was to explore the role of intra-operative T1 tilt, among other shoulder parameters as a potential parameter to predict post-operative SB in adolescent idiopathic scoliosis (AIS) patients.

Methods: A retrospective review of AIS patients with structural thoracic curves with minimum 2 year follow up was conducted from a single tertiary center. Standing pre-operative, 1st erect, 1 year and 2-year follow-up; and intra-operative final prone radiographs were reviewed along with clinical data. Patients were stratified into 2 cohorts: Group A-Final intra-operative T1 tilt ≤5° and Group B-Final intra-operative T1 tilt >5°. These groups were compared for post-operative SB as a whole and separately for patients with baseline right or left shoulder high and if UIV was T2 or T3/T4. Patients with optimal SB (Radiographic shoulder height (RSH) <2 cm) at 2 years were compared to sub-optimal SB (RSH ≥ 2 cm) with respect to multiple SB variables.

Results: 55 patients (mean age 15.1 years-old, 43 F, mean BMI 22, mean thoracic Cobb-49.8°) were included. Based on Lenke curve types, there were 13 patients with type 1A, 10 patients with 1B, 12 patients with 1C, 7 patients with 2A, 4 patients with 2B and 9 patients with type 3C. T1 tilt was significantly correlated with RSH, Clavicle angle difference (CAD), First Rib Angle (FRA), and UIV tilt at first erect, 1-year, and 2-year post-op radiographs (p < 0.05 for all). When comparing groups, A and B, Group A patients showed significantly better restoration of their 2-year SB parameters; RSH (6.8 vs 11.8 mm, p = 0.01), CAD (3.9 vs 9.1 p < 0.001) and T1 tilt (4.7 vs 7.8° p = 0.01). Similar results were found for patients with baseline right shoulder high; RSH (p = 0.04), CAD (p < 0.001) and T1 tilt (p < 0.001) and whether UIV was T2 or T3/T4. Eight patients with sub-optimal SB had worse intra-operative T1 tilt (p = 0.03) compared to 47 patients with optimal SB despite no difference in MT Cobb correction (83.1 vs 79.8%, p = 0.57).

Conclusion: Post-operative T1 tilt correlates with lateral shoulder parameters at first erect, 1 year, and 2-year radiographs. Therefore, T1 tilt can potentially be used as a surrogate to predict post-operative SB. Leveling intra-operative T1 tilt ≤5° is associated with better 2-year post-operative shoulder balance parameters irrespective of whether the UIV was T2 or T3/T4. Patients with sub-optimal SB at 2 years had worse final intra-operative T1 tilt despite similar percent correction of main thoracic curve for all patients.

Purpose: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion.

Methods: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively.

Results: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (- 30; p < 0.001), and shorter OR time (- 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions.

Conclusion: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions.

Level of evidence: III.

Purpose: A hands-on-wall (HOW) position for low-dose stereoradiography of adolescent idiopathic scoliosis (AIS) patients would allow for skeletal maturity assessment of the hand and wrist. Our aims were twofold: confirm the reliability and validity of skeletal maturity assessment using the HOW radiographs and compare the spinal and pelvic 3D parameters to those of standard hands-on-cheeks (HOC) stereoradiographs.

Methods: Seventy AIS patients underwent two successive stereoradiographs and a standard hand and wrist radiograph on the same day. Patients were randomly assigned to begin with HOW and follow with HOC, or vice versa. Raters assessed digital skeletal age (DSA), Sanders Simplified Skeletal Maturity (SSMS) and Thumb Ossification Composite Index (TOCI). 3D reconstructions of the spine and pelvis bones were performed for each stereoradiograph to measure nine clinically relevant spinal and pelvic 3D parameters.

Results: Inter-rater and intra-rater reliabilities were excellent for DSA, SSMS and TOCI with both standard radiographs and HOW (ICC > 0.95). Strong correlation was found between ratings of both imaging types (ICC > 0.95). In the 3D reconstructions, kyphosis and sacral slope were slightly decreased in the HOW position, but within the clinical margin of error. All other parameters did not differ significantly between positions (p < 0.05).

Conclusion: The results suggest that HOW stereoradiographs allow clinicians to assess skeletal maturity of the hand and wrist with adequate reliability and validity. We recommend that scoliosis clinics adopt the HOW position to assess skeletal maturity because there is no significant clinical impact on the spinal and pelvic evaluation, and on radiation exposure, cost or time.