Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version

BACKGROUND

Appearance concerns in individuals with adolescent idiopathic scoliosis can result in impairment in daily functioning, or body image disturbance. The Body Image Disturbance Questionnaire (BIDQ) is a self-reported, seven-question instrument that measures body image disturbance in general populations; no studies have specifically examined body image disturbance in those with adolescent idiopathic scoliosis. This study aimed to validate a modified version of the BIDQ in a population with adolescent idiopathic scoliosis and to establish discriminant validity by comparing responses of operatively and nonoperatively treated patients with those of normal controls.

METHODS

In the first phase, a multicenter study of forty-nine patients (mean age, fourteen years; thirty-seven female) with adolescent idiopathic scoliosis was performed to validate the BIDQ-Scoliosis version (BIDQ-S). Participants completed the BIDQ-S, Scoliosis Research Society (SRS)-22, Children's Depression Index (CDI), and Body Esteem Scale for Adolescents and Adults (BESAA) questionnaires. Descriptive statistics and Pearson correlation coefficients were calculated. In the second phase, ninety-eight patients with adolescent idiopathic scoliosis (mean age, 15.7 years; seventy-five female) matched by age and sex with ninety-eight healthy adolescents were enrolled into a single-center study to evaluate the discriminant validity of the BIDQ-S. Subjects completed the BIDQ-S and a demographic form before treatment. Independent-sample t tests and Pearson correlation coefficients were calculated.

RESULTS

The BIDQ-S was internally consistent (Cronbach alpha = 0.82), and corrected item total correlations ranged from 0.47 to 0.67. The BIDQ-S was significantly correlated with each domain of the SRS-22 and the total score (r = -0.50 to -0.72, p ≤ 0.001), with the CDI (r = 0.31, p = 0.03), and with the BESAA (r = 0.60, p < 0.001). BIDQ-S scores differed significantly between patients (1.50) and controls (1.06, p < 0.005), establishing discriminant validity.

CONCLUSIONS

The BIDQ-S is an internally consistent outcomes instrument that correlated with the SRS-22, CDI, and BESAA outcomes instruments in a scoliosis population. The scores of the patients with scoliosis indicated greater back-related body image disturbance compared with healthy controls. To our knowledge, this user-friendly instrument is the first to examine body image disturbance in adolescent idiopathic scoliosis, and it provides a comprehensive evaluation of how scoliosis-related appearance concerns impact psychosocial and daily functioning.

Preoperative Pulmonary Function in Patients With Operative Scheuermann Kyphosis

STUDY DESIGN

A multicenter, prospective study of consecutively enrolled surgical patients with Scheuermann kyphosis (SK).

OBJECTIVES

To evaluate the impact of SK on preoperative pulmonary function and to determine which radiographic criteria may help predict pulmonary impairment.

SUMMARY OF BACKGROUND DATA

Pulmonary function in SK is not well studied. Previous studies on adolescent idiopathic scoliosis revealed that certain factors, including the magnitude of the thoracic curve and the number of vertebrae involved, significantly affect pulmonary function.

METHODS

A total of 64 patients with SK were evaluated. Absolute and percent predicted forced vital capacity (FVC), forced expiratory volume in 1 second, and total lung capacity were collected preoperatively. Subjects were divided according to kyphosis apex (thoracic or thoracolumbar) and kyphosis magnitude groups, and compared. Correlation analysis was performed to evaluate the impact of gender, age, kyphosis magnitude, and apex on pulmonary function. American Thoracic Society guidelines were used to classify patients according to the severity of pulmonary impairment.

RESULTS

Mean age was 16 years (range 13-24 years), with 42 males. The percent predicted forced vital capacity was 95.8%, percent forced expiratory volume in 1 second was 92.5%, and percent total lung capacity was 106.2%. The percent predicted FVC differed significantly between the 71°-80° and 81°-90° groups (105% vs. 83%, respectively; p = .016) and the 71°-80° and greater than 90° groups (105% vs. 73%, respectively; p = .009). For percent predicted TLC, patients with greater than 90° had significantly lower average values than those in the 71°-80° range (79% vs. 115%, respectively; p = .016). Greatest kyphosis showed a fairly weak (r = -.24; p < .10) but significant correlation with percent predicted FVC. The percentage of patients with moderate to severe impairment (4%) was lowest in the 71°-80° range, which increased with increasing ranges of kyphosis magnitude: 81°-90° (11%) and greater than 90° (50%).

Are More Screws Better? A Systematic Review of Anchor Density and Curve Correction in Adolescent Idiopathic Scoliosis

STUDY DESIGN

Systematic review of clinical studies.

OBJECTIVES

To critically evaluate existing literature to determine whether increased anchor or implant density (screws, wires, and hooks per level fused) results in improved curve correction for adolescent idiopathic scoliosis (AIS) surgery.

SUMMARY OF BACKGROUND DATA

Wide variability exists in the number of screws used for AIS surgery. High numbers of pedicle screws are increasingly used, but there is limited evidence to support this as best practice.

METHODS

Online English-language databases were searched to identify articles addressing anchor density. Articles were reviewed for anchor type/number, radiographic measures, and patient-reported outcomes.

RESULTS

Of 196 references identified, 10 studies totaling 929 patients met the inclusion criteria. Reported mean anchor density varied from 1.06 to 2.0 implants per level fused. Mean percent coronal curve correction varied from 64% to 70%. Two studies (463 patients) analyzed hook, hybrid (combined hooks and screws), and screw constructs as a single cohort. Both found increased correction with high-density constructs (p = .01, p < .001), perhaps as a result of the hooks and hybrid constructs. Eight retrospective studies and 1 prospective randomized, controlled trial had predominantly screw constructs (466 patients). Increased anchor density was not associated with improved curve correction. The studies evaluating screw density are significantly underpowered to detect a difference in curve correction.

CONCLUSIONS

Wide heterogeneity in anchor density exists in the surgical treatment of AIS. Reports evaluating the effects of increased anchor density are mostly retrospective and significantly underpowered to detect a difference in curve correction and patient outcomes. At this time, there is insufficient evidence to show that anchor density affects clinical outcomes in AIS.

A multicenter analysis of factors associated with change in height after adolescent idiopathic scoliosis deformity surgery in 447 patients

Object

In the surgical management of adolescent idiopathic scoliosis (AIS), patients are often preoperatively informed that they will gain height as a result of their surgery. However, current estimations conflict significantly and do not have any clinical correlation. The authors developed a formula that would predict postoperative gains in height after deformity correction in AIS.

Methods

A large, multicenter, prospective database was retrospectively queried for AIS patients with Lenke Type 1, 2, or 3 curves having undergone posterior spinal fusion alone. A univariate and multivariate analysis was performed to identify which factors contributed significantly to changes in height.

Results

Four hundred forty-seven patients were included in the series. Factors correlating with changes in postoperative height included: upper thoracic curve magnitude, main thoracic curve magnitude, lumbar curve magnitude, T2–12 kyphosis, T5–12 kyphosis, curve flexibility, number of levels fused, presence of Ponte osteotomies, total preoperative coronal Cobb angle, change in coronal curve magnitude, total preoperative sagittal curvature, change in sagittal curvature, and thoracic curve correction.

When combined in a multivariate regression analysis the following variables remained significant: thoracic curve magnitude (p < 0.01), number of levels fused (p < 0.01), change in total sagittal curvature (p < 0.01), and the presence of osteotomies (p = 0.03). The contribution from the thoracic curve magnitude was significantly greater than any of the other parameters identified (R2 = 0.140). Change in height (in cm) = ([thoracic curve magnitude × 0.039] + [number of levels fused × 0.193] − [change in sagittal curvature × 0.033] + [x × 0.375]) − 1.858, where x = 1 if 1 or more osteotomies were performed and x = 0 if no osteotomy was performed.

Conclusions

The authors' results suggest that changes in the coronal plane contribute more significantly to height changes than those in the sagittal plane and approximately 0.39 cm of height gain can be expected for each 10° of coronal curve preoperatively. Unfortunately, a significant fraction of the postoperative height changes cannot be predicted by currently measured parameters.

Discriminative validity of the Scoliosis Research Society 22 questionnaire among five curve-severity subgroups of adolescents with idiopathic scoliosis

BACKGROUND CONTEXT

Previous studies of the Scoliosis Research Society (SRS) 22 discriminative validity have lacked sufficiently matched study groups and were limited to a comparison with three or fewer subgroups of disease severity.

PURPOSE

To evaluate the discriminative validity of SRS-22 by assessing the questionnaire's ability to discriminate among five groups of pretreatment adolescent idiopathic scoliosis (AIS) patients with increasing curve severity.

STUDY DESIGN

Retrospective review of prospectively administered surveys.

METHODS

Two hundred eighty-six SRS-22 questionnaires were issued to two AIS pretreatment patient populations: 67 nonoperative and 219 preoperative. Study subjects were separated into five subgroups depending on the major Cobb angle (nonoperative 0°-19° and 20°-40° and preoperative 41°-50°, 51°-60°, and >60°). Each group (n=31) was matched for age (within 1 year) and sex (23 females and 8 males), resulting in a total of 155 study subjects. Analysis of variance was used to determine statistically significant differences (p<.05) between the five subgroups' domains and total scores.

RESULTS

Significant differences between study groups were found within two of the four domains (pain and image) and the total score. Both nonoperative groups (0°-19° and 20°-40°) demonstrated significantly less pain than the preoperative group (41°-50°) and significantly better self-image than all three preoperative groups. Both nonoperative groups' total scores were significantly higher than all three preoperative groups' scores, with the exception of the 20° to 40° subgroup versus the >60° subgroup. No significant differences were found between groups within the same planned treatment category.

CONCLUSIONS

The SRS-22 questionnaire demonstrated good discriminative validity between small nonoperative curves and larger surgical curves within the pain, image, and total domains. However, SRS-22 lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limitation to the questionnaire's discriminative capacity. The discriminative validity of the Scoliosis Research Society (SRS) 22 has not been clearly defined. Our analysis of 155 adolescent idiopathic scoliosis patients evaluates the instrument's discriminative validity among five age- and sex-matched curve-severity subgroups. The SRS-22 questionnaire lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limit to the questionnaire's discriminative capacity.

Hospital cost analysis of neuromuscular scoliosis surgery

STUDY DESIGN

A retrospective review of 74 consecutive, surgical patients with neuromuscular scoliosis (NMS).

OBJECTIVE

This study evaluates the distribution of hospital and operating room costs incurred during surgical correction of NMS.

BACKGROUND DATA

Recent studies have demonstrated that surgical treatment improves both medical outcomes and the quality of life in patients with progressive NMS. Characterization of the costs incurred at the time of surgery and hospitalization will facilitate the identification of opportunities for cost reduction.

METHODS

Demographic data collected included gender, age, preoperative height, weight, and BMI. Major coronal curvatures and T5-T12 kyphosis were assessed from radiographs. Construct type and number of screws, hooks, and wires implanted were recorded. Surgical costs were calculated based on cost of surgical correction, hospital stay, and postoperative care.

RESULTS

Mean age was 15.8 ± 7.3 years; 57% were male. Comorbidities included cerebral palsy (28%) and familial dysautonomia (14%). The mean preoperative major curve magnitude was 60°; minor curve magnitude was 33°. Posterior approach (76%) and pedicle screws (75%) were predominantly utilized. The average length of hospitalization was 8 days (range: 3 to 47). There were six major complications (8%). The total surgical cost was $50,096 ± $23,998. The highest individual cost was for implants ($13,916; 24% of total costs). The second highest was inpatient room and ICU costs ($12,483; 22%); bone grafts were the third ($6,398; 11%). Increased major and minor structural curve, increased total (A/P) levels fused, and increased length of hospital stay predicted an increase in total cost.

CONCLUSIONS

Major contributors to cost in NMS surgery are implants, inpatient room and ICU costs, and bone grafts. Independent predictors of higher cost are the degree of major and minor structural curve, total number of A/P levels fused, and length of hospital stay. These conclusions provide insight into costs associated with care for a medically fragile and challenging patient population.

Fusionless surgery for scoliosis

Scoliosis is a very common condition, affecting approximately 7 million children in the United States. Treatment of this condition in young children can be challenging. A variety of techniques that avoid spinal fusion have been developed to manage scoliosis in this patient population. This review article describes several of these methods, including growing rods, prosthetic ribs, vertebral stapling, and vertebral tethering. Particular attention is given to literature discussing each technique.

Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases

BACKGROUND

Although achieving clinical success is the main goal in the surgical treatment of adolescent idiopathic scoliosis, it is becoming increasingly important to do so in a cost-effective manner. The goal of the present study was to determine the surgical and hospitalization costs, charges, and reimbursements for adolescent idiopathic scoliosis correction surgery at one institution.

METHODS

We performed a retrospective review of 16,536 individual costs and charges, including overall reimbursements, for 125 consecutive patients who were managed surgically for the treatment of adolescent idiopathic scoliosis by three different surgeons between 2006 and 2007. Demographic, surgical, and radiographic data were recorded for each patient. Stepwise multiple linear regression analysis was employed to assess independent correlation with total cost and charge. Nonparametric descriptive statistics were calculated for total cost with use of the Lenke curve-classification system.

RESULTS

The mean age of the patients was 15.2 years. The mean main thoracic curve measured 50 degrees, and the thoracolumbar curve measured 41 degrees. The cost varied with Lenke curve type: $29,955 for type 1, $31,414 for type 2, $31,975 for type 3, $60,754 for type 4, $32,652 for type 5, and $33,416 for type 6. Independently significant increases for total cost were found in association with the number of pedicle screws placed, the total number of vertebral levels fused, and the type of surgical approach (R(2) = 0.35, p <or= 0.03). Independently significant increases for reimbursement were found in association with the number of pedicle screws placed and the type of surgical approach (R(2) = 0.12, p <or= 0.02). The hospital was reimbursed 53% of total charges and 120% of total costs. Reimbursement was highly correlated with charge (r = 0.45, p < 0.001). For rehospitalizations, the hospital was reimbursed 65% of charges and 93% of costs.

CONCLUSIONS

The largest contributors to overall cost were implants (29%), intensive care unit and inpatient room costs (22%), operating room time (9.9%), and bone grafts (6%). There were three significant independent predictors of increased total cost: the surgical approach used, the number of pedicle screws placed, and the number of vertebral levels fused. This study characterizes the relative contributions of factors that contribute to total costs, charges, and reimbursements that can, in time, identify potential areas for cost reduction or redistribution of resources in the surgical treatment of adolescent idiopathic scoliosis.

A prospective, randomized, double-blinded single-site control study comparing blood loss prevention of tranexamic acid (TXA) to epsilon aminocaproic acid (EACA) for corrective spinal surgery

BACKGROUND

Multilevel spinal fusion surgery has typically been associated with significant blood loss. To limit both the need for transfusions and co-morbidities associated with blood loss, the use of anti-fibrinolytic agents has been proposed. While there is some literature comparing the effectiveness of tranexamic acid (TXA) to epsilon aminocaproic acid (EACA) in cardiac procedures, there is currently no literature directly comparing TXA to EACA in orthopedic surgery.

METHODS/DESIGN

Here we propose a prospective, randomized, double-blinded control study evaluating the effects of TXA, EACA, and placebo for treatment of adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NMS), and adult deformity (AD) via corrective spinal surgery. Efficacy will be determined by intraoperative and postoperative blood loss. Other clinical outcomes that will be compared include transfusion rates, preoperative and postoperative hemodynamic values, and length of hospital stay after the procedure.

DISCUSSION

The primary goal of the study is to determine perioperative blood loss as a measure of the efficacy of TXA, EACA, and placebo. Based on current literature and the mechanism by which the medications act, we hypothesize that TXA will be more effective at reducing blood loss than EACA or placebo and result in improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT00958581.

Thoracoscopic anterior instrumented fusion for adolescent idiopathic scoliosis with emphasis on the sagittal plane

BACKGROUND CONTEXT

Anterior fusion through an open thoracotomy restores kyphosis more reliably than posterior techniques in patients with thoracic adolescent idiopathic scoliosis (AIS). Video-assisted thoracoscopic spinal fusion and instrumentation (VATS) minimizes the morbidity, from soft tissue and muscle dissection that accompanies traditional open thoracotomy. To our knowledge, there has not been a comprehensive analysis of VATS with respect to radiographic and clinical outcomes in the sagittal plane.

PURPOSE

To measure the radiographic and clinical outcomes after VATS with emphasis on the sagittal plane.

STUDY DESIGN/SETTING

A retrospective, radiographic review of 26 consecutive patients with Lenke type-I AIS who underwent VATS.

METHODS

Radiographs of 26 consecutive patients with Lenke type-I AIS curves operated by a single surgeon were retrospectively reviewed after VATS. Sagittal and coronal parameters were compared with reported data for open anterior and posterior procedures.

RESULTS

There was an increase in kyphosis from baseline to final follow-up by 6.6 degrees (25%) from T2 to T12 (p<.0001), 8.7 degrees (50%) from T5 to T12 (p<.0001), and 8 degrees (54%) in the instrumented segment (p<.0001). Junctional kyphosis did not occur. No differences were detected in sagittal measurements between the first postoperative erect and the final radiographs. Patients experienced significant improvements from baseline to 2 years in Scoliosis Research Society-22 Health-Related Quality-of-Life Outcome Questionnaire scores (p<.0001).

CONCLUSIONS

Video-assisted thoracoscopic spinal fusion and instrumentation, in agreement with results reported for open anterior instrumentation, reliably restores or increases thoracic kyphosis while preserving junctional alignment in thoracic AIS.

Video-assisted thoracoscopic spinal fusion compared with posterior spinal fusion with thoracic pedicle screws for thoracic adolescent idiopathic scoliosis

BACKGROUND

Although the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis has been posterior spinal fusion, video-assisted thoracoscopic surgery recently has become a viable alternative. In the treatment of structural thoracic curves, video-assisted thoracoscopic surgery has demonstrated outcomes equivalent to those of posterior spinal fusion with use of an all-hook or hybrid pedicle screw-hook construct. No study to date, however, has compared this technique with posterior spinal fusion with thoracic pedicle screws, which has become the current standard of care.

METHODS

A matched-pair analysis of thirty-four consecutive patients (seventeen pairs) undergoing either video-assisted thoracoscopic surgery or posterior spinal fusion with thoracic pedicle screws for the treatment of structural scoliosis was performed; the study included eight male and twenty-six female patients with an average age of 15.0 years. Pairs were matched according to curve type and magnitude, patient age, and sex. Clinical data, the results of the Scoliosis Research Society questionnaire, and radiographic data were collected preoperatively and at a minimum of two years postoperatively and were compared between the groups.

RESULTS

Video-assisted thoracoscopic surgery was associated with significantly increased operative times (mean, 326 compared with 246 minutes; p = 0.033) and reduced blood loss (mean, 371 compared with 1018 mL; p = 0.001), but there were no differences between the groups in terms of the transfusion rate (18% compared with 29%; p = 0.69) or the length of stay. The percentage correction of the major curve was 57.3% for the video-assisted thoracoscopic surgery group and 63.8% for the posterior spinal fusion group (p = 0.08). With the numbers available, no differences were detected in terms of the cephalad thoracic curve, caudad compensatory lumbar curve, coronal balance, thoracic kyphosis, lumbar lordosis, sagittal balance, end vertebra tilt angle, or angle of trunk rotation measurements preoperatively or at the time of the latest follow-up. The average number of fused levels was 5.9 in the video-assisted thoracoscopic surgery group and 8.9 in the posterior spinal fusion group (p < 0.001). Relative to the Cobb end vertebra, the most caudad instrumented vertebra was 0.81 level more cephalad in the video-assisted thoracoscopic surgery group as compared with the posterior spinal fusion group (p = 0.004). No significant differences were detected in any of the questionnaire outcomes at any time point. Although both groups experienced similar improvement from baseline in terms of pulmonary function at two years, the posterior spinal fusion group had significantly improved peak flow measurements (p = 0.04) in comparison with the video-assisted thoracoscopic surgery group.

CONCLUSIONS

For single thoracic curves of <70 degrees in patients with a normal or hypokyphotic thoracic spine, video-assisted thoracoscopic surgery can produce equivalent radiographic results, patient-based clinical outcomes, and complication rates in comparison with posterior spinal fusion with thoracic pedicle screws, with the exception that posterior spinal fusion with thoracic pedicle screws may result in better major curve correction. The potential advantages of video-assisted thoracoscopic surgery over posterior spinal fusion with thoracic pedicle screws include reduced blood loss, fewer total levels fused, and the preservation of nearly one caudad fusion level, whereas the disadvantages include increased operative times and slightly less improvement in pulmonary function.

The parallax effect in the evaluation of range of motion in lumbar total disc replacement

BACKGROUND

Range of motion (ROM) has been shown to influence clinical outcomes of total disc replacement (TDR). While the parallax effect in image acquisition has been shown in the literature to influence the accuracy of a variety of measurements, this concept has not been investigated in the assessment of ROM analysis following TDR. We performed an evaluation of the influence of radiograph beam angle on "by hand" and on "gold standard" flexionextension ROM measurements in lumbar total disc replacement. The purpose of this study is to determine (1) the influence of X-ray beam angle on index level angle (ILA) measurements in lumbar TDR using the keel method, and (2) whether the out-of-plane radiographic beam effects cause a difference between true and calculated range of motion.

METHODS

Eight blinded orthopaedic surgeons used the keel method to calculate ROM measurements from radiographs of a flexible Sawbones model (Pacific Research Laboratories, Inc., Vashon, Washington) implanted with a ProDisc-L device (Synthes Spine, West Chester, Pennsylvania). Radiographs were obtained at beam angles of 0°, 5°, 10°, and 15° in the sagittal plane from the device center. Calculations were compared to measurements obtained by a validated digitized software method (Quantitative Motion Analysis, QMA, Medical Metrics, Inc., Houston, Texas). Inter- and intraobserver precision and accuracy were determined.

RESULTS

Compared with QMA, the radiographic keel method had an average error of 3.7°. No significant effect of variation in beam angle on interobserver precision (N = 16, P = .92) or accuracy (N = 16, P = 0.86) or intraobserver precision (N = 8, P = .09) or accuracy (N = 8, P = 0.07) of ROM measurements was identified. Repeat testing with QMA also revealed no effect of parallax and resulted in nearly identical ROM measurements.

CONCLUSIONS

Accuracy and precision of the keel method to determine ROM from index level angle measurements after TDR was not affected by increases in X-ray beam angles up to 15° from the device center.

CLINICAL RELEVANCE

Our study demonstrates that range of motion measurements are not influenced by parallax effect when using the keel method to determine index level angle measurements in lumbar total disc replacement.

Emerging minimally invasive technologies for the management of scoliosis

Surgery for scoliosis has evolved dramatically over the past century -- from posterior surgery and casting that resulted in poor deformity correction and high pseudarthrosis rates and that required prolonged bed rest to anterior thoracoscopic and miniopen approaches that result in reproducible curve correction ranging from 55% to 70% with high fusion rates. The future of scoliosis surgery lies in the application of growth-modulation approaches by way of minimally invasive techniques, which will result in curve correction while maintaining spinal motion and disc and motion segment integrity. The optimal approach will use genetic testing to predict curve progression, thereby providing the clinical data required for determining the appropriate candidate for the use of this strategy.

Reduction of high-grade isthmic and dysplastic spondylolisthesis in 5 adolescents

Treatment of high-grade isthmic and dysplastic spondylolisthesis in children and adolescents remains a challenge. Surgical treatment of spondylolisthesis has been recommended in adolescents with pain refractory to nonoperative modalities, slippage progression, or > 50% slippage on presentation. Controversy exists as to the optimal surgical approach for high-grade spondylolisthesis. In this report, we describe 5 cases of high-grade isthmic and dysplastic spondylolisthesis in adolescents and review the literature on surgical treatment for this entity. Operative records, charts, x-rays, and Scoliosis Research Society outcome questionnaires (SRS-22) were retrospectively evaluated for 5 consecutive patients diagnosed with and treated for high-grade spondylolisthesis. Each patient received treatment consisting of decompression, reduction, and circumferential fusion with transpedicular and segmental fixation from a posterior approach. Two patients had transient L5 nerve root deficit, which resolved within 3 months. Reduction benefits include a decrease in shear stresses (and resulting decreased rates of postoperative pseudarthrosis and slip progression), restoration of sagittal alignment and lumbosacral spine balance, and improvement in clinical deformity.

Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis. Surgical technique

BACKGROUND

Posterior spinal fusion with segmental instrumentation is the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis. More recently, anterior surgery and video-assisted thoracoscopic surgery with spinal instrumentation have become an option. The purpose of the present study was to compare the radiographic and clinical outcomes as well as pulmonary function in patients managed with either anterior thoracoscopic or posterior surgery.

METHODS

Radiographic data, Scoliosis Research Society patient-based outcome questionnaires, pulmonary function, and operative records were reviewed for fifty-one patients undergoing surgical treatment of scoliosis. Data were collected preoperatively, immediately postoperatively, and at the time of the final follow-up. The radiographic parameters that were analyzed included coronal curve correction, the most caudad instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. The operative parameters that were evaluated included the operative time, the estimated blood loss, the blood transfusion rate, the number of levels fused, the type of bone graft used, and the number of intraoperative and postoperative complications. The pulmonary function parameters that were analyzed included vital capacity and peak flow.

RESULTS

The thoracoscopic group included twenty-eight patients with a mean age of 14.6 years, and the posterior fusion group included twenty-three patients with a mean age of 14.3 years. The percent correction was 54.5% for the thoracoscopic group and 55.3% for the posterior group. With the numbers available, there were no significant differences between the two groups in terms of kyphosis (p = 0.84), coronal balance (p = 0.70), or tilt angle (p = 0.91) at the time of the final follow-up. The mean number of levels fused was 5.8 in the thoracoscopic group, compared with 9.3 levels in the posterior group (p < 0.0001). The estimated blood loss in the thoracoscopic group was significantly less than that in the posterior fusion group (361 mL compared with 545 mL; p = 0.03), and the transfusion rate in the thoracoscopic group was significantly lower than that in the posterior fusion group (14% compared with 43%; p = 0.01). Operative time in the thoracoscopic group was significantly greater than that in the posterior group (6.0 compared with 3.3 hours, p < 0.0001). There were no intraoperative complications in either group. Vital capacity and peak flow had returned to baseline levels in both groups at the time of the final follow-up. Patients in the thoracoscopic group scored higher than those in the posterior group in terms of the total score (p < 0.0001) and all of the domains (p < 0.01) of the Scoliosis Research Society questionnaire at the time of the final follow-up.

CONCLUSIONS

Thoracoscopic spinal instrumentation compares favorably with posterior fusion in terms of coronal plane curve correction and balance, sagittal contour, the rate of complications, pulmonary function, and patient-based outcomes. The advantages of the procedure include the need for fewer levels of spinal fusion, less operative blood loss, lower transfusion requirements, and improved cosmesis as a result of small, well-hidden incisions. However, the operative time for the thoracoscopic procedure was nearly twice that for the posterior approach. Additional study is needed to determine the precise role of thoracoscopic spinal instrumentation in the treatment of thoracic adolescent idiopathic scoliosis.

Thoracoscopic spinal fusion compared with posterior spinal fusion for the treatment of thoracic adolescent idiopathic scoliosis

BACKGROUND

Posterior spinal fusion with segmental instrumentation is the gold standard for the surgical treatment of thoracic adolescent idiopathic scoliosis. More recently, anterior surgery and video-assisted thoracoscopic surgery with spinal instrumentation have become available. The purpose of the present study was to compare the radiographic and clinical outcomes as well as pulmonary function in patients managed with either anterior thoracoscopic or posterior surgery.

METHODS

Radiographic data, Scoliosis Research Society patient-based outcome questionnaires, pulmonary function, and operative records were reviewed for fifty-one patients undergoing surgical treatment of scoliosis. Data were collected preoperatively, immediately postoperatively, and at the time of the final follow-up. The radiographic parameters that were analyzed included coronal curve correction, the most caudad instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. The operative parameters that were evaluated included the operative time, the estimated blood loss, the blood transfusion rate, the number of levels fused, the type of bone graft used, and the number of intraoperative and postoperative complications. The pulmonary function parameters that were analyzed included vital capacity and peak flow.

RESULTS

The thoracoscopic group included twenty-eight patients with a mean age of 14.6 years, and the posterior fusion group included twenty-three patients with a mean age of 14.3 years. The percent correction was 54.5% for the thoracoscopic group and 55.3% for the posterior group. With the numbers available, there were no significant differences between the two groups in terms of kyphosis (p = 0.84), coronal balance (p = 0.70), or tilt angle (p = 0.91) at the time of the final follow-up. The mean number of levels fused was 5.8 in the thoracoscopic group, compared with 9.3 levels in the posterior group (p < 0.0001). The estimated blood loss in the thoracoscopic group was significantly less than that in the posterior fusion group (361 mL compared with 545 mL; p = 0.03), and the transfusion rate in the thoracoscopic group was significantly lower than that in the posterior fusion group (14% compared with 43%; p = 0.01). Operative time in the thoracoscopic group was significantly greater than that in the posterior group (6.0 compared with 3.3 hours, p < 0.0001). There were no intraoperative complications in either group. Vital capacity and peak flow had returned to baseline levels in both groups at the time of the final follow-up. Patients in the thoracoscopic group scored higher than those in the posterior group in terms of the total score (p < 0.0001) and all of the domains (p < 0.01) of the Scoliosis Research Society questionnaire at the time of the final follow-up.

CONCLUSIONS

Thoracoscopic spinal instrumentation compares favorably with posterior fusion in terms of coronal plane curve correction and balance, sagittal contour, the rate of complications, pulmonary function, and patient-based outcomes. The advantages of the procedure include the need for fewer levels of spinal fusion, less operative blood loss, lower transfusion requirements, and improved cosmesis as a result of small, well-hidden incisions. However, the operative time for the thoracoscopic procedure was nearly twice that for the posterior approach. Additional study is needed to determine the precise role of thoracoscopic spinal instrumentation in the treatment of thoracic adolescent idiopathic scoliosis.

The learning curve associated with thoracoscopic spinal instrumentation

STUDY DESIGN

Consecutive case prospective radiographic and medical record review.

OBJECTIVE

To define the learning curve associated with thoracoscopic spinal instrumentation by evaluating operative data and early outcomes of 1 surgeon's (B.L.) cases.

SUMMARY OF BACKGROUND DATA

Thoracoscopic spinal instrumentation for the treatment of thoracic adolescent idiopathic scoliosis has emerged as an alternative to open anterior and posterior techniques. The technique is technically demanding and has been perceived as having a prohibitive learning curve.

METHODS

The operative reports, charts, and surgeon's database were used to evaluate operating time, estimated blood loss, levels fused, complication rate, blood transfusions, and curve correction, among other variables. For purposes of analysis, the entire cohort was divided into 2 groups of 28 and 29 patients, respectively, and then 4 groups of 14 patients (the last group with 15) were used for comparison.

RESULTS

The records of 57 patients were evaluated. No significant difference in estimated blood loss or number of levels fused was noted for either comparison (P = 0.46 and P = 0.66, respectively). There was no significant difference in blood transfusion requirements, with 7% in group 1 and 18% in group 2 (P = 0.35). Operating time was significantly less after 28 patients were operated on 6.2 +/- 1.3 hours versus 5.3 +/- 1.2 hours (P = 0.011). Percent curve correction was significantly better after 28 cases were performed, 54.4 +/- 17.9 in the former groups versus 65.7 +/- 10.4 in the latter half of cases (P = 0.005). Complications were evenly distributed throughout the series. No significant differences were observed between the 2 groups in terms of rate of complication (P = 0.50). No major complications, such as neurologic deficit or significant hemorrhage, were observed.

CONCLUSIONS

The learning curve associated with thoracoscopic spinal instrumentation appears to be acceptable. Significant differences were noted in operating time and percent curve correction after 28 cases. The complication rates remained stable throughout the surgeon's experience.

Single-staged double anterior and posterior spinal reconstruction for rigid adult spinal deformity: a report of four cases

BACKGROUND CONTEXT

Sequential anterior/posterior spinal reconstruction for rigid adult spinal deformity has become a standard operative option. Single-staged double anterior/posterior spinal reconstruction for rigid double major curvature has not been reported in the literature to date.

PURPOSE

To report a previously unreported approach for rigid double major curvature of the thoracic and thoracolumbar spine with emphasis on indications and avoiding complications.

STUDY DESIGN

Four cases of sequential double anterior/posterior spinal reconstruction are reported.

METHODS

Single-staged double anterior spinal reconstruction was performed on four adult patients with rigid thoracic and thoracolumbar scoliosis. Osteotomies were performed by the anterior and posterior approach and followed by posterior instrumentation. A right thoracotomy and left retropleural/retroperitoneal approach was performed for each patient followed by the posterior approach in a single stage.

RESULTS

Only one complication occurred, a posterior dural tear, treated without incident. A high level of patient satisfaction and return to activity was noted. Solid arthrodesis with good coronal and sagittal balance occurred in all patients.

CONCLUSIONS

Single-staged double anterior/posterior spinal reconstruction for rigid adult deformity can be performed safely and effectively with good patient outcome. The procedure should be reserved only for those patients with severe double major curvature of similar magnitude and rigidity.

Measurement Variability in the Assessment of Sagittal Alignment of the Cervical Spine

BACKGROUND

Reconstructive procedures of the cervical spine are being performed with increasing frequency. Maintenance of physiologic sagittal alignment is an essential component of reconstructive procedures of the spine. Two methods exist for measuring sagittal alignment in the cervical spine: the Gore and Cobb methods. An experimental study comparing Gore and Cobb measurement techniques for nonspondylotic and spondylotic cervical spines was conducted. The objectives were to assess the intra- and interobserver variability of both the Gore and the Cobb methods of measurement to determine the most reproducible technique for assessing sagittal alignment of the cervical spine.

METHODS

With use of C3 and C7 as the end vertebrae, lateral radiographs of 20 nonspondylotic (group 1) and 20 spondylotic (group 2) cervical spines were measured by the Gore and Cobb methods on three different occasions by three orthopaedic surgeons with different levels of experience.

RESULTS

For group 1, there was less intra- and interobserver variability for the Gore method than for the Cobb method (P < 0.05). Group 2 measurements were also less variable for the Gore method, although this was not statistically significant. Pooling all three observers, 95% confidence limits for intra- and inter-observer variability for the Gore method were 3 degrees and 6 degrees for group 1 and 4 degrees and 7 degrees for group 2, respectively. For the Cobb method, corresponding values were 4 degrees and 9 degrees for group 1 and 5 degrees and 9 degrees for group 2. Overall, intraobserver measurements were less variable than interobserver measurements (P < 0.01). There were no significant differences in variability based on experience level.

CONCLUSION

Measurements of cervical spine sagittal alignment by the Gore method are more reproducible than by the Cobb method.

Atypical presentation of an osteoid osteoma in a child

Osteoid osteomas are benign bone tumors that most commonly involve the long bones of the lower extremities, but do occur in the spine with some frequency. Patients with lesions in the spine typically present with back pain, scoliosis, and, less commonly, varying degrees of radicular leg pain. We report the case of a child with complaints of nonradicular leg pain. A combination of plain radiographs, scintigraphy, and axial imaging showed a lesion in the sacral spine consistent with an osteoid osteoma. After failed medical management, our patient was treated with intralesional excision, with complete resolution of symptoms.

Diagnosing spinal osteomyelitis: a comparison of bone and Ga-67 scintigraphy and magnetic resonance imaging

PURPOSE

The objective of this investigation was to compare the accuracies of bone and Ga-67 scintigraphy and magnetic resonance imaging (MRI) for diagnosing spinal osteomyelitis and to determine the optimal radionuclide approach to this disorder.

METHODS

Twenty-two patients, with 24 sites of possible spinal osteomyelitis, who underwent three-phase bone scintigraphy with SPECT, Ga-67 scintigraphy with SPECT, and MRI with and without contrast were included in this retrospective review. Bone scans were interpreted as three-phase studies, delayed planar images alone, delayed planar plus SPECT, and SPECT alone (to identify uptake patterns). Sequential bone/ Ga-67 images were interpreted as planar and as SPECT studies. Planar and SPECT Ga-67 images were also interpreted alone. Precontrast MRI studies were used to identify osteomyelitis, whereas postcontrast images were used to identify soft tissue infection.

RESULTS

Eleven sites of spinal osteomyelitis were identified. Tracer uptake in two contiguous vertebrae, as noted on SPECT, was the most accurate bone scan criterion for detecting spinal osteomyelitis (71 %). SPECT bone/Ga-67 was significantly more accurate (92%) than both planar bone/Ga-67 (75%) and bone SPECT (P = 0.15 and P = 0.2, respectively). SPECT Ga-67 was as accurate as SPECT bone/Ga-67 and as sensitive as MRI (91 %); the radionuclide study was slightly but not significantly more specific (92% vs. 77%) than MRI. Of 11 sites of extraosseous infection, 10 were identified on MRI, 9 on SPECT Ga-67, 7 on planar Ga-67, and none on bone scintigraphy.

CONCLUSIONS

Spinal osteomyelitis and accompanying soft tissue infection can be diagnosed accurately with a single radionuclide procedure: SPECT Ga-67. This procedure can be used as a reliable alternative when MRI cannot be performed and as an adjunct in patients in whom the diagnosis is uncertain.

Rheumatoid arthritis of the cervical spine

There is a high incidence of cervical involvement in patients with rheumatoid disease. Early evaluation of the neck, close follow-up with dynamic radiographs of the cervical spine, and careful neurological assessment are important in the care of these patients. Surgical stabilization should be considered early even in the absence of neurological findings when significant instability is noted since outcome is related to preoperative neurological function. The type of fusion performed is determined by a careful assessment of the location of instability, patient factors, and the experience of the surgeon with various techniques. The type of postoperative immobilization should be decided on an individual basis depending on the quality of fixation achieved at surgery. Patients must be observed closely in the postoperative period for development of early complications and followed-up for the appearance of pseudarthrosis or late instabilities.

Retrograde femoral nailing between an ankylosed hip and a stiff knee

We describe a case of retrograde nailing of a comminuted infraisthmal femur fracture between an ankylosed hip and a stiff knee stemming from heterotopic bone and soft-tissue contracture. A tibial nail directed through the medial femoral condyle was used. At 1 year follow-up the fracture has united anatomically, and the patient has been rehabilitated to his preinjury functional status.