Scheuermann’s kyphosis: surgical management

A Novel Surgical Indication for Scheuermann's Kyphosis

Scheuermann kyphosis can be treated surgically to restore proper sagittal alignment. Thoracic curves >70° are typically indicated for surgical intervention. However, patients who have reached their natural limit of compensatory lumbar hyperlordosis are at risk of accelerated degeneration. This can be determined by comparing lumbar lordosis on standing neutral radiographs and supine extension radiographs. Minimal additional lordosis in extension compared with neutral, abutment of the spinous processes, or greater lumbar lordosis standing than with attempted extension suggest the patient is maximally compensated. We present a case of an adolescent boy with Scheuermann kyphosis who had reached the limit of his hyperlordosis compensation reserve. He subsequently underwent a T4 to L2 posterior spinal fusion with T7 to T11 Ponte Smith-Petersen grade two osteotomies. He tolerated the procedure well with no intraoperative complications or neuromonitoring changes. The patient has continued to do well and progressed to normal activity at 5-month follow-up.

Long-term results of surgical correction of Scheuermann’s kyphosis

Objective. To analyze long-term results of surgical correction of kyphosis due to Scheuermann’s disease.

Material and Methods. Design: retrospective cohort study. The study group included 43 patients (m/f ratio, 34/9). The mean age was 19.1 (14–32) years; the mean postoperative follow-up was 6 ± 10 (5–20) years. Two-stage surgery including discectomy and interbody fusion followed by posterior correction and fusion was conducted in 35 cases (Group A). Eight patients (Group B) underwent only posterior correction and spinal fusion. The following parameters were determined for each patient: thoracic kyphosis (TK), lumbar lordosis (LL) (scoliotic deformity of the thoracic/thoracolumbar spine, if the curve magnitude was > 5°), sagittal vertical axis (SVA), sagittal stable vertebra (SSV), first lordotic vertebra (FLV), proximal junctional angle (PJA) and distal junctional angle (DJA). All measurements were performed immediately before surgery, one week after surgery, and at the end of the follow-up period. All patients answered the SRS-24 questionnaire after surgery and at end of the follow-up period.

Results. Groups were comparable in terms of age and gender of patients, body mass index and initial Cobb angle (p < 0.05). The curve decreased from 77.8° to 40.7° in Group A and from 81.7° to 41.6° in Group B. The loss of correction was 9.1° and 6.0° in groups A and B, respectively. The parameters of lumbar lordosis remained normal during the follow-up period. At implant density less than 1.2, deformity correction and correction loss were 44.5° (54.7 %) and 3.9°, respectively (p < 0.05). Proximal junctional kyphosis (PJK) was detected in 21 out of 43 patients (48.8 %). The frequency of PJK was 45.4 % among patients whose upper end vertebra was included in the fusion and 60 % among those whose upper end vertebra was not included. PJK developed in eight (47.8 %) out of 17 patients with kyphosis correction ≥ 50 % and in 13 (50.0 %) of those with correction < 50 %. The rate of DJK development was 39.5 %. The lower instrumented vertebra (LIV) was located proximal to the sagittal stable vertebra in 16 cases, with 12 (75 %) of them being diagnosed with DJK. In 27 patients, LIV was located either at the SSV level or distal to it, the number of DJK cases was 5 (18.5 %); p < 0.05. Only two patients with complications required unplanned interventions. According to the patient questionnaires, the surgical outcome score increases between the immediate and long-term postoperative periods for all domains and from 88.4 to 91.4 in total. The same applies to answer to the question about consent to surgical treatment on the same conditions: positive answers increased from 82 to 86 %.

Conclusions. Two-stage surgery, as a more difficult and prolonged one, has no advantages over one-stage operation in terms of correction magnitude and stability of the achieved effect. Surgical treatment improves the quality of life of patients with Scheuermann’s disease, and the improvement continues in the long-term postoperative period.

Surgical Procedures Used for Correction of Scheuermann's Kyphosis: A Meta-Analysis

Objectives

Scheuermann's kyphosis can cause severe back pain and cosmetic disorders to patients. Previous studies on surgical procedure selection for correction of Scheuermann's kyphosis have drawn controversial conclusions. Here, a meta-analysis was performed to figure out a better way between anterior-posterior (AP) combined procedures and posterior-only (PO) procedures.

Methods

We searched PubMed database and Ovid database, as well as Cochrane Library (between January 2009 and December 2020, around recent ten years), for studies reporting Scheuermann's kyphosis correction in an anterior way or a posterior way. Random effects meta-analysis regarding correction degrees and incidence of proximal junctional kyphosis (PJK) was performed.

Results

Finally, 13 unique studies including 586 patients (AP: 300; PO: 286) were identified and included for this meta-analysis. Overall, 6 AP cohorts and 10 PO cohorts were pooled regarding the correction degrees of kyphosis in the analysis, respectively. Pooled correction degrees in AP cohorts were 33.31 (95% CI: 27.48–39.15; I² = 86%, P < 0.001) and in PO cohorts were 31.16 (95% CI: 26.97–35.35; I² = 81.1%, P < 0.001). Comparison of correction between AP and PO cohorts did not indicate any significant difference. Likewise, postoperative PJK incidence showed no difference. Back pain can be caused by both AP and PO procedures, but which causes less pain remains to be conclusive. The PO approach showed less blood loss and shorter surgical duration as compared to the AP approach.

Conclusions

In summary, this meta-analysis shows similar treatment effects between AP and PO procedures in correcting Scheuermann's kyphosis, suggesting the advantage of PO procedures due to less blood loss and surgical duration. However, the postoperative complications PJK and distal junctional kyphosis (DJK) cannot be well concluded due to the limitation of existing data.

Evaluation and management of paediatric and adolescent back pain: Epidemiology, presentation, investigation, and clinical management: A narrative review

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

Sagittal Spinal and Pelvic Parameters in Patients With Scheuermann's Disease: A Preliminary Study

Background

Sagittal spinopelvic parameters remain poorly defined in patients with Scheuermann disease (SD). For example, although pelvic incidence (PI) should approximate lumbar lordosis (LL) by 10°, this is not true in patients with SD. This retrospective radiographic study was conducted to propose a new mathematical relationship between sagittal spinopelvic parameters in skeletally mature patients with SD.

Methods

The following formula (Δ) was proposed [(thoracic kyphosis - 45°) + (thoracolumbar kyphosis - 0°) + (PI - LL) = ± 10°] and validated with standard spino pelvic parameters in patients with skeletally mature SD without prior spine surgery at 2 centers between 2006 and 2015. The T1 pelvic angle (TPA) was used as a measure of global balance with normal maximum of 15°. Subgroup analysis was performed to compare Δ between balanced (TPA ≤ 15°) and unbalanced (TPA > 15°) patients with SD.

Results

In patients with SD (n = 30), half were female (n = 15), the average age was 39 years, and the average Δ was 2.4°. A significant correlation was discovered between Δ and both TPA (R ² = 0.75) and PI (R ² = 0.69). At TPA of 15°, average Δ was 9.2°. There was also a significant difference between balanced and unbalanced patients (-8.7° ± 11.6° versus 28.2° ± 19.7°, P = .0003).

Conclusions

This study of a new formula (Δ) to evaluate global sagittal balance in patients with SD found that accounting for the kyphosis maintained Δ within ± 10°. Further study is planned to determine whether maintaining and/or restoring a normal Δ is associated with improved outcomes in patients with SD after surgery.

Sternoclavicular dislocation as a possible complication for surgical Scheuermann's deformity correction: a case report

OBJECTIVE

We present a sternoclavicular dislocation as a non-reported complication after spinal kyphotic deformity surgical correction.

BACKGROUND

The sternocostal complex seems to have an important role in the pathology of Scheuermann's kyphotic deformity. A role for the sternoclavicular complex has never been reported in association with Scheuermann's disease pathology but could explain anterior sternoclavicular dislocation after spinal kyphotic deformity correction.

METHODS

A 19-year-old male patient underwent surgery for a 74° thoracic kyphosis associated with a 35° thoracic and a 50° lumbar scoliotic curve. In the early post-operative period, the patient developed pain over the left sternoclavicular joint articulation, with a very obvious lump. An X-ray disclosed an anterior sternoclavicular dislocation. After surgical treatment failed, the dislocation was repaired in a second surgical procedure with a flexion and lengthening osteotomy of the middle third of the clavicle followed by capsular repair reinforced with sternocleidomastoid fascia.

RESULTS

At an 8-year follow-up after his spine procedure and 6 years after his clavicular surgery, the patient had full shoulder range of motion and no joint pain, despite the presence of a new sternoclavicular anterior dislocation.

CONCLUSION

Sternoclavicular dislocation after spine kyphotic deformity correction is presented for the first time; however, it is not possible to establish a causative association. Additional studies are necessary to delineate the role of the sternoclavicular complex in Scheuermann's disease.

What Are the Indications for Spinal Fusion Surgery in Scheuermann Kyphosis?

BACKGROUND

Surgical indications for Scheuermann kyphosis are variable. We sought to evaluate the characteristics of patients undergoing operative versus nonoperative treatment of Scheuermann kyphosis to better understand current practices and the factors which contribute to the decision for surgical management.

METHODS

Multicenter prospective cohort study. We evaluated consecutive patients presenting with Scheuermann kyphosis. Patients underwent either surgical or nonoperative management according to surgeon and patient discretion. Preoperative patient-reported outcome measures (Scoliosis Research Society and Spinal Appearance Questionnaire scores), demographics, and radiographic characteristics were assessed.

RESULTS

Overall, 150 patients with Scheuermann kyphosis were enrolled, with 77 choosing nonoperative treatment and 73 treated operatively. Compared with the nonoperative cohort, patients treated operatively were older (16.3±2.0 vs. 15.1±2.2, P=0.0004), and had higher body mass index (26.3±7.2 vs. 22.7±6.5, P=0.003), had greater T2-T12 kyphosis (71±14 degrees vs. 61±12 degrees, P<0.001), increased pelvic incidence (46 vs. 41 degrees, P=0.03) and pelvic tilt (10 vs. 3 degrees, P=0.03). There was no detected difference in maximal sagittal Cobb angle in the operative versus nonoperative patients (73±11 vs. 70±12 degrees, P=0.11). Functionally, the operative patients had worse Scoliosis Research Society pain scores (3.7±0.9 vs. 4.1±0.7, P=0.0027) and appearance scores (2.9±0.7 vs. 3.4±0.8, P <0.0001).

CONCLUSIONS

Patients undergoing surgical management of Scheuermann disease were more likely to have large body mass index and worse pain scores. Other factors beyond radiographic measurement likely contribute to the decision for surgical management of Scheuermann kyphosis.

LEVEL OF EVIDENCE

Level II.

Posterior-Only Approach with Pedicle Screws for the Correction of Scheuermann's Kyphosis

Study Design

Retrospective study (level of evidence: level 3).

Purpose

The purpose of this study was to evaluate the clinical and radiological results of the posterior-only approach with pedicle screws for the treatment of Scheuermann's kyphosis (SK).

Overview of Literature

The correction of SK with instrumentation can be performed using posterior-only or combined anterior-posterior procedures. With the use of all-pedicle screw constructs in spine surgery, the posterior-only approach has become a popular option for the definitive treatment of SK. In a nationwide study involving 2,796 patients, a trend toward posterior-only fusion with lower complication rates was reported.

Methods

We retrospectively reviewed the data of patients who underwent posterior-only correction for SK between January 2005 and May 2013. Patients with a definite diagnosis of SK who fulfilled the minimum follow-up criterion of 24 months were included. The thoracic kyphosis (T5–T12), lumbar lordosis (L1–S1), and thoracolumbar junction (T10–L2) angles were measured from preoperative, postoperative, and last control radiographs. Sagittal balance, thoracic length, thoracic diameter, Voutsinas index and the sacral slope, pelvic tilt, proximal junction kyphosis, and distal junction kyphosis angles were also measured.

Results

Forty-five patients underwent surgery for the treatment of SK between 2005 and 2013. After applying the exclusion criteria, 20 patients (18 males and 2 females) with a mean age of 19 years were included. The mean thoracic kyphosis angle was 79.8 degrees preoperatively, 44.6 degrees postoperatively, and 44.9 degrees at the last control. There were statistically significant differences between preoperative and postoperative values in the thoracic kyphosis and lumbar lordosis angles, thoracic length, thoracic diameter, and Voutsinas index (p<0.05).

Conclusions

The clinical and radiological results of the current study suggest that posterior-only fusion is an efficient technique for the treatment of SK.

Spinal epidural lipomatosis - an easily ignored secondary intraspinal disorder in spinal kyphotic deformities

Background

A previous study reported a high prevalence of spinal epidural lipomatosis (SEL) in patients with Scheuermann kyphosis (SK) and suggested that it may play a role in the pathogenesis of this disease. According to our observation, however, SEL occurs in other spinal kyphotic deformities as well. The aim of this study was to test the hypothesis that SEL commonly occurs in patients with different types of kyphotic deformities as a secondary intraspinal disorder.

Methods

MR images of 16 patients with congenital kyphosis (CK), 40 patients with SK, 13 patients with tuberculotic kyphosis (TK), and 69 age- and sex-matched controls were retrospectively evaluated. The body mass index (BMI), kyphosis Cobb angle, and sagittal diameters of spinal epidural fat (EF) and the dural sac (DS) in the apical region (EF_A, DS_A) and non-kyphotic region (EF_N, DS_N) were measured. The EF ratios at the apical vertebral level (EFR_A) and in the non-kyphotic region (EFR_N) were calculated as EF / (EF + DS).

Results

EF_A and EFR_A were significantly higher among patients with CK, SK, and TK than among controls (P < 0.05). Seven CK patients (43.8%), 8 SK patients (20.0%), and 11 TK patients (84.6%) fulfilled the diagnostic criteria for SEL, while only 6.3, 2.5, and 0% of patients in the control groups did (P = 0.019, 0.014, and < 0.001, respectively). Spearman’s correlation analysis showed statistically significant correlations between the kyphosis Cobb angle and the amount of EF in all three patient groups.

Conclusions

SEL is a common secondary intraspinal disorder in different types of kyphotic deformities, and surgeons should pay increased attention to this intraspinal anomaly because excessive EF may compress the spinal cord and cause neurological deficits.

Influence of Sequential Ponte Osteotomies on the Human Thoracic Spine With a Rib Cage

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVES

The purpose of this study was to determine the change in range of motion (ROM) of the human thoracic spine and rib cage due to sequential Ponte osteotomies (POs).

SUMMARY OF BACKGROUND DATA

POs are often performed in deformity correction surgeries to provide flexibility in the sagittal plane at an estimated correction potential of 5° per PO, but no studies have evaluated the biomechanical impact of the procedure on a cadaveric model with an intact rib cage.

METHODS

Seven human thoracic cadavers with intact rib cages were loaded with pure moments in flexion, extension, axial rotation, and lateral bending for five conditions: intact, PO at T9-T10, PO at T8-T9, PO at T7-T8, and PO at T6-T7. Motion of T1, T6, and T10 were measured, and overall (T1-T12) and regional (T6-T10) ROMs were reported for each mode of bending at each condition.

RESULTS

POs increased ROM in flexion both overall (T1-T12) and regionally (T6-T10), although the magnitude of the increase was marginal (<1°/PO). No significant differences were found in axial rotation or lateral bending.

CONCLUSIONS

POs may increase sagittal correction potential before fusion in patients with hyperkyphosis, though more work should be done to determine the magnitude of the changes.

LEVEL OF EVIDENCE

Level V.

Orthotic treatment of idiopathic hyperkyphosis with Milwaukee brace

BACKGROUND

Hyperkyphosis with unknown reason is common in teenagers and can be corrected by orthotic management.

OBJECTIVES

Investigation of orthotic outcomes by Milwaukee brace.

METHODS

Sixty-one patients with idiopathic hyperkyphosis (> 45 degrees) were given Milwaukee brace before skeletal maturity. Hyperkyphosis was measured during the first visit without brace, in-brace, at the end of full-time and part time duration of treatment. After treatment completion, participants were categorized in two groups: with hyperkyphosis of 45 degrees and less (Group I) and more than 45 degrees (Group II). These groups were compared to interpret the treatment outcomes.

RESULTS

The mean kyphotic curve was 60.1 (SD ± 7.7) and 71 (SD = 10.1) degrees in Group I and II, respectively. The mean kyphotic curve at the time of full time and part time duration of treatment showed no significant difference in patients successfully completed the treatment (P = 0.10) while there was a significant difference between mean kyphotic curve in full time and part time treatment duration for patients with hyperkyphosis of more than 45 degrees (P < 0.05).

CONCLUSIONS

Hyperkyphosis of less than 70 degrees can be treated if the in-brace correction is saved in part-time duration.

Poor Radiological and Good Functional Long-term Outcome of Surgically Treated Scheuermann Patients

STUDY DESIGN

Cohort study.

OBJECTIVE

To analyze long-term clinical and radiological outcomes of surgically treated Scheuermann patients.

SUMMARY OF BACKGROUND DATA

Long-term clinical and radiological outcomes of surgery for Scheuermann kyphosis are unknown. A single-center cohort of 33 consecutive, surgically treated (between 1991 and 1998) Scheuermann patients was studied.

METHODS

Clinical and radiological data of 29 surgically treated Scheuermann patients were collected (posterior approach n = 13; combined anterior-posterior procedure n = 16), after a mean follow-up of 18 years. Oswestry Disability Index (ODI) scores were measured preoperatively (PRE) and twice postoperatively: 2 to 8 years postoperative (FU 1) and 14 to 21 years postoperative (FU 2). Visual Analog Score pain, Short Form-36 (SF-36), and EQ-5d scores were recorded at FU 2 only. Radiographs were analyzed for correction, distal and proximal junctional kyphosis, and implant failures.

RESULTS

Mean preoperative kyphosis of the corrected levels was 76° (range 60°-105°) and decreased to a Cobb of 58°(range 30°-105°) at FU 2. Median Visual Analog Score was 2.5 points (range 0-8) and median ODI score was 12 (range 0-62) at FU 2. The ODI score at FU 1 was significantly better as compared to PRE (P < 0.001) and FU 2 (P < 0.001). Also, anterior-posterior treated group had a significantly better ODI score as compared to the posterior-only group (P = 0.023). EQ-5d scores on mobility, usual activities, and pain/discomfort were worse compared to an age-matched population control group; however, SF-36 outcome scores were comparable.Proximal junctional kyphosis was present in 53% of patients, distal junctional kyphosis did not occur, and implant failure/removal had occurred in 69% of patients. Radiological complications do not relate with the ODI, EQ-5d, and SF-36 and 72% of the patients were satisfied.

CONCLUSION

Radiological results of this cohort were disappointing but did not relate to clinical outcome scores. Even lumbar pain could not prevent a high patient satisfaction and quality of life. Patients treated with a combined anterior-posterior approach tended to perform better.

LEVEL OF EVIDENCE

3.

Perioperative complications associated with spine surgery in patients with established spinal cord injury

BACKGROUND CONTEXT

Only a small percentage of patients with spinal cord injury (SCI) require consideration for reconstructive surgery after their initial injury. For those who do, perioperative complications can be frequent and significant. There has been very little published literature examining treatment of these patients and essentially nothing to guide the surgeon in perioperative decision making and management.

PURPOSE

To identify some of the common challenges associated with surgery in this patient population and review the literature to highlight the perioperative concerns in patients with chronic SCI.

STUDY DESIGN

Review article.

METHODS

A primary PubMed literature search was performed and reviewed for patients with chronic SCI with emphasis on the complications and difficulties encountered during surgical treatment of patients with chronic SCI.

RESULTS

For those who do proceed with surgery in this patient population, preoperative nutrition, bone density, and skin should be evaluated and optimized. Preoperative inferior vena cava filters should be considered. The integrity of the reconstruction will be extensively challenged. In addition, augmented fixation and bracing should be contemplated.

CONCLUSIONS

Patients with chronic SCI who require spinal reconstruction provide many unique challenges. Indications for surgery must be strong as perioperative complications can be frequent and long-term outcomes unpredictable. Close monitoring for postoperative complications is essential.

Comparison of Scheuermann's kyphosis correction by combined anterior-posterior fusion versus posterior-only procedure

INTRODUCTION

Conventional treatment of rigid deformity in Scheuermann's kyphosis (SK) in young patients includes a preliminary anterior spinal release and fusion (ASF) followed by posterior spinal fusion and instrumentation (PSF). However, recently there are more trends to do posterior-only surgery for correction of this deformity. The aim of our study was to compare clinical and radiological outcomes of ASF/PSF and PSF-only procedures in treatment of SK.

MATERIALS AND METHODS

In a prospective clinical and radiological review, thirty operated SK patients in two groups were evaluated. Group A: ASF/PSF technique (n: 16) and group B: PSF-only procedure (n: 14) were followed for at least 2 years (average 57.6 months). Two groups were well matched for the following four criteria: average age, flexibility status, posterior fusion levels, and preoperative Cobb's kyphosis angle. Oswestry disability index (ODI) and scoliosis research society questionnaire-30 (SRS-30) and radiological (kyphosis correction, correction loss, sagittal balance) parameters were evaluated before and after surgery and at the final follow-up.

RESULTS

In group A, primary thoracic Cobb's kyphosis, immediate post-operative kyphosis, and final follow-up kyphosis angle were 83.6°, 41.4° and 43°, respectively (P < 0.05). Correction rate and correction loss were 50.5 % and 1.6° ± 2.4, respectively. In group B, the corresponding values were 81.9°, 40.1° and 43.2°, respectively (P < 0.05). Correction rate and correction loss were 51 % and 3.1° ± 2.5, respectively. SRS-30 and ODI scores in group A were averaged 68.5 and 21.3 preoperatively and 128.7 and 6.25 at the final follow-up, respectively. In group B, the corresponding values were 64 and 23.2 preoperatively and 133.5 and 5.8 at the final follow-up, respectively.

CONCLUSIONS

Clinical and radiological parameters were similar in both groups after surgical correction while, complication rates, operation time and blood loss were significantly higher in ASF/PSF procedure.

Posterior-only correction of Scheuermann kyphosis using pedicle screws: economical optimization through screw density reduction

INTRODUCTION

Posterior-only approach using pedicle screws' fixation has emerged as the preferred surgical technique for Scheuermann kyphosis (SK) correction. Insertion of multiple pedicle screws while increasing stability increases also the risk of complications related to screw malpositioning and surgical cost. The optimal screw density required in surgical correction of SK remains unclear. This study compares the safety and efficacy of low screw density (LSD) versus high screw density (HSD) technique used in posterior-only correction of SK.

METHODS

Twenty-one patients underwent surgical correction of SK between 2007 and 2011 and were reviewed after a mean of 29 months. HSD technique (i.e., 100 % of available pedicles, averaged 25.2 ± 4 screws) was used in 10 cases and LSD technique (i.e., 54-69 % of available pedicles in a pre-determined pattern, averaged 16.8 ± 1.3 screws; p < 0.001) was used in 11 cases. Kyphosis correction was assessed by comparing thoracic kyphosis, lumbar lordosis and sagittal balance on preoperative and postoperative radiographs. Cost saving analysis was performed for each group.

RESULTS

Preoperative thoracic kyphosis, lumbar lordosis and sagittal balance were similar for both groups. The average postoperative kyphosis correction was similar in both HSD and LSD groups (29° ± 9° vs. 34° ± 6°, respectively; p = 0.14). Complication occurred in four patients (19 %) in the HSD group and in two patients (9 %) in the LSD group (p = 0.56). Three patients required re-operation. Compared to HSD using LSD saves 4,200 pounds sterling per patient in hardware and 88,200 pounds sterling for the entire cohort.

CONCLUSION

LSD technique is as safe and effective as HSD technique in posterior-only correction of SK. Implant-related cost could be reduced by 32 %.

Treatment stability of Milwaukee brace in idiopathic hyperkyphosis

BACKGROUND

The Milwaukee brace is an efficient method for correcting hyperkyphosis before skeletal maturity. However, loss of correction in long-term follow-up is inevitable.

OBJECTIVES

To determine loss of correction and factors affecting the loss of correction.

STUDY DESIGN

Retrospective study.

METHODS

A total of 49 corrected patients by Milwaukee brace participated minimum 2 years after treatment completion. The participants were categorized into two groups based on their roentgenograms: Group 1 (n = 36) had kyphotic curves of 45° or less and Group 2 (n = 13) had kyphotic curves of more than 45°.

RESULTS

The mean loss of corrections for Group 1 and Group 2 were 3.80° (ranges = 0°-13°) and 12.92° (ranges = 8°-22°), respectively. Group 1 showed no significant difference between the average hyperkyphosis of the patients for the part-time and full-time treatment duration (p = 0.02). By contrast, a significant difference was observed between the average hyperkyphosis of patients in Group 2 for the part-time and full-time treatment duration (p < 0.05).

CONCLUSIONS

Patients with kyphosis of 60° or less who can save the correction in full-time orthotic treatment in part-time treatment may have the least loss of correction over time.

CLINICAL RELEVANCE

As the orthotic treatment is a time-consuming method that needs the close collaboration of patient and treatment team, it is possible that clinicians predict the probable result of treatment and efficiency of orthotic treatment. Thus, a clinician can abandon orthotic treatment and refer the patient for an operation.

Back pain in children and adolescents

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Surgical treatment of Scheuermann's kyphosis using a combined antero-posterior strategy and pedicle screw constructs: efficacy, radiographic and clinical outcomes in 111 cases

INTRODUCTION

There is sparse literature on how best to correct Scheuermann's kyphosis (SK). The efficacy of a combined strategy with anterior release and posterior fusion (AR/PSF) with regard to correction rate and outcome is yet to be determined.

MATERIALS AND METHODS

A review of a consecutive series of SK patients treated with AR/PSF using pedicle screw-rod systems was performed. Assessment of demographics, complications, surgical parameters and radiographs including flexibility and correction measures, proximal junctional kyphosis angle (JKA + 1) and spino-pelvic parameters was performed, focusing on the impact of curve flexibility on correction and clinical outcomes.

RESULTS

111 patients were eligible with a mean age of 23 years, follow-up of 24 months and an average of eight levels fused. Cobb angle at fusion level was 68° preoperatively and 37° postoperatively. Flexibility on traction films was 34 % and correction rate 47 %. Postoperative and follow-up Cobb angles were highly correlated with preoperative bending films (r = 0.7, p < 0.05). Screw density rate was 87 %, with increased correction with higher screw density (p < 0.001, r = 0.4). Patients with an increased junctional kyphosis angle (JKA + 1) were at higher risk of revision surgery (p = 0.049). 22 patients sustained complication, and 21 patients had revision surgery. 42 patients with ≥24 months follow-up were assessed for clinical outcomes (follow-up rate for clinical measures was 38 %). This subgroup showed no significant differences regarding baseline parameters as compared to the whole group. Median approach-related morbidity (ArM) was 8.0 %, SRS-sum score was 4.0, and ODI was 4 %. There was a significant negative correlation between the SRS-24 self-image scores and the number of segments fused (r = -0.5, p < 0.05). Patients with additional surgery had decreased clinical outcomes (SRS-24 scores, p = 0.004, ArM, p = 0.0008, and ODI, p = 0.0004).

CONCLUSION

The study highlighted that AR/PSF is an efficient strategy providing reliable results in a large single-center series. Results confirmed that flexibility was the decisive measure when comparing surgical outcomes with different treatment strategies. Findings indicated that changes at the proximal junctional level were impacted by individual spino-pelvic morphology and determined by the individually predetermined thoracolumbar curvature and sagittal balance. Results stressed that in SK correction, reconstruction of a physiologic alignment is decisive to achieving good clinical outcomes and avoiding complications.

Round and angular kyphosis in paediatric patients

Structural kyphosis is a posterior convex deformity of the spine that may appear in childhood then worsen with growth, most notably during the pubertal growth spurt. The abnormal curvature may be smooth, defining round kyphosis, or may display a sharp angular pattern. Angular kyphosis is the more severe of the two forms. The main causes of round kyphosis are postural kyphosis and Scheuermann's disease. The spontaneous outcome is favourable, and round kyphosis is well tolerated in adulthood. The treatment relies on orthopaedic methods in the overwhelming majority of cases. Surgery is reserved for severe rigid kyphosis in older children and for kyphosis responsible for refractory pain or neurological deficits. Surgical treatment carries a non-negligible risk of neurological, gastrointestinal, mechanical, and septic complications, which should be explained clearly to the family. Advances in contemporary posterior instrumentation have considerably limited the indications for anterior approaches. Many conditions may cause angular kyphosis, whose greater severity is related to a greater potential for progression and neurological impairment. Clinical investigations are in order to identify the cause and to plan the surgical strategy. Early surgery may be indicated, via a combined anterior and posterior approach. Anterior strut grafting, anterior or posterior osteotomies, or even vertebral column resections may be necessary to correct a major deformity.

Acutely progressing paraplegia caused by traumatic disc herniation through posterior Schmorl's node opening into the spinal canal in lumbar Scheuermann's disease

STUDY DESIGN

A case report.

OBJECTIVE

To report an unusual neurologic complication caused by traumatic disc herniation through atypical posterior Schmorl's node (SN) opening into the spinal canal in lumbar Scheuermann's disease.

SUMMARY OF BACKGROUND DATA

Neurologic complications in Scheuermann's disease are rare and disc hernia has been reported as one of the causes of neural compression. However, there has been no report on acutely progressing paraplegia caused by traumatic disc herniation through an atypical posterior SN opening into the spinal canal in lumbar Scheuermann's disease.

METHODS

A clinical and radiologic review of such a case of traumatic disc herniation through an atypical posterior SN that resulted in acutely progressing paraplegia in Scheuermann's disease was performed.

RESULTS

The patient presented with severe back pain after a fall, without any neurologic abnormalities. Computed tomographic scan revealed lumbar Scheuermann's disease, acute compression fracture of T12, and a large posterior SN with "trough-like" indentation of the lower endplate of T12 opening into the spinal canal. Abruptly progressing paraplegia occurred in less than 24 hours after the first visit and the magnetic resonance imaging revealed severe spinal cord compression by large disc extrusion with superior migration at T12-L1 through the atypical posterior SN at the lower endplate of T12. The patient underwent posterior decompression and discectomy at T12-L1 through transfacet pedicle-sparing approach. Postoperatively, the patient showed immediate improvement in the sensory deficit on L1 dermatome and the perianal area and motor function of the hip flexors to grade 2 without further neurologic improvement, at 2-year follow-up.

CONCLUSION

The case report highlights the clinical significance of the atypical posterior SN that could be a channel for large disc extrusion after a traumatic event in Scheuermann's disease and the clinical importance of surgeon's close attention to the possibility of abruptly progressing neurologic compromise in this situation.

Prospective evaluation of physical activity in patients with idiopathic scoliosis or kyphosis receiving brace treatment

Bracing is an established method of conservative treatment for adolescent idiopathic scoliosis and kyphosis. Compliance among adolescents is frequently inadequate due to the discomfort of wearing a brace, cosmetic issues, and fear on the part of patients and parents that bracing may reduce everyday physical activities. The aim of this prospective, controlled study was to objectify the impact of spinal bracing on daily step activity in patients receiving conservative treatment for adolescent idiopathic scoliosis (AIS) or adolescent kyphosis (AK). Forty-eight consecutive patients (mean age 13.4 ± 2.3 years), consisting of 38 AIS patients (33 girls, 5 boys) and 10 AK patients (6 girls, 4 boys) were included. Once the decision to carry out bracing had been taken and while the patients were waiting for the individual brace to be built, step activity was assessed without braces by means of step activity monitoring (SAM) for seven consecutive days. After 8 weeks of brace wearing, step activity was assessed during regular brace treatment, again for seven consecutive days. In addition, brace-wearing times were simultaneously recorded using temperature probes implanted in the braces to measure compliance. Before and during brace treatment, patients completed the Scoliosis Research Society (SRS-22) questionnaire. The SAM was worn for an average of 12.7 ± 1.5 h/day during the first measurement and 12.3 ± 1.9 h on average during the second measurement. The mean gait cycles (GCs) per day and per hour before treatment were 5,036 ± 1,465 and 395 ± 105, respectively. No significant reduction in step activity was found at the follow-up measurement during bracing, at 4,880 ± 1,529 GCs/day and 403 ± 144 GCs/h. Taking the 23-h recommended time for brace wearing as a basis (100%), patients wore the brace for 72.7 ± 27.6% of the prescribed time, indicating an acceptable level of compliance. Girls showed a higher compliance level (75.6 ± 25.6%) in comparison with boys (56.7 ± 31.9%), although the difference was not significant (P = 0.093). The SRS-22 total score showed no differences between the two measurements (2.57 ± 0.23 vs. 2.56 ± 0.28). Implementing a simultaneous and objective method of assessing step activity and brace-wearing times in everyday life proved to be feasible, and it expands the information available regarding the impact of bracing on patients' quality of life. The results clearly show that brace treatment does not negatively interfere with daily step activity in AIS and AK patients. This is an important finding that should help reduce patients' and parents' worries concerning bracing.

Scheuermann’s kyphosis; current controversies

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth.

The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.

Orthopaedic management of Hurler's disease after hematopoietic stem cell transplantation: a systematic review

OBJECTIVE

The introduction of hematopoietic stem cell transplantation (HSCT) has significantly improved the life-span of Hurler patients (mucopolysaccharidosis type I-H, MPS I-H). Yet, the musculoskeletal manifestations seem largely unresponsive to HSCT. In order to facilitate evidence based management, the aim of the current study was to give a systematic overview of the orthopaedic complications and motor functioning of Hurler's patients after HSCT.

METHODS

A systematic review was conducted of the medical literature published from January 1981 to June 2010. Two reviewers independently assessed all eligible citations, as identified from the Pubmed and Embase databases. A pre-developed data extraction form was used to systematically collect information on the prevalence of radiological and clinical signs, and on the orthopaedic treatments and outcomes.

RESULTS

A total of 32 studies, including 399 patient reports were identified. The most frequent musculoskeletal abnormalities were odontoid hypoplasia (72%), thoracolumbar kyphosis (81%), genu valgum (70%), hip dysplasia (90%) and carpal tunnel syndrome (63%), which were often treated surgically during the first decade of life. The overall complication rate of surgical interventions was 13.5%. Motor functioning was further hampered due to reduced joint mobility, hand dexterity, motor development and longitudinal growth.

CONCLUSION

Stem cell transplantation does not halt the progression of a large range of disabling musculoskeletal abnormalities in Hurler's disease. Although prospective data on the quantification, progression and treatment of these deformities were very limited, early surgical intervention is often advocated. Prospective data collection will be mandatory to achieve better evidence on the effect of treatment strategies.

Scheuermann's thoracic kyphosis in the adolescent patient

Scheuermann's thoracic kyphosis is a condition characterized by increased posterior rounding of the thoracic spine in association with structural deformity of the vertebral elements. It is a structural deformity of the spine that is classically characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. The cause of the deformity remains unknown but it is believed to be multifactorial, and it likely has a genetic component as well. Most adolescent patients seek orthopaedic evaluation for increased rounding and deformity of the thoracic spine that is occasionally associated with back pain. Parental concerns are also often related to the cosmetic deformity and the progressive nature of the condition. Bracing has been demonstrated to be an effective nonsurgical treatment modality for the skeletally immature child and/or adolescent with a progressive deformity. Operative management has been advocated for adolescents with progressive kyphosis measuring over 70°, for those who have had progression despite bracing, for patients with intractable back pain, and also for patients with unacceptable cosmetic deformity. Surgical options include posterior spinal arthrodesis with or without anterior spinal release via thoractomy or video-assisted thoracoscopic surgery (VATS). This article will review the diagnosis, pathophysiology, physical examination findings, and the nonoperative and surgical treatment options for adolescent patients with Scheuermann's kyphosis of the thoracic spine.

Review for the generalist: evaluation of low back pain in children and adolescents

Back pain is common in children and adolescents. Most cases of back pain are non-specific and self-limiting. In children and adolescents, pain is usually related to the posterior elements of the spine and disc-related problems are rare. Serious pathology, including malignancy and infection needs to be excluded. Evaluation and management is challenging and requires a thorough history and physical exam, and understanding of the immature skeleton. Diagnostic imaging is useful in the evaluation of a child or adolescent with low back pain and can help guide management. This article will review common causes of back pain in the pediatric population.

MULTIPLE SEGMENTAL OSTEOTOMIES TO THE KYPHOSIS CORRECTION

OBJECTIVE

To evaluate the results of the surgical treatment of the spinal Kyphosis using the Ponte's technique (multiple posterior osteotomies).

METHODS

Ten patients (8 with Scheuermann's kyphosis and 2 with kyphosis after laminectomy) submitted to surgical correction of kyphotic deformity greater than 70° were retrospectively assessed. The age at the surgical time ranged from 12 to 20 years old (mean age16.8 years ± 2.89). The radiographic parameters evaluated were the kyphosis, the lordosis and the scoliosis - whenever present. The presence of proximal and distal junctional kyphosis, loss of correction, and complications as implants loosening and breakage were also assessed. The radiographic parameters were evaluated at the preoperative, early postoperative and late postoperative time.

RESULTS

The patients were followed through a period that ranged from 24 to 144 months (65.8 ±39.92). The mean value of the kyphosis was 78.8° ± 7.59° (Cobb) before surgery and 47.5° ± 12.54° at late follow up, with mean correction of 33.9° ± 9.53° and lost correction of 2.2°.

CONCLUSION

The surgical treatment of the thoracic kyphosis using multiples posterior osteotomies presented a good correction of the deformity and minimal lost of correction during follow up.

SMITH–PETERSEN OSTEOTOMY IN THORACOLUMBAR DEFORMITY SURGERY

OBJECTIVE

To describe the technique and indications of a Smith–Petersen osteotomy in spinal deformity surgery.

METHODS

Pertinent literature was reviewed to describe the indications and reported complications of this corrective technique.

RESULTS

The operative nuances of the technique are described.

CONCLUSION

A Smith-Petersen osteotomy is a safe and effective surgical technique to obtain correction of spinal deformity in both the sagittal and coronal planes.

Pediatric scoliosis and kyphosis

Pediatric spinal deformity is a common manifestation of multiple disorders. The clinical picture varies depending on the age at presentation, the severity of the curve at the time of diagnosis, and the underlying cause. Knowledge of the natural history of these varied conditions, the dynamics of growth in the developing spine, and normal axial skeletal biomechanics are fundamental in planning an appropriate treatment. Furthermore, in many instances the spinal anomaly is just part of the problem in a globally affected patient. Treatment alternatives must be judged based on their capacity to positively alter the natural course of the disease and provide a long-standing solution into a patient's adulthood.