Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence

Comparison of Perioperative Complication Rates in Congenital Scoliosis Patients With and Without Tethered Spinal Cord

BACKGROUND

Congenital early onset scoliosis (C-EOS) often co-occurs with tethered spinal cord syndrome (TSCS), necessitating surgical intervention to address both conditions to prevent worsening neuromuscular function. Detethering can be done concurrently with spinal deformity correction (SDC), before SDC, or not done at all. This study explores perioperative complications in C-EOS patients with and without TSCS who underwent SDC with growing instrumentation or fusion. We hypothesize that C-EOS patients with a history of TSCS who underwent SDC with either growing instrumentation or fusion experienced higher rates of perioperative complications compared with those without TSCS. Among patients with a history of TSCS, we hypothesize that those who were detethered had fewer perioperative complications than those who were not detethered.

METHODS

Data from 751 C-EOS patients from an international spine registry were reviewed. After applying inclusion and exclusion criteria, 477 patients were divided into groups: those with TSCS (n=90) and those without (n=387). Among TSCS patients, the majority underwent detethering (n=54), whereas 36 did not. Demographics, magnetic resonance imaging (MRI) findings, treatment history, and surgical complications were assessed. Statistical analyses were conducted to compare demographic and clinical parameters, including complication rates, using appropriate tests. Postoperative complications were further categorized according to the modified Clavien-Dindo-Sink (mCDS) classification system.

RESULTS

Comparing C-EOS patients with and without TSCS revealed no significant differences in age at first MRI (P=0.52), pre-index major coronal curve (P=0.43), pre-index maximum sagittal kyphosis (P=0.113), the number of growth-friendly procedures (P=1.00), resection (P=0.071), osteotomy (P=0.081), intraoperative complications (P=0.088), postoperative complications (P=0.41), hardware failure (P=0.78), infections (P=0.26), and neurological complications (P=0.42). Postoperative complications further categorized using the mCDS demonstrated no significant differences between the groups (P=0.144). No significant differences were found in age at first MRI (P=0.60), pre-index major coronal curve (P=0.90), pre-index maximum sagittal kyphosis (P=0.50), resection (P=0.20), or osteotomy (P=0.47) between the detethered and not detethered cohorts. However, a higher percentage of TSCS patients without detethering underwent a growth-friendly procedure (P=0.003). In addition, TSCS patients without detethering experienced higher rates of postoperative complications (P=0.009), hardware failure (P=0.005), and infections (P=0.031) compared with those who underwent detethering. No differences were noted for intraoperative (P=0.059) or neurological (P=0.190) complications based on detethering status. Similarly, postoperative complications using the mCDS revealed that patients who were not detethered had higher rates of complications (P=0.017).

CONCLUSIONS

Although there were no significant differences between C-EOS patients with and without TSCS, this study underscores the importance of detethering in C-EOS patients with concurrent TSCS. Detethering significantly reduced the risk of postoperative complications, hardware failure, and infection after SDC with growing instrumentation or fusion. However, given that the not detethered group had a higher frequency of growth-friendly procedures, these findings should be interpreted with caution. These findings highlight the potential benefits of detethering in improving surgical outcomes for C-EOS patients undergoing SDC with growing instrumentation or fusion.

LEVEL OF EVIDENCE

III.

Concave Side Apical Control in Early Onset Scoliosis Managed with Growing Rods

Objective

To evaluate curve correctability, complications, and rate of growth following treatment.

Background

Distraction-founded techniques such as traditionally growing rods or magnetically controlled growing rods are the almost globally accepted management patterns for early onset scoliosis. However, periodic lengthening operations are still needed. Moreover, an MCGR is difficult to contour, and implant-associated problems are common. We developed concave side apical control of the growing rod in which an additional anchor site is inserted at the apex to enhance stability and assist in the adjustment of axial deformity.

Methods

Entirely skeletally immature early onset scoliosis (EOS) cases with a progressive curve of >40° and without bone or soft tissue weakness were appropriate for this study. Coronal Cobb angle, sagittal parameters, complications, spinal length, and reoperations were documented with at least a 3-year follow-up.

Results

In this study, 15 patients were involved. The mean age was 7 years. The mean preoperative Cobb angle was 48°, which postoperatively became 12° with the percentage of coronal correction reaching 75.73%. The mean Cobb angle degrees of correction were 39°. T1-S1 height increased by 10 mm/year. Postoperative complications occurred in two cases with single rod technique and rod breakage.

Conclusions

The concave side apical control of the growing rod seems to be a hopeful surgical procedure for the management of EOS. Curve correctability in patients was 60% and can be sustained for a minimum of 2 years. Reoperations and complications might not be constricted, but the complication frequency looks more reasonable than in the current systems.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ.

METHODS

An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups.

RESULTS

Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure.

CONCLUSION

The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery

PURPOSE

To establish expert consensus on various parameters that constitute elevated risk during spinal deformity surgery and potential preventative strategies that may minimize the risk of intraoperative neuromonitoring (IONM) events and postoperative neurological deficits.

METHODS

Through a series of surveys and a final virtual consensus meeting, the Delphi method was utilized to establish consensus among a group of expert spinal deformity surgeons. During iterative rounds of voting, participants were asked to express their agreement (strongly agree, agree, disagree, strongly disagree) to include items in a final set of guidelines. Consensus was defined as ≥ 80% agreement among participants. Near-consensus was ≥ 60% but < 80% agreement, equipoise was ≥ 20% but < 60%, and consensus to exclude was < 20%.

RESULTS

Fifteen of the 15 (100%) invited expert spinal deformity surgeons agreed to participate. There was consensus to include 22 determinants of high-risk (8 patient factors, 8 curve and spinal cord factors, and 6 surgical factors) and 21 preventative strategies (4 preoperative, 14 intraoperative, and 3 postoperative) in the final set of best practice guidelines.

CONCLUSION

A resource highlighting several salient clinical factors found in high-risk spinal deformity patients as well as strategies to prevent neurological events was successfully created through expert consensus. This is intended to serve as a reference for surgeons and other clinicians involved in the care of spinal deformity patients.

LEVEL OF EVIDENCE

Level V.

Depth Vision-Based Assessment of Bone Marrow Mesenchymal Stem Cell Differentiation Capacity in Patients with Congenital Scoliosis

Congenital scoliosis (CS) is a lateral curvature of one or more segments of the spine due to spinal dysplasia during fetal life. CS is clinically defined as a curvature of the spine >10° due to structural abnormalities of the vertebrae during the embryonic period. Its etiology is unknown, but recent studies suggest that it may be closely related to genetic factors, environmental factors, and developmental abnormalities. The induction methods and modern applications of bone marrow MSCs provide a reference for in-depth human research on the induction of differentiation of bone marrow MSCs into osteoblasts. In this paper, by reviewing and organizing the literature on bone marrow MSCs, we summarized and analyzed the biological properties and preparation of bone marrow MSCs, the methods of inducing osteoblasts, the applications in tissue engineering bone, the problems faced, and the future research directions and proposed a method to assess the differentiation ability of bone marrow MSCs in patients with congenital scoliosis based on depth visual characteristics and the change of the method. The method reveals and evaluates the multidirectional differentiation potential of bone marrow MSCs, which can be induced to differentiate into osteoblasts in vitro and can be used to construct bone tissue engineering scaffolds in vitro using tissue engineering techniques. Based on the properties of bone marrow MSCs, their application in congenital scoliosis patients for trauma repair, cell replacement therapy, hematopoietic support, and gene therapy is quite promising. It is necessary to carry out research on the mechanism of osteogenic differentiation of bone marrow MSCs to provide guidance and reference value for their induced differentiation into osteoblasts.

Diagnosis and treatment of congenital scoliosis

Background: Congenital scoliosis is caused by anomalies of the vertebra, such as hemivertebra or unsegmented bar, which result in asymmetric growth of the spine. The disruption of vertebra development during embryogenesis may be accompanied by other congenital multi-organ anomalies. The progression of the scoliotic curve may also hinder the development of other organs.Current Concepts: Hemivertebra excision and short spinal fusion have demonstrated favorable outcomes. However, the need for spinal growth and lung development has led to new treatment modalities. Growth-friendly surgeries, such as with a growing rod or vertical expandable rib-based distraction device, have demonstrated good results with curve correction while maintaining spinal growth. Although the outcome of conservative treatment for congenital scoliosis is questionable, casting may be effective as a “time-buying strategy” to delay the need for surgery.Discussion and Conclusion: It is essential to decide on a treatment plan considering the progression of the curve and growth of the spine and lungs through an individualized approach.