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Lau D, Kurland DB, Neifert S, Pahys J, Samdani A, Hwang S. Learning Curve Associated With Thoracoscopic Anterior Vertebral Body Tether and Double Anterior Vertebral Body Tether for Idiopathic Scoliosis: Analysis of Three Independent Surgeons. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01194. [PMID: 38888348 DOI: 10.1227/ons.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Anterior vertebral body tether (VBT) is a fusionless approach to treat idiopathic scoliosis, and surgeons are beginning to implement the technique into current practice. This study aims to evaluate the learning curve for single and double VBT. METHODS A retrospective review of 3 surgeons' first 40 single and 20 double VBT was performed. Skeletally immature patients with idiopathic scoliosis who underwent thoracic (single) or thoracolumbar (double) VBT were included. Thoracic VBT was done via video-assisted thoracoscopic surgery and lumbar VBT through a mini-open retroperitoneal approach. Primary outcomes of interest were operative time, radiation exposure, and radiographic correction. Pooled and individual-surgeon analyses were performed. RESULTS A total of 180 patients were included: 120 single and 60 double. Mean age was 12.7 years, and 87.8% were female. Mean segments tethered was 7.8 in single and 11.0 in double. Mean preoperative thoracic scoliosis was 51.5: single 50.5° and double 53.3°. Mean lumbar scoliosis was 36.4°: single 30.0° and double 49.0°. Average operating time was 276.2 minutes; double VBT was significantly longer (217.3 vs 394.0 minutes, P < .001). Mean blood loss was 198.5 mL, and mean fluoroscopy dose was 73.0 mGy. For single VBT, there was a decrease in operative time (283.3-174.8 minutes, P < .001) and fluoroscopy dose (70.1-53.5 mGy, P = .047) over time. Every 10 cases resulted in a 31.4 minute decrease in operative time (P < .001). There were no intraoperative complications. Single VBT resulted in 54.9% thoracic curve correction. Double VBT achieved 53.0% thoracic and 56.7% lumbar correction. There were no differences in curve correction across the learning curve. CONCLUSION VBT is viable fusionless surgical option for scoliosis. As expected, increased experience resulted in shorter operative time; the threshold for such improvement seems to be 10 cases. Importantly, adequate and consistent curve correction can be achieved at the start of the learning curve while mitigating complications.
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Affiliation(s)
- Darryl Lau
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - David B Kurland
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Sean Neifert
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Joshua Pahys
- Department of Neurosurgery, Shriners Children's Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amer Samdani
- Department of Neurosurgery, Shriners Children's Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven Hwang
- Department of Neurosurgery, Shriners Children's Philadelphia, Philadelphia, Pennsylvania, USA
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Alasadi H, Rajjoub R, Alasadi Y, Wilczek A, Lonner BS. Vertebral body tethering for adolescent idiopathic scoliosis: a review. Spine Deform 2024; 12:561-575. [PMID: 38285164 DOI: 10.1007/s43390-023-00806-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE Adolescent Idiopathic Scoliosis (AIS) remains the most common type of pediatric scoliosis, mostly affecting children between ages 10 and 18. Vertebral body tethering (VBT) offers a non-fusion alternative to the gold standard spinal fusion that permits flexibility and some growth within instrumented segments. This article will serve as a comprehensive literature review of the current state-of-the-art of VBT in relation to radiographic and clinical outcomes, complications, and the learning curve associated with the procedure. METHODS A systematic literature review was conducted on PubMed, Scopus, and Web of Science from April 2002 to December 2022. Studies were included if they discussed VBT and consisted of clinical studies in which a minimum 2-years follow-up was reported, and series that included anesthetic considerations, learning curve, and early operative morbidity. RESULTS Forty-nine studies spanning the period from April 2002 to December 2022 were reviewed. CONCLUSION This article illustrates the potential benefits and challenges of the surgical treatment of AIS with VBT and can serve as a basis for the further study and refinement of this technique ideally as a living document that will be updated regularly.
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Affiliation(s)
- Husni Alasadi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yazan Alasadi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley Wilczek
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Baron S Lonner
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Chief of Minimally Invasive Scoliosis Surgery and Pediatric Spine, Department of Orthopaedic Surgery, Mount Sinai Hospital, Icahn School of Medicine, 5 E 98th St., 4th Floor, New York, NY, 10029, USA.
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Sullivan MH, Jackson TJ, Milbrandt TA, Larson AN, Kepler CK, Sebastian AS. Evidence-based Indications for Vertebral Body Tethering in Spine Deformity. Clin Spine Surg 2024; 37:82-91. [PMID: 37684718 DOI: 10.1097/bsd.0000000000001521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 06/21/2023] [Indexed: 09/10/2023]
Abstract
Posterior spinal fusion has long been established as an effective treatment for the surgical management of spine deformity. However, interest in nonfusion options continues to grow. Vertebral body tethering is a nonfusion alternative that allows for the preservation of growth and flexibility of the spine. The purpose of this investigation is to provide a practical and relevant review of the literature on the current evidence-based indications for vertebral body tethering. Early results and short-term outcomes show promise for the first generation of this technology. At this time, patients should expect less predictable deformity correction and higher revision rates. Long-term studies are necessary to establish the durability of early results. In addition, further studies should aim to refine preoperative evaluation and patient selection as well as defining the benefits of motion preservation and its long-term effects on spine health to ensure optimal patient outcomes.
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Sullivan MH, Yu L, Schueler BA, Nassr A, Guerin J, Milbrandt TA, Larson AN. Radiation exposure in navigated techniques for AIS: is there a difference between pre-operative CT and intraoperative CT? Spine Deform 2024; 12:349-356. [PMID: 37870680 DOI: 10.1007/s43390-023-00772-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Utilization of navigation improves pedicle screw accuracy in adolescent idiopathic scoliosis (AIS). Our center switched from intraoperative CT (ICT) to an optical navigation system that utilizes pre-operative CT (PCT). We aim to evaluate the radiation dose and operative time for low-dose ICT compared to standard and low-dose PCT used for optical navigation in AIS patients undergoing posterior spinal fusion. METHODS A single-center matched-control cohort study of 38 patients was conducted. Nineteen patients underwent ICT navigation (O-arm) and were matched by sex, age, and weight to 19 patients who underwent PCT for use with an optical-guided navigation (7D, Seaspine). A total of 418 levels were instrumented and reviewed. PCT was either a standard dose (N = 7) or a low dose (N = 12). The mean volume CT dose index, dose-length product, overall effective dose (ED), ED per level instrumented, and operative time per level were compared. RESULTS ED per level instrumented was 0.061 ± 0.029 mSv in low-dose PCT and 0.14 ± 0.05 mSv in low-dose ICT (p < 0.0001). ED per level instrumented was significantly higher in standard PCT (1.46 ± 0.39 vs. 0.14 ± 0.03 mSv; p < 0.0001). Mean operative time per level was 31 ± 7 min for ICT and 33 ± 3 min for PCT (p = 0.628). CONCLUSION Low-dose PCT resulted in 0.70 mSv exposure per case and 31 min per level, standard-dose was 16.95 mSv, while ICT resulted in 1.34-1.62 mSv and a similar operative time. Use of a standard-dose PCT involves radiation exposure about 9 times higher than ICT and 23 times higher than low-dose PCT per level instrumented. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Mikaela H Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lifeng Yu
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Julie Guerin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Todd A Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Metaizeau JD, Denis D. Posterior Vertebral Body Tethering: A Preliminary Study of a New Technique to Correct Lenke 5C Lumbar Curves in Adolescent Idiopathic Scoliosis. CHILDREN (BASEL, SWITZERLAND) 2024; 11:157. [PMID: 38397271 PMCID: PMC10887278 DOI: 10.3390/children11020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/21/2023] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Vertebral body tethering has been approved for adolescent scoliosis correction. The usual approach is anterior, which is relatively easy for the thoracic spine, but becomes much more challenging for the lumbar curves, with a higher rate of complications. The purpose of this study was to describe and evaluate the first results of a new posterior vertebral body tethering (PVBT) technique using pedicle screws through a posterolateral Wiltse approach. Twenty-two patients with 5C idiopathic scoliosis (Lenke classification) were included in this retrospective study, with a follow up of 2 years after surgery. The lumbar and thoracic curves were measured pre-operatively (POS), at first standing (FS) and at 2 years (2Y). Complications were also analysed. A significant improvement of 30.7° was observed for lumbar curve magnitude between POS and 2Y. Both the thoracic kyphosis and the lumbar lordosis remained stable. Thirteen complications were noted: three led to posterior arthrodesis, three needed a revision with a good outcome, and the seven others (overcorrections, screw breakage or pull-out) achieved a good result. PVBT seems an effective technique for the management of type 5 C adolescent idiopathic scoliosis. The complication rate seems high but is probably secondary to the learning curve of this new technic as it concerns only the first half of the patients.
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Welborn MC, Blakemore L, Handford C, Miyanji F, Parent S, El-Hawary R. Thoracolumbar curve behavior after selective thoracic anterior vertebral body tethering in Lenke 1A vs Lenke 1C curve patterns. Spine Deform 2023; 11:897-907. [PMID: 36892744 PMCID: PMC9996552 DOI: 10.1007/s43390-023-00664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/04/2023] [Indexed: 03/10/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective database. OBJECTIVES The purpose of this study is to evaluate changes in the thoracic and thoracolumbar/lumbar curves and truncal balance in patients treated with selective thoracic anterior vertebral body tethering (AVBT) with Lenke 1A vs 1C curves at a minimum of 2 years follow-up. Lenke 1C curves treated with selective thoracic AVBT demonstrate equivalent thoracic curve correction and reduced thoracolumbar/lumbar curve correction compared to Lenke 1A curves. Additionally, at the most recent follow-up, both curve types demonstrate comparable coronal alignment at C7 and the lumbar curve apex, though 1C curves have better alignment at the lowest instrumented vertebra (LIV). Rates of revision surgery are equivalent between the two groups. METHODS A matched cohort of 43 Risser 0-1, Sanders Maturity Scale (SMS) 2-5 AIS pts with Lenke 1A (1A group)and 19 pts with Lenke 1C curves (1C group) treated with selective thoracic AVBT and a minimum of 2-year follow-up were included. Digital radiographic software was used to assess Cobb angle and coronal alignment on preoperative, postoperative and subsequent follow-up radiographs. Coronal alignment was assessed by measuring the distance from the center sacral vertical line (CSVL) to the midpoint of the LIV, apical vertebra for thoracic and lumbar curves and C7. RESULTS There was no difference in the thoracic curve measured preoperatively, at first erect, pre-rupture or at the most recent follow-up, nor was there a significant difference in C7 alignment (p = 0.057) or apical thoracic alignment (p = 0.272) between the 1A and 1C groups. Thoracolumbar/lumbar curves were smaller in the 1A group at all-time points. However, there was no significant difference between the percent correction between the two groups thoracic (p = 0.453) and thoracolumbar/lumbar (p = 0.105). The Lenke 1C curves had improved coronal translational alignment of the LIV at the most recent follow-up p = 0.0355. At the most recent follow-up the number of patients considered to have successful curve correction (Cobb angle correction of both the thoracic and thoracolumbar//lumbar curves to ≤ 35 degrees), was equivalent between Lenke 1A and Lenke 1C curves (p = 0.80). There was also no difference in the rate of revision surgery between the two groups (p = 0.546). CONCLUSION This is the first study to compare the impact of lumbar curve modifier type on outcomes in thoracic AVBT. We found that Lenke 1C curves treated with selective thoracic AVBT demonstrate less absolute correction of the thoracolumbar/lumbar curve at all time points but have equivalent percent correction of the thoracic and thoracolumbar/lumbar curves. The two groups have equivalent alignment at C7 and the thoracic curve apex, and Lenke 1C curves have better alignment at the LIV at the most recent follow-up. Furthermore, they have an equivalent rate of revision surgery compared to Lenke 1A curves. Selective thoracic AVBT is a viable option for selective Lenke 1C curves, but despite equivalent correction of the thoracic curve, there is less correction of the thoracolumbar/lumbar curve at all-time points.
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Affiliation(s)
| | - Laurel Blakemore
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- CEO, Pediatric Specialists of Virginia, Fairfax, VA, USA
| | - Cameron Handford
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Orthopaedics, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Firoz Miyanji
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Orthopedics, British Columbia Children's Hospital, Vancouver, Canada
| | - Stefan Parent
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Département de Chirurgie, Sainte-Justine University Hospital Center, Université de Montréal, 3175 Côte-Sainte-Catherine, Montreal, Canada
| | - Ron El-Hawary
- , 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Department of Surgery, IWK Health Centre Dalhousie University, Halifax, Canada
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Trobisch PD, Castelein R, Da Paz S. Radiographic outcome after vertebral body tethering of the lumbar spine. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07740-2. [PMID: 37133761 DOI: 10.1007/s00586-023-07740-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/21/2023] [Accepted: 04/22/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Multiple studies have analyzed the outcome after thoracic Vertebral Body Tethering (VBT). The results seem reproducible with most studies reporting coronal correction rates around 50% and a tether breakage rate near 20% at two years follow-up. There is a paucity of data on lumbar VBT, and no study has yet analyzed the radiographic outcome after lumbar VBT in a double tether technique at two years follow-up, which was the aim of this study. METHODS This is a retrospective, single surgeons' data analysis of all consecutive immature patients who have had VBT of the lumbar spine (to L3 or L4) between January 2019 and September 2020. Primary interest focused on coronal curve correction at two years post-operatively. Suspected tether breakages were analyzed separately and defined as an angular change of more than 5° between two adjacent screws. RESULTS Forty-one patients were eligible for this study and 35 (85%) had complete two-year follow-up data. Average age at surgery was 14.3 years. All patients had a Sanders stage of 7 or below. Average curve correction for thoracolumbar/lumbar curves at two years follow-up was 50%. 90% of patients had at least one level with a suspected tether breakage. No patient required a revision surgery within two years from surgery but two patients were surgically revised after two years. CONCLUSION VBT in the lumbar spine resulted in 50% coronal curve correction two years post-operatively despite a tether breakage in 90% of patients.
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Affiliation(s)
- Per D Trobisch
- Eifelklinik St. Brigida, Spine Surgery, Kammerbruchstr. 8, 52152, Simmerath, Germany.
| | - Rene Castelein
- University Medical Center Utrecht, Heidelberglaan 100, 3584 CZ, Utrecht, The Netherlands
| | - Stephanie Da Paz
- Eifelklinik St. Brigida, Spine Surgery, Kammerbruchstr. 8, 52152, Simmerath, Germany
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Haber L, Starring H, Newcomb N, Larson AN, Desai B, Roybal J, Fant W, Milbrandt T, Boeyer M, Marks M, Newton P, Samdani A, Miyanji F, Hoernschemeyer D. Drain options after vertebral body tethering. Spine Deform 2023; 11:367-372. [PMID: 36219390 DOI: 10.1007/s43390-022-00595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/17/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Since the introduction of vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS), a variety of post-operative chest drainage systems have been utilized. Most surgeons use formal chest tubes with a Pleur-evac, while others use smaller bulb suction drains (e.g., Blake drain). In addition, some centers utilize pleural closure. This multicenter study evaluates whether drain type or pleural closure impact perioperative and 90 day complication rates. METHODS A retrospective review was conducted from three institutions with established VBT programs. All preoperative, perioperative and 90 day postoperative data were analyzed to determine differences in outcomes between three cohorts: standard chest tube (SCT), standard chest tube with pleural closure (SCTPC) and 10 French Bulb drain (BD). RESULTS 104 patients were identified for the study. 57 SCT, 25 SCTPC and 22 BD. All data are listed in order: SCT, SCTPC, BD. Length of stay (3.7, 4.3, 3.0 days) was less in the BD group (p = 0.009); post-operative drainage (460, 761, 485 cc) was less in the SCT and BD groups (p < 0.001); intra-operative estimated blood loss (EBL) 146, 382, 64 cc was less in the BD group (p < 0.001). No significant difference in number of days (3.2, 3.2, and 2.8 days) drainage was in place, groups (p = 0.311). Complication profile was similar with 2 chest tube reinsertions in the SCT and one hemothorax that resolved spontaneously in BD group. CONCLUSIONS In this series of 104 patients, SCT, SCTPC and BD all had a similar safety profile. All three methods were safe and effective in managing post-operative chest drainage after thoracic VBT. In the series, BD group had significantly shorter LOS than both groups that used chest tubes. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Lawrence Haber
- Department of Orthopaedic Surgery, Ochsner Clinic Foundation, 1415 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Hunter Starring
- Department of Orthopaedic Surgery, Ochsner Clinic Foundation, 1415 Jefferson Hwy, New Orleans, LA, 70121, USA.
| | - Nicholas Newcomb
- University of Queensland-Ochsner Clinical School, New Orleans, LA, USA
| | - A Noelle Larson
- Department of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bhumit Desai
- Department of Orthopaedic Surgery, Ochsner Clinic Foundation, 1415 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Jessica Roybal
- Department of Pediatric Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Whitney Fant
- Department of Orthopaedic Surgery, Ochsner Clinic Foundation, 1415 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Todd Milbrandt
- Department of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Melanie Boeyer
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA
| | | | - Peter Newton
- Division Orthopedics and Scoliosis, Rady Children's Hospital, San Diego, CA, USA
| | - Amer Samdani
- Department of Pediatric Orthopedic Surgery, Shriners Children's Philadelphia, Philadelphia, PA, USA
| | - Firoz Miyanji
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Dan Hoernschemeyer
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA
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Soini V, Raitio A, Helenius I, Helenius L, Syvänen J. A retrospective cohort study of bleeding characteristics and hidden blood loss after segmental pedicle screw instrumentation in neuromuscular scoliosis as compared with adolescent idiopathic scoliosis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100190. [PMID: 36561891 PMCID: PMC9763505 DOI: 10.1016/j.xnsj.2022.100190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022]
Abstract
Background Progressive scoliosis in neuromuscular patients often requires a long instrumented spinal fusion. Previous studies have shown larger intraoperative blood loss in these patients than those with adolescent idiopathic scoliosis (AIS), but the total blood loss composed of visible and hidden blood loss has not been described in this patient population. The aim of our study was to investigate the bleeding characteristics and hidden blood loss related to spinal fusion in neuromuscular scoliosis (NMS) as compared to AIS patients. Methods A retrospective cohort study with prospective data collection of NMS patients undergoing segmental pedicle screw instrumentation at a university hospital between 2009 and 2021. A comprehensive statistical analysis was performed regarding intra- and postoperative blood loss compared to patient characteristics such as age and diagnosis. Hidden blood loss was estimated and compared to the total blood loss. We standardized amount of bleeding with patient weight and fusion level for further analysis. Consecutive AIS patients served as a control population. Eighty-one consecutive patients with NMS (mean age 15.2 years, 37 females) were included and their bleeding characters were compared with 199 AIS patients (mean age 15.8 years, 143 females). The primary outcome was total blood loss including intraoperative, 24-hour drain output and hidden blood loss. Secondary outcome measures included requirement for blood transfusion. Results Neuromuscular patients had a significantly larger total blood loss with mean values of 1914 mL in the NMS and 1357 mL in the AIS groups, respectively (p<0.001). The hidden blood loss was also significantly larger in NMS than in AIS group (566 ± 533 mL vs. 398 ±411 mL, p=0.0332). Neuromuscular scoliosis was also associated with significantly greater weight and levels of fused adjusted intraoperative bleeding (1.79 ml/kg/fused level in NMS vs. 0.87 ml/kg/fused level in AIS vs. p< 0.0001) and hidden blood loss (1.00 ml/kg/levels fused vs. 0.65 ml/kg/fused levels, p=0.053). NMS diagnosis was also a risk factor for greater hidden blood loss in multivariable analysis (p=0.0011). 24-hour drain output was similar in the NMS and AIS groups. Male gender was a risk factor for greater hidden blood loss in the NMS group (p=0.0429). Fifty-nine (73%) NMS and 27 (14%) AIS patients received allogenic red blood cell infusions perioperatively (p<0.001). Conclusions Hidden blood loss constitutes one-third of total blood loss in children undergoing segmental pedicle screw instrumentation for neuromuscular scoliosis. Hidden blood loss is significantly greater in the neuromuscular as compared with idiopathic scoliosis. Hidden blood loss should be considered in the perioperative management of NMS.
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Affiliation(s)
- Venla Soini
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Department of Surgery, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Vaasa, Finland
| | - Arimatias Raitio
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki, and Helsinki University Hospital, Finland,Department of Paediatric Orthopaedic Surgery, Helsinki New Children's Hospital, Helsinki, Finland
| | - Linda Helenius
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Johanna Syvänen
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Corresponding author at: Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, FI-20520 Turku, Finland.
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Zhu F, Qiu X, Liu S, Man-Chee Cheung K. Minimum 3-year experience with vertebral body tethering for treating scoliosis: A systematic review and single-arm meta-analysis. J Orthop Surg (Hong Kong) 2022; 30:10225536221137753. [PMID: 36420934 DOI: 10.1177/10225536221137753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Over the past 12 years, vertebral body tethering (VBT) has been gradually promoted for treating scoliosis, but there are few published studies, with only short-term follow-up. This study aimed to systematically review VBT efficacy and safety for treating scoliosis. METHODS PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies on VBT treatment of scoliosis published up to November 2021. Two researchers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Data on clinical efficacy, unplanned reoperations, and complications were extracted. The meta-analysis was performed with R 4.1.0. RESULTS Twenty-six studies involving 1045 patients were included in the meta-analysis. The correction rate of major curve immediately post-operation was 46.6% ± 13.8% (16%-69%) and that at final follow-up was 53.2% ± 17.9% (16%-79%). The single-arm meta-analysis results of all included studies showed that VBT was effective in general. The overall clinical success rate was 73.02% (95% confidence interval [CI]: 68.31%-78.05%). The pooled overall unplanned reoperation rate was 8.66% (95% CI: 5.53%-13.31%). The overall incidence rate of complications was 36.8% (95% CI: 23.9%-49.7%). The subgroup analysis based on follow-up time indicated that patients with follow-up time >36 months had increased clinical success rate, unplanned reoperation rate, and incidence rate of complications compared with those with <36 months' follow-up time. The preliminary results showed that after 36 months of follow-up, only 7.17% (95% CI: 4.81%-10.55%) of patients required posterior spinal fusion (PSF) surgery and nearly 93% of patients avoided spinal fusion surgeries. CONCLUSIONS The current evidence from at least 3-year follow-up in different countries indicates that VBT is an effective surgical approach for treating scoliosis, with 73.88% of patients achieving clinical success. Nevertheless, about one in seven patients (15.8%) required unplanned reoperations, but only 7.17% required PSF. About half (52.17%) of the patients experienced complications. Due to the limitation of the study number and quality, our conclusion may be biased and requires verification by further studies with longer follow-up times.
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Affiliation(s)
- Feng Zhu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
| | - Xin Qiu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
| | - Shunan Liu
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Kenneth Man-Chee Cheung
- Department of Spinal Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
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Kolz JM, Neal KM. Hidden blood loss in adolescent idiopathic scoliosis surgery. Orthop Traumatol Surg Res 2022; 108:103216. [PMID: 35093565 DOI: 10.1016/j.otsr.2022.103216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS) have higher blood loss than other pediatric orthopedic surgeries. There is a paucity of literature estimating the hidden blood loss (HBL) in patients with AIS undergoing PSF. The purpose of this study was to compare intraoperative and postoperative estimated blood loss (EBL) in patients undergoing PSF for AIS to determine HBL. HYPOTHESIS With contemporary blood loss prevention strategies, HBL will be higher than intraoperative EBL. MATERIAL AND METHODS Over a 3-year period, 67 patients with preoperative and postoperative hemoglobin (Hgb) measurements undergoing PSF for AIS were evaluated. Intraoperative EBL was estimated using a volumetric method and recorded by a perfusionist managing a cell saver machine. Total perioperative EBL was estimated using the validated formula: EBL=weight (kg)×age sex factor×(preoperative Hgb - postoperative Hgb)/preoperative Hgb. HBL was calculated as the total perioperative EBL minus the intraoperative EBL. RESULTS Calculated total EBL was higher than intraoperative EBL (771±256mL vs. 110±115mL, p<0.001). Mean HBL after wound closure was 660±400mL. Patients 14 years or greater (p=0.03), with a BMI≥25kg/m2(p=0.02) and with surgical times over 3.5hours (p=0.05) had increased HBL. Multivariate analysis determined BMI≥25kg/m2 (OR 9.91; CI, 1.01-104.26; p=0.05) was associated with increased HBL. Allogenic blood transfusion was rare (4%) and associated with increased HBL (897±112mL vs. 540±402mL, p=0.05). DISCUSSION For patients undergoing PSF for AIS there is more HBL after wound closure than intraoperative blood loss. This HBL is higher in older patients who undergo longer operations and have a BMI≥25kg/m2. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| | - Kevin M Neal
- Department of Pediatric Orthopedic Surgery, Nemours, Jacksonville, Florida, USA
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Vertebral Body Tethering: Indications, Surgical Technique, and a Systematic Review of Published Results. J Clin Med 2022; 11:jcm11092576. [PMID: 35566702 PMCID: PMC9099651 DOI: 10.3390/jcm11092576] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 02/01/2023] Open
Abstract
Vertebral body tethering (VBT) represents a new surgical technique to correct idiopathic scoliosis using an anterior approach, spinal instrumentation with vertebral body screws, and a cable compressing the convexity of the curve. According to the Hueter-Volkmann principle, compression reduces and distraction increases growth on the growth plates. VBT was designed to modulate spinal growth of vertebral bodies and hence, the term ‘growth modulation’ has also been used. This review describes the indications and surgical technique of VBT. Further, a systematic review of published studies was conducted to critically evaluate the results and complications of this technique. In a total of 23 included studies on 843 patients, the preoperative main thoracic curve corrected from 49 to 23 degrees in a minimum 2 year follow-up. The complication rate of VBT was 18%. The results showed that 15% of VBT patients required reoperations for pulmonary or tether-related issues (10%) and less than 5% required conversion to spinal fusion. While the reported median-term results of VBT appear promising, long-term results of this technique are currently lacking.
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Larson AN. Innovation With Ethics in Pediatric Orthopaedics. J Pediatr Orthop 2022; 42:S39-S43. [PMID: 35405701 DOI: 10.1097/bpo.0000000000002099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgeons should thoughtfully consider whether to introduce a new procedure into their practice. Considerations include the severity of the condition, potential risk of harm, treatment alternatives, patient population, ability to appropriately consent patient/families, and available clinical and institutional resources as well as published evidence and regulatory status. Whenever possible, new procedures should be standardized, studied, and reported upon so that the greater community can learn from experience and refine the indications to minimize risks for future patients. Small scale innovation can readily be introduced into practice. Surgeons should always strive to systemically study new procedures so as to be able to assess benefits and effects.
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Affiliation(s)
- A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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