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Ogura Y, Larson AN, Blakemore L, Miyanji F, Andras LM, Parent S, El-Hawary R, Welborn MC. Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis. Spine Deform 2024; 12:1025-1031. [PMID: 38556582 DOI: 10.1007/s43390-024-00855-6] [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: 09/13/2023] [Accepted: 02/26/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT. METHODS Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD. RESULTS Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0. CONCLUSION CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.
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Affiliation(s)
- Yoji Ogura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - A Noelle Larson
- Department of Pediatric Orthopedic Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Laurel Blakemore
- Department of Pediatric Orthopaedic Surgery, Pediatric Specialists of Virginia, Merrifield, VA, USA
| | - Firoz Miyanji
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay M Andras
- Department of Pediatric Orthopedic Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Stefan Parent
- Department of Orthopaedic Surgery, Hospital Ste-Justine (HSJ), Montreal, QC, Canada
| | - Ron El-Hawary
- Department of Orthopaedic Surgery, IWK Health Centre, Halifax, NS, Canada
| | - Michelle Cameron Welborn
- Shriners Hospital for Children Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA.
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Ohrt-Nissen S, Heegaard M, Andersen T, Gehrchen M, Dahl B, Tøndevold N. Bracing in severe skeletally immature adolescent idiopathic scoliosis: does a holding strategy change the surgical plan? 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 2024; 33:2457-2462. [PMID: 38607405 DOI: 10.1007/s00586-024-08246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/28/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE The purpose of the study was to assess the changes in flexibility during night-time bracing in skeletally immature adolescent idiopathic scoliosis (AIS) with curves in the surgical range. MATERIALS AND METHODS We included a consecutive cohort of 89 AIS patients with curves ≥ 45° and an estimated growth potential. All patients were eventually treated with fusion surgery, and all patients had side-bending radiographs prior to both bracing and surgery. Curves were classified as structural or non-structural curves according to Lenke at both timepoints. RESULTS The main curve progressed by a mean of 12 ± 10° and the secondary curve by 8 ± 8°. Flexibility of the main curve decreased from 50 ± 19% to 44 ± 19% (p = 0.001) and the underlying curve from 85 ± 21% to 77 ± 22% (p = 0.005). In 69 patients (79%), the Lenke category did not progress during bracing. In 14 patients (15%), the progression in Lenke type occurred in the thoracic region (i.e., Lenke type 1 to type 2), while six patients (7%) progressed in the lumbar region (i.e., type 1 to type 3). In the 69 patients that did not progress, we found that the last touched vertebra moved distally by one or two levels in 26 patients. CONCLUSIONS This is the first study to describe that curve flexibility decreases during bracing in severe AIS. However, this had only a modest impact on the surgical strategy. Bracing as a holding strategy can be applied, but the risk of losing flexibility in the lumbar spine should be outweighed against the risks of premature fusion surgery.
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Affiliation(s)
- Søren Ohrt-Nissen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark.
| | - M Heegaard
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - Thomas Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - M Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - B Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
| | - N Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet University of Copenhagen, Inge Lehmansvej 6, 2100, Cph E, Copenhagen, Denmark
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Grabala P. Minimally Invasive Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis-A Surgical Technique Video. J Pers Med 2024; 14:548. [PMID: 38929769 PMCID: PMC11205236 DOI: 10.3390/jpm14060548] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Spinal deformities in children and adolescents can be easily divided into those occurring and diagnosed before the age of 10-early-onset scoliosis-and those occurring and diagnosed after the age of 10-late-onset scoliosis. When the curvature continues to progress and exceeds a Cobb angle of more than 60-65 degrees, surgical treatment should be considered. The most common treatment procedure for EOS is the surgical correction of the deformity using standard growing rods (SGRs), and in the case of congenital defects with additional hemivertebrae, it is the resection of the hemivertebra and short fusion. Minimally invasive controlled growing rods (MICGRs) need to be distracted every 6-9 months through a minimally invasive approach that involves sedation and neuromonitoring to obtain the best possible correction while minimizing complications. The aim of our study is to present a less-invasive surgical technique for MICGR implantation based on a two-case presentation-early-onset idiopathic scoliosis and congenital kyphosis. The surgical technique is the less-invasive percutaneous and subfascial implantation of MICGRs without long incisions in the back. CONCLUSIONS The use of MICGRs is an alternative and safe surgical technique for patients undergoing surgical treatment for EOS. Without the risk of metallosis, like in other implant systems, and the need for replacement after 2 years of use, like in using magnetically controlled growing rods (MCGRs), the MICGR system can be used as a less-invasive procedure, allowing for the avoidance of many periodic invasive procedures in children with a wider opening of the spine (like in using standard growing rods), minimizing the number of planned hospitalizations, reducing the length of hospital stays, and reducing the physical and mental burdens on young patients, parents, and families.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, Medical University of Bialystok, Medical University of Bialystok Children’s Clinical Hospital, ul. Waszyngtona 17, 15-274 Bialystok, Poland;
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Department of Neurosurgery with Department of Interventional Neurology, Medical University of Bialystok, Medical University of Bialystok Clinical Hospital, ul. M. Sklodowskiej-Curie 24A, 15-276 Balystok, Poland
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Tsirikos AI, Ahuja K, Khan M. Minimally Invasive Surgery for Adolescent Idiopathic Scoliosis: A Systematic Review. J Clin Med 2024; 13:2013. [PMID: 38610778 PMCID: PMC11012693 DOI: 10.3390/jcm13072013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Minimally invasive surgical (MIS) techniques have gained popularity as a safe and effective alternative to open surgery for degenerative, traumatic, and metastatic spinal pathologies. In adolescent idiopathic scoliosis, MIS techniques comprise anterior thoracoscopic surgery (ATS), posterior minimally invasive surgery (PMIS), and vertebral body tethering (VBT). In the current systematic review, the authors collected and analyzed data from the available literature on MIS techniques in AIS. Methods: The articles were shortlisted after a thorough electronic and manual database search through PubMed, EMBASE, and Google Scholar. Results: The authors included 43 studies for the review; 14 described the outcomes with ATS, 13 with PMIS, and 16 with VBT. Conclusions: While the efficacy of the ATS approach is well-established in terms of comparable coronal and sagittal correction to posterior spinal fusion, the current use of ATS for instrumented fusion has become less popular due to a steep learning curve, high pulmonary and vascular complication rates, implant failures, and increased non-union rates. PMIS is an effective alternative to the standard open posterior spinal fusion, with a steep learning curve and longer surgical time being potential disadvantages. The current evidence, albeit limited, suggests that VBT is an attractive procedure that merits consideration in terms of radiological correction and clinical outcomes, but it has a high complication and re-operation rate, while the most appropriate indications and long-term outcomes of this technique remain unclear.
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Affiliation(s)
- Athanasios I. Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Children and Young People, Edinburgh EH16 4TJ, UK; (K.A.); (M.K.)
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Mulford KL, Regan C, Nolte CP, Pinter ZW, Milbrandt TA, Larson AN. Automated measurements of interscrew angles in vertebral body tethering patients with deep learning. Spine J 2024; 24:333-339. [PMID: 37774982 DOI: 10.1016/j.spinee.2023.09.011] [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: 04/15/2023] [Revised: 09/10/2023] [Accepted: 09/16/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND CONTEXT Vertebral body tethering is the most popular nonfusion treatment for adolescent idiopathic scoliosis. The effect of the tether cord on the spine can be segmentally assessed by comparing the angle between two adjacent screws (interscrew angle) over time. Tether breakage has historically been assessed radiographically by a change in adjacent interscrew angle by greater than 5° between two sets of imaging. A threshold for growth modulation has not yet been established in the literature. These angle measurements are time consuming and prone to interobserver variability. PURPOSE The purpose of this study was to develop an automated deep learning algorithm for measuring the interscrew angle following VBT surgery. STUDY DESIGN/SETTING Single institution analysis of medical images. PATIENT SAMPLE We analyzed 229 standing or bending AP or PA radiographs from 100 patients who had undergone VBT at our institution. OUTCOME MEASURES Physiologic Measures: An image processing algorithm was used to measure interscrew angles. METHODS A total of 229 standing or bending AP or PA radiographs from 100 VBT patients with vertebral body tethers were identified. Vertebral body screws were segmented by hand for all images and interscrew angles measured manually for 60 of the included images. A U-Net deep learning model was developed to automatically segment the vertebral body screws. Screw label maps were used to develop and tune an image processing algorithm which measures interscrew angles. Finally, the completed model and algorithm pipeline was tested on a 30-image test set. Dice score and absolute error were used to measure performance. RESULTS Inter- and Intra-rater reliability for manual angle measurements were assessed with ICC and were both 0.99. The segmentation model Dice score against manually segmented ground truth across the 30-image test set was 0.96. The average interscrew angle absolute error between the algorithm and manually measured ground truth was 0.66° and ranged from 0° to 2.67° in non-overlapping screws (N=206). The primary modes of failure for the model were overlapping screws on a right thoracic/left lumbar construct with two screws in one vertebra and overexposed images. An algorithm step which determines whether an overlapping screw was present correctly identified all overlapping screws, with no false positives. CONCLUSION We developed and validated an algorithm which measures interscrew angles for radiographs of vertebral body tether patients with an accuracy of within 1° for the majority of interscrew angles. The algorithm can process five images per second on a standard computer, leading to substantial time savings. This algorithm may be used for rapid processing of large radiographic databases of tether patients and could enable more rigorous definitions of growth modulation and cord breakage to be established.
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Affiliation(s)
- Kellen L Mulford
- Orthopedic Surgery Artificial Intelligence Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Christina Regan
- Orthopedic Surgery Artificial Intelligence Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Charles P Nolte
- Orthopedic Surgery Artificial Intelligence Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Zachariah W Pinter
- Orthopedic Surgery Artificial Intelligence Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Todd A Milbrandt
- Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - A Noelle Larson
- Orthopedic Surgery Artificial Intelligence Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA; Mayo Clinic Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
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Nicolini LF, Oliveira RC, Ribeiro M, Stoffel M, Markert B, Kobbe P, Hildebrand F, Trobisch P, Simões MS, de Mello Roesler CR, Fancello EA. Tether pre-tension within vertebral body tethering reduces motion of the spine and influences coupled motion: a finite element analysis. Comput Biol Med 2024; 169:107851. [PMID: 38113683 DOI: 10.1016/j.compbiomed.2023.107851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023]
Abstract
Anterior Vertebral Body Tethering (VBT) is a novel fusionless treatment option for selected adolescent idiopathic scoliosis patients which is gaining widespread interest. The primary objective of this study is to investigate the effects of tether pre-tension within VBT on the biomechanics of the spine including sagittal and transverse parameters as well as primary motion, coupled motion, and stresses acting on the L2 superior endplate. For that purpose, we used a calibrated and validated Finite Element model of the L1-L2 spine. The VBT instrumentation was inserted on the left side of the L1-L2 segment with different cord pre-tensions and submitted to an external pure moment of 6 Nm in different directions. The range of motion (ROM) for the instrumented spine was measured from the initial post-VBT position. The magnitudes of the ROM of the native spine and VBT-instrumented with pre-tensions of 100 N, 200 N, and 300 N were, respectively, 3.29°, 2.35°, 1.90° and 1.61° in extension, 3.30°, 3.46°, 2.79°, and 2.17° in flexion, 2.11°, 1.67°, 1.33° and 1.06° in right axial rotation, and 2.10°, 1.88°, 1.48° and 1.16° in left axial rotation. During flexion-extension, an insignificant coupled lateral bending motion was observed in the native spine. However, VBT instrumentation with pre-tensions of 100 N, 200 N, and 300 N generated coupled right lateral bending of 0.85°, 0.81°, and 0.71° during extension and coupled left lateral bending of 0.32°, 0.24°, and 0.19° during flexion, respectively. During lateral bending, a coupled extension motion of 0.33-0.40° is observed in the native spine, but VBT instrumentation with pre-tensions of 100 N, 200 N, and 300 N generates coupled flexion of 0.67°, 0.58°, and 0.42° during left (side of the implant) lateral bending and coupled extension of 1.28°, 1.07°, and 0.87° during right lateral bending, respectively. Therefore, vertebral body tethering generates coupled motion. Tether pre-tension within vertebral body tethering reduces the motion of the spine.
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Affiliation(s)
- Luis Fernando Nicolini
- Group of Analysis and Mechanical Design - GRANTE, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil; Mechanical and Aerospace Technology Laboratory (NUMAE), Dep. of Mechanical Engineering, Federal University of Santa Maria, Brazil.
| | - Rafael Carreira Oliveira
- Group of Analysis and Mechanical Design - GRANTE, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil
| | - Marx Ribeiro
- Group of Analysis and Mechanical Design - GRANTE, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil; Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Marcus Stoffel
- Institute of General Mechanics (IAM), RWTH Aachen University, Germany
| | - Bernd Markert
- Institute of General Mechanics (IAM), RWTH Aachen University, Germany
| | - Philipp Kobbe
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | | | - Marcelo Simoni Simões
- Biomechanical Engineering Laboratory - LEBm, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil
| | - Carlos Rodrigo de Mello Roesler
- Group of Analysis and Mechanical Design - GRANTE, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil; Biomechanical Engineering Laboratory - LEBm, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil
| | - Eduardo Alberto Fancello
- Group of Analysis and Mechanical Design - GRANTE, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil; Biomechanical Engineering Laboratory - LEBm, Dep. of Mechanical Engineering, Federal University of Santa Catarina, Brazil
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