Fusionless surgery for scoliosis: 2-17 year radiographic and clinical follow-up

Is Minimally Invasive Bipolar Technique a Better Alternative to Long Fusion for Adult Neuromuscular Scoliosis?

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To report the results for an alternative technique based on minimally invasive fusion-less surgery. This approach is original in that it corrects deformities by proximal and distal fixation, with reliable pelvic fixation through the use of iliosacral screws on osteoporotic bones.

METHODS

Adult cerebral palsy patients requiring spinal correction surgery were included prospectively between 2015 and 2019. The technique involved the use of a double-rod construct anchored proximally by four clawed hooks and distally by iliosacral screws, in a minimally invasive approach. Cobb angle and pelvic obliquity were measured before and after initial surgery and at final follow-up. Complications and functional results were reviewed. This group (P) was compared with a second group (R) of patients who underwent surgery between 2005 and 2015, for whom data were collected retrospectively.

RESULTS

Thirty-one patients were included in group P, and 15 in group R. The two groups were comparable for demographic data and deformity. At most recent follow-up (3 years for group P [2-6] and 5 years for group R [2-16]), neither correction nor surgical complications differed between the two groups. However, group P had 50% less blood loss and a lower medical complication rate than group R.

CONCLUSIONS

Our results confirm the effectiveness of this minimally invasive technique for neuromuscular scoliosis in adults. The results were similar to those obtained with the usual techniques, but with fewer medical complications. Confirmation of these results is now required for a longer follow-up period.

Neurofibromatosis Type 1 with Severe Dystrophic Kyphosis: Surgical Treatment and Prognostic Analysis of 27 Patients

OBJECTIVE

The aim of the present study was to explore the surgical treatment and prognosis of 27 cases of neurofibromatosis type 1 with severe dystrophic kyphosis.

METHODS

We performed surgical treatment for scoliosis and kyphosis caused by dystrophic curves at Peking Union Medical College Hospital, Beijing, China from December 2015 to December 2017. The study included 21 patients with moderate to severe kyphosis, 12 males and 9 females, with an average age of 14.95 ± 6.05 years. All patients had kyphosis angles greater than 70° and had more than four skeletal developmental defects. A total of 6 patients with severe kyphosis, 2 males and 4 females, with an average age of 12.5 years, had more than five skeletal developmental defects with a kyphosis angle greater than 90° or a lumbar kyphosis angle greater than 40°. According to the patient's own situation, we adopted a low-grade surgery scheme (grades 1 or 2) or a high-grade surgery scheme (grades 3-6). The low-grade surgery was mainly lower articular surface resection or pontodestomy, and the high-grade surgery was mainly apical vertebral body or upper discectomy. All patients were followed up to determine their prognosis.

RESULTS

Statistical analysis showed that there was a significant difference in preoperative and postoperative scores between the two groups (P < 0.05), and scoliosis correction showed that surgical treatment had a significant effect on scoliosis kyphosis. The mean follow-up time was 66.7 months. Follow-up results showed that 50% of complications after internal fixation were related to high-level surgery. Complications included displacement of the titanium cage, removal of the lamina hook, formation of pseudoarthrosis, and internal fixation failure (with a rate of 7.7%-14.3%). In contrast, there were no associated symptoms for low-grade surgery. In addition, the results showed that gender, age, extent of resection, height, and body mass index had no significant effect on preoperative, postoperative, and prognostic indicators of patients (P > 0.05).

CONCLUSION

Early identification of dysplastic scoliosis-related deformities plays an important role in surgical planning and prognosis, and low-level surgical procedures are more favorable for patients' prognosis.

Effect of Surgical Approach on Pulmonary Function in Adolescent Idiopathic Scoliosis Patients: A Systemic Review and Meta-analysis

STUDY DESIGN

Systemic review and meta-analysis.

OBJECTIVE

To analyze the effect of spinal fusion and instrumentation for adolescent idiopathic scoliosis (AIS) on absolute pulmonary function test (PFTs).

SUMMARY OF BACKGROUND DATA

Pulmonary function is correlated with severity of deformity in AIS patients and studies that have analyzed the effect of spinal fusion and instrumentation on PFTs for AIS have reported inconsistent results. There is a need to analyze the effect of spinal fusion on PFTs with stratification by surgical approach.

METHODS

Our analysis included 22 studies. Cohen's d effect sizes were calculated for absolute PFT outcome measures with 95% confidence intervals (CI). Meta-analyses were performed at each postoperative time frame for six homogeneous surgical approaches: (i) combined anterior release and posterior fusion with instrumentation; (ii) combined video assisted anterior release and posterior fusion with instrumentation without thoracoplasty; (iii) posterior fusion with instrumentation without thoracoplasty; (iv) anterior fusion with instrumentation and without thoracoplasty; (v) video assisted anterior fusion with instrumentation without thoracoplasty; and (vi) any scoliosis surgery with additional thoracoplasty.

RESULTS

Anterior spinal fusion with instrumentation, any scoliosis surgery with concomitant thoracoplasty, or video-assisted anterior fusion with instrumentation for AIS had similar absolute PFTs at their 2 year postoperative follow up compared with their preoperative PFTs (effect sizes ranging from -0.2-0.2 with all CI crossing "0"). Posterior spinal fusion with instrumentation (with or without an anterior release) demonstrated small to moderate increases in PFTs 2 years postoperatively (effect sizes ranging from 0.35-0.65 with all CI not crossing "0").

CONCLUSION

Anterior fusion with instrumentation, regardless of the approach, and any scoliosis surgery with concomitant thoracoplasty do not lead to significant change in pulmonary functions 2 year after surgery. Posterior spinal fusion with instrumentation (with or without an anterior release) resulted in small to moderate increases in PFTs.

LEVEL OF EVIDENCE

N/A.

Advances in nonfusion techniques for the treatment of scoliosis in children

Scoliotic deformity in young children is a challenge for the spinal surgeon. Though traditional spinal correction and fusion techniques can improve these deformities, they inhibit growth of the spine. Nonfusion technologies are an effective approach to this problem. They not only correct the spinal deformity, but also allow the spine to keep growing and developing. These techniques include the growing rod, stapling, pedicle screw tethering, the vertical expandable prosthetic titanium rib (VEPTR), and multi-vertebrae wedge osteotomy. This is a review of advances in nonfusion techniques for the treatment of scoliosis in children.

Clinical efficacy of the vertebral wedge osteotomy for the fusionless treatment of paralytic scoliosis

STUDY DESIGN

Pre-post intervention study using outcome measure design.

OBJECTIVE

To evaluate the clinical efficacy and functional impact of a fusionless treatment for paralytic scoliosis at 2-year follow-up.

SUMMARY OF BACKGROUND DATA

It has been shown that 67% of pediatric patients with progressive paralytic scoliosis require spinal fusion to correct the curve. However, maintenance of spinal flexibility, motion, and potential growth is desirable.

METHODS

Fourteen patients with scoliosis secondary to spinal cord injury or myelodysplasia underwent a fusionless vertebral wedge osteotomy. Thirteen patients were available for minimum 2-year follow-up, using standard scoliosis radiographs. The functional impact of the procedure was evaluated using the Pediatric Outcomes Data Collection Instrument (PODCI), the Functional Independence Measure (FIM), and the Canadian Occupational Performance Measure (COPM).

RESULTS

At a minimum 2-year follow-up, 10 patients of 13 (77%) had improvement of greater than 5 degrees in their coronal Cobb angle. Two (15%) patients' curves measured the same (+/-5 degrees). One patient's curve had worsened by 12 degrees as compared to the preoperative Cobb angle. The overall average correction of the 13 patients was 56.1%. Two patients required fusion with an average delay to fusion of 30 months. At current follow-up, range of motion across the treated levels averaged 43 degrees (range 8 degrees to 103 degrees). The FIM showed no changes pre to post, and the PODCI scores showed some increases at 2-year follow-up. Clinical and statistical improvement in performance and satisfaction scores was seen pre to post on the Canadian Occupational Performance Measure.

CONCLUSION

Vertebral wedge osteotomy is potentially an effective treatment option for paralytic scoliosis. At 2-year follow-up, there was no loss of function as measured by the PODCI and FIM, and there was improvement in the COPM. Cobb angle measurements were either improved or maintained in 12 of 13 patients. Although 2 patients required fusion, they had an average of 2.5 years of subsequent growth before surgery.

Congenital thoracolumbar spine deformities

Congenital thoracolumbar spinal deformities are a common and frequent reason for referral to spine surgeons. Neurosurgeons also treat many neurological diagnoses which may result in a progressive spinal deformity, such as scoliosis. Here we review a variety of congenital anomalies and address the maldevelopments associated with each, as well as the appropriate evaluation of such patients including nonoperative and operative approaches. Advances in the field of spinal deformity correction now allow us to better treat individuals with these types of deformities. It is important for the practicing neurosurgeon to be knowledgeable of surgical and nonsurgical treatments of patients with congenital thoracolumbar spinal deformities in order to better understand which patients will ultimately progress and necessitate surgical treatment.

Surgery for idiopathic scoliosis: currently applied techniques

This review discusses the basic knowledge and recent innovation of surgical treatment for scoliosis. Surgical treatment for scoliosis is indicated, in general, for a curve exceeding 45 to 50 degrees by the Cobb's method on the basis that: Curves larger than 50 degrees progress even after skeletal maturity.Curves larger than 60 degrees cause loss of pulmonary function, and much larger curves cause respiratory failure.Greater the curve progression, the more difficult it is to treat with surgery. Posterior fusion with instrumentation has been the standard form of surgical treatment for scoliosis. In modern instrumentation systems, more anchors are used to connect the rod and the spine, resulting in better correction and less frequent implant failures. Segmental pedicle screw constructs or hybrid constructs using pedicle screws, hooks, and wires are the trend of today. Anterior instrumentation surgery was once the choice of treatment for thoracolumbar and lumbar scoliosis because better correction could be obtained with shorter fusion levels. But in the recent times, superiority of anterior surgery for the thoracolumbar and lumbar scoliosis has been questioned. Initial enthusiasm for anterior instrumentation for the thoracic curve using video assisted thoracoscopy has faded out.

Adolescent idiopathic scoliosis (AIS) - an indication for surgery? A systematic review of the literature

PURPOSE

Historically, the treatment options for AIS, the most common form of scoliosis are: Exercises, in-patient rehabilitation, braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no review on prospective controlled trials for surgical treatment. The aim of this review was to perform a systematic search of the Pub Med literature to reveal the evidence on scoliosis surgery.

METHODS

A systematic review has been performed using the Pub Med database. Literature has been searched for the outcome parameter; 'rate of progression' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

RESULTS

No controlled study, not in the short, mid or long term, searched within the review, has been found to reveal evidence to support the hypothesis that the effects of surgery as a treatment option for AIS is superior to natural history.

CONCLUSIONS

No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.

Surgical treatment of scoliosis: a review of techniques currently applied

In this review, basic knowledge and recent innovation of surgical treatment for scoliosis will be described. Surgical treatment for scoliosis is indicated, in general, for the curve exceeding 45 or 50 degrees by the Cobb's method on the ground that:

1) Curves larger than 50 degrees progress even after skeletal maturity.

2) Curves of greater magnitude cause loss of pulmonary function, and much larger curves cause respiratory failure.

3) Larger the curve progress, more difficult to treat with surgery.

Posterior fusion with instrumentation has been a standard of the surgical treatment for scoliosis. In modern instrumentation systems, more anchors are used to connect the rod and the spine, resulting in better correction and less frequent implant failures. Segmental pedicle screw constructs or hybrid constructs using pedicle screws, hooks, and wires are the trend of today.

Anterior instrumentation surgery had been a choice of treatment for the thoracolumbar and lumbar scoliosis because better correction can be obtained with shorter fusion levels. Recently, superiority of anterior surgery for the thoracolumbar and lumbar scoliosis has been lost. Initial enthusiasm for anterior instrumentation for the thoracic curve using video assisted thoracoscopic surgery technique has faded out.

Various attempts are being made with use of fusionless surgery. To control growth, epiphysiodesis on the convex side of the deformity with or without instrumentation is a technique to provide gradual progressive correction and to arrest the deterioration of the curves. To avoid fusion for skeletally immature children with spinal cord injury or myelodysplasia, vertebral wedge ostetomies are performed for the treatment of progressive paralytic scoliosis. For right thoracic curve with idiopathic scoliosis, multiple vertebral wedge osteotomies without fusion are performed. To provide correction and maintain it during the growing years while allowing spinal growth for early onset scoliosis, technique of instrumentation without fusion or with limited fusion using dual rod instrumentation has been developed. To increase the volume of the thorax in thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis, vertical expandable prosthetic titanium ribs has been developed.

Fusionless treatment of scoliosis

The recent investigations of convex anterior vertebral body stapling have offered promising early results with use of improved implants and techniques. The use of a shape memory alloy staple tailored to the size of the vertebral body, the application of several staples per level, the instrumentation of the Cobb levels of all curves, and the employment of minimally invasive thoracoscopic approaches all offer substantial improvements over previous fusionless techniques. Patient selection may also play a role in the current success of these fusionless treatments, with perhaps the ideal candidates for this intervention possessing smaller and more flexible curves. Long-term results of the effects on the instrumented motion segments and adjacent spine are not yet available.

Evidence basis for management of spine and chest wall deformities in children

STUDY DESIGN

: Review of relevant studies, including levels of evidence.

OBJECTIVE

: To review research on growth of the spine and chest wall and treatment of deformities. To place this knowledge in context of evidence-based assessment.

SUMMARY OF BACKGROUND DATA

: Knowledge of the growth of the spine, chest wall, and lung in the normal and deformity states has evolved among independent specialties over the past 60 years. Interest in the interrelationship has blossomed as more tools for assessment and treatment have developed. Spine-based and chest wall-based treatment options now exist, as well as options of resection versus gradual distraction.

METHODS

: Peer-reviewed research published on the growth of the spine, lung, chest wall, and treatment of their deformities was reviewed. Treatment methods and outcomes were compared. Ranking of the levels of evidence was performed where possible.

RESULTS

: Most studies of these topics are Level III and IV studies, consisting of case-control studies and case series. This limitation arises because of the rarity and heterogeneity of the disorders affecting the growing spine and chest wall. The natural history of most types of spinal/chest wall deformities is not known with accuracy. Some experimental evidence informs the treatments which involve modulation of the growth of the spine. However, accurate models of the deformities themselves are lacking. Improvements in imaging and measurement offer options for more accurate patient comparison.

CONCLUSION

: The natural history and results of treatment of deformities of the spine and chest wall offer much opportunity for further evidence-based research.