Reliability of radiographic parameters in neuromuscular scoliosis

Biomechanical analysis of a trans-discal, multi-level stabilization screw (MLSS) at the upper instrumented vertebra (UIV) of long posterior thoracolumbar instrumentations

PURPOSE

To evaluate proximal junctional biomechanics of a MLSS relative to traditional pedicle screw fixation at the proximal extent of T10-pelvis posterior instrumentation constructs (T10-p PSF).

METHODS

A previously validated three-dimensional osseoligamentous spinopelvic finite element (FE) model was used to compare proximal junctional range-of-motion (ROM), vertebral body stresses, and discal biomechanics between two groups: (1) T10-p with a T10-11 MLSS ("T10-11 MLSS") and (2) T10-p with a traditional T10 pedicle screw ("Traditional T10-PS").

RESULTS

The T10-11 MLSS had a 5% decrease in T9 cortical bone stress compared to Traditional T10-PS. Conversely, the T10 and T11 bone stresses increased by 46% and 98%, respectively, with T10-11 MLSS compared to Traditional T10-PS. Annular stresses and intradiscal pressures (IDP) were similar at T9-T10 between constructs. At the T10-11 disc, T10-11 MLSS decreased annular stresses by 29% and IDP by 48% compared to Traditional T10-PS. Adjacent ROM (T8-9 & T9-10) were similar between T10-11 MLSS and Traditional T10-PS. T10-11 MLSS had 39% greater ROM at T10-11 and 23% less ROM at T11-12 compared to Traditional T10-PS.

CONCLUSIONS

In this FE analysis, a T10-11 MLSS at the proximal extent of T10-pelvis posterior instrumentation resulted in increased T10 and T11 cortical bone stresses, decreased discal annular stress and IDP and increased ROM at T10-11, and no change in ROM at the adjacent level. Given the complex and multifactorial nature of proximal junctional kyphosis, these results require additional biomechanical and clinical evaluations to determine the clinical utility of MLSS on the proximal junctions of thoracolumbar posterior instrumented fusions.

Pelvic Fixation Technique Using the Ilio-Sacral Screw for 173 Neuromuscular Scoliosis Patients

Pelvic fixation remains one of the main challenging issues in non-ambulatory neuromuscular scoliosis (NMS) patients, between clinical effectiveness and a high complication rate. The objective of this multicenter and retrospective study was to evaluate the outcomes of a technique that was applied to treat 173 NMS patients. The technique is not well-known but promising; it uses the ilio-sacral screw, combined with either the posterior spinal fusion or fusionless bipolar technique, with a minimum follow-up of two years. The mean operative age of the patients was 13 ± 7 years. The mean preoperative main coronal curve was 64° and improved by a mean of -39° postoperatively. The mean preoperative pelvic obliquity was 23°, which improved by a mean of -14° postoperatively. No decrease in the frontal or sagittal correction was observed during the last follow-up. The sitting posture improved in all cases. Twenty-nine patients (17%) had a postoperative infection: twenty-six were treated with local debridement and antibiotics, and three required hardware removal. Fourteen mechanical complications (8%) occurred: screw malposition (n = 6), skin prominence (n = 1), and connector failure (n = 1). This type of surgery is associated with a high risk for infection. Comorbidities, rather than the surgery itself, were the main risk factors that led to complications. The ilio-sacral screw was reliable and effective in correcting pelvic obliquity in NMS patients. The introduction of intraoperative navigation should minimize the risk of screw misplacement and facilitate revision or primary fixation.

Reliability and sensitivity of radiographic measures of hip dysplasia in childhood Charcot-Marie-Tooth disease

BACKGROUND

Hip dysplasia is a lack of femoral head coverage and disruption of hip and acetabular alignment and congruency, with severity ranging from mild subluxation in nascent at-risk hips to complete dislocation. Presentation of hip dysplasia in neuromuscular conditions can be sub-clinical or associated with a limp with or without hip pain, abductor and flexor weakness and reduced hip range of motion. Untreated hip dysplasia leads to early onset osteoarthritis requiring hip arthroplasty in early adulthood. Hip dysplasia occurs in 6-20% of children with Charcot-Marie-Tooth disease, however little is known about the reliability and sensitivity of detection on plain film pelvic radiographs.

METHODS

14 common measures of hip dysplasia on anteroposterior pelvis radiographs were independently assessed by 2 orthopaedic specialists in 30 ambulant children with Charcot-Marie-Tooth disease. Hip health was also categorised based on clinical impression to assess the sensitivity of radiographic measures to identify hip dysplasia status.

RESULTS

8 measures (acetabular index, head width, lateral centre-edge angle, lateral uncoverage, medial joint width, migration percentage, neck shaft angle, triradiate status) exhibited 'excellent' reliability between clinical evaluators. 5 of the 30 patients (17%) were identified as having nascent hip dysplasia. Reliable radiographic measures that significantly distinguished between nascent hip dysplasia and healthy hips were acetabular index, lateral centre edge angle, medial joint width and migration percentage.

CONCLUSIONS

We have identified a subset of reliable and sensitive radiographic hip measures in children with Charcot-Marie-Tooth disease to prioritise during hip screening to mitigate the deleterious effects of hip dysplasia, pain and disability in adulthood.

RADIOGRAPHIC EVALUATION OF SURGICAL CORRECTION OF SCOLIOSIS DUE TO CEREBRAL PALSY USING INTRA-OPERATIVE TRACTION AND NEW CORRECTION TECHNIQUE WITH 3RD PROVISIONAL ROD

ABSTRACT Objective: Evaluate the radiographic results of patients with cerebral palsy and Lonstein and Akbarnia type II scoliosis who underwent intraoperative halofemoral traction (IFAT) and correction with a 3rd provisional nail. Methods: Retrospective case series study. Were evaluated preoperative (PRE), traction (TR), immediate (POI), and late (POT) total spine radiographs. Were verified the angular value of the main curve (COBB), pelvic obliquity (OP), trunk balance in the coronal plane (CSVA), vertical sagittal alignment (SVA), curve flexibility, and percentage of correction in the final PO. Friedam and Wilcoxon tests were performed (p<0.05). Results: Twenty-one patients were included in the study, with a mean age of 16 (±4.13). There was a statistical difference when comparing COBB PRE with TRACTION to POI and POT (p=0.0001), OP in PRE with TRACTION, and between PRE and POT (p=0.0001). There was a statistical difference in coronal (CSVA) and sagittal (SVA) balance concerning PRE and POT. The percentage of correction for the main curve was 55.75% (± 11.11), and for the O P, 64.86% (± 18.04). Conclusion: The correction technique using the 3rd provisional nail technique and intraoperative traction presents a correction power of 55.75% of the proximal curve and 64% of the pelvic obliquity. In addition, it is easy to assemble, has a short surgical time, and causes little loss of correction during follow-up. Level of Evidence III B; I study a series of retrospective cases.

COMPARISON BETWEEN TWO METHODS OF MEASURING PELVIC OBLIQUITY IN CEREBRAL PALSY AND MYELOMENINGOCELE

ABSTRACT Objective: To evaluate the intra- and inter-observer reproducibility of the evaluation of the pelvic obliquity (PO) in patients with neuro-muscular deformities via the method that uses the iliac crests and the method that uses the upper endplate of S1 and to determine whe ther there is a relationship between the methods. Methods: The digitized panoramic radiographies of thirty patients with cerebral paralysis or myelomeningocelein outpatient monitoring were evaluated by four examiners: two experienced spinal surgeons and two fellows. Two radiographs were excluded because analysis was impossible. All exams were obtained in accordance with the periodic monitoring protocol in the sitting position, using digitized film and a film-focus distance of 110 cm Results: High intra- and inter-observer agreement was observed both for method that uses the iliac crests and the method that evaluates the S1 endplate. However, no significant relationship between the two methods was observed. Conclusions: The methods evaluated had good reproducibility and agreement among the observers. It was confirmed that, on account of the existent linear relation, it is possible to estimate the value of the iliac crest method knowing the value obtained by the S1 plateau multiplied by 0.76. There was no agreement between the iliac crest and S1 plateau PO evaluation methods. Level of evidence IV; Retrospective cross-sectional study.

Natural history, outcome measures and trial readiness in LAMA2-related muscular dystrophy and SELENON-related myopathy in children and adults: protocol of the LAST STRONG study

BACKGROUND

SELENON (SEPN1)-related myopathy (SELENON-RM) is a rare congenital myopathy characterized by slowly progressive proximal muscle weakness, early onset spine rigidity and respiratory insufficiency. A muscular dystrophy caused by mutations in the LAMA2 gene (LAMA2-related muscular dystrophy, LAMA2-MD) has a similar clinical phenotype, with either a severe, early-onset due to complete Laminin subunit α2 deficiency (merosin-deficient congenital muscular dystrophy type 1A (MDC1A)), or a mild, childhood- or adult-onset due to partial Laminin subunit α2 deficiency. For both muscle diseases, no curative treatment options exist, yet promising preclinical studies are ongoing. Currently, there is a paucity on natural history data and appropriate clinical and functional outcome measures are needed to reach trial readiness.

METHODS

LAST STRONG is a natural history study in Dutch-speaking patients of all ages diagnosed with SELENON-RM or LAMA2-MD, starting August 2020. Patients have four visits at our hospital over a period of 1.5 year. At all visits, they undergo standardized neurological examination, hand-held dynamometry (age ≥ 5 years), functional measurements, questionnaires (patient report and/or parent proxy; age ≥ 2 years), muscle ultrasound including diaphragm, pulmonary function tests (spirometry, maximal inspiratory and expiratory pressure, sniff nasal inspiratory pressure; age ≥ 5 years), and accelerometry for 8 days (age ≥ 2 years); at visit one and three, they undergo cardiac evaluation (electrocardiogram, echocardiography; age ≥ 2 years), spine X-ray (age ≥ 2 years), dual-energy X-ray absorptiometry (DEXA-)scan (age ≥ 2 years) and full body magnetic resonance imaging (MRI) (age ≥ 10 years). All examinations are adapted to the patient's age and functional abilities. Correlation between key parameters within and between subsequent visits will be assessed.

DISCUSSION

Our study will describe the natural history of patients diagnosed with SELENON-RM or LAMA2-MD, enabling us to select relevant clinical and functional outcome measures for reaching clinical trial-readiness. Moreover, our detailed description (deep phenotyping) of the clinical features will optimize clinical management and will establish a well-characterized baseline cohort for prospective follow-up.

CONCLUSION

Our natural history study is an essential step for reaching trial readiness in SELENON-RM and LAMA2-MD.

TRIAL REGISTRATION

This study has been approved by medical ethical reviewing committee Region Arnhem-Nijmegen (NL64269.091.17, 2017-3911) and is registered at ClinicalTrial.gov ( NCT04478981 ).

Unmet Needs of Surgical Care for Children: A Case Study in the Brazilian Publicly-Financed Health System

Objective  To measure and document the clinical impact of the waiting time for surgical treatment of patients with spinal deformities in a quaternary center in Brazil.

Methods  In total, 59 patients with spinal deformity waiting for surgery on our hospital's list were evaluated to observe the impact of the waiting time on the progression of the deformity. Patient evaluation was performed using the SRS-22r questionnaire for health-related quality of life (HRQL) and radiographic images to evaluate the deformity of the spine at the time the patients were included in the waiting list and at the most recent appointment. The radiographic parameters selected for comparison were: Cobb angle of the primary and secondary curves, coronal alignment, apical vertebral translation, pelvic obliquity, sagittal vertebral axis, kyphosis (T5-T12), and lordosis (L1-S1).

Results  Low HRQL scores according to the SRS-22r questionnaire were observed in patients waiting for surgery. The radiographic parameters showed progression of the deformity on the initial evaluation when compared with the most recent follow-up evaluation.

Conclusion  The patients waiting for surgical treatment of spinal deformities in our center showed relatively low HRQL scores and radiographic progression of the deformity.

The Variability of Pelvic Obliquity Measurements in Patients with Neuromuscular Scoliosis

Pelvic obliquity (PO), or pelvic alignment in the coronal plane, is an important radiographic parameter to indicate fusion levels and judge success of scoliosis correction in patients with neuromuscular scoliosis. There are multiple commonly used techniques to measure PO that have good to excellent interrater and intrarater reliability, but these different methods yield inconsistent values when used on the same radiograph. This study evaluates the inconsistency in the magnitude of PO measurements for patients with neuromuscular scoliosis among 5 common measurement techniques.

Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis

STUDY DESIGN

Single-center retrospective cohort analysis.

OBJECTIVE

The aim of this study was to evaluate risk factors associated with the development of proximal junctional kyphosis (PJK) in pediatric neuromuscular scoliosis (NMS).

SUMMARY OF BACKGROUND DATA

PJK is a common cause of reoperation in adult deformity but has been less well reported in pediatric NMS.

METHODS

Sixty consecutive pediatric patients underwent spinal fusion for NMS with a minimum 2-year follow-up. PJK was defined as >10° increase between the inferior end plate of the upper instrumented vertebra (UIV) and the superior end plate of the vertebra two segments above. Regression analyses as well as binary correlational models and Student t tests were employed for further statistical analysis assessing variables of primary and compensatory curve magnitudes, thoracic kyphosis, proximal kyphosis, lumbar lordosis, pelvic obliquity, shoulder imbalance, Risser classification, and sagittal profile.

RESULTS

The present cohort consisted of 29 boys and 31 girls with a mean age at surgery of 14 ± 2.7 years. The most prevalent diagnoses were spinal cord injury (23%) and cerebral palsy (20%). Analysis reflected an overall radiographic PJK rate of 27% (n = 16) and a proximal junctional failure rate of 7% (n = 4). No significant association was identified with previously suggested risk factors such as extent of rostral fixation (P = 0.750), rod metal type (P = 0.776), laminar hooks (P = 0.654), implant density (P = 0.386), nonambulatory functional status (P = 0.254), or pelvic fixation (P = 0.746). Significant risk factors for development of PJK included perioperative use of halo gravity traction (38%, P = 0.029), greater postoperative C2 sagittal translation (P = 0.030), decreased proximal kyphosis preoperatively (P = 0.002), and loss of correction of primary curve magnitude at follow-up (P = 0.047). Increase in lumbar lordosis from post-op to last follow-up trended toward significance (P = 0.055).

CONCLUSION

Twenty-seven percent of patients with NMS developed PJK, and 7% had revision surgery. Those treated with halo gravity traction or with greater postoperative C2 sagittal translation, loss of primary curve correction, and smaller preoperative proximal kyphosis had the greatest risk of developing PJK.Level of Evidence: 4.

Reproducibility of the classification of early onset scoliosis (C-EOS)

STUDY DESIGN

Reproducibility study.

OBJECTIVES

Assess the agreement and reliability of the classification of early onset scoliosis (C-EOS). C-EOS is a promising tool for patients with early onset scoliosis (EOS). However, the reliability has only been examined without measuring radiographs and not including the annual progression rate (APR) modifier.

METHODS

We included a single-center consecutive cohort of patients diagnosed with EOS seen in our outpatient clinic. Patients had no previous spine surgery. Four raters rated 60 cases. Two anterior-posterior full-spine radiographs, taken minimum 6 months apart, and one sagittal radiograph were measured twice by all raters in a blinded test-retest setup. Results were assessed using crude frequency of overall agreement (OA), intra- and inter-rater Fleiss kappa (κ) statistics, and intraclass correlation coefficient (ICC). We calculated the 95% limits of agreement (LOA) for major curve angle (MCA), kyphosis, and APR using a linear mixed-effects model. Inter- and intra-rater LOA were analyzed for each etiology separately.

RESULTS

Mean age was 8.7 ± 3.4 years and the etiology were congenital/structural (n = 20), idiopathic (n = 19), neuromuscular (n = 13), or syndromic (n = 8). For etiology, OA was 75.8% and κ = 0.80. For major curve angle, OA was 84.2%, κ = 0.86, ICC = 0.97, and LOA = 12.8°. For kyphosis, OA was 55.8%, κ = 0.52, ICC = 0.87, and LOA = 20.6°. For APR, OA was 76.7%, κ = 0.61, ICC = 0.77, and LOA = 17.4°/year. Inter- and intra-rater LOA were generally largest for neuromuscular and smallest for idiopathic patients.

CONCLUSIONS

We found substantial agreement for etiology, however, with disagreement in certain cases. The reliability of MCA was excellent; however, somewhat lower for kyphosis and APR with less accuracy. The measurement errors of MCA, kyphosis, and APR depended largely on the etiology. Regarding APR, LOA exceeded the 10°/year increments proposed in the C-EOS, suggesting a revision of this optional modifier.

LEVEL OF EVIDENCE

Diagnostic study level 1.

Does an intrathecal baclofen pump impact scoliosis progression and complicate posterior spine fusion in patients with cerebral palsy?

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

In patients with cerebral palsy (CP), we determine the impact of intrathecal baclofen pumps (ITBPs) on scoliosis curve progression before posterior spine fusion (PSF) and its effects on surgical outcome.

BACKGROUND

Children with CP can have rapid scoliosis progression, and high rates of surgical complications can be encountered. It is unknown whether the presence of pre-existing ITBP results in more difficult surgery and higher complication rates in similarly affected children.

METHODS

This is a single-center retrospective study of CP patients undergoing PSF over a 15-year period. Demographics, comorbidities, curve magnitudes, and surgical methods were compared between patients with ITBP and those without. Postoperative complications, length of intensive care unit/hospital stay, drain use and output volume, and need for further surgery were also compared. Curve progression analysis after ITBP placement was performed on a subgroup of patients with high-quality consistent radiographs.

RESULTS

Nineteen patients with ITBP and 49 patients without ITBP met inclusion criteria. Age, comorbidities, number of levels fused, and fixation techniques during PSF were not significantly different between cohorts. ITBP patients were more likely to have PSF with osteotomy (p = 0.022). Increased intraoperative neurosurgical consultations were found for patients with ITBP (42.1% vs. 4.0%; p < 0.001). Median surgical time was 1.2 h greater in patients with ITBP (6.7 vs. 5.5 h, p = 0.039). There was no difference in hospital course and complications in patients with ITBP and those without ITBP. Thirty-one patients without ITB were compared with 15 ITBP patients for curve progression before PSF, demonstrating a mean rate of scoliosis progression of 9.6° ± 6.7°/year and 14.8° ± 9.1°/year (p = 0.0346), respectively.

CONCLUSION

The presence of an ITBP appears to be associated with the increase in scoliosis progression; and these patients will likely have a more challenging spine fusion. Fortunately, the final outcome is not affected by ITBP.

LEVEL OF EVIDENCE

Level III.

Scoliosis in Duchenne muscular dystrophy children is fully reducible in the initial stage, and becomes structural over time

BACKGROUND

Patients with Duchenne muscular dystrophy (DMD) often develop scoliosis that progresses rapidly after loss of ambulation. Management of scoliosis is crucial because it affects both life expectancy and quality of life of patients with DMD. Spinal orthosis attempts to prevent or delay scoliosis using spinal support at three points of the controlling mechanism; the curve should be flattened by the pressure. Therefore, it is assumed that spine flexibility could be a significant influencing factor for the effectiveness of braces. Hence, we attempted to investigate the flexibility of scoliosis in non-ambulant patients with DMD.

METHODS

We reviewed the medical records of 273 boys who were genetically identified as having DMD, and finally, 50 boys with serial records of radiographs after loss of ambulation were finally enrolled. And among them, only 31 patients developed scoliosis. Spine radiographs in sitting and supine positions were also reviewed to obtain Cobb angle, curve flexibility, and pelvic obliquity. Flexibilities (%) were calculated by the difference in angles between the sitting and supine positions divided by the angle at the sitting position, multiplied by 100.

RESULTS

Among 31 boys who had scoliosis, all but 2 boys with curves went through a sequential course of 1) no scoliosis, 2) nonstructural scoliosis, when scoliosis was only measurable in the sitting position, and 3) structural scoliosis, when scoliosis was also detectable in the supine position. Flexibility decreased each year after detection of scoliosis in those who developed scoliosis the first year, from 75.5 ± 5.0% to 57.1 ± 10.5% and to 49.1 ± 10.0% (mean ± standard deviation). Spinal flexibility was significantly correlated with curve magnitude of scoliosis in both sitting and supine position (p < 0.05, respectively).

CONCLUSIONS

There is a period of fully reducible curve in DMD patients at the initial stage of scoliosis. Afterward, as spinal curve progresses, flexibility decreases over time. To detect the scoliosis when the curve is fully reducible, scoliosis curve in DMD patients should be evaluated dynamically, including radiographs of at least in two different positions.

Inter- and Intraobserver Reliability of Pelvic Obliquity Measurement Methods in Patients With Cerebral Palsy

STUDY DESIGN

Retrospective, chart review.

OBJECTIVES

The identification and management of pelvic obliquity in neuromuscular scoliosis can be difficult; therefore, appropriate evaluation of this pathology is important. Variations in presentation have resulted in various methods of measurement, without a consensus or gold standard measurement. This study is the evaluation of reliability of five methods commonly used to determine pelvic obliquity in the frontal plane.

SUMMARY OF BACKGROUND DATA

Previous studies have used five different methods (ie, the Maloney method, the O'Brien method, the Osebold method, the Allen and Ferguson method, and the Lindseth method) to determine pelvic obliquity in the frontal plane.

METHODS

Radiographic images of 50 patients with neuromuscular scoliosis involving the pelvic girdle were identified and evaluated by a team of 5 raters. Each rater was instructed to apply five commonly used methods of measuring pelvic obliquity. The same raters were asked to rate the same radiographs again after a minimum of one month. The interobserver reliability was assessed using the intraclass correlation coefficient (ICC) and the intraobserver analysis was assessed using the Pearson correlation. A rating greater than 0.8 was considered excellent reliability.

RESULTS

The Maloney method showing the highest interobserver reliability of ICC of 0.965 and 0.964. The Lindseth method had the lowest ICC, but all the methods were considered highly reliable by the rating classification system. The Maloney method also showed the highest intraobserver reliability, ranging from 0.845 to 0.962. The Allen and Ferguson method had the lowest intraobserver reliability.

CONCLUSIONS

Many of the methods tested had excellent reliability in this study, but our data suggest the Maloney method is the most reliable method of measuring pelvic obliquity on a frontal view radiograph.

LEVEL OF EVIDENCE

Level III, retrospective, comparative study.

Perioperative complications and risk factors in neuromuscular scoliosis surgery

OBJECTIVE High rates of perioperative complications are associated with deformity correction in neuromuscular scoliosis. The current study aimed to evaluate complications associated with surgical correction of neuromuscular scoliosis and to characterize potential risk factors. METHODS Data were retrospectively collected from a single-center cohort of 102 consecutive patients who underwent spinal fusions for neuromuscular scoliosis between January 2008 and December 2016 and who had a minimum of 6 months of follow-up. A subgroup analysis was performed on data from patients who had at least 2 years of follow-up. Univariate and multivariate regression analyses, as well as binary correlational models and Student t-tests, were employed for further statistical analysis. RESULTS The present cohort had 53 boys and 49 girls with a mean age at surgery of 14.0 years (± 2.7 SD, range 7.5-19.5 years). The most prevalent diagnoses were cerebral palsy (26.5%), spinal cord injury (24.5%), and neurofibromatosis (10.8%). Analysis reflected an overall perioperative complication rate of 27% (37 complications in 27 patients), 81.1% of which constituted major complications (n = 30) compared to a rate of 18.9% for minor complications (n = 7). Complications were predicted by nonambulatory status (p = 0.037), increased intraoperative blood loss (p = 0.012), increased intraoperative time (p = 0.046), greater pelvic obliquity at follow-up (p = 0.028), and greater magnitude of sagittal profile at follow-up (p = 0.048). Pulmonary comorbidity (p = 0.001), previous operations (p = 0.013), history of seizures (p = 0.046), diagnosis of myelomeningocele (p = 0.046), increase in weight postoperatively (p < 0.005), and increased lumbar lordosis at follow-up (p = 0.015) were identified as risk factors for perioperative infection. CONCLUSIONS These results suggest that in neuromuscular scoliosis, patients with preexisting pulmonary compromise and greater intraoperative blood loss have the greatest risk of experiencing a major perioperative complication following surgical deformity correction.

Impact of patient position on coronal Cobb angle measurement in non-ambulatory myelodysplastic patients

OBJECTIVE

The purpose of this study was to assess the impact of patient position on the magnitude of the coronal Cobb angle measurements in relation to the change of position using plain radiograph on non-ambulatory children with myelodysplasia. Whole-spine radiographs with the patient sitting generally are preferred for the diagnosis and monitoring of progression of scoliosis in neuromuscular patients. Supine, supine traction, and sitting push-up positions have been used as substitutes, although there is no general consensus validating if these positions correlate with the sitting position. The magnitude of the Cobb angles in neuromuscular scoliosis may vary greatly depending on the position of the patient.

METHODS

Radiographs of 39 myelodysplastic, non-ambulatory children were evaluated to assess the impact of change in positions (unsupported sitting, sitting push-up, supine, and supine traction) on coronal Cobb angle measurement using plain whole-spine radiographs.

RESULTS

The mean difference in thoracic Cobb angle measurements between sitting and all other positions ranged from 6° to 12°. At the lumbar level, the Cobb angles ranged from 12° to 16°.

CONCLUSIONS

Statistically significant differences in the Cobb angle measurements were identified between plain radiographs of the whole spine with the patient in the unsupported sitting position compared to sitting push-up, supine, and supine traction positions. The data support that the magnitude of the Cobb angles in neuromuscular scoliosis varies greatly depending on the position of the patient.

LEVEL OF EVIDENCE

III.

Impact of neurological level and spinal curvature on pulmonary function in adults with spina bifida

PURPOSE

To describe pulmonary function and determine the impact of neurological level, scoliosis, and obesity on pulmonary function in people with spina bifida (SB).

METHODS

Participants with SB (N= 29) (15 females; age, 30 ± 12 years) completed spirometry and body plethysmographic lung volume testing. Univariate and multivariate regression analyses were used to describe the factors associated with pulmonary function in people with SB.

RESULTS

Distribution of category of impairment in pulmonary function was: 55% (n= 16) restricted, 6.9% (n= 2) spirometric restricted, 1 combined obstructed and restricted, and 35.5% (n= 10) normal. In univariate analyses, neurological level was negatively associated with pulmonary function parameters, i.e., forced vital capacity (FVC) (p= 0.005), forced expiratory volume in 1 second (FEV1) (p= 0.008), total lung capacity (TLC) (p= 0.001), and degree of scoliosis were inversely associated with FVC (p= 0.005), FEV1 (p= 0.003), and TLC (p= 0.004). In multivariate models, level of lesion and degree of scoliosis independently contributed to the degree of lung function impairment. Restrictive pulmonary function was observed in 9/10 (90%) of those with thoracic neurological levels and was associated with decreased inspiratory capacity (IC) and expiratory reserve volume (ERV). Lumbar level lesions were associated with either normal lung function or an isolated reduction in FVC due to reduction in only ERV and preserved TLC representing spirometric restriction.

CONCLUSIONS

High prevalence of restrictive pulmonary physiology is present in people with SB, with more rostral neurological levels and greater degree of scoliosis associated with a higher degree of pulmonary function impairment.

A chronic care model for spina bifida transition

Providing comprehensive transition care for adolescents and young adults with spina bifida (AYASB) requires a structured approach to addressing chronic condition management, self-management, care coordination, and health care navigation that is adaptable to the various levels of cognitive ability, physical function, and family/community environments within the population. This commentary (1) highlights AYASB transition program needs identified in the literature and within a local community, (2) analyzes advantages and limitations of published AYASB transition care models in addressing these needs, (3) demonstrates how a spina bifida (SB) transition clinic used the Chronic Care Model (CCM) to develop a comprehensive AYASB transition program, and (4) examines the potential feasibility in adapting this model to other SB clinics. A SB-specific transition clinic based on the CCM model facilitates the complex chronic care management and transition planning for AYASB. Further study is needed to evaluate health care outcomes using the CCM for SB transition.

RELATIONSHIP BETWEEN FUNCTION AND PRESENCE AND TYPE OF DEFORMITY IN PATIENTS WITH CEREBRAL PALSY

ABSTRACT Objective: To evaluate the gross motor function (GMFCS) with respect to the prevalence and type of scoliosis in patients with cerebral palsy (CP). Methods: This was an analytical, cross-sectional study. We evaluated medical records and imaging studies of 100 patients randomly assigned to a specialist rehabilitation center for the care of such patients. The patients were classified according the gross motor function (GMFCS) and those with deformities were classified as per the kind of scoliosis through the classification of Lonstein and Akbarnia). A correlation was made among the presence of deformity, the variables of the type of deformity and motor function by GMFCS. Results: Of the 100 patients evaluated, 69 had scoliosis. The mean age of patients with scoliosis was higher than that of patients without deformity (12.63 and 10.46 years). Thirty-nine (57%) patients had spastic tetraparesis and 32 (46%) spastic diparesis. The most frequent curve pattern was the thoracolumbar and the average angular value of the main curve was 27 degrees. There was a positive correlation between the presence of scoliosis and GMFCS level V. There was also a positive correlation between the Lonstein Group II and GMFCS V. Conclusion: There is a positive correlation between the presence of scoliosis and greater involvement of gross motor function (GMFCS V). In patients with deformities, there is also a positive correlation between the Group II of Lonstein and GMFCS V.

Correction of Pelvic Obliquity After Spinopelvic Fixation in Children With Cerebral Palsy: A Comparison Study With Minimum Two-Year Follow-up

STUDY DESIGN

Single institution cohort data were collected prospectively and reviewed retrospectively.

OBJECTIVES

This study aims to compare outcomes among three different instrumentation types: unit rod, iliac screws, and sacral alar iliac (SAI) screws in terms of pelvic obliquity correction in children with cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

The optimal choice for spinopelvic fixation in CP scoliosis with pelvic obliquity is controversial.

METHODS

Patients with minimum 2 years' follow-up were divided into three groups according to instrumentation type and matched based on preoperative pelvic obliquity and coronal major curve magnitude. Radiographic measurements included horizontal pelvic obliquity angle (PO), spinopelvic angle (SPA), coronal and sagittal Cobb angles, and T1 pelvic angle. Procedures were performed in one pediatric institution between 2004 and 2012. All measurements were performed by a single independent reviewer who was not involved in the procedures.

RESULTS

Seventy-seven patients (42 unit rod, 14 iliac screw, and 21 SAI screw) were included. Gender and age distribution was similar across all groups (56% males, 44% females, mean age 13.5 years). Mean follow-up was 3.6 years. Comparing pre- and postoperative measurements, there was a significant decrease (p < .05) in PO, SPA, and coronal major cob angle in all groups. No significant loss of correction occurred during follow-up. Postoperatively, TPA improved in all groups. Nonsymptomatic loosening was noted in 59% of unit rods, 57% of iliac screws, and 52% of SAI screws. One prominent iliac screw needed removal. One nonsymptomatic rod fracture, one infected pseudarthrosis, and one rod malposition occurred in unit rod group.

CONCLUSIONS

This study suggests that for correction of pelvic obliquity in cerebral palsy scoliosis, iliac and SAI screws were similar to the unit rod in comparative effectiveness and implant safety profile.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

The Natural History of Scoliosis in Females With Rett Syndrome

STUDY DESIGN

Population-based longitudinal observational study.

OBJECTIVE

To describe the prevalence of scoliosis in Rett syndrome, structural characteristics and progression, taking into account the influences of age, genotype, and ambulatory status.

SUMMARY OF BACKGROUND DATA

Scoliosis is the most common orthopedic comorbidity in Rett syndrome yet very little is known about its natural history and influencing factors such as age, genotype, and ambulatory status.

METHODS

The infrastructure of the Australian Rett Syndrome Database was used to identify all cases with confirmed Rett syndrome in Australia and collect data on genotype and walking status. We identified radiological records and described the Cobb angle of each curve. Time to event analysis was used to estimate the median age of onset of scoliosis and the log-rank test to compare by mutation type. Latent class group analysis was used to identify groups for the trajectory of walking status over time and a multilevel linear model used to assess trajectories of scoliosis development by mutation type and walking status. We used a logistic regression model to estimate the probability of developing a scoliosis with a Cobb angle >60° at 16 years in relation to Cobb angle and walking status at 10 years of age.

RESULTS

The median age of scoliosis onset was 11 years with earliest onset in those with a p.Arg255 mutation or large deletion. Scoliosis was progressive for all mutation types except for those with the p.Arg306Cys mutation. Scoliosis progression was reduced when there was capacity to walk independently or with assistance. Cobb angle and walking ability at age 10 can be reliably used to identify those who will develop a very severe scoliosis by age 16.

CONCLUSION

These data on prognosis of scoliosis inform clinical decision making about the likelihood of progression to very severe scoliosis and the need for surgical management.

LEVEL OF EVIDENCE

4.

The radiological assessment of pelvic obliquity in cerebral palsy and the impact on hip development

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe's angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

Are S1 Screws a Useful Adjunct to Iliac Screws in Long Fusions to the Sacrum in Cerebral Palsy?

STUDY DESIGN

Multicenter prospective database review of patients with cerebral palsy (CP) and spinal deformity.

OBJECTIVE

To determine if the type of distal fixation is associated with improved correction of coronal deformity or pelvic obliquity (PO) at 2 years in long posterior fusions to the sacrum.

SUMMARY OF BACKGROUND DATA

Multiple techniques are utilized for distal fixation in patients with CP. Although there is emerging evidence that the augmentation of iliac screws with S1 screws may be beneficial, this remains controversial.

METHODS

A prospective, multicenter database was used to identify patients with CP who underwent long posterior fusions to the sacrum. Eighty-eight patients were included, 52 with iliac screws (I) and 36 with iliac and S1 screws (IS) for distal fixation. Preoperative, first erect, and 2-year follow-up radiographs and complications were analyzed. Statistical analysis was performed using ANOVA and repeated measures ANOVA with significance set at P < 0.05.

RESULTS

Scoliosis was the primary deformity in greater than 90% of patients in both groups (P=0.84). Preoperative coronal deformity was similar (I = 83°, IS = 87°, P = 0.49), but correction was better with the use of S1 screws on the first erect radiograph and at 2 years (I = 35°, IS = 22°, P = 0.001), reflecting correction of 58% and 74% for iliac and iliac-S1 screws, respectively (P < 0.001). Preoperative PO was similar (I = 29°, IS = 30°, P = 0.71) and was noted to improve more in the iliac-S1 group by 2 years (I = 11°, IS = 5°, P = 0.004), representing correction of 60% and 77% for the iliac and iliac-S1 groups, respectively (P = 0.018). There was no difference in the rate of major (P = 0.27) or minor (P = 0.65) complications in either group.

CONCLUSION

Bilateral S1 and iliac screws are associated with improved spinal deformity and PO correction at 2 years in the CP population. Two points of distal fixation, S1, and ilium should be considered for this population.

LEVEL OF EVIDENCE

3.

Rigid Instrumentation for Neuromuscular Scoliosis Improves Deformity Correction Without Increasing Complications

STUDY DESIGN

Retrospective chart and radiographic review.

OBJECTIVE

To evaluate spinopelvic fixation technical advancements for the treatment of neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Implants for vertebral and pelvic fixation have evolved without data demonstrating the benefit for neuromuscular scoliosis. The aim of this study was to evaluate this evolution in terms of deformity correction, complications, and implant cost.

METHODS

Patients treated with posterior spinal fusion to the pelvis for neuromuscular scoliosis with minimum 1-year follow-up from 1998 to 2012 were reviewed. Constructs were defined as nonrigid (>50% sublaminar wire fixation with Galveston or iliac screw pelvic fixation) and rigid (≥50% pedicle screw fixation with iliac or sacral alar iliac screw pelvic fixation).

RESULTS

Eighty patients were identified: cerebral palsy (55%), myelomeningocele (16%), syndrome (8%), muscular dystrophy (15%), or other neuromuscular disorders (6%). A total of 95% were nonambulatory. Mean follow-up was 3.9 years (range 1-12 years). Construct types were 23 nonrigid and 57 rigid. Estimated construct cost was greater in the rigid group at $15,488 as compared with $3128 in the nonrigid group despite the lower anchor density in the rigid construct group (1.38 vs. 1.80, P < 0.001). Open anterior releases were more frequently performed in the nonrigid group (13/23 vs. 5/57, P < 0.001). Deformity correction at final follow-up was significantly greater for both Cobb angle and pelvic obliquity in the rigid group. The rates of wound infection, wound dehiscence, implant prominence, and mechanical failure of the fixation were not significantly different. The pseudarthrosis rate requiring revision surgery was 22% in nonrigid group and 5% in the rigid group (P = 0.026).

CONCLUSION

Advances in spinopelvic fixation have resulted in improved deformity correction with lower rates of pseudarthrosis and a decreased need for anterior release. This study demonstrates the benefits of modern spinopelvic fixation techniques.

Preventing proximal junctional failure in long segmental instrumented cases of adult degenerative scoliosis using a multilevel stabilization screw technique

BACKGROUND

The authors sought to demonstrate the safety and effectiveness of the multilevel stabilization screw (MLSS) technique in decreasing the incidence of proximal junctional failure in long segmental instrumented fusions for adult degenerative scoliosis.

METHODS

Institutional review board approval was obtained and all patients with adult spinal deformity who underwent the MLSS technique were analyzed. A neuro-radiologist and spine-focused neurosurgeon not involved with the surgical treatment performed radiographic analysis. Proximal junctional angle was defined as the caudal endplate of the upper instrumented vertebra (UIV) to the cephalad endplate of two supradjacent vertebrae above the UIV. The UIV is defined as the most cephalad vertebra completed captured by the instrumentation. Abnormal proximal junctional kyphosis (PJK) was defined as proximal junctional sagittal Cobb angle >10 degrees and proximal junction sagittal Cobb angle at least 10 degrees greater than the preoperative measurement. The presence of both is criteria necessary to be considered abnormal.

RESULTS

Twenty patients with degenerative scoliosis underwent the MLSS technique with the upper-instrumented vertebrae in the proximal thoracic spine. Fifteen patients met inclusion criteria with greater than 12 months radiographic and clinical follow up. Three patients were excluded due to lack of follow up imaging and two patients were excluded due to the inability to measure the UIV. Age range was 44-84 years with a mean of 66. Eleven of the 15 patients were over the age of 60 at the time of surgery. The male-to-female ratio was 4:11. Body mass index (BMI) range was 24-44 with a mean of 31.5 units. The follow up period ranged from 14 to 58 months with an average follow up of 30 months. The mean change in Cobb angle at the proximal junction was 4.00 degrees with a range from -0.92 to 9.13 degrees. There were no fractures or instrumentation failures at or near the proximal junction. There was no revision surgeries performed for proximal junctional failure. Retrospective clinical questionnaires revealed that surgical expectations were met in 15 of 19 patients surveyed, 79%. One patient was not reachable for a postoperative phone interview. In patients who were not satisfied with their overall experience, the change in Cobb angle ranged from -0.92 to 9.13 degrees with an average change of 3.90 degrees. Whereas patients reporting an overall positive experience had a change in Cobb angle range from -0.12 to 8.07 degrees with an average change of 4.05 degrees.

CONCLUSION

PJK and failure are well-recognized suboptimal outcomes of long-segmental fusions of the thoracolumbar spine that can lead to significant neurological morbidity and costly revision surgeries. With no known proximal junction failures to date, the MLSS technique has shown promising results in preventing adverse proximal junctional conditions and can be safely performed under fluoroscopy guidance. Future direction includes a comparative study establishing the relative risk of developing PJK with this novel technique versus a traditional long-segmental thoracolumbar fusion.

The long-term outcome of patients treated operatively and non-operatively for scoliosis deformity secondary to spina bifida

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood.

We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these, 34 (75.6%) had been treated operatively and 11 (24.4%) non-operatively. After a mean follow-up of 14.1 years (standard deviation (sd) 4.3) clinical, radiological and health-related quality of life (HRQOL) outcomes were evaluated using the Spina Bifida Spine Questionnaire (SBSQ) and the 36-Item Short Form Health Survey (SF-36).

Although patients in the two groups were demographically similar, those who had undergone surgery had a larger mean Cobb angle (88.0º (sd 20.5; 50.0 to 122.0); versus 65.7º (sd 22.0; 51.0 to 115.0); p < 0.01) and a larger mean clavicle–rib intersection difference (12.3 mm; (sd 8.5; 1 to 37); versus 4.1 mm, (sd 5.9; 0 to 16); p = 0.01) than those treated non-operatively. Both groups were statistically similar at follow-up with respect to walking capacity, neurological motor level, sitting balance and health-related quality of life (HRQOL) outcomes.

Spinal fusion in SBC scoliosis corrects coronal deformity and stops progression of the curve but has no clear effect on HRQOL.

Cite this article: Bone Joint J 2014; 96-B:1244–51

The Relationship of Gross Motor Functional Classification Scale Level and Hip Dysplasia on the Pattern and Progression of Scoliosis in Children With Cerebral Palsy

PURPOSE

The primary aim of the study was to determine whether progression and magnitude of scoliosis were related to the Gross Motor Functional Classification Scale (GMFCS) and whether laterality (and associated pelvic obliquity) of the spinal curvature affected severity of recurrent hip subluxation in patients with cerebral palsy who had undergone varus derotational osteotomy (VDRO).

METHODS

A total 115 patients underwent VDRO surgery at a single institution between 1980 and 2001. Adequate radiographs were available for 98 patients. Average age at time of VDRO was 6.5 years and follow-up post-VDRO was 8.2 years. Children were divided into lower severity (GMFCS 1-3; 13 patients), high severity (GMFCS 4; 42 patients), and highest severity (GMFCS 5; 43 patients). A single observer measured all spine radiographs using standardized technique. A separate observer measured hip migration index on all pelvis radiographs.

RESULTS

There was a significant increase in coronal deformity over time in each GMFCS category (p < .0001). The GMFCS 1-3 and GMFCS 4 groups had nearly identical time trends, each increasing at roughly 1° to 2° annually, whereas the GMFCS 5 group increased by 3.5°/year (p = .0153). Increasing Cobb angle was not a significant predictor of severity of recurrent subluxation. Furthermore, there was no significant difference in severity of recurrent hip subluxation when hips were evaluated based on whether they were on the same side as the concavity or convexity of the scoliosis (ie, high or low side of pelvic obliquity).

CONCLUSIONS

The relationship between GMFCS and rate of scoliosis progression differed between groups. Severity of hip subluxation did not increase significantly over time after VDRO, nor was it significantly related to magnitude or laterality of scoliosis in children in this cohort.

SIGNIFICANCE

Treatment decisions regarding hip subluxation and scoliosis in patients with cerebral palsy may be made independent of each other.

Neuromuscular scoliosis

Scoliosis is a common deformity in many types of neuromuscular disease. Severe spinal curvature can cause difficulty in sitting. Conservative and surgical treatment of neuromuscular scoliosis differs from idiopathic scoliosis, being more complex and with a higher complications rate. Non-surgical measures rarely fully control progressive scoliosis, but aim to prevent spinal deformities secondary to muscular hypotonia or contracture. Twenty-four hour bracing should be adjusted throughout growth, and may induce functional impairment and loss of independence. Corrective surgery requires multidisciplinary management and perioperative screening. Pelvic obliquity is commonly associated with neuromuscular scoliosis, making sitting difficult: correction needs to be considered during surgical planning. The goal of surgical correction is to obtain and maintain a well-balanced spine above a well-positioned pelvis. Preoperative multidisciplinary assessment enables potential problems of terrain to be anticipated. Respiratory function investigation will guide possible non-invasive perioperative ventilation. Nutritional and psychosocial assessment should also be incorporated in this preparation, as should overall postoperative care. Implementing this overall strategic planning can achieve a good surgical and functional result in the vast majority of cases.

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications.

International spinal cord injury musculoskeletal basic data set

OBJECTIVES

To develop an International Spinal Cord Injury (SCI) Musculoskeletal Basic Data Set as part of the International SCI Data Sets to facilitate consistent collection and reporting of basic musculoskeletal findings in the SCI population.

SETTING

International.

METHODS

A first draft of an SCI Musculoskeletal Basic Data Set was developed by an international working group. This was reviewed by many different organizations, societies and individuals over 9 months. Revised versions were created successively.

RESULTS

The final version of the International SCI Musculoskeletal Basic Data Set contains questions on neuro-musculoskeletal history before spinal cord lesion; presence of spasticity/spasms; treatment for spasticity within the last 4 weeks; fracture(s) since the spinal cord lesion; heterotopic ossification; contracture; the location of degenerative neuromuscular and skeletal changes due to overuse after SCI; SCI-related neuromuscular scoliosis; the method(s) used to determine the presence of neuromuscular scoliosis; surgical treatment of the scoliosis; other musculoskeletal problems; if any of the musculoskeletal challenges above interfere with activities of daily living. Instructions for data collection and the data collection form are freely available on the International Spinal Cord Society (ISCoS) website (www.iscos.org.uk).

CONCLUSION

The International SCI Musculoskeletal Basic Data Set will facilitate consistent collection and reporting of basic musculoskeletal findings in the SCI population.

The role of the neuromuscular medicine and physiatry specialists in the multidisciplinary management of neuromuscular disease

The neuromuscular medicine and physiatry specialists are key health care providers who work cooperatively with a multidisciplinary team to provide coordinated care for individuals with neuromuscular diseases (NMDs). The director or coordinator of the team must be aware of the potential issues specific to NMDs and be able to access the interventions that are the foundations for proper care in NMD. Ultimate goals include maximizing health and functional capacities, performing medical monitoring and surveillance to inhibit and prevent complications, and promoting access and full integration into the community to optimize quality of life.

Effect of direct vertebral body derotation on the sagittal profile in adolescent idiopathic scoliosis

PURPOSE

We sought to clarify the effect of applying derotation maneuvers in the correction of adolescent idiopathic scoliosis (AIS) on the sagittal plane.

METHODS

We retrospectively queried a large, multicenter, prospectively collected database for patients who underwent surgical correction of AIS. All patients had at least 2 years of follow-up and documentation as to whether or not a derotation maneuver was performed during surgery. All patients underwent posterior spinal fusion with pedicle screw constructs. Patients who underwent concurrent anterior procedures were excluded.

RESULTS

A total of 323 patients were identified, of whom 66 did not have direct vertebral body derotation (DVBD) maneuvers applied during the deformity correction. The remaining 257 had a vertebral body derotation maneuver performed during their surgical correction. Although no significant differences were identified between the two groups when comparing pre-op and post-op thoracic kyphosis using T2-12 and T5-12 endplates, the absolute change in angulation measured from T2-12 was significantly different between the two groups. Postoperatively, the derotation group had a mean decrease in thoracic kyphosis of 5.1±15.3° as compared to 10.8±18.9° in the control group, P = 0.03.

CONCLUSION

Although patients in both groups had decreased mean thoracic kyphosis postoperatively, application of DVBD in the correction of scoliosis did not additionally worsen the sagittal profile.

Variability of expert opinion in treatment of early-onset scoliosis

BACKGROUND

In contrast with treatment recommendations for adolescent idiopathic scoliosis, there are no clear algorithms for treating patients with early-onset scoliosis. There has been rapid expansion of treatment options for children with early-onset scoliosis, including casting, growth rods, the vertical expandable prosthetic titanium rib, and anterior vertebral stapling.

QUESTIONS/PURPOSES

Given the range of treatment options, we assessed variability in decision making regarding treatment of patients with early-onset scoliosis.

METHODS

We presented 12 clinical and radiographic vignettes about patients with early-onset scoliosis to 13 experienced spine surgeons who are members of the Chest Wall and Spine Deformity Study Group. The reviewers were asked to choose type of treatment, type of construct, construct location, and whether a thoracotomy should be performed.

RESULTS

All 13 surgeons agreed regarding the need for surgery in eight of the 12 cases. When the reviewers chose surgery, 76% (40%-100%) selected the vertical expandable prosthetic titanium rib; of those selecting that approach, 61% (0%-100%) coincided on using it bilaterally. Agreement was 20% (0%-60%) for growing rods and 4% (0%-25%) for fusions. Among all cases, agreement regarding whether instrumentation should extend to the pelvis was 71% (50%-100%). In all but two cases, at least 85% of surgeons recommended against a thoracotomy.

CONCLUSIONS

Although most surgeons agreed about the indication for surgery, we found wide variability in choice of construct type, number of constructs, and level of instrumentation.

Mensuração da curva escoliótica pela técnica de cobb intraobservadores e interobservadores e sua importância clínica

OBJETIVO: Analisar a mensuração manual do ângulo de Cobb entre profissionais com diferentes experiências da área de Ortopedia e Traumatologia e Cirurgia da Coluna Vertebral, para observar se existem diferenças na avaliação das radiografias de pacientes portadores de escoliose idiopática intra e interobservadores, a ponto de influenciar no tratamento e seguimento desses pacientes. MÉTODOS: Foram utilizadas para este estudo 22 radiografias simples da coluna toracolombar, póstero-anterior, de pacientes portadores de escoliose idiopática, em acompanhamento regular no ambulatório do Grupo da Coluna do Hospital São Paulo. Os exames foram avaliados por quatro diferentes categorias de profissionais ortopedistas e cirurgiões da coluna vertebral e realizada a mensuração das curvas escolióticas através do método de Cobb. As vértebras terminais das curvas não foram previamente marcadas. Somente foram mensuradas as curvas principais (consideradas as de maior valor angular) de cada radiografia. A reprodutibilidade das mensurações feitas pelos diferentes Observadores (inter-observadores) e entre as duas mensurações de cada Observador (intraobservador) foi analisada pelo Coeficiente de Correlação Intraclasse (CCI). RESULTADOS: Foram observadas, quanto às medidas dos ângulos, concordâncias excelentes entre as avaliações intraobservadores, e observadas concordâncias excelentes entre as avaliações interobservadores, uma vez que o CCI em todas as situações manteve-se maior que 0,75, o que representa excelente reprodutibilidade. CONCLUSÃO: Concluímos que houve concordância excelente (CCI > 0,75) na avaliação dos ângulos nas mensurações das curvas escolióticas intra e interobservadores. Ao mesmo tempo, as mensurações apresentaram variação de até 13,58º intraobservadores, e de até 12,72º interobservadores.

Comparison between Operated Muscular Dystrophy and Spinal Muscular Atrophy Patients in terms of Radiological, Pulmonary and Functional Outcomes

STUDY DESIGN

Retrospective comparative study.

PURPOSE

To study and compare the surgical outcomes of muscular dystrophy (MD) and spinal muscle atrophy (SMA).

OVERVIEW OF LITERATURE

There are few reports that have evaluated and compared the surgical outcomes of MD and SMA patients.

METHODS

The patients (n = 35) were divided into two groups: a MD group with 24 patients and a SMA group with 11 patients. The average follow-up period was 21 months. All patients were operated for scoliosis correction using posterior instrumentation and fusion. In the immediate postoperative period, all efforts were made to reduce the pulmonary complications using non-invasive positive pressure ventilation and a coughing assist devices. The patients were evaluated by radiograph in terms of the Cobb's angle, pelvic obliquity, T1 translation, thoracic kyphosis and lumbar lordosis. The pulmonary function and self-image satisfaction were also assessed.

RESULTS

There was a lower correction rate in the MD group (41.5%) than in the SMA group (48.3%), even though the curves were smaller in the MD group. The correction in the pelvic obliquity was significantly better in the SMA group (p = 0.03). The predicted vital capacity showed a 4% reduction in the MD group 1 year after surgery, while the SMA group showed a 10% reduction. The peak cough flow and end tidal PCO(2) did not deteriorate and were well maintained. The average score for the improvement in self-image satisfaction postoperatively was 3.96 and 4.64 for the MD and SMA groups, respectively. The total complication rate was 45.7%; 14.3% of which were respiratory-related.

CONCLUSIONS

Surgical intervention for MD and SMA may be performed safely in patients with a very low forced vital capacity (< 30%) through aggressive preoperative and postoperative rehabilitation efforts.

Management of spinal deformity in cerebral palsy

An understanding of the three-dimensional components of spinal deformity in children with cerebral palsy is necessary to recommend treatments that will positively affect these patients' quality of life. Management of these deformities can be challenging and orthopedic surgeons should be familiar with the different treatments available for this patient population. This article discusses the incidence, causes, natural history, and treatment of patients with scoliosis.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities

OBJECTIVE

This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Tratamento cirúrgico da escoliose em pacientes com amiotrofia espinhal com parafusos pediculares (instrumental de 3ª geração) e complicações precoces

OBJETIVO: avaliar a utilização de artrodese via posterior com parafusos pediculares para correção da escoliose em pacientes com amiotrofia espinhal. MÉTODOS: realizou-se um estudo retrospectivo de 16 pacientes com amiotrofia espinhal submetidos à artrodese via posterior exclusiva, com parafusos pediculares. Foi avaliado o perfil geral dos pacientes e o potencial de correção do ângulo de Cobb e da obliquidade pélvica, além das complicações precoces. RESULTADOS: o ângulo de Cobb pré-operatório foi em média de 94,6º (65 a 132º), no pós-operatório de 40,4º (2 a 70º), percentual de correção de 57,2%. A obliquidade pélvica pré-operatória foi em média 34,7º (25 a 56º), no pós-operatório foi para 11,3º (0 a 20º), com percentual de correção de 67,4%. Cinco pacientes tiveram complicações precoces (31,2%) com boa resolução. CONCLUSÕES: o tratamento cirúrgico da escoliose em pacientes com amiotrofia espinhal por meio de artrodese via posterior utilizando parafusos pediculares tem grande potencial de correção da deformidade coronal e da obliquidade pélvica, sem grandes complicações no pós-operatório precoce.

Can the caudal extent of fusion in the surgical treatment of scoliosis in Duchenne muscular dystrophy be stopped at lumbar 5?

Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in Duchenne muscular dystrophy (DMD) and is recommended to correct pelvic obliquity. The caudal extent of instrumentation and fusion in the surgical treatment of scoliosis in DMD has remained a matter of considerable debate, and there have been few studies on the use of segmental pedicle screw instrumentation for this pathology. From 2004 to 2007, a total of 28 patients with DMD underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. All patients had a curve with the apex at L2 or higher preoperatively. Preoperative coronal curve averaged 74 degrees, with a postoperative mean of 14 degrees, and 17 degrees at the last follow-up. The pelvic obliquity improved from 17 degrees preoperatively to 6 degrees postoperatively, and 6 degrees at the last follow-up. Good sagittal plane alignment was recreated after surgery and maintained long term. In 23 patients with a preoperative L5 tilt of less than 15 degrees, the pelvic obliquity was effectively corrected to less than 10 degrees and maintained by adequately addressing spinal deformity, while five patients with a preoperative L5 tilt of more than 15 degrees had a postoperative pelvic obliquity of more than 15 degrees. Segmental pedicle screw instrumentation and fusion to L5 was effective and safe in patients with DMD scoliosis with a minimal L5 tilt (<15 degrees) and a curve with the apex at L2 or higher, both initially and long term, obviating the need for fixation to the sacrum/pelvis. Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with DMD scoliosis with stable L5/S1 articulation as evidenced by a minimal L5 tilt of less than 15 degrees, even though pelvic obliquity was significant. There was no major complication. With rigid segmental pedicle screw instrumentation, the caudal extent of fusion in the treatment of DMD scoliosis should be determined by the degree of L5 tilt. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of DMD scoliosis.

Management of fractures of the pedicle after instrumentation with transpedicular screws: A report of three patients

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment.

Pressure mapping as an outcome measure for spinal surgery in patients with myelomeningocele

STUDY DESIGN

A retrospective analysis of prospectively collected data on a cohort of 19 myelomeningocele patients undergoing spino-pelvic deformity surgery.

OBJECTIVE

To examine if greater curve correction with third generation spinal implants correlate with improved pressure distribution and resolution, or prevention of skin ulcerations in myelomeningocele patients.

SUMMARY OF BACKGROUND DATA

Children born with myelomeningocele have often complex spino-pelvic deformities leading to skin ulcerations.

METHODS

A cohort of 19 consecutive wheelchair dependent patients with myelodisplastic spinal deformities, who underwent spinal surgery, was prospectively followed with regular pressure mappings for a minimum of 2 years. Standard spino-pelvic radiologic measurements were obtained. Sitting pressure mappings were obtained over the study period using the Force Sensitive Applications from Vista Medical (Winnipeg, Manitoba, Canada). Statistical analysis was done using SAS (SAS Institute Inc, Cary, NC). Paired t-test and Wilcox on Signed Rank test was used where applicable. Significance was taken to be P<0.05.

RESULTS

Surgery significantly corrected radiographic parameters, specifically, Cobb angle (52%), pelvic obliquity (89%), and to a lesser degree pelvic tilt. Stratifying the data based on fixation type showed that the M-W construct was able to significantly correct pelvic obliquity. While significant changes in radiographic variables were observed after surgery, this was not the case with the various pressure mapping variables. Only minor changes after surgery were observed in the average pressure, maximum pressure, and variable coefficient of pressure. What was observed was an improvement in the overall distribution from anterior/posterior and right/left. While the values only approached statistical significance (P=0.053) for right/left, however, this did not appear to be clinically significant regarding skin ulceration.

CONCLUSION

Despite significant surgical corrections in radiographic parameters, these resulted in small changes in pressure distributions and do not appear to influence skin ulceration in the myelomeningocele patient. Pressure mapping may not be a useful tool in predicting outcome of spinal surgery. Factors which were proven to influence pressure distribution are the sagittal pelvic orientation and also achieving coronal spine balance.

Guidelines for management of scoliosis in Rett syndrome patients based on expert consensus and clinical evidence

STUDY DESIGN

Modified Delphi technique.

OBJECTIVE

To develop guidelines for the clinical management of scoliosis in Rett syndrome through evidence review and consensus expert panel opinion.

SUMMARY OF BACKGROUND DATA

Rett syndrome is a rare disorder and clinical expertise is thus with small case series. Scoliosis is a frequent association and the evidence base dealing with scoliosis management in this syndrome is limited. Parents of affected girls and women have expressed needs for more information about scoliosis and Rett syndrome.

METHODS

An initial draft of scoliosis guidelines was created based on literature review and open-ended questions where the literature was lacking. Perspectives of four parents of Rett syndrome patients informed this initial draft. Access to an online and a Microsoft Word formatted version of the draft were then sent to an international, multidisciplinary panel of clinicians via e-mail with input sought using a 2-stage modified Delphi process to reach consensus agreement. Items included clinical monitoring and intervention before the diagnosis of scoliosis; monitoring after the diagnosis of scoliosis; imaging; therapy and conservative management; bracing; and preoperative, surgical, and postoperative considerations.

RESULTS

The first draft contained 71 statements, 65 questions. The second draft comprised 88 items with agreement to strong agreement achieved on 85, to form the final guideline document. A comprehensive, life-span approach to the management of scoliosis in Rett syndrome is recommended that takes into account factors such as physical activity, posture, nutritional and bone health needs. Surgery should be considered when the Cobb angle is approximately 40 degrees to 50 degrees and must be supported by specialist management of anesthesia, pain control, seizures, and early mobilization.

CONCLUSION

Evidence- and consensus-based guidelines were successfully created and have the potential to improve care of a complex comorbidity in a rare condition and stimulate research to improve the current limited evidence base.

Scoliosis surgery in cerebral palsy: differences between unit rod and custom rods

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate the differences in intraoperative factors and postoperative results between pediatric patients with cerebral palsy (CP) treated with unit rods and those treated with custom-bent rods.

SUMMARY OF BACKGROUND DATA

No prior study has directly compared unit and custom-bent rods for CP.

METHODS

We retrospectively analyzed the clinical and radiographic data of 157 children with CP who underwent posterior spinal fusion. Of those 157, we treated 79 with unit rods and 78 with custom-bent rods. Minimum follow-up was 2 years.

RESULTS

Intraoperatively, unit rod surgeries were associated with significantly shorter mean surgical time (339 and 379 minutes, respectively; P = 0.04), longer mean intensive care unit stay (4 vs. 3 days, respectively; P = 0.001), and longer mean hospital stay (14 vs. 13 days; P = 0.006) than custom-bent rod procedures. The mean estimated blood loss was higher for unit rods (2124 vs. 1885 mL, respectively), but not significantly so. After surgery, unit rod surgeries were associated with significantly more mean pelvic obliquity correction (74% vs. 22%, respectively; P = 0.002), more mean clinically apparent implant prominence at 2-year follow-up (12 vs. 2 instances; P = 0.03; most were proximal), and a higher mean infection rate (15% vs. 5%, respectively; P = 0.03). There were no significant differences in final major Cobb correction, curves with an apex above or below T10, implant-related reoperations, or neurologic complications. The only factor that was statistically correlated with the overall complication rate for both groups was absolute curve magnitude (P = 0.04).

CONCLUSION

Compared with custom-bent rods, unit rods provided superior correction of pelvic obliquity but were associated with higher transfusion requirements, higher infection rates, more proximal fixation problems, and longer intensive care unit and hospital stays.

Examination of the newborn with congenital scoliosis: focus on the physical

Although scoliosis at birth is rare, conditions at birth and in the newborn period predispose newborns to the development of scoliosis in later life. Scoliosis is congenital when associated with abnormal vertebral segmentation regardless of the age of diagnosis. Other conditions may predispose neonates to vertebral damage or the development of sustained uneven forces on the developing spine. Although it is difficult to know which newborns will progress to developing scoliosis, it is important to be aware of risk factors to provide anticipatory education for parents and to arrange appropriate follow-up after discharge. This article reviews the embryology of vertebral formation and risk factors for the development of scoliosis. The discussion includes the incidence, risk factors, genetics, associated problems, physical examination, and nursing implications of the infant with congenital scoliosis.

The impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy

BACKGROUND

Intrathecal baclofen (ITB) is an effective treatment of spasticity in patients with cerebral palsy. However, several recent reports have raised concerns that the treatment may be associated with a rapid progression of scoliosis. The objective of this study was to further examine the effect of ITB treatment on the progression of scoliosis in patients with cerebral palsy.

METHODS

Spastic cerebral palsy patients who were ITB candidates were followed radiographically. Baseline Cobb angles of the primary curve were measured during the period of ITB pump insertion and at the most recent follow-up visit. Each patient was matched with a control patient by the diagnosis of cerebral palsy, age, sex, topographic involvement, and initial Cobb angle. The mean rate of change in Cobb angle was compared between ITB and control patients using paired t test. A multiple linear regression model was used to examine the difference, controlling for age, sex, topographic involvement, and initial Cobb angle.

RESULTS

Fifty ITB patients and 50 controls were included in the analysis. There was no statistically significant difference between the mean change in Cobb angle in ITB patients (6.6 degrees per year) compared with the matched control patients (5.0 degrees per year, P = 0.39). The results from the multiple regression analysis also failed to show a statistically significant difference (0.92 degrees per year difference between ITB patients and controls, P = 0.56).

CONCLUSIONS

The progression of scoliosis in cerebral palsy patients with ITB treatment is not significantly different from those without ITB treatment. The findings suggest that patients receiving ITB experience a natural progression of scoliosis similar to the natural history reported in the literature.

LEVEL OF EVIDENCE

Level III.