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Chehrassan M, Nikouei F, Shakeri M, Moeini J, Jafari B, Mahabadi EA, Ghandhari H. Factors Related to Proximal Junctional Kyphosis and Device Failure in Patients with Early-Onset Scoliosis Treated with a Traditional Dual Growing Rod: A Single Institution Study. Asian Spine J 2024; 18:236-243. [PMID: 38454749 PMCID: PMC11065516 DOI: 10.31616/asj.2023.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/25/2023] [Accepted: 11/26/2023] [Indexed: 03/09/2024] Open
Abstract
STUDY DESIGN Observational study. PURPOSE Investigation of factors related to proximal junctional kyphosis (PJK) and device failure in patients with early-onset scoliosis. OVERVIEW OF LITERATURE The use of growth-friendly devices, such as traditional dual growing rod (TDGR) for the treatment of earlyonset scoliosis (EOS), may be associated with important complications, including PJK and device failure. METHODS Thirty-five patients with EOS and treated with TDGR from 2014 to 2021 with a minimum follow-up of 2 years were retrospectively evaluated. Potential risk factors, including demographic factors, disease etiology, radiological measurements, and surgical characteristics, were assessed. RESULTS PJK was observed in 19 patients (54.3%), and seven patients (20%) had device failure. PJK was significantly associated with global final kyphosis change (p=0.012). No significant correlation was found between the rod angle contour, type of implant, connector design, and the risk of PJK or device failure. CONCLUSIONS Treatment of EOS with TDGR is associated with high rates of complications, particularly PJK and device failure. The device type may not correlate with the risk of PJK and device failure. The progression of thoracic kyphosis during multiple distractions is an important risk factor for PJK.
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Affiliation(s)
| | - Farshad Nikouei
- Bone and Joint Reconstruction Research Center, Shafa Orthopaedic Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | - Mohammadreza Shakeri
- Bone and Joint Reconstruction Research Center, Shafa Orthopaedic Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | | | - Behnam Jafari
- Bone and Joint Reconstruction Research Center, Shafa Orthopaedic Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | - Ebrahim Ameri Mahabadi
- Bone and Joint Reconstruction Research Center, Shafa Orthopaedic Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | - Hasan Ghandhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopaedic Hospital, Iran University of Medical Sciences, Tehran,
Iran
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Arhewoh RE, Marigi I, McCarthy R, Skaggs D, Sponseller P, Luhmann S. Changes in sagittal balance and pre-existing junctional angle influence development of proximal junctional kyphosis in growth guidance systems for early-onset scoliosis. Spine Deform 2024; 12:239-246. [PMID: 37612433 DOI: 10.1007/s43390-023-00754-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/05/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Proximal junctional kyphosis (PJK) has been reported to occur at a rate of about 30% in traditional growing rods (GR) and magnetically controlled growing rods (MCGR). Growth guidance systems (GGS) have non-rigid, gliding fixation along rods, which may mitigate PJK. There have been no studies done in shilla around PJK, hence this study aimed to assess the occurrence, risk factors, and timeline of PJK. METHODS A prospective, multicenter database was queried for EOS patients who underwent surgery utilizing GGS. INCLUSION CRITERIA < 10 years at index surgery and > 2 year follow-up. RESULTS Sixty-five patients (thirty-six female) met inclusion criteria. Mean age at index surgery was 6.2 y/o (2-9); mean follow-up was 66 m. Most common etiologies were syndromic (n = 23). Mean thoracic kyphosis at pre-op was 41.8°, post-op was 35.5°, and final was 42.2°. Mean PJA at pre-op was 6.15°, post-op 1 was 4.2°, and final was 15.6°. Incidence of PJK at post-op was 35% and final was 43%. Pre-op sagittal balance and change in sagittal balance from pre-op to post-op were associated with post-op PJK (p = 0.05, 0.02). Change in spinal height from pre-op to post-op was associated with PJK at final (p = 0.04). Interestingly, increased PJA at pre-op was significantly associated with decreased PJK at post-op and final (p = 0.01, 0.03). CONCLUSION PJK was identified in 43% of patients post-operatively after GGS for EOS. Pre-op PJA was negatively correlated with an increased incidence of PJK. Changes in sagittal balance, in either direction, was the strongest predictor for development of PJK post-operatively.
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Affiliation(s)
- Reme Emmanuel Arhewoh
- Department of Orthopaedic Surgery, St Louis Children's Hospital, Washington University School of Medicine, Saint Louis, MO, 63110, USA
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ian Marigi
- Department of Orthopaedic Surgery, St Louis Children's Hospital, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Richard McCarthy
- Department of Orthopaedics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, 72205, USA
| | - David Skaggs
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Paul Sponseller
- Division of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Scott Luhmann
- Department of Orthopaedic Surgery, St Louis Children's Hospital, Washington University School of Medicine, Saint Louis, MO, 63110, USA.
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Kim G, Sammak SE, Michalopoulos GD, Mualem W, Pinter ZW, Freedman BA, Bydon M. Comparison of surgical interventions for the treatment of early-onset scoliosis: a systematic review and meta-analysis. J Neurosurg Pediatr 2022; 31:342-357. [PMID: 36152334 DOI: 10.3171/2022.8.peds22156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/03/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Several growth-preserving surgical techniques are employed in the management of early-onset scoliosis (EOS). The authors' objective was to compare the use of traditional growing rods (TGRs), magnetically controlled growing rods (MCGRs), Shilla growth guidance techniques, and vertically expanding prosthetic titanium ribs (VEPTRs) for the management of EOS. METHODS A systematic review of electronic databases, including Ovid MEDLINE and Cochrane, was performed. Outcomes of interest included correction of Cobb angle, T1-S1 distance, and complication rate, including alignment, hardware failure and infection, and planned and unplanned reoperation rates. The percent changes and 95% CIs were pooled across studies using random-effects meta-analysis. RESULTS A total of 67 studies were identified, which included 2021 patients. Of these, 1169 (57.8%) patients underwent operations with TGR, 178 (8.8%) Shilla growth guidance system, 448 (22.2%) MCGR, and 226 (11.1%) VEPTR system. The mean ± SD age of the cohort was 6.9 ± 1.2 years. The authors found that the Shilla technique provided the most significant improvement in coronal Cobb angle immediately after surgery (mean [95% CI] 64.3% [61.4%-67.2%]), whereas VEPTR (27.6% [22.7%-33.6%]) performed significantly worse. VEPTR also performed significantly worse than the other techniques at final follow-up. The techniques also provided comparable gains in T1-S1 height immediately postoperatively (mean [95% CI] 10.7% [8.4%-13.0%]); however, TGR performed better at final follow-up (21.4% [18.7%-24.1%]). Complications were not significantly different among the patients who underwent the Shilla, TGR, MCGR, and VEPTR techniques, except for the rate of infections. The TGR technique had the lowest rate of unplanned reoperations (mean [95% CI] 15% [10%-23%] vs 24% [19%-29%]) but the highest number of planned reoperations per patient (5.31 [4.83-5.82]). The overall certainty was also low, with a high risk of bias across studies. CONCLUSIONS This analysis suggested that the Shilla technique was associated with a greater early coronal Cobb angle correction, whereas use of VEPTR was associated with a lower correction rate at any time point. TGR offered the most significant height gain at final follow-up. The complication rates were comparable across all surgical techniques. The optimal surgical approach should be tailored to individual patients, taking into consideration the strengths and limitations of each option.
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Affiliation(s)
- Gloria Kim
- 1Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - Sally El Sammak
- 2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota; and.,Departments of3Neurologic Surgery and
| | - Giorgos D Michalopoulos
- 2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota; and.,Departments of3Neurologic Surgery and
| | - William Mualem
- 2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota; and.,Departments of3Neurologic Surgery and
| | | | | | - Mohamad Bydon
- 2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota; and.,Departments of3Neurologic Surgery and
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Yang B, Xu L, Wang M, Wang B, Zhu Z, Qiu Y, Sun X. Unmatched rod contouring at the proximal end predisposes to occurrence of junctional kyphosis in early-onset scoliosis patients undergoing traditional growing rods treatment. BMC Musculoskelet Disord 2022; 23:624. [PMID: 35768808 PMCID: PMC9241211 DOI: 10.1186/s12891-022-05564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
STUDY DESIGN A retrospective case series. OBJECTIVE To investigate whether unmatched rod contouring at the proximal end predisposed to the occurrence of proximal junctional kyphosis (PJK) in early-onset scoliosis (EOS) patients after traditional growing rods (TGR) treatment. TGR treatment has become a mainstay of treatment for EOS patients. PJK is one of the most common alignment-related complications. METHODS A consecutive series of EOS patients who had undergone TGR treatment were retrospectively reviewed. They were divided into PJK and non-PJK groups according to the occurrence of PJK or not. Demographic data, surgical strategies, and radiographic parameters were recorded and compared between groups. Proximal junctional angle (PJA) was defined as the angle between the caudal endplate of the UIV and the cephalad endplate of the second supradjacent vertebra above the UIV, while proximal rod contouring angle (PRCA) was defined as the angle of proximal rod contouring, which was represented by the angle between the cephalad endplate of the UIV and the caudal endplate of the second vertebra caudal to the UIV. Unmatched proximal rod contouring was regarded if the postoperative PRCA-PJA difference was greater than 5°. RESULTS This study finally included 73 patients. The mean age at the index surgery was 6.5 ± 2.2 years (range, 2-10 years). Mean follow-up lasted 5.0 ± 1.7 years (range, 2-9 years). They received mean 4.6 ± 1.6 lengthening procedures. There were 13 patients who were observed with PJK (18%). In comparison with the non-PJK group, the PJK group showed a larger preoperative major curve (82 ± 21° vs 70 ± 17°, P = 0.041) and global kyphosis (57 ± 6° vs. 44 ± 15°, P = 0.044). In addition, the PJK group had significantly larger postoperative PJA (10 ± 3 vs. 5 ± 3, P<0.001) and greater postoperative PJA-PRCA (6 ± 3 vs. 3 ± 3, P = 0.031). The proportion of patients with unmatched proximal rod contouring in PJK group was significantly higher than that in the non-PJK group (69% vs. 25%). Multiple logistic regression showed that preoperative GK>50°, postoperative PJA>10 and postoperative unmatched proximal rod contouring were the risk factors in predicting PJK after TGR treatment. CONCLUSION Approximately 18% EOS patients experienced PJK after TGR treatment. Unmatched proximal rod contouring may be an independent risk factor of PJK occurrence, in addition to greater preoperative GK and larger postoperative PJA. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Bo Yang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Muyi Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.,Medical School of Nanjing University, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Afliated Drum Tower Hospital, Medical School of Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.
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Early outcomes of growth friendly instrumentation in children with Williams syndrome. Spine Deform 2022; 10:717-725. [PMID: 35000131 DOI: 10.1007/s43390-021-00453-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Although scoliosis and kyphosis have been associated with Williams Syndrome (WS), no previous literature has reported on surgical treatment for early onset scoliosis (EOS) in WS. The aim of this case series is to report on the outcomes of spine deformity surgery in patients with EOS and WS and any perioperative anesthetic or cardiovascular complications. METHODS One multicenter database was queried for all patients with WS who underwent growth-friendly (GF) treatment before age 12 between 2000 and 2017. Demographics, surgical, and growth-friendly data were queried. Radiographs were measured for curve magnitude, T1-T12 length, and T1-S1 length. RESULTS Seven patients were analyzed (3 males, 4 females). Patients were at a median age of 2.8 years at initial surgery with median follow-up 3.6 years (range 2.0-12 years) after index surgery. The initial surgical treatments were as follows: 2 traditional growing rods (TGR), 2 magnetically controlled growing rods (MCGR), and 3 vertical expandable prosthetic titanium ribs (VEPTR). The median duration of growth-friendly treatment was 5.0 years (range, 2.6-10.4 years) with a median number of 9 device lengthenings. The median improvement in coronal curve magnitude from preoperative to most recent follow-up was 19° (range, 54°-9°). Three patients have completed GF treatment: one underwent definitive fusion, and two are under observation with apparent spontaneous fusion and retain the original GF implants. No peri-operative anesthetic or cardiovascular complications occurred. CONCLUSIONS Few studies have reported on surgical outcomes in WS patients with EOS. In this case series, 6/7 patients experienced curve improvement with growth-friendly spine instrumentation. This study suggests that growth-friendly instrumentation for severe EOS in WS can be used for control of spinal deformity while allowing for further growth. Associated complications were typical of distraction-based EOS surgical treatment. There were 62 total procedures with general anesthesia, but no perioperative cardiac complications occurred.
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Abstract
Childhood socio-economic status (SES), a measure of the availability of material and social resources, is one of the strongest predictors of lifelong well-being. Here we review evidence that experiences associated with childhood SES affect not only the outcome but also the pace of brain development. We argue that higher childhood SES is associated with protracted structural brain development and a prolonged trajectory of functional network segregation, ultimately leading to more efficient cortical networks in adulthood. We hypothesize that greater exposure to chronic stress accelerates brain maturation, whereas greater access to novel positive experiences decelerates maturation. We discuss the impact of variation in the pace of brain development on plasticity and learning. We provide a generative theoretical framework to catalyse future basic science and translational research on environmental influences on brain development.
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Affiliation(s)
- Ursula A Tooley
- Neuroscience Graduate Group, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle S Bassett
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA
- Department of Electrical and Systems Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA
- Department of Physics & Astronomy, College of Arts & Sciences, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Santa Fe Institute, Santa Fe, NM, USA
| | - Allyson P Mackey
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA.
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Bouthors C, Dukan R, Glorion C, Miladi L. Outcomes of growing rods in a series of early-onset scoliosis patients with neurofibromatosis type 1. J Neurosurg Spine 2020; 33:373-380. [PMID: 32330884 DOI: 10.3171/2020.2.spine191308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early-onset scoliosis (EOS) is not uncommon in patients with neurofibromatosis type 1 (NF1). Despite conservative treatment, spinal deformities progress and require early surgical intervention. To avoid potential interference with chest and trunk growth, growing rods (GRs) have been used effectively in EOS of various etiologies. In this study the authors sought to analyze the outcomes of GRs in EOS patients with NF1. METHODS This was a retrospective single-center cohort study that included consecutive EOS patients with NF1 who were treated with GRs and were followed up for a minimum of 2 years. Clinical and radiological analyses were performed preoperatively and until the last follow-up. RESULTS From to 2008 to 2017, 18 patients (6 male, 12 female) underwent GR surgery (14 single GRs, 4 dual GRs) at a mean age of 8 ± 2.1 years. Mean follow-up was 5 ± 2.4 years. Fifty-five lengthenings were performed at a mean rate of 3 lengthenings per patient (range 0-7). Ten of 14 single GRs (71%) were converted into dual GRs during treatment. No patient underwent definitive posterior spinal fusion (PSF) at GR treatment completion. The mean initial and last follow-up major curves were 57° and 36°, respectively (p < 0.001, 37% correction). The average T1-S1 increase was 13 mm/yr. Six of 9 hyperkyphotic patients had normal kyphosis at last follow-up. There were 26 complications involving 13 patients (72%), with 1 patient who required unplanned revision. The primary complications were instrumentation related, consisting of 17 proximal hook dislodgments, 6 distal pedicle screw pullouts, and 2 rod fractures. Only 1 patient experienced a mechanical complication after dual GR implantation. There were no wound infections. CONCLUSIONS The GR technique provided satisfactory spinal deformity control in EOS patients with NF1 while allowing substantial spinal growth. Adequately contoured dual GRs with proximal hooks placed in nondystrophic regions should be used to minimize implant-related complications. Surgeons should not attempt to correct kyphosis at GR implantation.
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The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset: Mean 4.5-Year Follow-up. J Pediatr Orthop 2020; 40:261-266. [PMID: 32501899 DOI: 10.1097/bpo.0000000000001516] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS). METHODS A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed. RESULTS At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038). CONCLUSIONS In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs. LEVEL OF EVIDENCE Level III.
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