METHODS: An online REDCap questionnaire was circulated to surgeons in the Asia-Pacific region during the period of July 2019 to September 2019 to inquire about various components of nonoperative treatment for AIS. Aspects under study included access to screening, when MRIs were obtained, quality-of-life assessments used, role of scoliosis-specific exercises, bracing criteria, type of brace used, maturity parameters used, brace wear regimen, follow-up criteria, and how braces were weaned. Comparisons were made between middle-high income and low-income countries, and experience with nonoperative treatment.
RESULTS: A total of 103 responses were collected. About half (52.4%) of the responders had scoliosis screening programs and were particularly situated in middle-high income countries. Up to 34% obtained MRIs for all cases, while most would obtain MRIs for neurological problems. The brace criteria were highly variable and was usually based on menarche status (74.7%), age (59%), and Risser staging (92.8%). Up to 52.4% of surgeons elected to brace patients with large curves before offering surgery. Only 28% of responders utilized CAD-CAM techniques for brace fabrication and most (76.8%) still utilized negative molds. There were no standardized criteria for brace weaning.
CONCLUSION: There are highly variable practices related to nonoperative treatment for AIS and may be related to availability of resources in certain countries. Relative consensus was achieved for when MRI should be obtained and an acceptable brace compliance should be more than 16 hours a day.
OBJECTIVE: This study looked into whether crossbar can reliably measure Upper Instrumend Vertebra (UIV) tilt angle intraoperatively and accurately predict the UIV tilt angle postoperatively and at final follow-up.
SUMMARY OF BACKGROUND DATA: Postoperative shoulder imbalance is a common cause of poor cosmetic appearance leading to patient dissatisfaction. There were no reports describing the technique or method in measuring the UIV tilt angle intraoperatively. Therefore, this study was designed to look into the reliability and accuracy of the usage of intraoperative crossbar in measuring the UIV tilt angle intraoperatively.
METHODS: Lenke 1 and 2 Adolescent Idiopathic Scoliosis patients who underwent instrumented Posterior Spinal Fusion using pedicle screw constructs with minimum follow-up of 24 months were recruited for this study. After surgical correction, intraoperative UIV tilt angle was measured using a crossbar. Immediate postoperative and final follow up UIV tilt angle was measured on the standing anteroposterior radiographs.
RESULTS: A total of 100 patients were included into this study. The reliability of the intraoperative crossbar to measure the optimal UIV tilt angle intraoperatively was determined by repeated measurements by assessors and measurement by different assessors. We found that the intra observer and inter observer reliability was very good with intraclass correlation coefficient values of >0.9. The accuracy of the intraoperative crossbar to measure the optimal UIV tilt angle intraoperatively was determined by comparing this measurement with the postoperative UIV tilt angle. We found that there was no significant difference (P>0.05) between intraoperative, immediate postoperative, and follow-up UIV tilt angle.
CONCLUSIONS: The crossbar can be used to measure the intraoperative UIV tilt angle consistently and was able to predict the postoperative UIV tilt angle. It was a cheap, simple, reliable, and accurate instrument to measure the intraoperative UIV tilt angle.
METHODS: Forty-eight patients were recruited. Inclusion criteria were AIS patients who have had PSF surgery more than 10 years ago. Patients were divided into G1: LIV L3 or higher and G2: LIV L4 or lower. MRI evaluation was classified using Pfirrmann grades. Pfirrmann scores were average of Pfirrmann grades for all unfused discs below LIV. SRS-22r, SF-36, Oswestry Disability Index (ODI) and Modified Cincinnati Sports Activity Scale (MCSAS) were used.
RESULTS: There were 19 patients in G1 and 29 patients in G2. Demographic parameters showed no significant differences. We found no significant differences in Pfirrmann grades or scores between G1 and G2. There was significant correlation between age and mean Pfirrmann scores (r = 0.546, p
METHODS: In this retrospective study of prospectively collected data, 1057 AIS patients operated between 2012 and 2019 were included. Main outcome measures were operative time, intraoperative blood loss, allogeneic blood transfusion rate, length of hospital stay after surgery, complication rate, and mean drop of haemoglobin (Hb) level. We documented the number of fusion levels, screw density, and postoperative radiographic parameters.
RESULTS: There were 917 females and 140 males. Majority were Lenke 1 curve type (46.9%). Mean age was 15.6 ± 3.7 years, with mean BMI of 18.6 ± 3.2 kg/m2. Mean operative time was 146.8 ± 49.4 min. Average intraoperative blood loss was 952.9 ± 530.4 ml with allogeneic blood transfusion rate of 5%. Mean screw density was 1.27 ± 0.21 screws per fusion level. Average hospital stay after surgery was 3.5 ± 0.9 days. Twenty-four complications were documented: twelve superficial infections (1.14%), five transient neurological deficits (0.47%), two deep infections (0.19%), two superior mesenteric artery syndrome, and one case each (0.09%) for massive intraoperative blood loss, intraoperative seizure, and lung atelectasis.
CONCLUSION: AIS patients treated with single-staged PSF using pedicle screw construct had a 0.95% rate of major complications and 1.32% rate of minor complications. Rate of neurologic complication was 0.47% while non-neurologic postoperative complications was 1.80% with infection being the leading complication at 1.32%.
PURPOSE: To evaluate the inter-rater reliability of Rajasekaran's kyphosis classification through a multicenter validation study.
OVERVIEW OF LITERATURE: The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation.
METHODS: A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations.
RESULTS: The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte's (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6).
CONCLUSIONS: Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.
METHODS: Case report.
RESULTS: The use pre-operative halo-ring traction for a duration of 6 weeks in this case lead to improvement in cobb angle from 123.3°, kyphotic angle 87.1° to cobb angle of 78.0°, kyphotic angle 57.2° (on bending and stress films). The operation was completed in 150 min, blood loss 1050 ml (25 ml/kg), and cell salvage of 490 ml. He was immediately extubated post correction, but monitored in ICU for a day. Total length of stay was 8 days without any perioperative morbidity or allogeneic blood transfusion. Final post-operative radiograph showed a cobb angle of 44.2°, kyphotic angle 22.8°. Follow up at 27 months showed solid union with no significant loss of correction.
CONCLUSION: From this case experience, pre-operative halo traction is a useful surgical strategy in patients with Fontan circulation with severe kyposcoliosis to achieve adequate correction without additional osteotomies to minimize the risk of surgical correction.
OBJECTIVE: The aim of this study was to analyze the proximal thoracic (PT) flexibility and its compensatory ability above the "potential UIV."
SUMMARY OF BACKGROUND DATA: Shoulder and neck imbalance can be caused by overcorrection of the main thoracic (MT) curve due to inability of PT segment to compensate.
METHODS: Cervical supine side bending (CSB) radiographs of 100 Lenke 1 and 2 patients were studied. We further stratified Lenke 1 curves into Lenke 1-ve: PT side bending (PTSB) 80.0% of cases of the PT segment were unable to compensate at T3-T6. In Lenke 1+ve curves, 78.4% were unable to compensate at T6, followed by T5 (75.7%), T4 (73.0%), T3 (59.5%), T2 (27.0%), and T1 (21.6%). In Lenke 1-ve curves, 36.4% of cases were unable to compensate at T6, followed by T5 (45.5%), T4 (45.5%), T3 (30.3%), T2 (21.2%), and T1 (15.2%). A significant difference between Lenke 1-ve and Lenke 1+ve was observed from T3 to T6. The difference between Lenke 1+ve and Lenke 2 curves was significant only at T2.
CONCLUSION: The compensation ability and the flexibility of the PT segments of Lenke 1-ve and Lenke 1+ve curves were different. Lenke 1+ve curves demonstrated similar characteristics to Lenke 2 curves.
LEVEL OF EVIDENCE: 3.
Purpose: To report the perioperative and radiological outcomes of single-stage posterior passive correction and fusion (SSPPCF) in adolescent patients who present with congenital scoliosis.
Overview of Literature: The surgical treatment for congenital scoliosis is complex. There is no definitive guide on surgical options for skeletally matured adolescent patients who have congenital scoliosis.
Methods: Patients with congenital scoliosis who underwent SSPPCF using a pedicle screw system were reviewed. We identified the following three surgical indications: (1) hemivertebra or wedge vertebra over the thoracic or thoracolumbar region with structural lumbar curves, (2) hemivertebra or wedge vertebra at the lumbar region with significant pelvic obliquity or sacral slanting, and (3) mixed or complex congenital scoliosis. The demographic, perioperative, and radiographic data of these patients were collected.
Results: Thirty-four patients were reviewed. The mean patient age was 14.6±3.4 years. There were 13 hemivertebrae, three wedged vertebrae, two butterfly vertebrae, three hemivertebrae with butterfly vertebra, eight unsegmented bars, and five multiple complex lesions. The average surgical duration was 219.4±68.8 minutes. The average blood loss was 1,208.4±763.5 mL. Seven patients required allogeneic blood transfusion. The mean hospital stay duration was 6.1±2.5 days. The complication rate was 11.8% (4/34): one patient had severe blood loss, one had rod breakage, and two had distal adding-on. The Cobb angle reduced from 65.9°±17.4° to 36.3°±15.3° (p<0.001) with a correction rate (CR) of 44.8%±17.4%. The regional kyphotic angle decreased from 39.9°±20.5° to 27.5°±13.9° (p=0.001) with a CR of 19.3%±49.6%. Radiographic parameters (radiographic shoulder height, clavicle angle, T1 tilt, cervical axis, pelvic obliquity, coronal balance, and apical vertebral translation) showed significant improvement postoperatively.
Conclusions: SSPPCF was a feasible option for adolescent patients with congenital scoliosis who were skeletally matured.
OBJECTIVE: The primary objective of this study was to assess the conformity of the radiological neck and shoulder balance parameters throughout a follow-up period of more than 2 years.
SUMMARY OF BACKGROUND DATA: Postoperative shoulder and neck imbalance are undesirable features among Adolescent Idiopathic Scoliosis patients who underwent Posterior Spinal Fusion. There are many clinical and radiological parameters used to assess this clinical outcome. However, we do not know whether these radiological parameters conform throughout the entire follow-up period.
METHODS: This was a retrospective study done in a single academic institution. Inclusion criteria were patients with scoliosis who underwent posterior instrumented spinal fusion with pedicle screw fixation and attended all scheduled follow-ups for at least 24 months postoperatively. Radiological shoulder parameters were measured from both preoperative antero-posterior and postoperative antero-posterior radiographs. Lateral shoulder parameters were: Radiographic Shoulder Height, Clavicle Angle (Cla-A), Clavicle-Rib Intersection Difference, and Coracoid Height Difference. Medial shoulder and neck parameters were: T1 Tilt and Cervical Axis (CA).
RESULTS: The radiographs of 50 patients who had surgery done from November 2013 to November 2015 were analyzed. Mean age of this cohort was 16.3 ± 7.0 years. There were 38 (76%) female patients and 12 (24%) male patients. Mean final follow-up was 38.6 ± 5.8 months. When conformity assessment of the radiological parameter using the interclass coefficient correlation was done, we found that all parameters had significant correlation (P
OBJECTIVE: To determine whether the severity of the curve magnitude in Lenke 1 and 2 Adolescent Idiopathic Scoliosis (AIS) patients affects the distance and position of the aorta from the vertebra.
SUMMARY OF BACKGROUND DATA: There were studies that looked into the position of the aorta in scoliotic patients but none of them documented the change in distance of the aorta to the vertebra in relation to the magnitude of the scoliosis.
METHODS: Patients with Lenke 1 and 2 AIS who underwent posterior spinal fusion using pedicle screw construct and had a preoperative computed tomography (CT) scan performed were recruited. The radiological parameters measured on preoperative CT scan were: Aortic-Vertebral Distance (AVD), Entry-Aortic Distance (EAD), Aortic-Vertebral angle (AVA), Pedicle Aorta angle/Aortic Alpha angle (α angle), and Aortic Beta angle (β angle).
RESULTS: Thirty-nine patients were recruited. Significant moderate to strong positive correlation was found between AVD and Cobb angle from T8 to T12 vertebrae (r = 0.360 to 0.666). The EAD was generally small in the thoracic region (T4-T10) with mean EAD of less than 30 mm. Among all apical vertebrae, the mean AVD was 5.9 ± 2.2 mm with significant moderate-strong positive correlation to Cobb angle (r = 0.580). The mean α angle was 37.7 ± 8.7° with significant weak positive correlation with Cobb angle (r = 0.325).
CONCLUSION: The larger the scoliotic curve, the aorta was located further away from the apical vertebral wall. The aorta has less risk of injury from the left lateral pedicle screw breach in larger scoliotic curve at the apical region. The distance from the pedicle screw entry point to the wall of the aorta was generally small (less than 30 mm) in the thoracic region (T4-T10).
LEVEL OF EVIDENCE: 4.