OBJECTIVE: This study analyzed the flexibility of the unfused thoracic segments above the "potential upper instrumented vertebrae (UIV)" (T1-T12) and its compensatory ability in Lenke 5 and 6 curves using supine side bending (SSB) radiographs.
STUDY DESIGN: A retrospective study was used.
PATIENT SAMPLE: This study comprised 100 patients.
OUTCOME MEASURES: The ability of the unfused thoracic segments above the potential UIV, that is, T1-T12, to compensate in Lenke 5 and 6 curves was determined. We also analyzed postoperative radiological outcome of this cohort of patients with a minimum follow-up of 12 months.
METHODS: Right and left SSB were obtained. Right side bending (RSB) and left side bending (LSB) angles were measured from T1 to T12. Compensatory ability of thoracic segments was defined as the ability to return to neutral (center sacral vertical line [CSVL]) with the assumption of maximal correction of lumbar curve with a horizontal UIV. The Lenke 5 curves were classified as follows: (1) Lenke 5-ve (mobile): main thoracic Cobb angle <15° and (2) Lenke 5+ve (stiff): main thoracic Cobb angle 15.0°-24.9°. This study was self-funded with no conflict of interest.
RESULTS: There were 43 Lenke 5-ve, 31 Lenke 5+ve, and 26 Lenke 6 curves analyzed. For Lenke 5-ve, >70% of thoracic segments were able to compensate when UIV were at T1-T8 and T12 and >50% at T9-T11. For Lenke 5+ve, >70% at T1-T6 and T12, 61.3% at T7, 38.7% at T8, 3.2% at T9, 6.5% at T10, and 22.6% at T11 were able to compensate. For Lenke 6 curve, >70% at T1-T6, 69.2% at T7, 19.2% at T8, 7.7% at T9, 0% at T10, 3.8% at T11, and 34.6% at T12 were able to compensate. There was a significant difference between Lenke 5-ve versus Lenke 5+ve and Lenke 5-ve versus Lenke 6 from T8 to T11. There were no significance differences between Lenke 5+ve and Lenke 6 curves from T1 to T11.
CONCLUSIONS: The compensatory ability of the unfused thoracic segment of Lenke 5+ve curves was different from the Lenke 5-ve curves, and it demonstrated characteristics similar to the Lenke 6 curves.
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 present study investigated the effectiveness of chewing gum on promoting faster bowel function and its ability to hasten recovery for patients with adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF) surgery.
SUMMARY OF BACKGROUND DATA: Sham feeding with chewing gum had been reported to reduce the incidence of postoperative ileus by accelerating recovery of bowel function.
METHODS: We prospectively recruited and randomized 60 patients with AIS scheduled for PSF surgery into treatment (chewing gum) and control group. The patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth were assessed and recorded at 12, 24, 36, 48, and 60 hours postoperatively. The timing for the first fluid intake, first oral intake, sitting up, walking, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay were also assessed and recorded.
RESULTS: We found that there were no significant differences (P > 0.05) in patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth between treatment (chewing gum) and control groups. We also found that there were no significant difference (P > 0.05) in postoperative recovery parameters, which were the first fluid intake, first oral intake, sitting up after surgery, walking after surgery, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay between both groups. The wound pain was the worst at 12 hours postoperatively, which progressively improved in both groups. The abdominal pain progressively worsened to the highest score at 48 hours in the treatment group and 36 hours in the control group before improving after that. The pattern of severity and recovery of wound pain and abdominal pain was different.
CONCLUSION: We found that chewing gum did not significantly reduce the abdominal pain, promote faster bowel function, or hasten patient recovery.
LEVEL OF EVIDENCE: 1.
OBJECTIVE: To determine the parents'/patients' perception on the informed consent process prior to posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients.
SUMMARY OF BACKGROUND DATA: Understanding parents/patients perspective on the process is important in order to achieve the goal of consent and prevent medico-legal implications.
METHODS: Fifty AIS patients operated between August 2019 and November 2019 were prospectively recruited. Parents'/patients' perceptions on three sections were evaluated: the process of the informed consent, specific operative risk which they were most concerned with and the accountability of surgeons for the surgical risks. These data were ranked and scored using a 5-point Likert Scale. Preferences were reported in mean and standard deviation. Differences in terms of preferences were studied using One-way analysis of variance (ANOVA) analysis and deemed significant when P
OBJECTIVE: The aim of this study was to compare the perioperative outcome of posterior spinal fusion (PSF) between overweight (OW) adolescent idiopathic scoliosis (AIS) patients and the healthy-weight (HW) patients using propensity score matching analysis.
SUMMARY OF BACKGROUND DATA: Obesity was found to increase postoperative surgical complications compared with the nonobese group. In scoliosis correction surgery, association of OW and perioperative risks had been explored, but most studies were retrospective in nature.
METHODS: From 374 patients, two comparable groups were matched using propensity score matching analysis with one-to-one nearest neighbor matching and a caliper of 0.2. There were 46 HW and OW patients in each group. The main outcome measures were intraoperative blood loss, use of allogeneic blood transfusion, operative time, duration of hospital stay post-surgery, total patient-controlled analgesia (PCA) morphine usage, perioperative complications, side bending flexibility (SBF), and correction rate (%).
RESULTS: The mean age was 13.3 ± 1.7 and 13.2 ± 1.7 years for HW and OW groups, respectively. The majority of the patients were Lenke 1 curves; 32.6% (HW) and 26.1% (OW) with an average Cobb angle of 69.0 ± 19.1° and 68.8 ± 18.4° for each group, respectively. The two groups were comparable. The operation time was 145.2 ± 42.2 and 154.4 ± 48.3 minutes for HW and OW groups, respectively (P > 0.05). The intraoperative blood loss was almost similar in both groups; 955.1 ± 497.7 mL (HW group) and 1011.8 ± 552.7 mL (OW group) (P > 0.05). Total PCA morphine used was higher in OW group (30.4 ± 22.7 mg) than in the HW group (16.2 ± 11.3 mg). No complication was observed in HW group, while in OW group, one patient (2.2%) developed intraoperative seizure.
CONCLUSION: OW AIS patients (≥85th percentile) had similar mean operative time, intraoperative blood loss, allogeneic transfusion rate, length of stay, and perioperative complications compared with HW AIS patients.
LEVEL OF EVIDENCE: 3.
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: The aim of this study was to determine and evaluate the trajectory of surgical wound pain from day 1 to day 14 after posterior spinal fusion (PSF) surgery in patients with adolescent idiopathic scoliosis (AIS).
SUMMARY OF BACKGROUND DATA: Information regarding how the postoperative pain improves with time offers invaluable information not only to the patients and parents but also to assist the clinician in managing postoperative pain.
METHODS: AIS patients who were planned for elective PSF surgery from September 2015 to December 2015 were prospectively recruited into this study. All patients underwent a similar pain management regimen with patient-controlled anesthesia (PCA) morphine, acetaminophen, celecoxib, and oxycodone hydrochloride.
RESULTS: A total of 40 patients (36 F:4 M) were recruited. The visual analogue score (VAS) pain score was highest at 12 hours postoperation (6.0 ± 2.3). It reduced to 3.9 ± 2.2 (day 4), 1.9 ± 1.6 (day 7), and 0.7 ± 1.1 (day 14). The total PCA usage in all patients was 12.4 ± 9.9 mg (first 12 hours), 7.1 ± 8.0 mg (12 to 24 hours), 5.6 ± 6.9 (24-36 hours), and 2.1 ± 6.1 mg (36-48 hours). The celecoxib capsules usage was reducing from 215.0 ± 152.8 mg at 24 hours to 55.0 ± 90.4 mg on day 14. The acetaminophen usage was reducing from 2275 ± 1198 mg at 24 hours to 150 ± 483 mg at day 14. Oxycodone hydrochloride capsules consumption rose to the peak of 1.4 ± 2.8 mg on day 4 before gradually reducing to none by day 13.
CONCLUSION: With an adequate postoperation pain regimen, significant pain should subside to a tolerable level by postoperative day 4 and negligible by postoperative day 7. Patient usually can be discharged on postoperative day 4 when the usage of PCA morphine was not required.
LEVEL OF EVIDENCE: 2.
OBJECTIVE: Anterior-alone surgery has gained wider reception for subaxial cervical spine facets dislocation. Questions remain on its efficacy and safety as a stand-alone entity within the contexts of concurrent facet fractures, unilateral versus bilateral dislocations, anterior open reduction, and old dislocation.
METHODS: A systematic review was performed with search strategy using translatable MESH terms across MEDLINE, EMBASE, VHL Regional Portal, and CENTRAL databases on patients with subaxial cervical dislocation intervened via anterior-alone approach. Two reviewers independently screened for eligible studies. PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) flow chart was adhered to. Nine retrospective studies were included. Narrative synthesis was performed to determine primary outcomes on spinal fusion and revisions and secondary outcomes on new occurrence or deterioration of neurology and infection rate.
RESULTS: Nonunion was not encountered across all contexts. A total of 0.86% of unilateral facet dislocation (1 out of 116) with inadequate reduction due to facet fragments between the facet joints removed its malpositioned plate following fusion. No new neurological deficit was observed. Cases that underwent anterior open reduction did not encounter failure that require subsequent posterior reduction surgery. One study (N = 52) on old dislocation incorporated partial corpectomy in their approach and limited anterior-alone approach to cases with persistent instability.
CONCLUSIONS: This systematic review supports the efficacy and success of anterior reduction, fusion, and instrumentation for cervical facet fracture dislocation. It is safe from a neurological standpoint. Revision rate due to concurrent facet fracture is low. Certain patients may require posteriorly based surgery or in specific cases combined anterior and posterior procedures.
METHODS: The mean follow-up for 60 AIS (Lenke 1 and Lenke 2) patients was 49.3 ± 8.4 months. Optimal UIV tilt angle was calculated from the cervical supine side bending radiographs. Lateral shoulder imbalance was graded using the clinical shoulder grading. The clinical neck tilt grading was as follows: Grade 0: no neck tilt, Grade 1: actively correctable neck tilt, Grade 2: neck tilt that cannot be corrected by active contraction and Grade 3: severe neck tilt with trapezial asymmetry >1 cm. T1 tilt, clavicle angle and cervical axis were measured. UIVDiff (difference between post-operative UIV tilt and pre-operative Optimal UIV tilt) and the reserve motion of the UIV were correlated with the outcome measures. Patients were assessed at 6 weeks and at final follow-up with a minimum follow-up duration of 24 months.
RESULTS: Among patients with grade 0 neck tilt, 88.2 % of patients had the UIV tilt angle within the reserve motion range. This percentage dropped to 75.0 % in patients with grade 1 neck tilt whereas in patients with grade 2 and grade 3 neck tilt, the percentage dropped further to 22.2 and 20.0 % (p = 0.000). The occurrence of grade 2 and 3 neck tilt when UIVDiff was <5°, 5-10° and >10° was 9.5, 50.0 and 100.0 %, respectively (p = 0.005). UIVDiff and T1 tilt had a positive and strong correlation (r2 = 0.618). However, UIVDiff had poor correlation with clavicle angle and the lateral shoulder imbalance.
CONCLUSION: An optimal UIV tilt might prevent neck tilt with 'medial' shoulder imbalance due to trapezial prominence and but not 'lateral' shoulder imbalance.