BACKGROUND:Anterior vertebral body tethering (AVBT) has been introduced as a means of correcting scoliosis without fusion. The purpose of this study was to compare outcomes for patients with thoracic ...idiopathic scoliosis between a group of patients who underwent AVBT and a matched cohort of patients treated with posterior spinal fusion and instrumentation (PSF).
METHODS:A retrospective study of patients who underwent AVBT and PSF for idiopathic scoliosis was conducted. The inclusion criteria were determined on the basis of the AVBT cohortprimary thoracic idiopathic scoliosis with a curve magnitude between 40° and 67°, Risser stage of ≤1, age of 9 to 15 years, no prior spine surgery, index surgery between 2011 and 2016, and minimum follow-up of 2 years. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups.
RESULTS:There were 23 patients in the AVBT cohort and 26 patients in the PSF cohort. The mean follow-up (and standard deviation) was similar between groups3.4 ± 1.1 years for the AVBT group and 3.6 ± 1.6 years for the PSF group (p = 0.6). Preoperatively, the groups were similar in all measurements of radiographic and clinical deformity, with mean main thoracic curves of 53° ± 8° for the AVBT group and 54° ± 7° for the PSF group (p = 0.4). At the time of final follow-up, the AVBT cohort had significantly more residual deformity, with a mean thoracic curve of 33° ± 18° compared with 16° ± 6° for the PSF group (p < 0.001). There were 9 revision procedures in the AVBT cohort (with 3 conversions to PSF and 3 more pending) and none in the PSF cohort. Revisions occurred at a mean postoperative time of 2.3 years (range, 1.2 to 3.7 years). Twelve patients (52%) had evidence of broken tethers; of these patients, 4 underwent revision. The post-intervention patient-reported outcomes were similar.
CONCLUSIONS:Both AVBT and PSF resulted in postoperative correction; however, 2-year correction was better maintained in the PSF group. There were no differences in post-intervention patient-reported outcomes. AVBT resulted in less deformity correction and more revision procedures than PSF, but resulted in the delay or prevention of PSF in the majority of patients.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background Obtaining accurate measurements of scoliosis from two-dimensional (2-D) radiographs can be challenging because of the three-dimensional (3-D) nature of the deformity. Previous studies have ...shown that the sagittal plane, in particular, is misrepresented on 2-D radiographs because of the influence of axial plane rotation. The purpose of the current study was to define a methodology for measuring the 3-D segmental sagittal alignment of the spine in patients with adolescent idiopathic scoliosis (AIS) and to assess the effect of axial plane rotation on differences between 3-D and 2-D measures of deformity. Methods Preoperative and postoperative EOS images of 120 consecutive patients with AIS (primary thoracic curves) treated with segmental thoracic pedicle-screw instrumentation were analyzed in the “3-D sagittal plane.” The technique measured 3-D kyphosis or lordosis in the specific plane of sagittal motion for each spinal motion segment. The kyphosis (+) and lordosis (−) values of the segments from T 0025 to T 0060 were summed to give the 3-D measurement of T5-T12 kyphosis. These values were compared with the standard 2-D measurements of T5-T12 kyphosis on lateral radiographs, and a correlation analysis with regard to axial plane rotation of the apex was performed. Results The average age (and standard deviation) of the patients was 14 ± 2 years. The mean preoperative Cobb angle on the standard 2-D view was 55° ± 10° and on the 3-D view was 52° ± 9° (p ≤ 0.001). On the 3-D view, the mean preoperative T5-T12 kyphosis was 6° ± 14°, and the kyphosis significantly increased to 26° ± 6° postoperatively (p < 0.001). The T5-T12 kyphosis on the standard 2-D view measured 18° ± 13° preoperatively and 27° ± 6° postoperatively (p < 0.001). The difference between the 2-D and 3-D measurements of T5-T12 kyphosis strongly correlated with apical vertebral rotation (r = 0.85; p < 0.01). Conclusions Routine 2-D measurements of thoracic kyphosis erroneously underestimate the preoperative loss of kyphosis in AIS because of errors associated with axial plane rotation, an inherent component of thoracic scoliosis. Level of Evidence Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.
Anterior vertebral body tethering (AVBT) has been introduced as a means of correcting scoliosis without fusion. The purpose of this study was to compare outcomes for patients with thoracic idiopathic ...scoliosis between a group of patients who underwent AVBT and a matched cohort of patients treated with posterior spinal fusion and instrumentation (PSF).
A retrospective study of patients who underwent AVBT and PSF for idiopathic scoliosis was conducted. The inclusion criteria were determined on the basis of the AVBT cohort: primary thoracic idiopathic scoliosis with a curve magnitude between 40° and 67°, Risser stage of ≤1, age of 9 to 15 years, no prior spine surgery, index surgery between 2011 and 2016, and minimum follow-up of 2 years. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups.
There were 23 patients in the AVBT cohort and 26 patients in the PSF cohort. The mean follow-up (and standard deviation) was similar between groups: 3.4 ± 1.1 years for the AVBT group and 3.6 ± 1.6 years for the PSF group (p = 0.6). Preoperatively, the groups were similar in all measurements of radiographic and clinical deformity, with mean main thoracic curves of 53° ± 8° for the AVBT group and 54° ± 7° for the PSF group (p = 0.4). At the time of final follow-up, the AVBT cohort had significantly more residual deformity, with a mean thoracic curve of 33° ± 18° compared with 16° ± 6° for the PSF group (p < 0.001). There were 9 revision procedures in the AVBT cohort (with 3 conversions to PSF and 3 more pending) and none in the PSF cohort. Revisions occurred at a mean postoperative time of 2.3 years (range, 1.2 to 3.7 years). Twelve patients (52%) had evidence of broken tethers; of these patients, 4 underwent revision. The post-intervention patient-reported outcomes were similar.
Both AVBT and PSF resulted in postoperative correction; however, 2-year correction was better maintained in the PSF group. There were no differences in post-intervention patient-reported outcomes. AVBT resulted in less deformity correction and more revision procedures than PSF, but resulted in the delay or prevention of PSF in the majority of patients.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND:Anterior spinal growth tethering (ASGT) has been shown to alter spinal growth with the potential to correct scoliosis while maintaining spine flexibility. The purpose of this study was to ...report the 2 to 4-year outcomes of ASGT in skeletally immature patients with thoracic scoliosis.
METHODS:We conducted a retrospective review of patients with thoracic scoliosis who underwent ASGT with a minimum of 2 years of follow-up. Patient demographics, perioperative data, and radiographic outcomes are reported. A “successful” clinical outcome was defined as a residual curve of <35° and no posterior spinal fusion indicated or performed at latest follow-up.
RESULTS:Seventeen patients met the inclusion criteria. The etiology was idiopathic for 14 and syndromic for 3. The mean follow-up was 2.5 years (range, 2 to 4 years). Preoperatively, all patients were at Risser stage 0, with a mean age at surgery of 11 ± 2 years (range, 9 to 14 years). There was an average of 6.8 ± 0.5 vertebrae tethered per patient. The average thoracic curve magnitude was 52° ± 10° (range, 40° to 67°) preoperatively, 31° ± 10° immediately postoperatively, 24° ± 17° at 18 months postoperatively, and 27° ± 20° at latest follow-up (51% correction; range, 5% to 118%). Revision surgery was performed in 7 patients4 tether removals due to complete correction or overcorrection, 1 lumbar tether added, 1 tether replaced due to breakage, and 1 revised to a posterior spinal fusion. In 3 additional patients, posterior spinal fusion was indicated due to progression. Eight (47%) of the patients had a suspected broken tether. Ten (59%) of the 17 were considered clinically successful.
CONCLUSIONS:Despite most patients having some remaining skeletal growth at the time of review, the results of the current study demonstrate that at mid-term follow-up, ASGT showed a powerful, but variable, ability to modulate spinal growth and did so with little perioperative and early postoperative risk. Fusion was avoided for 13 of the 17 patients. The overall success rate was 59%, with a 41% revision rate. Understanding the parameters leading to success or failure will be critical in advancing a reliable definitive nonfusion treatment for progressive scoliosis in the future.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
STUDY DESIGN.A prospective multicenter study.
OBJECTIVE.To evaluate the effects of sparing lumbar motion segments on spinal mobility and Scoliosis Research Society-22 scores at 10 years after spinal ...fusion for major thoracic adolescent idiopathic scoliosis (AIS).
SUMMARY OF BACKGROUND DATA.In surgical correction for major thoracic AIS, the long-term benefits of sparing lumbar motion segments remain unclear.
METHODS.A prospective multicenter registry was reviewed and patients with major thoracic AIS (Lenke types 1–4) and availability of both preoperative and 10-year postoperative mobility data were included. Spinal fusions ending at L1 or above were defined as thoracic fusions (T), and at L2 or below as thoracic and lumber fusions (T + L). Spinal mobility was evaluated with a measuring tape. The excursions between the starting and ending positions were measured using the distance from the spinous processes of C7 to S1 for forward flexion (FF), and the distance from the tip of the middle finger to the floor for lateral flexion (LF). Substantial reduction of mobility was defined as a reduction rate (a ratio of postoperative change divided by preoperative mobility) of 40% or more. Motion data were correlated with lowest instrumented vertebra levels and group comparisons were performed.
RESULTS.We identified 151 patients (average age, 25.1 years). The spinal mobility decreased with more distal lowest instrumented vertebrae (FF, rho = 0.208; right LF, 0.257; left LF, 0.371; P ≤ 0.01). Consequently, the incidence of substantial reduction of mobility was lower in the T group (n = 109) than in the T + L group (n = 42) (FF17.4% vs. 50%, LF14.8% vs. 51.2%; P < 0.001). Patients with substantial reduction in LF had lower Scoliosis Research Society-22 scores for pain, function, satisfaction, and total scores than those without substantial reduction at 10-year follow-up (P < 0.05).
CONCLUSION.The sparing of lumbar motion segments demonstrated clinically significant benefits at 10-year postoperatively.Level of Evidence2
BACKGROUND:Reporting accurate surgical complication rates to patients and their families is important in the management of adolescent idiopathic scoliosis (AIS). In this study, we report the rate of ...major complications following the surgical treatment of AIS both in the perioperative period and among patients with a minimum of 2 years of follow-up.
METHODS:We reviewed the prospectively collected data of a multicenter registry of patients who underwent surgical treatment of AIS during the period of 1995 to 2014 in order to identify all complications. A complication was defined as “major” if it resulted in reoperation or in spinal cord or nerve root injury, or was life-threatening. A total of 3,582 patients with preoperative and early postoperative data (4 to 6 weeks of follow-up) were included. A subset of 2,220 patients with a minimum of 2 years of follow-up comprised the cohort for delayed complications. Overall complication rates were calculated, as was the percentage of complications according to the year of the index surgery and type of surgical approach.
RESULTS:The mean age of the 3,582 patients at the time of surgery was 14.8 ± 2.2 years. The average major curve magnitude was 56° ± 13° for thoracic curves and 51° ± 11° for lumbar. In 365 patients, anterior spinal fusion (ASF) with instrumentation was performed, and in 3,217 patients, posterior spinal fusion (PSF) with instrumentation was performed; 142 patients in the PSF group underwent concomitant anterior release. There were 192 major complications, with 93 (2.6%) occurring perioperatively. Perioperative complications included wound-related (1.0% of the patients), neurologic (0.5%), pulmonary (0.4%), instrumentation-related (0.4%), and gastrointestinal (0.2%) complications. One patient died. The mean annual perioperative major complication rate based on the year of surgery ranged from 0% to 10.5%. The complication rate by surgical approach was 3.0% for ASF and 2.6% for PSF (2.4% for PSF only and 5.6% for PSF with anterior release). The major complication rate for the 2,220 patients with at least 2 years of follow-up was 4.1%; all but 1 had a reoperation (4.1%). The majority of these major complications were wound and instrumentation-related (1.9% and 0.8%, respectively).
CONCLUSIONS:After surgery for AIS, a 2.6% rate of perioperative major complications and a 4.1% rate of major complications at 2 or more years after surgery can be anticipated. The complication rate decreased over the period of study.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Purpose
Utilizing 2D measurements, previous studies have found that in AIS, increased thoracic Cobb and decreased thoracic kyphosis contribute to pulmonary dysfunction. Recent technology has improved ...our ability to measure and understand the true 3D deformity in AIS. The purpose of this study was to evaluate which 3D radiographic measures predict pulmonary dysfunction.
Methods
One hundred and sixty-three surgically treated AIS patients with preoperative PFTs (FEV, FVC, TLC) and EOS
®
imaging were identified at a single center. Each spine was reconstructed in 3D to obtain the true coronal, sagittal, and apical rotational deformities. These were then correlated with the patient’s preoperative PFT measurements. Regression analysis was performed to determine the relative effect of each radiographic measure.
Results
There were 124 thoracic and 39 lumbar major curves. The range of preoperative thoracic and lumbar 3D coronal angle was 11–115° and 11–98°, respectively. The range of preoperative thoracic 3D kyphosis (T5–T12) and thoracic apical vertebral rotation was −56 to 44° and 0–29°, respectively. Increasing thoracic 3D Cobb and thoracic vertebral rotation and decreasing thoracic 3D kyphosis most significantly correlated with decreasing pulmonary function, especially FEV. In patients with the largest degree of thoracic deformity (3D Coronal Cobb > 80°, 3D thoracic lordosis >20°, and absolute apical rotation >25°), the majority of patients had moderate to severe pulmonary impairment (≤65 % predicted). 3D thoracic kyphosis was the most consistent predictor of FEV (
r
2
= 0.087), FVC (
r
2
= 0.069), and TLC (
r
2
= 0.098) impairment.
Conclusions
Larger thoracic coronal, sagittal, and axial deformities increase the risk of pulmonary impairment in patients with AIS. Of these, decreasing 3D thoracic kyphosis is the most consistent predictor. This information can guide surgeons in the decision making process for determining which surgical techniques to utilize and which component of the deformity to focus on.
BACKGROUND:Anterior cruciate ligament (ACL) reconstruction failure is relatively common in young high-risk athletes. The purpose of this study was to examine a single center’s 10-year experience with ...ACL reconstructions in pediatric and adolescent patients to better define short-term failure rates and risk factors for revision ACL surgery.
METHODS:This institutional review board-approved retrospective study included all patients who underwent a primary ACL reconstruction between 2002 and 2013. Chart and radiographic review was performed to assess patient demographic, injury, and surgical data including growth plate status, concomitant ligament/meniscus/cartilage injury, surgical procedures, femoral drilling technique, graft source and type, femoral and tibial fixation devices, and graft size. Graft failures had to be confirmed both with clinical examination and magnetic resonance imaging or the patient had to undergo a revision ACL reconstruction. Potential factors associated with failure were evaluated using either parametric or nonparametric analysis as appropriate.
RESULTS:A total of 561 ACL reconstructions were performed that met our inclusion criteria. The average patient age was 15.4 years (range, 5 to 19 y) and 53% of the patients were male. In all, 54 failures were identified for a 9.6% failure rate. Soft tissue grafts were twice as likely to fail compared with patellar tendon grafts (13% vs. 6%; P<0.001). Multivariate analysis revealed that graft choice (soft tissue vs. patellar tendon) was the primary variable predictive of failure (P<0.05), with interactions/mediating effects contributed by maturity (growth plate status) and ACL technique (P<0.05). The average time to failure was 13.6 months and hamstring grafts and anatomic femoral tunnels were both found to fail earlier (P<0.05). During the study period, approximately 8% of patients sustained a contralateral ACL injury.
CONCLUSIONS:ACL failure rates in adolescent and pediatric patients vary based on patient age, graft selection, and surgical technique. Bone patellar tendon bone autografts had the lowest failure rate in this high-risk population.
LEVEL OF EVIDENCE:Level IV—retrospective case series.
Retrospective analysis of prospectively collected multicenter series.
To evaluate the sagittal profile of surgically treated adolescent idiopathic scoliosis (AIS) patients.
With the increasing ...popularity of segmental pedicle screw spinal instrumentation, thoracic kyphosis (TK) is often sacrificed to achieve coronal and axial plane correction.
Radiographs of AIS patients with a Lenke type 1 deformity and minimum 2-year follow-up after selective thoracic fusion (lowest instrumented vertebra of T11, T12, or L1) were evaluated. Changes in TK were correlated with changes in lumbar lordosis (LL). Patients were divided according to approach (open/thoracoscopic anterior vs. posterior). Analysis of variance was used to compare pre and postoperative radiographic measures.
Two hundred fifty-one patients (age: 14 +/- 2 years) were included. Sixty seven percentages of the patients had anterior surgery (97 open anterior, 71 thoracoscopic) and 33% (83 patients) had posterior spinal fusion. A decrease in postoperative TK was significantly correlated (P < or = 0.001) with a decrease in LL at first erect (r = 0.3), 1 year (r = 0.4) and 2 years (r = 0.4), independent of surgical approach. LL decreased significantly at the first erect regardless of approach (P = 0.003); however, at 2-year postoperative TK and LL were significantly decreased after a posterior approach (P < or = 0.001) when compared with an anterior approach that added kyphosis. The decrease in LL (5.6 degrees +/- 9.7 degrees) was nearly twice the decrease in TK (2.8 degrees +/- 11.4 degrees) in the posterior group at 2-years.
Given that thoracic AIS is often associated with a preexisting reduction in TK, ideal surgical correction should address this deformity. Procedures which further reduce TK also reduce LL. It is unclear if the loss of LL from thoracic scoliosis correction will compound the loss of LL that occurs with age and lead to further decline in sagittal balance. With this concern, we recommend a posterior column lengthening and/or an anterior column shortening to achieve restoration of normal TK and maximal LL.
Observational case control.
The objective of this study was to evaluate the prevalence of opioid use two years after surgical correction of adolescent idiopathic scoliosis (AIS) and its association ...with preoperative mental health.
Studies of opiate use have reported that up to 80% of users began their addiction with misuse of prescription opioids. Identifying opioid use and those at risk in the AIS population is critical for optimal outcomes.
A query of a multicenter prospective AIS surgical fusion registry was performed to identify patients of all curve types with responses to question 11 on the Scoliosis Research Society-22 questionnaire at two years postoperative. Question 11 asks about pain medication usage for the patient's back with five specific responses: narcotics daily, narcotics weekly or less, non-narcotics daily, non-narcotics weekly/less, or none. Ordinal regression was used to evaluate the association between preoperative Scoliosis Research Society-22 Mental Health (MH) domain scores and two-year postoperative pain medication usage.
A total of 2595 patients who underwent surgery from 2002 to 2019 met inclusion. The average primary curve was 56±12°, average age 14.7±3 years, and 81.5% were female. Forty (1.5%) patients reported utilizing opioids two years after surgery, and a significant difference in preoperative MH scores was observed. Patients taking daily opioids postoperatively had the lowest median preoperative MH score (3.75), followed by non-narcotic group (4), and no medication (4.2, P <0.001). Three patients reporting opioid use postoperatively reported preoperative usage. The rate of two-year postoperative medication use based on the year of surgery demonstrated a small linear decrease in opioid use over time, with a slight increase in nonopioid daily use.
Less than 2% of patients reported taking opioids for back pain two years after surgical correction of AIS. A lower MH score before surgery may place a patient at increased risk for opioid use two years after surgery. An analysis of the year of surgery suggests that changes in prescription practices over time may be occurring.
4.
