Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Pediatric Spine 10 articles


Joseph C. Risser Sr., 1892–1982

M. M. Manring PhD, Jason Calhoun MD [object Object]

Vertebral Column Resection for the Treatment of Severe Spinal Deformity

Lawrence G. Lenke MD, Brenda A. Sides MA, Linda A. Koester BS, Marsha Hensley RN, Kathy M. Blanke RN

The ability to treat severe pediatric and adult spinal deformities through an all-posterior vertebral column resection (VCR) has obviated the need for a circumferential approach in primary and revision surgery, but there is limited literature evaluating this new approach. Our purpose was therefore to provide further support of this technique. We reviewed 43 patients who underwent a posterior-only VCR using pedicle screws, anteriorly positioned cages, and intraoperative spinal cord monitoring between 2002 and 2006. Diagnoses included severe scoliosis, global kyphosis, angular kyphosis, or kyphoscoliosis. Forty (93%) procedures were performed at L1 or cephalad in the spinal cord (SC) territory. Seven patients (18%) lost intraoperative neurogenic monitoring evoked potentials (NMEPs) data during correction with data returning to baseline after prompt surgical intervention. All patients after surgery were at their baseline or showed improved SC function, whereas no one worsened. Two patients had nerve root palsies postoperatively, which resolved spontaneously at 6 months and 2 weeks. Spinal cord monitoring (specifically NMEP) is mandatory to prevent neurologic complications. Although technically challenging, a single-stage approach offers dramatic correction in both primary and revision surgery of severe spinal deformities.,[object Object]

Shilla Growing Rods in a Caprine Animal Model: A Pilot Study

Richard E. McCarthy MD, Daniel Sucato MD, Joseph L. Turner MS, Hong Zhang MD, MeLeah A. W. Henson MS, Kathryn McCarthy MD There are few good surgical options that allow for continued spinal growth in patients with early-onset scoliosis. The “Shilla” is a growth guidance system that does not require repeated surgical lengthenings. The Shilla system guides growth at the ends of dual rods with the apex of the curve corrected, fused, and fixed to the rods. The growth occurs through the extraperiosteally implanted pedicle screws that slide along the rods at either end of the construct. We implanted 11 2-month-old immature goats with the dual rod system and euthanized all 11 goats 6 months postoperatively. We evaluated plain radiographs, regular computed tomography, microcomputed tomography, physical and histologic examinations, and a microscopic wear analysis. All of the goat spines grew with the implants in place; growth occurred in both the thoracic and lumbar ends of the rods for a total average of 48 mm. None of the implants failed, although we observed minor wear at the rod/screw interface. Growth guidance with the Shilla rod system allowed for continued growth in this goat model.

Radiographic Classification of Complications of Instrumentation in Adolescent Idiopathic Scoliosis

John M. Flynn MD, Randal R. Betz MD, Michael F. O’Brien MD, Peter O. Newton MD In spinal deformity surgery, techniques and implants must be assessed for their safety and efficacy. Regulatory bodies, third-party payors, and patients will increasingly scrutinize treatment methods based on the frequency of adverse events. We therefore developed a classification of adverse hardware-related events using plain radiographic criteria. We analyzed the adverse events in 466 patients surgically treated for adolescent idiopathic scoliosis for a Type 1 (Lenke et al.) curve. We used plain radiographic films to define complications as either serious radiographic adverse events or radiographic adverse events in four technique groups: posterior spinal fusion with hooks and/or hybrid systems, posterior spinal fusion using mostly pedicle screws, open anterior spinal fusion, and thoracoscopic anterior spinal fusion. We defined serious radiographic adverse events as those requiring subsequent surgery. The minimum followup was 2 years. We found a reoperation rate ranging from 4.5% (open anterior spinal fusion) to 8.8% (posterior spinal fusion with hooks); we found no difference in the incidence of serious radiographic adverse events between surgical techniques. Among serious radiographic adverse events, the most common problems were revision for lumbar progression, rod breakage, and proximal screw pullout in the anterior spinal fusions and instrumentation removal for pain and infection in the posterior spinal fusions. We propose a new radiographic system of adverse hardware-related events for patients with Type 1 adolescent idiopathic scoliosis.,[object Object]

Infection Rate after Spine Surgery in Cerebral Palsy is High and Impairs Results: Multicenter Analysis of Risk Factors and Treatment

Paul D. Sponseller MD, Suken A. Shah MD, Mark F. Abel MD, Peter O. Newton MD, Lynn Letko MD, Michelle Marks MS, PT [object Object],[object Object]

A History of Bracing for Idiopathic Scoliosis in North America

Reginald S. Fayssoux MD, Robert H. Cho MD, Martin J. Herman MD The care of the patient with scoliosis has a history extending back over two millennia with cast and brace treatment being a relatively recent endeavor, the modern era comprising just over half a century. Much of the previous literature provides a modest overview with emphasis on the history of the operative management. To better understand the current concepts of brace treatment of scoliosis, an appreciation of the history of bracing would be helpful. As such, we review the history of the treatment of scoliosis with an emphasis on modern brace treatment, primarily from a North American perspective. Our review utilizes consideration of historical texts as well as current treatises on the history of scoliosis and includes discussion of brace development with their proponents’ rationale for why they work along with an appraisal of their clinical outcomes. We provide an overview of the current standards of care and the braces typically employed toward that standard including: the Milwaukee brace, the Wilmington brace, the Boston brace, the Charleston brace, the Providence brace and the SpineCor brace. Finally, we discuss future trends including improvements in methods of determining the critical period of peak growth velocity in children with scoliosis, the exciting promise of gene markers for progressive scoliosis and “internal bracing” options.

The Usefulness of VEPTR in the Older Child With Complex Spine and Chest Deformity

Amer F. Samdani MD, Tricia St. Hilaire BS, John B. Emans MD, John T. Smith MD, Kit Song MD, Robert J. Campbell MD, Randal R. Betz MD

The vertical expandable prosthetic titanium rib (VEPTR) was originally designed to treat chest and spine deformities in young children. However, older children with complex spinal deformities may also benefit from placement of a VEPTR when vertebral column resections are deemed too risky neurologically. We report: (1) the changes in Cobb angle, T1 angle, and head tilt; and (2) the occurrence of complications in children older than 10 years of age treated with VEPTR. From a database of 214 patients treated in a Food and Drug Administration Investigational Device Exemption study of VEPTR, we identified 10 patients with assorted diagnoses who underwent surgery after age 10 and had a minimum of 24-month followup (mean, 39.6 months; range, 24–75 months). No patient sustained neurologic injury. Patients underwent an average of five lengthenings. The mean preoperative Cobb angle was 64.7° and improved to 48.4°. Head shift improved an average of 3.8 cm. Two device-related complications occurred (both in the same patient). Four patients have since undergone definitive spinal fusion. For a select group of patients 10 years of age or older, the VEPTR offers a reasonable alternative to potentially risky vertebral column resections for correcting deformities in selected patients.,[object Object]

Brace Management in Adolescent Idiopathic Scoliosis

Jonathan R. Schiller MD, Nikhil A. Thakur MD, Craig P. Eberson MD Skeletally immature patients with adolescent idiopathic scoliosis are at risk for curve progression. Although numerous nonoperative methods have been attempted, including physical therapy, exercise, massage, manipulation, and electrical stimulation, only bracing is effective in preventing curve progression and the subsequent need for surgery. Brace treatment is initiated as either full-time (TLSO, Boston) or nighttime (Charleston, Providence) wear, although patient compliance with either mode of bracing has been a documented problem. We review the natural history of adolescent idiopathic scoliosis, identify the risks for curve progression, describe the types of braces available for treatment, and review the indications for and efficacy of brace treatment.,[object Object]

Do Intraoperative Radiographs in Scoliosis Surgery Reflect Radiographic Result?

Ronald A. Lehman MD, Lawrence G. Lenke MD, Melvin D. Helgeson MD, Tobin T. Eckel MD, Kathryn A. Keeler MD It is often difficult to predict postoperative radiographic curve magnitude and balance parameters while performing intraoperative correction during scoliosis surgery. We asked whether there was a radiographic correlation between intraoperative long-cassette scoliosis film and postoperative standing radiographs of adolescent idiopathic scoliosis with pedicle screw instrumentation. We retrospectively reviewed 44 patients with adolescent idiopathic scoliosis who underwent posterior instrumentation with pedicle screws. We made preoperative, intraoperative (after instrumentation and correction), and standing postoperative radiographic measurements (eg, curve magnitudes, coronal and sagittal balance, disc angles) and compared those for the intra- and postoperative radiographs. The intraoperative long-cassette scoliosis film correlated with the immediate postoperative standing film for all curve correction and balance parameters. The routine use of a long-cassette intraoperative scoliosis film provides the surgeon with a valuable tool to guide intraoperative decision-making and foreshadows the correction and balance obtained on the immediate postoperative film.,[object Object]