Ahmet Yılmaz Şarlak

Juvenile idiopathic scoliosis treated with posterior arthrodesis and segmental pedicle screw instrumentation before the age of 9 years: a 5-year follow-up.

Study designRetrospective study.ObjectiveTo evaluate the radiological results of fusion with segmental pedicle screw fixation in juvenile idiopathic scoliosis with a minimum 5-year follow-up.Summary of background dataProgression of spinal deformity after posterior instrumentation and fusion in immature patients has been reported by several authors. Segmental pedicle screw fixation has been shown to be effective in controlling both coronal and sagittal plane deformities. However, there is no long term study of fusion with segmental pedicle screw fixation in these group of patients.MethodsSeven patients with juvenile idiopathic scoliosis treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 7.4 years (range 5–9 years) at the time of the operation. All the patients were followed up 5 years or more (range 5–8 years) and were all Risser V at the most recent follow up. Three dimensional reconstruction of the radiographs was obtained and 3DStudio Max software was used for combining, evaluating and modifying the technical data derived from both 2d and 3d scan data.ResultsThe preoperative thoracic curve of 56 ± 15° was corrected to 24 ± 17° (57% correction) at the latest follow-up. The lumbar curve of 43 ± 14° was corrected to 23 ± 6° (46% correction) at the latest follow-up. The preoperative thoracic kyphosis of 37 ± 13° and the lumbar lordosis of 33 ± 13° were changed to 27 ± 13° and 42 ± 21°, respectively at the latest follow-up. None of the patients showed coronal decompensation at the latest follow-up. Four patients had no evidence of crankshaft phenomenon. In two patients slight increase in Cobb angle at the instrumented segments with a significant increase in AVR suggesting crankshaft phenomenon was seen. One patient had a curve increase in both instrumented and non instrumented segments due to incorrect strategy.ConclusionIn juvenile idiopathic curves of Risser 0 patients with open triradiate cartilages, routine combined anterior fusion to prevent crankshaft may not be warranted by posterior segmental pedicle screw instrumentation.

Treatment of fixed thoracolumbar kyphosis in immature achondroplastic patient: posterior column resection combined with segmental pedicle screw fixation and posterolateral fusion

A 13-year-old male achondroplastic dwarf with fixed thoracolumbar kyphosis was treated by segmental pedicle screw fixation, posterolateral fusion combined with one stage two level posterior column resection. Preoperative and postoperative kyphosis angles were 97 and 32°, respectively. Combination of segmental pedicle instrumentation with posterior column resection is a treatment option even in immature achondroplastic patients.

Isolated pedicle screw instrumented correction for the treatment of thoracic congenital scoliosis.

Study Design Retrospective study. Objective To evaluate the radiologic results of fusion with segmental pedicle screw fixation in neglected thoracic congenital curves with a mean follow-up of 51.3 months (range: 24 to 108 mo). Summary of Background Data Segmental pedicle screw fixation has been shown to be effective both in correcting and controlling the idiopathic spinal deformities. However, the choice of treatment modality is more controversial in neglected thoracic congenital curves of the aged. Methods Fourteen patients with thoracic congenital curves treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 14.9 years (range: 10 to 25 y) at surgery. Deformity correction was achieved by compression of the convex deformity side with resection of apical 3 ribs. Radiologic analyses of coronal and sagittal plane included Cobb angles of the major compensatory curves, apical vertebrae translation, and sagittal Cobb angles, respectively. Results In the coronal plane, the preoperative mean major curve Cobb angle of 52.3 degree (range: 32.6 to 66.7 degrees) was corrected to 25.3 degree (range: 7.2 to 44.8 degree) and the mean compensatory curve Cobb angle of 23.6 degree (range: 10.3 to 34.8 degrees) was corrected to 15.9 degree (range: 5.7 to 30.6 degrees). The mean translation of apical vertebrae was 28.8 mm (range: 4.7 to 53.6 mm) before surgery and 15.5 mm (range: 2.4 to 41.3 mm) after surgery. In the sagittal plane, the mean preoperative and postoperative sagittal T5 to T12 angles were 34.8 degree (range: 16.5 to 44.7 degrees) and 27.3 degree (range: 10.4 to 43.5 degrees), respectively. The mean preoperative and postoperative sagittal T12 to S1 angles were 47.2 degree (range: 23.4 to 65.1 degrees) and 41.3 degree (range: 23.8 to 62.7 degrees), respectively. Conclusion In the neglected thoracic congenital deformities of the aged, with posterior pedicle instrumented fusion, an acceptable correction can be achieved with relatively low morbidity.

An unusual type of lateral compression injury of the pelvis tilt fracture with anterior displacement.

Tilt fracture is the most unusual variant of pelvic lateral compression injury. The major problem was reported to be protrusion of the pubic ramus into the perineum by posterior-inferior displacement of the fragment. Tilt fragment with anterior and inferior displacement has not been reported in English speaking literature to our knowledge. Anterior tilt fragment can cause significant morbidity in terms of vascular injury, pelvic stability and acetabular fracture.

Distal fusion level selection in Lenke 1A curves according to axial plane analyses

BACKGROUND CONTEXT In adolescent idiopathic scoliosis (AIS), identification of curve patterns and determination of fusion levels are most important for correcting deformity, improving trunk balance, and saving motion segments. Lenke 1A scoliosis is the most common type of AIS, accounting for around 16% of all AIS; however, how to determine the lower instrumented vertebrae in this common curve type is unclear. PURPOSE The aim was to classify Lenke 1A curves according to lumbar axial plane analyses to determine optimal distal fusion level selection. STUDY DESIGN This was a retrospective study. PATIENT SAMPLE This study included 69 consecutive patients with AIS (13 males and 56 females) of Lenke Type 1A curve who underwent posterior correction and fusion of the thoracic spine between 2001 and 2013 in a single center. OUTCOME MEASURES Coronal, sagittal, and axial parameters were measured from plain radiographs that were obtained at initial medical examination of the patients. METHODS Coronal and sagittal plane and whole spine segmental vertebra rotations from thoracic 1 to lumbar 5 were evaluated by using Drerup method. As a result of analysis of axial plane, all patients with Lenke 1A curves were divided into three groups depending on lumbar vertebral rotation. In Group I, the rotation of lumbar vertebral rotation was accepted as neutral. In Group II, the direction of lumbar vertebral rotation was same with other vertebrae in the main curve. In Group III, the rotation of lumbar vertebral rotation had opposite direction with vertebrae in the main curve. RESULTS In Group I curves, the mean position of lower end vertebrae (LEVs) was more frequently at T11, neutral vertebra (NV)-last touched vertebra (LTV) at T12, and stable vertebra (SV) at L2. In Group II curves, the mean position of LEV was more frequent at L1, LTV at L2, NV at L3, and SV at L4, whereas in Group III curves, the median position of LEV-NV-LTV was frequently at T12 and that of SV at L1. Then, Group I to III curves between Group II curves showed the gap differences of NV-LEV, SV-LEV to be significantly different. Similarly, the SV was not more than two segments distal from LEV in Group I and Group III but more than two to three segments from LEV in Group II. CONCLUSIONS Our analysis suggested that not all Lenke 1A curves yield satisfactory outcome with the same fusion extend although a high percentage of the patients with Lenke 1A curves have shown satisfactory outcome with NV fusion. Thus, it seems that some Lenke 1A curves may require fusion to SV.

Kyphoscoliosis of an acrogigantic patient treated by pedicle subtraction osteotomy and posterior pedicle instrumented fusion

Acromegaly is a disorder of disproportionate skeletal, tissue, and organ growth, with a prevalence of 40–70 cases per million persons and an annual incidence of three to four new cases per million persons [1]. A small proportion of patients may develop gigantism if growth hormone (GH) exposure occurs before epiphyseal plate closure. Besides the local mass effect of pituitary tumor, disease pathogenesis involves GH hypersecretion by tumorous pituitary somatotrophic cells and results in multiple metabolic and structural dysfunctions. Up to 21 % of patients exhibit kyphoscoliosis [2]. Surgery and medical and radiation therapy have specific advantages and disadvantages that should be weighed and tailored very carefully for each patient. No single algorithm applies to all patients [3]. Large retrospective studies of acromegaly patients indicate an average 10-year reduction in life expectancy, with at least doubling of standardized mortality rates due to cardiovascular, cerebrovascular, metabolic, and respiratory comorbidities [4]. Recent studies reflect the positive impact of multimodal therapy on mortality outcomes [5]. It has even been suggested that normal insulin-like growth factor (IGF) level in patients with acromegaly predict a normal expected mortality rate [6]. The negative impact of sagittal malalignment with regard to disability, pain, and poor health-related quality of life has been well documented [7]. Spinal osteotomy and pedicle-screw instrumentation combination have demonstrated excellent radiographic and clinical outcomes for correcting sagittal malalignment [8]; to our knowledge, however, it has not been reported in kyphoscoliotic deformity of an acrogigantic patient. Whereas structures at risk when using a pedicle screw seem similar to those in patients with other types of spinal deformities, decreased vascular resistance [9–11] and fragile aorta [12] pose significant risk of aorta rupture in the surgical correction of sagittal malalignment with osteotomy in acrogigantism. The purpose of this case report is to discuss patientspecific risk factors and vertebral morphology for efficient and safe pedicle fusion and subtraction osteotomy (PSO) in an acrogigantic patient with kyphoscoliosis.