Athanasios I. Tsirikos

Comparison of One-stage versus Two-stage Anteroposterior Spinal Fusion in Pediatric Patients With Cerebral Palsy and Neuromuscular Scoliosis

Study Design. A retrospective study was performed including 45 pediatric patients with spastic quadriplegic cerebral palsy and neuromuscular scoliosis who underwent anteroposterior spinal fusion. Objectives. To evaluate the outcomes and complications of one-stage and two-stage combined anteroposterior spine fusion and to document which procedure is more efficacious and provides better results. Summary of Background Data. Circumferential spinal arthrodesis has been proven to achieve better scoliotic curve correction, decreasing significantly the risk of pseudarthrosis and progression of the deformity. There have been a few studies comparing same-day versus staged anteroposterior spinal surgery in mixed populations with neuromuscular scoliosis, but not in an isolated group of pediatric patients with spastic cerebral palsy. Methods. The medical records and radiographs of all patients were reviewed, and the results were statistically analyzed. The complications were divided into medical, subcategorized into major and minor, and technical. Results. There was no statistically significant difference (P > 0.05) between one-stage (Group 1) and two-stage (Group 2) patients, considering age at surgery, preoperative scoliosis angle, pelvic obliquity, kyphosis angle, lordosis angle, levels of anterior release, percentage of scoliosis correction, radiographic follow-up, hospitalization time, and intensive care unit stay. Sequentially performed spinal procedures (Group 1) were associated with increased intraoperative blood loss, prolonged operative time, and a considerably higher incidence of medical and technical complications, including two perioperative deaths. Conclusion. Two-stage anteroposterior spinal fusion provides safer and more consistent results with several advantages over the single-stage procedure in the management of patients with cerebral palsy and neuromuscular scoliosis.

Surgical correction of scoliosis in pediatric patients with cerebral palsy using the unit rod instrumentation.

Study Design. Retrospective clinical and radiographic consecutive case series of 2 surgeons. Objective. The purpose of this study was to present a large consecutive series of patients with cerebral palsy who were treated with the Unit rod instrumentation at a single institution. The goal was to report the incidence of surgical complications, degree of deformity correction, reoperation rate, prevalence of pseudarthrosis, and the caretakers’ perceived outcome. Summary of Background Data. Children with cerebral palsy frequently develop scoliosis that requires surgical correction. Segmental instrumentation has been the primary mode of treatment. There are no reported large series with long-term follow up. Methods. This study was a retrospective review of 287 children treated with the Unit rod instrumentation. This instrumentation with fusion included the whole spine (between C7 and T3 into the pelvis) with 242 posterior-only and 45 anterior-posterior procedures. Of this group, 241 patients were observed for more than 2 years. This review focused on the rate of complications and radiographic outcome of the treatment. Parent and caretaker interviews were conducted to define perceived functional outcome after surgery. Results. Scoliosis was corrected from a mean of 76° to 25° (68%). Pelvic obliquity was corrected from a mean of 17° to 5° (71%). In posterior-only procedures the average blood loss was 2.8 L, ICU stay was 4.9 days, and the hospital stay was 19.6 days. In combined procedures, the average blood loss was 3.4 L, ICU stay was 6.7 days, and the hospital stay was 24.5 days. Major complications included 3 perioperative deaths, 18 deep wound infections [12 early deep infections in a total of 287 patients (4.2%); 6 late deep infections in a total of 236 patients (2.5%)], and 2 patients with septicemia who recovered after prolonged antibiotic management. Caretakers’ survey reported a 96% satisfaction rate. Conclusion. The Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate.

Spinal deformity in neurofibromatosis type-1: diagnosis and treatment

Spinal deformity is the commonest orthopaedic manifestation in neurofibromatosis type-1 and is categorized into dystrophic and non-dystrophic types. Management should be based on a meticulous assessment of the spine with plain radiography and magnetic resonance imaging (MRI) to rule out the presence of dysplastic features that will determine prognosis and surgical planning. MRI of the whole spine should also be routinely obtained to reveal undetected intraspinal lesions that could threaten scheduled surgical interventions. Non-dystrophic curvatures can be treated with similar decision-making criteria to those applied in the management of idiopathic scoliosis. However, close observation is necessary due to the possibility of modulation with further growth and due to the increased reported risk of pseudarthrosis after spinal fusion. The relentless progressive nature of dystrophic curves necessitates aggressive operative treatment, which often has a significant toll on the quality of life of affected patients through their early childhood. Bracing of dystrophic curves has been unsuccessful. Combined anterior/posterior spinal arthrodesis including the entire structural component of the deformity is indicated in most cases, particularly in the presence of associated sagittal imbalance. This should be performed using abundant autologous bone graft and segmental posterior instrumentation to minimize the risk of non-union and recurrence of the deformity.

Congenital Anomalies of the Ribs and Chest Wall Associated with Congenital Deformities of the Spine

BACKGROUND Congenital anomalies of the ribs and chest wall as well as Sprengel deformity of the shoulder are often associated with congenital deformities of the spine. It has been suggested that rib anomalies may adversely affect the progression of the spinal deformity. METHODS We conducted a retrospective study of the medical records and spine radiographs of 620 consecutive patients with congenital deformities of the spine; 497 patients (80%) had scoliosis; eighty-eight patients (14%), kyphoscoliosis; and thirty-five patients (6%), kyphosis. The rib anomalies were classified into simple and complex, and the presence of a Sprengel deformity of the shoulder was recorded. The rate of scoliosis deterioration without treatment before the age of eleven years, as well as the patient age and curve size at the time of surgery, was compared for different types of vertebral abnormalities in patients with and without rib anomalies. RESULTS A total of 119 patients (19.2%) had rib anomalies, which were most commonly associated with congenital scoliosis (111 patients; 93%) and were much less frequently associated with congenital kyphoscoliosis or kyphosis (eight patients). The rib anomalies were simple in ninety-five patients and complex in twenty-four. Eighty-five patients (71%) with rib abnormalities had a scoliosis due to a unilateral failure of vertebral segmentation, and seven patients had mixed or unclassifiable vertebral anomalies. In contrast, only sixteen of 203 patients with a scoliosis due to a hemivertebra alone had rib anomalies. The rib anomalies were most frequently associated with a thoracic or thoracolumbar scoliosis (102 patients; 92%) and occurred on the concavity in eighty-two patients (74%), the convexity in twenty-two patients (20%), and were bilateral in seven patients. The Sprengel deformity occurred in forty-five patients and most frequently in association with a thoracic scoliosis due to a unilateral failure of vertebral segmentation (twenty-seven patients). No significant difference was detected in the rate of curve progression without treatment in patients with and without rib anomalies. The only exception was the mean age at the time of surgery, which was higher for patients with a unilateral unsegmented bar without rib anomalies (p = 0.005). In addition, no significant difference was found with regard to any tethering effect due to the site of the rib fusions on the concavity of the scoliosis, i.e., whether they were in close approximation to the spine or were more lateral (p > 0.05). CONCLUSIONS Congenital rib anomalies occur most commonly on the concavity of a thoracic or thoracolumbar congenital scoliosis that is due to a unilateral failure of vertebral segmentation, and they do not appear to have an adverse effect on curve size or rate of progression.

Spondylolysis and spondylolisthesis in children and adolescents.

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.

Life expectancy in pediatric patients with cerebral palsy and neuromuscular scoliosis who underwent spinal fusion.

The aim of this study was to document the rate of survival among 288 severely affected pediatric patients (154 females, 134 males) with spasticity and neuromuscular scoliosis who underwent spinal fusion (mean age at surgery 13 years 11 months, SD 3 years 4 months), and to identify exposure variables that could significantly predict survival times. Kaplan-Meier survival analysis was performed demonstrating a mean predicted survival of 11 years 2 months after spinal surgery for this group of globally involved children with cerebral palsy (CP). Coxs proportional hazards model was used to evaluate predictive efficacy of exposure variables, such as sex, age at surgery, level of ambulation, cognitive ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in hospital, and days in the intensive care unit. Number of days in intensive care unit after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. This demonstrated statistically significant predictability for decreased life expectancy after spinal fusion in children with CP.

Scheuermann’s kyphosis; current controversies

This review of the literature presents the current understanding of Scheuermanns kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth. The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.

Distal hamstring lengthening in ambulatory children with cerebral palsy: primary versus revision procedures.

To document the benefits and limitations of distal hamstring lengthening (HL), 61 children (105 limbs) with cerebral palsy treated by distal HL with complete preoperative and postoperative evaluations were reviewed. There was significant improvement in popliteal angle, fixed knee flexion contracture, knee angle at foot contact (FC), and mid-stance knee extension after HL. On the other hand, the hip power generation peak decreased, and the anterior pelvic tilt increased. For the repeated HL (22 limbs), the fixed knee flexion contracture and knee flexion at FC improved. In a group of ten patients (17 limbs) with further postoperative follow up evaluations, the only significant clinical finding related to hamstring function between the first postoperative and the follow up evaluations with no intervening surgery was an increase in the popliteal angle of 20 degrees. Because the popliteal angle may increase over time after HL with no other directly related gait changes, the indications for repeated HL should include fixed knee flexion contracture and increased knee flexion at FC. The increase in the popliteal angle alone should not be considered an indication for repeated HL.

Bilateral Legg-Calvé-Perthes disease: presentation and outcome.

Most patients who develop Legg-Calve-Perthes disease have unilateral involvement. For those children who do develop bilateral involvement, the disease and its outcome have not been characterized. This study reviewed the records and radiographs of 83 patients (20 girls and 63 boys) with bilateral Legg-Calve-Perthes disease. The patients were then divided into 3 groups based on the Waldenstrom stage at the time of the first radiograph. In Group I (26 patients), both hips were in the same stage. In Group II (45 patients), the hips were in a different stage. In Group III (12 patients), the first hip was well into the remodeling stage by the time the second hip became affected. Twenty of the 83 patients (24%) were girls. There were significantly more lateral pillar group A hips on the second side than the first side in Groups II and III, and only 10 of the 45 patients (22%) in these groups had more severe disease in the second hip. When compared with data from a group of hips with unilateral involvement, there were significantly more hips with a Catterall group I rating in the patients with bilateral involvement. In general, the Stulberg et al. class assigned appeared to be independent of bilaterality. It appears that the development of bilateral disease is an independent event. The data in the present study do not support that onset of disease in one hip leads to disease or causes a more severe disease in the second hip.

Traumatic Lumbosacral Dislocation: Report of Two Cases

Study Design. A retrospective study of 2 patients with traumatic lumbosacral dislocation. Objectives. To discuss the difficulty in making diagnosis and the effect of surgical treatment. Summary of Background Data. Traumatic lumbosacral dislocation is an uncommon injury, which creates diagnostic difficulty and is typically managed by open reduction internal fixation of the lumbosacral spine. Methods. Medical notes and imaging of the 2 patients were reviewed. Results. Both patients were engaged in high-energy accidents and had concomitant injuries. Patient 1 was initially misdiagnosed as having L5 lytic spondylolisthesis and was treated with a lumbar corset. She developed progressive low back and left leg pain. Eleven months after the accident, a bilateral lumbosacral dislocation with right S1 superior facet fracture, disc rupture, posterior soft tissue disruption, and a resultant Grade 4 L5–S1 traumatic spondylolisthesis was identified. She underwent open reduction, followed by a staged anteroposterior spinal arthrodesis using instrumentation with excellent results. Patient 2 sustained a unilateral L5–S1 facet dislocation without neurologic deficit, which reduced spontaneously. The evaluation demonstrated a grossly disturbed posterior ligamentous complex adjacent to the lumbosacral articulation. A combined anteroposterior spinal fusion with instrumentation was performed with favorable outcome. Conclusion. Meticulous clinical examination and careful imaging assessment, including CT and MRI, assist an early diagnosis in cases of lumbosacral dislocation. Open reduction and circumferential bony fusion restore segmental stability and painless function.