Halil G. Demirkiran

Serial derotational casting in congenital scoliosis as a time-buying strategy.

Background: Serial casting is an effective treatment modality in early-onset idiopathic scoliosis; however, the role of this method in congenital scoliosis is not well studied. Methods: A total of 11 patients with progressive congenital scoliosis were treated with serial cast application. Age at initial cast application, magnitudes of the congenital, compensatory and sagittal deformities, coronal balance, T1 to T12 height, number of casts and time-in cast per patient, subsequent surgical interventions, and complications were evaluated. Results: Mean age at the first cast application was 40 months, and the average number of cast changes was 6.2 per patient. There were no major complications. The average precasting curve magnitude was 70.7 degrees (range, 44 to 88 degrees) and was significantly reduced to 55.1 degrees (range, 16 to 78 degrees) at the latest follow-up (P=0.005). The average precasting compensatory curve was 55.8 degrees (range, 38 to 72 degrees) and was significantly reduced to 39.8 degrees (range, 23 to 62 degrees) at the latest follow-up (P=0.017). Average T1 to 12 height increased from 12.8 cm at post-first cast to a 14.6 cm at the latest follow-up (P=0.04). Average time in cast was 26.3 months (range, 13 to 49 mo). During the treatment period, none of the patients required surgery for curve progression. Conclusions: Serial derotational casting is a safe and effective time-buying strategy to delay the surgical interventions in congenital deformities in the short-term follow-up. Level of Evidence: Level IV, case series.

Reliability and Validity of the Adapted Turkish Version of the Early-onset Scoliosis-24-Item Questionnaire (EOSQ-24).

Introduction: Early-onset scoliosis (EOS) can have negative effects on the developing thorax, lungs, and quality of life in general. Children with EOS can face various health problems and require recurring hospitalization and surgeries. Radiographic parameters are insufficient to evaluate the severity and efficacy of treatment in EOS. Early-onset Scoliosis Questionnaire (EOSQ)-24 questionnaire is a new instrument developed for this specific age group. To date, reliability of this questionnaire has not yet been interrogated in wide patient groups from different cultures. The aim of this study was to evaluate the validity and reliability of culturally adapted Turkish version of the EOSQ-24. Methods: Forward translation and back translation of the English version of the EOSQ-24 was done, and all steps for cross-cultural adaptation process were performed properly by an expert committee. Turkish version of the EOSQ-24 and Child Health Questionnaire-Parent Form-50 (CHQ-PF-50) were applied to 61 (24 male, 37 female) EOS patients. The average age of these patients was 9.1±3.1 years (0.4 to 14.3 y), and 50 of them had undergone surgical treatment. Data quality was assessed by mean, median, percentage of missing data, and extent of ceiling and floor effects. Reliability was assessed by internal consistency using Cronbach’s &agr; and item-total correlations. The construct validity was evaluated by comparing the results of the EOSQ-24 with the Turkish version of the CHQ-PF-50. Subgroup analyses were applied for sex, diagnosis, treated/untreated, mobilization ability, and complications. Results: The item response to the EOSQ-24 was high with a small number of missing answers (1.6% to 3.3%). Of the 24 items, 22 were evenly distributed. This resulted in a floor effect in 0% to 21.7% of patients, and a ceiling effect in 1.6% to 68.3%. The calculated Cronbach’s &agr; for the 24-item scale was 0.909, indicating excellent reliability. Construct validity showed that high correlations between the EOSQ and the CHQ by means of similar domains. Correlation coefficient was between 0.348 and 0.688 (P=0.0001). Subgroup analyses also showed significant difference in treated/untreated patients (P=0.032) and mobilization ability (P=0.001). Discussion: The Turkish adaptation of the EOSQ-24 exhibits favorable psychometric properties and excellent reliability, validating its use in this population. Level of Evidence: Level III—diagnostic study.

The Development of Thoracic Vertebral Sagittal Morphology During Childhood

STUDY DESIGN This is a cross-sectional descriptive study objectives to describe normal development of thoracic vertebrae during childhood and document contribution of individual vertebral shape to the sagittal alignment. SUMMARY OF BACKGROUND DATA Sagittal spinal alignment changes during growth. The changes in sagittal alignment during adolescent growth spurt as well as the individual shapes of thoracic vertebrae have been implicated as factors for the development of adolescent idiopathic scoliosis (AIS). The contribution of individual vertebral shape to the sagittal alignment and the changes in the vertebral shape with growth is not known. METHODS Sagittal computed tomographic (CT) scans of thoracic vertebrae were examined in children without any evidence of spinal deformity. Vertical distances between the endplates at the most anterior and most posterior sides of vertebral body were measured as anterior vertebral height (aVH) and posterior vertebral height (pVH), respectively. RESULTS There were a total of 133 CT scans done on 71 male and 62 female children. The children were grouped as follows: Group I (0-2 years of age), Group II (3-6 years of age), Group III (7-9 years of age), Group IV (10-12 years of age), and Group V (13-16 years of age). A-P ratios of vertebral heights were grouped as T1-T5, T6-T8, and T9-T12. Measurements demonstrated that the anterior and posterior heights in each vertebra grew longitudinally and consistently with increasing age. The aVH/pVH ratio of each individual vertebra showed no significant difference according to age. Measurements of thoracic vertebrae on sagittal spinal CT images did not show any differences in the relative growth and heights of the anterior versus posterior walls of the vertebral bodies in any of the segments in any age or age group. CONCLUSIONS The sagittal alignment changes during growth are likely related to maintenance of sagittal balance rather than the shapes of individual vertebrae. LEVEL OF EVIDENCE Level II.

Convex Hemiepiphysiodesis: Posterior/anterior in-situ Versus Posterior-only With Pedicle Screw Instrumentation: An Experimental Simulation in Immature Pigs.

Study Design: Experimental study. Background: Convex growth arrest (CGA) has been commonly used in the treatment of long-sweeping congenital deformities of the immature spine. As there are major drawbacks about the anterior procedure in the conventional CGA method, a new modification has been documented that using only posterior spinal approach with pedicle screw instrumentation. The aim of the study was to compare posterior-only CGA using pedicle screws with combined anterior/posterior in-situ CGA for the findings in histologic, radiologic, and manual palpation examinations in an immature pig model. Methods: Twelve 10-weeks old pigs were grouped into 2. In group 1, posterior-only, pedicle screw instrumented CGA was performed on the left side of L1-L4 vertebrae. In group 2, conventional combined posterior and anterior CGA was performed to the left side of L1-L4 vertebrae without instrumentation. All animals were killed twelve weeks after surgery. T11-L5 segments were en-bloc resected and radiologic, histologic, and manual palpation examinations were done. Results: Marked scoliotic (12.2±2.5 and 9.2±1.3 in group 1 and 2, respectively) and kyphotic (11.2±1.0 degrees for the group 1 and 12±5.2 degrees for the group 2, respectively) deformities were noted in both groups, which were caused by hemiepiphysiodesis effect. Anterior and posterior parts of group 2 and posterior part of group 1 demonstrated fusion in histologic and radiologic analyzes. In anterior part of the group 1, marked narrowing on the disk spaces and thinning of growth plates were noted in radiologicg examination, chondrocyte degeneration, and newly-formed bone trabeculae in disk-space were noted in histological examination. In manual palpation, no motion was detected in group 1 and motion was detected in only one segment of one animal in group 2. Conclusions: Anterior growth of the vertebrae can be controlled by application of posterior transpedicular screws and rod. Such an effect can eliminate the need for anterior surgical intervention in convex hemiepiphysiodesis procedures. Clinical Relevance: The instrumented CGA technique provides a satisfactory epiphysiodesis effect both anteriorly and posteriorly, as previously demonstrated by clinical studies.

Surgical Management of Progressive Thoracolumbar Kyphosis in Mucopolysaccharidosis: Is a Posterior-only Approach Safe and Effective?

Background: According to the current literature, the recommended surgical treatment is circumferential spinal fusion, including both anterior and posterior procedures, for progressive thoracolumbar kyphosis in mucopolysaccharidosis (MPS). The purpose of this study was to report our experience with the posterior-only approach and instrumented fusion for MPS kyphosis. Methods: Six consecutive patients with MPS and thoracolumbar junctional kyphosis managed with the posterior-only approach were included. Demographic data, the type of MPS, medical comorbidities, and accompanying clinical manifestations were recorded. Measurements recorded on radiographs for the study included the presence of any coronal-plane deformity, fusion levels, changes in the local kyphosis angle (LKA), proximal and distal junctional kyphosis angles, and the apical vertebral wedge angle. Results: The average age at the time of surgery was 6.6 (range, 4 to 12) years. The average follow-up duration was 52.6 (range, 44 to 64) months. The mean preoperative LKA of 63.1±15.8 (range, 48 to 92) degrees decreased to a mean of 16.6±8.4 (range, 5 to 30) degrees immediately after surgery. At the latest follow-up, the mean LKA was 19.6±8.8 (range, 8 to 34) degrees. Apical vertebral listhesis was reduced in all patients with surgical correction. The average apical vertebral wedge angle of 15 (range, 11 to 19) degrees at the early postoperative period decreased to 4.6 (range, 2 to 7) degrees at the latest follow-up. Adjacent-segment problems occurred in 2 patients. There were no neurological complications or implant failures in any of the patients. Conclusions: Posterior-only corrective techniques and instrumented fusion with pedicle screws for progressive thoracolumbar junctional kyphosis in MPS patients are safe and effective methods. Its results are comparable to those achieved with conventional circumferential fusion. However, patients should be monitored closely for adjacent-segment problems. Level of Evidence: Level IV—retrospective case series.

Thoracic Spine Growth Revisited: How Accurate Is the Dimeglio Data?

Study Design. Cross-sectional descriptive study. Objective. To describe the normal rate pattern of thoracic spine growth in children without any spinal deformity. Summary of Background Data. The knowledge of thoracic spine growth and height is important for growing spine treatment and the decision of final fusion. Currently, pediatric spinal deformity is approached as early onset and late onset with an understanding of the fast growth during the first 5 years of life. The growth data that support this classification is often cited but has not been reconfirmed with follow-up studies. Methods. Sagittal computed tomography (CT) reformations of thoracic vertebrae were examined in children without spinal deformity. The sagittal CT cut at the widest canal diameter was identified and the measurements were performed on this image. The length of the thoracic spine was measured from the posterosuperior corner of T1 to the posteroinferior corner of the T12. Results. One hundred forty-four thoracic CT scans satisfied the inclusion criteria. The analysis of the data identified two break points in the growth velocity; one at the end of the 4th year of life and the other at the beginning of the 12th year. Specifically, growth rate between 1 and 4 years was 1.71 cm/yr, between 4 and 8 years was 0.55 cm/yr, between 8 and 10 was 0.74 cm/yr, between 10 and 12 was 0.69 cm/yr, and between 12 and 16 was 1.61 cm/yr. Conclusion. The results show that in growing children the thoracic spine demonstrates two major growth spurts. The initial growth spurt is between the birth to the end of the fourth year of life and the second is between the 12 and 16 years of age. Between 4 and 12 years there is a steady but slower increase in thoracic height. The findings show that the fastest growth velocity may be limited to a younger age group than previously believed. This data will help guide growth friendly management strategies. Level of Evidence: 2

Spinal Instrumentation in Growing Children Retards the Natural Development of Pelvic Incidence.

BACKGROUND Pelvic incidence increases gradually throughout growth until skeletal maturity. Growing rod instrumentation has been suggested to have a stabilizing effect on the development of the normal sagittal spinal alignment. The purpose of this study is to determine the effect of fixed sagittal plane caused by dual growing rod instrumentation on the natural progression of sagittal spinopelvic parameters in children with idiopathic or idiopathic-like early onset scoliosis. METHODS Hospital records of children with growing rod instrumentation from 4 separate institutions were reviewed retrospectively. Inclusion criteria were idiopathic or idiopathic-like early onset scoliosis, treatment with dual growing rods with lower instrumented vertebra L4 or upper and more than 2 years of follow-up. Instrumentation levels, magnitudes of major curve, thoracic kyphosis (T2-T12), lumbar lordosis (L1-S1) and pelvic incidence were recorded from preoperative and postoperative standing whole-spine radiographs. Estimated pelvic incidence was also calculated for each patient as if their spines had not been instrumented using the previous normative data. RESULTS A total of 37 patients satisfied the inclusion criteria. Average age at initial surgery was 7.4±1.8 years (range, 4 to 12 y). Mean follow-up time was 71±26 months (range, 27 to 120 mo). Mean preoperative Cobb angle of 59±13.5 (range, 30 to 86) degrees was reduced to 35.1±17.5 (range, 11 to 78) degrees at the last follow-up. Mean preoperative T2-T12 kyphosis angle was 46.2±14.9 degrees (range, 22 to 84 degrees). At the latest follow-up, it was 44.8±16.2 degrees (range, 11 to 84 degrees) (P=0.93). Mean L1-S1 lordosis angle was 50.5±10.7 degrees (range, 30 to 72 degrees) preoperatively. At the latest follow-up, mean L1-S1 lordosis angle was 48.8±12.7 degrees (range, 26 to 74 degrees) (P=0.29). Mean preoperative pelvic incidence was 45.7±7.9 degrees (range, 30 to 68 degrees). At the latest follow-up, it was 46.7±8.4 degrees (range, 34 to 72 degrees) (P=0.303). The estimated average pelvic incidence was 49.5 degrees (P=0.012). CONCLUSIONS Previously reported developmental changes of the sagittal spinal parameters were not observed in children who underwent posterior spinal instrumentation. Our findings suggest that spinal instrumentation impedes the natural development of the sagittal spinal profile. LEVEL OF EVIDENCE Level IV-this is a retrospective case-series.BACKGROUND Pelvic incidence increases gradually throughout growth until skeletal maturity. Growing rod instrumentation has been suggested to have a stabilizing effect on the development of the normal sagittal spinal alignment. The purpose of this study is to determine the effect of fixed sagittal plane caused by dual growing rod instrumentation on the natural progression of sagittal spinopelvic parameters in children with idiopathic or idiopathic-like early onset scoliosis. METHODS Hospital records of children with growing rod instrumentation from 4 separate institutions were reviewed retrospectively. Inclusion criteria were idiopathic or idiopathic-like early onset scoliosis, treatment with dual growing rods with lower instrumented vertebra L4 or upper and more than 2 years of follow-up. Instrumentation levels, magnitudes of major curve, thoracic kyphosis (T2-T12), lumbar lordosis (L1-S1) and pelvic incidence were recorded from preoperative and postoperative standing whole-spine radiographs. Estimated pelvic incidence was also calculated for each patient as if their spines had not been instrumented using the previous normative data. RESULTS A total of 37 patients satisfied the inclusion criteria. Average age at initial surgery was 7.4±1.8 years (range, 4 to 12 y). Mean follow-up time was 71±26 months (range, 27 to 120 mo). Mean preoperative Cobb angle of 59±13.5 (range, 30 to 86) degrees was reduced to 35.1±17.5 (range, 11 to 78) degrees at the last follow-up. Mean preoperative T2-T12 kyphosis angle was 46.2±14.9 degrees (range, 22 to 84 degrees). At the latest follow-up, it was 44.8±16.2 degrees (range, 11 to 84 degrees) (P=0.93). Mean L1-S1 lordosis angle was 50.5±10.7 degrees (range, 30 to 72 degrees) preoperatively. At the latest follow-up, mean L1-S1 lordosis angle was 48.8±12.7 degrees (range, 26 to 74 degrees) (P=0.29). Mean preoperative pelvic incidence was 45.7±7.9 degrees (range, 30 to 68 degrees). At the latest follow-up, it was 46.7±8.4 degrees (range, 34 to 72 degrees) (P=0.303). The estimated average pelvic incidence was 49.5 degrees (P=0.012). CONCLUSIONS Previously reported developmental changes of the sagittal spinal parameters were not observed in children who underwent posterior spinal instrumentation. Our findings suggest that spinal instrumentation impedes the natural development of the sagittal spinal profile. LEVEL OF EVIDENCE Level IV-this is a retrospective case-series.