Hazem Elsebaie

Next generation of growth-sparing techniques: preliminary clinical results of a magnetically controlled growing rod in 14 patients with early-onset scoliosis.

Study Design. Prospective nonrandomized study. Objective. To report the preliminary results of magnetically controlled growing rod (MCGR) technique in children with progressive early-onset scoliosis. Summary of Background Data. The growing rod (GR) technique is a viable alternative for treatment of early-onset scoliosis. High complication rate is attributed to frequent surgical lengthening. The safety and efficacy of MCGR were recently reported in a porcine model. Methods. Multicenter study of clinical and radiographical data of patients who underwent MCGR surgery and at least 3 distractions. Distractions were performed in clinic without anesthesia/analgesics. T1–T12 and T1–S1 heights and the distraction distance inside the actuator were measured after lengthening. Results. Fourteen patients (7 girls, 7 boys) with a mean age of 8 years, 10 months (3 yr, 6 mo to 12 yr, 7 mo) had 14 index surgical procedures. Of the 14, 5 had single-rod (SR) surgery and 9 had dual-rod (DR) surgery, with overall 68 distractions. Diagnoses were idiopathic (N = 5), neuromuscular (N = 4), congenital (N = 2), syndromic (N = 2), and neurofibromatosis (N = 1). Mean follow-up was 10 months (5.8–18.2). The Cobb angle changed from 60° to 34° after initial surgery and 31° at latest follow-up. During distraction period, T1–T12 height increased by 7.6 mm for SR (1.09 mm/mo) and 12.12 mm for DR (1.97 mm/mo). T1–S1 height gain was 9.1 mm for SR (1.27 mm/mo) and 20.3 mm for DR (3.09 mm/mo). Complications included superficial infection in 1 SR, prominent implant in 1 DR, and minimal loss of initial distraction in 3 SR after index. Partial distraction loss observed after 14 of the 68 distractions (1 DR and 13 SR) but regained in subsequent distractions. There was no neurological deficit or implant failure. Conclusion. Preliminary results indicated MCGR was safe and provided adequate distraction similar to standard GR. DR achieved better initial curve correction and greater spinal height during distraction compared with SR. No major complications were observed during the follow-up.

In vivo distraction force and length measurements of growing rods: which factors influence the ability to lengthen?

Study Design. Prospective, intraoperative force measurement in consecutive lengthening procedures in a series of growing-rod patients undergoing lengthening. Objective. The purpose of this study was to measure the forces and amount of distraction over time in early onset scoliosis patients treated with growing rods. Summary of Background Data. Growing rods are one of the current techniques used in the treatment of early onset scoliosis, and the goal of the growing-rod technique is to achieve deformity correction, maintaining spinal growth at the same time. Gradual stiffening or spontaneous fusion of the spine can interfere with the ability to lengthen. In addition, diminished acquired length with serial distraction are common observations and need to be evaluated and quantified. Methods. Distraction forces were measured prospectively during 60 consecutive lengthening procedures in 26 patients. All patients had single submuscular rod constructs with side-to-side connectors. For each measurement, output from a transducer on a dedicated pair of distraction calipers was recorded at zero load status and the force was then recorded at every 1 mm lengthening; length was obtained at each event and was recorded in millimeters. Results. The force required to distract the spine doubled at the 5th lengthening procedure (mean 368 N ± 54 N), and the distraction force was significantly higher at the fifth lengthening compared with the previous lengthening (P <0.01). Mean length achieved at each distraction decreased over time such that by the fifth lengthening, consistently 8 mm or less was achieved. Conclusion. Distraction forces increase significantly after repeated lengthening of growing-rod constructs, and the length obtained at each procedure exhibits a decreasing trend.

The surgical treatment of congenital kyphosis.

Study Design. Retrospective study with clinical and radiologic evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebra (HV). The management of congenital kyphosis has been described in the literature using a variety of techniques. The presentation of patients at diagnosis is discussed. The question of when to begin treatment is reviewed. The pitfalls in the management and how to avoid these are discussed. The different published techniques are reviewed. We present our own techniques and our results of treatment of congenital kyphosis in very young children. Objective. To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurologic compromise. We aim to systematically review the literature and to present our own experience in the management of these deformities, so that the issues common to treating physicians may be explored. Summary of Background Data. A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique. Methods. Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. Thirteen patients had a single posterolateral HV and 2 patients had a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range, 8–33). Mean follow-up period was 6.8 years. Thirteen HV were located in the thoracolumbar junction (T10–L2) and 2 in the thoracic spine. Results. The average operating time of procedure was 150 minutes (range, 130–210 minutes). The average blood loss was 180 mL (range, 100–330 mL), equivalent to a mean external blood volume loss of 15% (range, 11%–24%). Preoperative segmental Cobb angle averaging 34° at last follow-up. Compensatory coronal cranial and caudal curves were corrected by 50%. The angle of segmental kyphosis averaged 39° (range, 20°–80°) before surgery and 21° (range, 11°–40°) at last follow-up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last follow-up. One case with initial kyphosis of 80° continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

All pedicle screw instrumentation for Scheuermann's kyphosis correction: is it worth it?

BACKGROUND CONTEXT Scheuermanns kyphosis has long been treated by a two-staged fusion and instrumentation with a hybrid construct using hooks, pedicle screws, and sublaminar wires. Recent interest in all pedicle screw constructs led to its use in the treatment of Scheuermanns kyphosis. Evaluation of this newly described application is needed. PURPOSE To compare the results of segmental all pedicle screw constructs versus two-staged hybrid instrumentation in patients with Scheuermanns kyphosis analyzing the amount of correction and incidence of complications. STUDY DESIGN Retrospective case series reporting on two groups of patients with Scheuermanns kyphosis treated with single-staged all pedicle screws technique versus two-staged anterior release and posterior hybrid instrumentation followed-up for a minimum of 2 years. PATIENT SAMPLE The study included 33 patients divided into two groups. The average age was 15 years+9 months and 16 years+8 months, respectively. The average preoperative dorsal kyphosis was 85.5 degrees (Group 1) and 79.8 degrees (Group 2). OUTCOME MEASURES The deformity was measured by Cobbs method preoperatively, postoperatively, and at final follow-up. Operative time and blood loss were also measured and recorded. The results of the Scoliosis Research Society (SRS)-30 questionnaire were also reviewed. METHODS The study included 16 patients who underwent a single-staged correction by segmental all pedicle screw constructs and multiple-level posterior osteotomies (Group 1) and 17 who underwent a two-staged fusion and instrumentation with a hybrid construct (Group 2). RESULTS Both groups were followed for a minimum of 2 years. The deformity correction of Group 1 had an average of 52.2% postoperatively with 2.4% loss at final follow-up in comparison to Group 2 where the correction was 48.7% postoperatively with 3.1% loss at final follow-up. The operative time was considerably less in Group 1 with an average of 215 minutes than Group 2 with an average of 315 minutes. The average blood loss was 620cc in Group 1 and 910cc in Group 2. The SRS-30 questionnaire in Group 1 averaged 134 and in Group 2 averaged 120. CONCLUSIONS The use of multiple-level all pedicle screws technique allowed a rigid anchor for posterior correction of the deformity with less operative time, blood loss, and hospital stay without the need for anterior release. A better correction was achieved and preserved with the use of all pedicle screw constructs. This technique is a useful modality in the treatment of Scheuermanns kyphosis.

Magnetically controlled Growing Rods for Early-onset Scoliosis: A Multicenter Study of 23 Cases With Minimum 2 years Follow-up.

Study Design. Retrospective study. Objective. To report 2-year clinical and radiographic results of patients treated with magnetically controlled growing rods (MCGR). Summary of Background Data. MCGR for early-onset scoliosis has been reported to provide adequate spinal growth and curve correction by eliminating surgical lengthening procedures. This study was designed to report the results of MCGR patients with 2-year follow-up. Methods. A retrospective study of MCGR patients with the following inclusion criteria: (i) major curve size ≥30°, (ii) T1-T12 height <22 cm, (iii) <11-years old; all at the time of index surgery was performed. Of 54 patients enrolled, 23 had 2-year follow-up. Both primary and conversion patients were evaluated at baseline 6, 12, and 24 months. Results. Mean preoperative age in the primary group was 6.6 ± 2.6 years versus 8.3 ± 2.2 years for the conversion group. A total of 41 adverse events occurred in 11 patients, of which 14 events were implant related. Major coronal curve magnitude improved from 61.3° to 34.3° from baseline to postoperation in primary cases and from 49.4° to 43.8° in conversion cases. Curve correction was maintained for 2 years in both groups. T1-S1 height improved from 252.7 to 288.9 mm in primary cases and was maintained for 2 years. However, conversion cases had some decline in T1- S1 height (270.3 at baseline to 294.4 mm post-MCGR and 290.2 mm at 2-year follow-up; mean loss of 4.2 mm (1.5%) from postoperation to 2 years, P > 0.05). Conclusion. This study showed satisfactory curve correction and growth is achieved among primary cases. T1-S1 height in conversion cases had a slight decline in 2 years. However, this decline was not statistically significant. Level of Evidence: 3

Neuromuscular scoliosis treated by segmental third-generation instrumented spinal fusion

We aimed to investigate whether the outcome and complications of surgical treatment of neuromuscular curves with segmental third-generation instrumentation could compare with those reported with standard second-generation instrumentation. The clinical and radiologic data of a single surgeons consecutive series of patients with neuromuscular scoliosis treated with two types of newer-generation instrumentation and posterior or anteroposterior approaches were retrospectively and independently reviewed. The results of this study support the concept that third-generation instrumentation is able to provide at least as good results as second-generation instrumentation in the treatment of neuromuscular scoliosis patients, at the expense of a lower complication rate.

Anterior instrumentation and correction of congenital spinal deformities under age of four without hemivertebrectomy: a new alternative.

Study Design. Retrospective clinical and radiologic evaluation of a single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion. Objective. To determine the safety and efficacy of a new technique in the management of progressive congenital spinal deformities due to failure of formation in the very young age. Summary of Background Data. Several techniques have been reported for the surgical treatment of young children with congenital spinal deformities. There have been concerns regarding epidural bleeding, neurologic complications, pedicle screws placement, implant failure, and prominence of posterior constructs in this very young age group. A single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion can offer a new alternative which can avoid these concerns. Methods. Twelve patients with progressive congenital spinal deformities due to failure of formation were retrospectively reviewed after adopting the above mentioned technique. All patients included in the study presented with a single hemivertebra. The mean age at time of surgery was 2 years 7 months (range, 1 year and 9 months to 3 years and 10 months). The average follow-up period was 3 years and 1 month (range, 2 years to 4 years and 5 months). Results. There were no cases of intra or postoperative neurologic or implant related complications. There was 1 superficial infection. All patients showed solid radiologic fusion. The mean scoliosis angle improved from 48.3° (range, 34°–58°) preoperative to 17.2° (range, 11°–25°). The mean angle of kyphosis improved from 23.2° (range, 16°–57°) before surgery to 11.7° (range, 4°–16°). Conclusion. A single-stage partial corpectomy of the hemivertebra with anterior instrumentation and simultaneous posterior noninstrumented fusion offers a safe alternative method in treating patients with congenital hemivertebra under the age of 4 years.

Clinical Examination and Associated Comorbidities of Early Onset Scoliosis

Young children with spinal deformities often present with associated comorbidities that often confound clinical decision-making. The initial clinical evaluation serves as the foundation for constructing an individualized and effective treatment plan. While the physical and radiological examination of the spine is central to the workup, it is equally important to look beyond the spine to discern underlying medical conditions and realize the overall health of the child. The baseline evaluation should always include a detailed medical history, particularly if the child has received previous treatment for his or her spinal deformity or other existing medical conditions. Regardless of etiology – congenital, idiopathic, neuromuscular, or syndromic – understanding the natural history of the spinal deformity is of paramount importance. Prior to selecting and initiating treatment, the treating physician must have a clear sense of all spinal and non-spinal abnormalities as their late discovery can jeopardize the results of treatment and increase the risk of complications. Assembling a multi-disciplinary team to assess and manage multiple comorbidities can optimize the medical management of complex patients.

Comorbidities Associated with Early Onset Scoliosis

Spinal deformities in the growing spine can be associated with other organ system abnormalities; such associa- tion, which implies a greater-than-random tendency for abnormalities to occur together, can be attributable to many causes. Both spinal deformity and the other abnormalities can have the same origin, they can have a cause effect relationship in a reciprocal way and some- times no clear reason for this association could be iden- tified. The time of presentation may not be synchronous and, in many times, depends on the causal relationship.