Lawrence I. Karlin

Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients.

BACKGROUND Previous reports have indicated high complication rates associated with non-fusion surgery in patients with early-onset scoliosis. This study was performed to evaluate the clinical and radiographic complications associated with growing-rod treatment. METHODS Data from the multicenter Growing Spine Study Group database were evaluated. Inclusion criteria were growing-rod treatment for early-onset scoliosis and a minimum of two years of follow-up. Patients were divided into treatment groups according to rod type (single or dual) and rod location (subcutaneous or submuscular). Complications were categorized as wound, implant, alignment, and general (surgical or medical). Surgical procedures were classified as planned and unplanned. RESULTS Between 1987 and 2005, 140 patients met the inclusion criteria and underwent a total of 897 growing-rod procedures. The mean age at the initial surgery was six years, and the mean duration of follow-up was five years. Eighty-one (58%) of the 140 patients had a minimum of one complication. Nineteen (27%) of the seventy-one patients with a single rod had unplanned procedures because of implant complications, compared with seven (10%) of the sixty-nine patients with dual rods (p ≤ 0.05). Thirteen (26%) of the fifty-one patients with subcutaneous rod placement had wound complications compared with nine of the eighty-eight patients (10%) with submuscular rod placement (p ≤ 0.05). The patients with subcutaneous dual rods had more wound complications, more prominent implants, and more unplanned surgical procedures than did those with submuscular dual rods (p ≤ 0.05). The risk of complications occurring during the treatment period decreased by 13% for each year of increased patient age at the initiation of treatment. The complication risk increased by 24% for each additional surgical procedure performed. CONCLUSIONS Regardless of treatment modality, the management of early-onset scoliosis is prolonged; therefore, complications are frequent and should be expected. Complications can be reduced by delaying initial implantation of the growing rods if possible, using dual rods, and limiting the number of lengthening procedures. Submuscular placement reduces wound and implant-prominence complications and reduces the number of unplanned operations.

Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial.

BACKGROUND Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. METHODS This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications. RESULTS The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. CONCLUSIONS With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

The relationship between preoperative nutritional status and complications after an operation for scoliosis in patients who have cerebral palsy.

The records of forty-four patients who had cerebral palsy and spastic quadriplegia and in whom a spinal arthrodesis had been done for scoliosis were reviewed to determine if the preoperative nutritional status of the patients was associated with the rate of postoperative complications. The patients were divided into two groups: Group 1 consisted of twenty-four patients who had a preoperative level of serum albumin of at least thirty-five grams per liter (3.5 milligrams per cent) and a total blood-lymphocyte count of at least 1.5 grams per liter (1500 cells per cubic millimeter), and Group 2 consisted of twenty patients who had a preoperative level of serum albumin of less than thirty-five grams per liter (3.5 milligrams per cent) and a total blood-lymphocyte count of less than 1.5 grams per liter (1500 cells per cubic millimeter). The patients in Group 1 had a significantly lower rate of infection, a shorter period of endotracheal intubation after the operation, and a shorter period of hospitalization.

A reassessment of spinal stabilization in severe cerebral palsy

A homogenous population of 37 institutionalized patients with scoliosis and severe cerebral palsy was evaluated to assess the impact of spinal stabilization on comfort, function, health, and ease of nursing care. Through a prospective care-burden study, a 34-month retrospective analysis, and a healthcare worker questionnaire, 17 fused patients with a mean current scoliosis of 35 degrees were compared with 20 nonfused patients with a mean scoliosis of 76 degrees. No clinically significant differences were noted in pain or pulmonary medication utilization or therapy, decubiti, function, or time for daily care. Nevertheless, the majority of healthcare workers believed that the fused patients were more comfortable.

Safety and efficacy of growing rod technique for pediatric congenital spinal deformities.

Background Growing rod surgery is a modern alternative treatment for young children with early onset scoliosis. This is the first study focused on its use in progressive congenital spinal deformities. Methods A retrospective study of 19 patients from the international multicenter Growing Spine Study Group with progressive congenital spinal deformities undergoing growing rod surgery who had a minimum of 2 years follow-up. We analyzed demographic and radiographic data including age at initial surgery, number of abnormal vertebrae per patient, number of lengthenings postoperatively, Cobb angle of the major curve preoperative, postoperative initial and at last follow-up, T1-S1 length, space available for the lung (SAL), length of follow up, and complications. Results The mean age at surgery was 6.9 years (range: 3.2 to 10.7 y). The mean number of affected vertebrae per patient was 5.2 (range: 2 to 9 vertebrae). The mean number of lengthening was 4.2 (range: 1 to 10 lengthening) per patient. The major Cobb angle improved from 66 degrees (range: 40 to 95 degrees) preoperatively to 45 degrees (range: 13 to 79 degrees) initial postoperative and 47 degrees (range: 18 to 78 degrees) at the last follow-up. The mean T1-S1 length increased from 268.3 mm (range: 192 to 322 mm) postoperatively to a mean of 315.4 mm (range: 261 to 357 mm) at last follow-up. The mean T1-S1 length increase was 11.7 mm/y. The SAL ratio increased from 0.81 preoperatively to 0.94 at latest follow-up. The mean postoperative follow-up was 4 years (range: 2 to 6.6 y). Five patients (38%) had undergone final fusion and 14 are still under treatment. Complications have occurred in 8 patients (42%). There were 14 (14%) complications in 100 procedures: 11 implant related, 2 pulmonary, and 1 postoperative infection. There were no neurological complications. Conclusions Growing rods are a safe and effective treatment technique in selected patients with congenital spinal deformities. The deformity, spinal growth, and the SAL improved. The incidence of complication was relatively low. Level of Evidence Level IV, case series.

Transoesophageal echocardiography during scoliosis repair: comparison with CVP monitoring

PurposeAccurate haemodynamic assessment during surgical repair of scoliosis is crucial to the care of the patient. The purpose of this study was to compare transoesophageal echocardiography (TEE) with central venous pressure monitoring in patients with spinal deformities requiring surgery in the prone position.MethodsTwelve paediatric patients undergoing corrective spinal surgery for scoliosis/kyphosis in the prone position were studied. Monitoring included TEE, intra-arterial and central venous pressure monitoring (CVP). Haemodynamic assessment was performed prior to and immediately after positioning the patient prone on the Relton-Hall table. Data consisted of mean arterial blood pressure (mBP), heart rate (HR), CVP, left ventricular end-systolic and end-diastolic diameters (LVESD and LVEDD respectively) and fractional shortening (FS). Right ventricular (RV) function and tricuspid regurgitation (TR) were assessed qualitatively. Analysis was performed using descriptive statistics, Student’s t test, sign rank, and correlation analysis.ResultsThere was an increase in CVP (8.7 mmHg to 17.7 mmHg;P <.01), and decreases in LVEDD (37.1 mm to 33.2 mm;P <.05), and mean blood pressure (75.0 mmHg to 65.7 mmHg;P <.05) when patients were placed in the prone position. Fractional shortening, LVESD, and HR did not change from the supine to the prone position. Right ventricular systolic function and tricuspid regurgitation were unchanged.ConclusionThese data indicate that the CVP is a misleading monitor of cardiac volume in patients with kyphosis/scoliosis in the prone position. This is consistent with previous studies. In this clinical situation, TEE may be a more useful monitoring tool to assess on-line ventricular size and function.RésuméObjectifL’évaluation hémodynamique précise pendant la correction chirurgicale d’une scoliose est déterminante pour les soins donnés au patient. Le but de l’étude actuelle était de comparer l’échographie transoesophagienne (ETO) au monitorage de la pression veineuse centrale chez les patients souffrant de déformations rachidiennes nécessitant une chirurgie en décubitus ventral.MéthodesDouze patients pédiatriques devant subir, en décubitus ventral, une chirurgie de correction pour une scoliose ou une cyphose ont été étudiés. Le monitorage comprenait l’ETO, la mesure de la pression intra-artérielle et de la pression veineuse centrale (PVC). Lévaluation hémodynamique a été faite avant et immédiatement après l’installation du patient en décubitus ventral sur la table Relton-Hall. Les données comportaient la tension artérielle moyenne (TAm), la fréquence cardiaque (FC), la PVC, les diamètres ventriculaires gauches télosystolique et télodiastolique (DVGTS et DVGTD respectivement) et le raccourcissement fractionnaire (RF). La fonction du ventricule droit (VD) et la régurgitation tricuspidienne (RT) ont été évaluées qualitativement. L’analyse a été réalisée à partir de statistiques descriptives, du test t de Student, du test de rang et de l’analyse de corrélation.RésultatsIl y a eu un accroissement de la PVC (de 8,7 mmHg à 17,7 mmHg;P <,0l), et une diminution du DVGTD (de 37,1 mm à 33,2 mm;P < 0,05) et de la tension artérielle moyenne (de 75,0 mmHg à 65,7 mmHg;P < 0,05) quand les patients ont été placés en décubitus ventral. Le raccourcissement fractionnaire, le DVGTS et la FC n’ont pas été modifiés lors du changement de position, de la position couchée au décubitus ventral. La fonction systolique du ventricule droit et la régurgitation tricuspidienne n’ont pas changé.ConclusionCes résultats indiquent que la PVC n’est pas un moniteur fiable du volume cardiaque chez les patient souffrant de cyphose ou de scoliose, placés en décubitus ventral. Cela correspond aux études antérieures. Dans cette situation clinique, l’ETO peut être un outil de surveillance plus utile pour une évaluation en ligne de la taille et de la fonction ventriculaires.

Segmental spinal dysgenesis.

Segmental spinal dysgenesis is characterized by focal agenesis or dysgenesis of the lumbar or thoracolumbar spine, with focal abnormality of the underlying spinal cord and nerve roots. Children are symptomatic at birth with lower limb deformities and neurological deficits that may be segmental. Myelography and computed tomography disclose hypoplastic or absent vertebrae and atrophic or absent neural elements adjacent to the bony deformity; the spinal column distal to the abnormality may be partially bifid, but is otherwise normal. Spinal ultrasonography was a helpful diagnostic adjunct in one patient. Surgery may be helpful in decompressing partially functioning spinal cord or nerve roots, but may exaggerate the tendency toward spinal instability. The embryology of this abnormality is not clear, but two children had other anomalies suggesting a spinal dysraphic syndrome, and its cause is probably related to a segmental maldevelopment of the neural tube.

Early Onset Scoliosis: Modern Treatment and Results

Background: Early onset scoliosis (EOS) is a potentially fatal, challenging group of diseases the management of which has markedly changed in the last decade. The purpose of this review is to provide the reader with a brief description of each of these new therapeutic modalities, their indications for use, and early clinical results. Methods: A systematic review of peer-reviewed publications and abstracts related to the treatment of EOS in the last decade was carried out and synthesized into a review of modern treatment methods. Results: Recent advances in techniques and understanding of preserving the thoracic space have improved the morbidity and mortality of children with progressive EOS. Derotational casting may be used in younger patients with curves between 25 and 60 degrees. The vertical expandable prosthetic titanium rib is best suited for patients with thoracic insufficiency syndrome. Single or dual growing rods may be used alone or in combination with vertical expandable prosthetic titanium rib to treat patients with progressive EOS who are not candidates for casting. Shilla technique is an alternative to growing rods that avoids the morbidity of repeated lengthenings but is not as well proven as the techniques described above. Other methods such as automatic growing rods and growth modulation techniques are still investigational, and their role needs to be defined after further study. Conclusions: Recent advances have improved the treatment of children with EOS. Treatment continues to be challenging with complication rates higher than treatment of idiopathic scoliosis. Level of Evidence: Level V.

Multiple level injuries in pediatric spinal trauma

BACKGROUND The incidence of concomitant, particularly noncontiguous, spine injuries in the pediatric population has not been well described. There is a balance between limiting radiation exposure and not missing concomitant injuries; understanding of this risk of concomitant spine injuries in this population is important. We hypothesize that the rate of concomitant spinal injuries in children is similar to adults. METHODS The trauma registry of a pediatric trauma center was queried for all patients who sustained spine injuries over a 10-year period. Patient demographics, presence of other injuries, treatment, location and nature of the spine injury, as well as presence of multiple level injuries were determined. RESULTS One hundred and ninety-five patients with spine injuries were noted. Patients over age 8 years accounted for 76% of spine injuries (148 of 195). Concomitant injuries to other levels in the spine occurred in 32% of the patients (62 of 195); 6% of these secondary injuries were noncontiguous and were at least three levels away from the primary injury. All of the concomitant injuries were either in the thoracic or in the upper lumbar spine. Neurovascular status and mechanism of injury were not different between patients sustaining concomitant injuries or not. CONCLUSIONS Pediatric spine injuries are more common in patients over age 8 years of age; these patients are more likely to have multiple levels of injury. Of patients sustaining a spine injury, 6% had noncontiguous second fractures, which is a rate similar to adults. Imaging studies evaluating patients with spinal injuries should include at least three levels above and below the primary level of injury as well as the entire thoracic spine and thoracolumbar junction.

Visual field defect after posterior spine fusion.

Study Design. Case report and literature review. Objectives. Review cases and literature regarding visual loss following posterior spine fusion for scoliosis and emphasize right-to-left atrial shunt as a risk factor for paradoxical embolus resulting in a postoperative visual field defect. Summary of Background Data. The existing literature discusses various possible etiologies of postoperative visual loss including direct pressure, hypotension, blood loss, and anemia. One study shows higher rates of cerebral microemboli in patients with right-to-left atrial shunts. Methods. Chart and literature review. Results. A paradoxical embolus to a branch of the central retinal artery resulted in a unilateral quadrant defect (homonymous quadrantanopsia) in a girl with a previously undiagnosed right-to-left atrial shunt. Conclusions. Right-to-left atrial shunts may predispose to cerebral emboli during scoliosis surgery. These emboli may be a cause of postoperative visual field defects.