Lotfi Miladi

Iliosacral screw fixation for pelvic obliquity in neuromuscular scoliosis : A long-term follow-up study

Study Design. This was a retrospective review of a consecutive series of patients with neuromuscular spinal deformity who underwent posterior fusion and pelvic fixation using a long construct and an iliosacral screw. Objectives. To evaluate the risks and benefits of iliosacral screw fixation. Summary of Background Data. Neuromuscular scoliosis with pelvic obliquity poses one of the most challenging instrumentation problems, mainly because of the poor bone quality frequently found within the sacrum. Complications include failure of instrumentation, loss of sacral fixation, loss of lumbar lordosis, and a high rate of nonunion. Methods. One hundred fifty‐four patients with neuromuscular scoliosis and pelvic obliquity underwent posterior arthrodesis with pelvic fixation using an iliosacral screw. Anteroposterior scoliosis Cobb angle, frontal pelvic obliquity, and sacral inclination angle were measured before surgery, immediately after surgery, and at the 5‐year and 3‐month follow‐up examination. Influence of etiology, severity of deformity, and associated anterior release at the scoliotic curve above also were assessed. Results. Correction of scoliosis Cobb angle ranged from 53% to 70%, and loss of correction ranged from 3% to 14% at the last follow‐up examination. Correction of pelvic obliquity ranged from 60% to 84%, and loss of correction was mild. Sacral inclination angle approached normal values in all patients, except for those with myelomeningocele who had preoperative pelvic retroversion. Loss of correction ranged from 0.3° to 5.4° at the last follow‐up examination. Complications and loss of correction mostly were encountered in patients with myelomeningocele and spinal muscular atrophy. Conclusions. Iliosacral screw fixation in neuromuscular scoliosis is technically standardized and easy and offers mechanically efficient and stable fixation.

Importance of pelvic compensation in posture and motion after posterior spinal fusion using CD instrumentation for idiopathic scoliosis.

Study Design. Posture and motion analysis after a Cotrel-Dubousset instrumentation. Objectives. To investigate the compensation role of pelvis. Summary of Background Data. Few existing studies found no compensation at the lower unfused level but did not investigate the pelvis. Methods. Thirty patients were analyzed before surgery then at short-, medium-, and long-term postoperative follow-up. Calibrated x-rays with three-dimensional reconstruction yielded quantification of pelvic parameters. Noninvasive optoelectronic system allowed analyzing subjects first in standing position, then during flexion-extension, lateral bending, and axial rotation. Skin markers were used to quantify three-dimensional orientation of the shoulders, trunk and pelvis, and their range of motion (ROM). Results. Ten patients among 21 had after surgery more than 5° change of pelvic incidence. In flexion, global ROM decreased from preoperative to postoperative phase (P < 0.05). Global ROM variation was not correlated to that of lower unfused segment, while it was highly correlated to pelvic ROM variation (r2 = 0.78 at medium follow-up). Conclusion. This study underlines the central role of pelvis in balance and motion of the patients before and after surgery.

Three-dimensional stereoradiographic modeling of rib cage before and after spinal growing rod procedures in early-onset scoliosis

BACKGROUND Early-onset scoliosis frequently leads to major thoracic deformity and pulmonary restrictive disease. Growing rods surgical techniques were developed to achieve a satisfactory correction of the spinal curves during growth. The effect on the rib cage deformity has not yet been documented. The purpose of this study was to analyze the changes of the thoracic geometry after implantation of a growing rod, and to evaluate a stereoradiographic reconstruction method among young scoliotic patients. METHODS Four patients were enrolled in the study, and four additional patients in the reproducibility study. Three-dimensional spine and rib cage models were generated after low-dose stereoradiographic imaging (EOS). Three-dimensional parameters were computed before and after surgery. Intra and inter-observer reproducibility was calculated, and the accuracy was assessed in comparison to volumetric CT-scan. FINDINGS The average Cobb angle was reduced from 50.8 degrees to 26 degrees . The surgery resulted in a complex 3D effect on the rib cage, combining frontal, lateral, and axial rotation. This effect was dependent of the side (concave or convex), and the position relative to the apical vertebra. Mean errors in comparison to CT-scan were 3.5mm. INTERPRETATION The results on the spinal deformity are comparable to other series. The effect on the rib cage is of a smaller magnitude than in the case of a spinal arthrodesis. A longer follow-up is necessary to confirm the positive effect on the rib cage deformity. Further research should be performed to improve the reproducibility of 3D parameters.

Posterior spinal fusion in neuromuscular scoliosis using a tibial strut graft : results of a long-term follow-up

Study Design. Risks and benefits of using a tibial graft for posterior spinal fusion in neuromuscular scoliosis were evaluated in a long-term follow-up study. A consecutive series of 72 patients underwent posterior spinal fusion for neuromuscular scoliosis. Objectives. Radiologic outcome was assessed to evaluate the quality of the spinal fusion. Patients were followed serially to detect donor site complications. Mean follow-up was 17 years and 8 months (minimum: 6 years, 6 months). Summary of Background Data. Mean age of the patients at the time of surgery was 15 years. Progression of the curvature was minimal at last follow-up (mean progression at last follow-up: lumbar curve, 4.5°; thoracic curve, 5.3°). Concerning donor site complications, four patients had a leg length discrepancy of less than 2 cm at last follow-up. This complication was related to tibial overgrowth at the donor site. Methods. Solid fusion was defined in this long-term study as the absence of modification of the radiologic aspect at last follow-up in addition to the presence of a massive contiguous trabecular fusion mass. Results. The fusion appeared to be solid in all patients. No obvious pseudarthrosis could be documented. The constant successful outcome differs significantly from spinal fusion that uses bank bone. The absence of stress fracture was correlated to the low level of constraint in this essentially nonambulatory population. Conclusions. This experience indicates that the tibial graft deserves consideration in posterior spinal fusion for neuromuscular scoliosis.

Magnetic Powered Extensible Rod for Thorax or Spine

The use of growing rods may be necessary in early onset scoliosis, deformities associated with abnormalities of the rib cage, and in progressive scoliosis with failure of non-operative treatment regardless of its etiology.

Osteotomy and distraction of the anterior segment of the pelvic ring in epispadias repair: case report.

We report a new therapeutic approach for bladder exstrophy and epispadias in one case of failed epispadias repair. The width of the pelvis was measured by what we defined as the anteroposterior diameter (APD) on combined transverse computed tomography (CT) scan cuts of the pelvis. The APD was half the normal value in an incontinent patient with failed epispadias repair. He underwent a supraacetabular osteotomy of the pelvis with progressive anterior distraction of the anterior segment of the pelvic ring. Four months later, hardware was removed, and the APD was near normal value. Within 9 months of follow-up, the patient was dry day and night. We believe that in patients with failed exstrophy and epispadias repair, APD seems to be a predictive criterion for continence, and results of the reconstructive surgery with osteotomy should be improved by distraction of the anterior segment of the pelvic ring.

Lower incidence of fracture after IV bisphosphonates in girls with Rett syndrome and severe bone fragility

Background Classic Rett Syndrome (RS) is a disabling condition mainly caused by MECP2 mutations. Girls with RS are at risk of developing bone fragility and fractures at a young age which results in pain and may seriously impair quality of life. Objective To retrospectively assess the safety and efficacy of IV bisphosphonates on fracture, bone mineral density (BMD) and bone markers in RS girls with bone fragility. Methods RS girls received either IV pamidronate (n = 19) or IV zoledronate (n = 1) for 2 years. Results Of 20 patients studied (age: 12.5 years [6; 39]), 14 were non-ambulatory. The incidence of fracture decreased from 37 fractures in 20 patients, to 1 fracture during or after treatment (follow-up: 3.1 years [1.5; 5]). The spine BMD Z-score improved from -3.2 [-5.6; -0.1] to -2.2 [-3.8; 0.0], p = 0.0006. Most parents reported decreases in chronic pain and 2 patients started to walk. Urinary calcium excretion decreased from 0.7 [0.18; 1.5] to 0.2 [0.03; 0.67] mM/mM of creatinine (p = 0.0001). Pamidronate was well tolerated. Conclusion RS girls should be screened for impaired bone mineralization and preventive measures should be taken. In girls experiencing fractures, IV bisphosphonates constitute a beneficial adjuvant treatment to diminish the risk of fracture and restore bone density.

New concepts in scoliosis treatment

This special issue on spinal deformity in the European Spine Journal addresses some of the challenges the deformity community has been faced over the last two decades and gives some insight into the future directions. Obviously, it was not possible to give an exhaustive list of papers dealing with innovation in scoliosis management, as this would have required a whole textbook. However, the editors of this supplement of the European Spine Journal are proud to present a well thought selection of key papers about contemporary scoliosis treatment in a special focus issue—in addition to quite a number of relevant peer-reviewed deformity and scoliosis papers published and clustered in the regular issues of the European Spine Journal throughout the year. The European Spine Journal is not only the official Journal of EuroSpine—the Spine Society of Europe—but through that also of the European Spinal Deformity Society (ESDS), which has been merged already quite some years ago with the SSE. In this sense, the European Spine Journal is also the leading European scientific publication about the pathology and treatment of scoliosis and deformities. On the pediatric side, we have seen fantastic advances in the understanding of the etiology of scoliosis, the treatment of chest wall deformity along with congenital spine conditions. These advances have often been made possible thanks to the use of animal models. Keeping up with the growth of the child remains still one of the challenges to achieve, so we can have safer and simpler surgeries with fewer complications and no sequential operations. Instrumentation for scoliosis has evolved to mostly pedicle screw instrumentation, however, one can wonder if the pedicle screw fixation rage has not gone too far and if we have not created some problems, as we have observed on the pediatric side with changes in the sagittal profile of our patients and some complications. A paper on anterior spine surgery is, therefore, here to show us that pedicle screw instrumentation is not the only treatment option for our pediatric deformities. On the adult side, these new instrumentations have created junctional disorders, which are far from being resolved and represent the new challenges to overcome. There is an urgent need to better understand the whole pathobiology and pathomechanics of the adult deformity, specifically in elderly patients with concomitant diverse pathologies, as the number of patients with this pathology is rapidly increasing due to the aging of the society. The role of the sagittal profile and new understanding on how pelvic parameters are determinant in our pediatric and adult patient has now gained wide acceptance. Complex osteotomies in rigid spinal deformities have evolved, and once performed only by a few centers, these complex osteotomies gain more and more acceptance with their powerful correction. Minimal invasive surgery and spinal deformity seem to be like two opposite concepts; however, this may represent the future of some of the adult spinal deformity. Whether done as one of the steps of the reconstruction or for the whole procedure, and only for simple case, deserves discussion. At last, all these new technologies and advances can only be accepted if we perform a thorough evaluation of their success, complications and outcomes. A review of all the current outcome tools in scoliosis was necessary, so we are able to demonstrate our continuous improvement in treating such an ailment as scoliosis. We wish the reader will take on these new issues to question himself or herself on where spinal deformities stand today and prepare them to face the new challenges ahead.