Nima Kabirian

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.

Anterior column realignment (ACR) for focal kyphotic spinal deformity using a lateral transpsoas approach and ALL release.

Study Design: Retrospective case series. Objectives: Introduce and evaluate the safety of a new technique of anterior column realignment (ACR) using a lateral transpsoas approach with release of anterior longitudinal ligament and annulus for correction of focal kyphotic deformity. Summary of Background Data: Spinal sagittal imbalance can adversely affect the long-term outcomes of patients with spinal deformity. Methods: Clinical and radiographic review of patients who underwent ACR. Results: Seventeen consecutive patients (12 females; 5 males) with a mean age of 63 years (range, 35–76 y) and a mean follow-up of 24 months (range, 12–82 mo) were identified. Fourteen of 17 (82%) had previous spine surgery and 12/17 (71%) had previous fusion. Twelve of the 17 (71%) underwent ACR for adjacent segment disease. Fifteen patients (88%) had Smith-Petersen osteotomies at the ACR level. The mean motion segment angle was 9 degrees preoperatively, which corrected to −19 degrees after ACR and to −26 degrees after posterior instrumentation. Motion segment angle was maintained at −23 degrees at the latest follow-up. The mean lumbar lordosis was −16 degrees preoperatively, which improved to −38 degrees after ACR and to −45 degrees after posterior instrumentation. Lumbar lordosis was maintained at −51 degrees at the latest follow-up. Pelvic tilt averaged 34 degrees before ACR and improved to 24 degrees after ACR and posterior instrumentation and maintained at 25 degrees at the latest follow-up. Patients with preoperative negative T1 spinopelvic inclination (T1SPI) corrected from −6 to −2 degrees and those with 0 or positive T1SPI corrected from 5 to −3 degrees after ACR at the latest follow-up. Eight patients (47%) had 10 complications. Four complications occurred after ACR. Two of 4 were neurological (1 persistent weakness) and 1 was vascular injury during anterior plate removal. Conclusion: Compared with posterior-based techniques, our preliminary results of ACR showed similar correction capacity and similar rate of morbidities for the treatment of focal kyphotic spinal deformity. Careful case selection, attention to the details of the technique, and enough experience are prudent elements for a desirable outcome.

Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences.

BACKGROUND Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment. METHODS A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention. RESULTS Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05). CONCLUSIONS The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Traumatic complete lateral dislocation at the lumbosacral junction: a case report.

Study Design: This is a case report. Objective: To present a novel case of lumbosacral dislocation and its surgical management. Summary of Background Data: Complete lumbosacral dislocations are rare injuries that ensue as a result of high-energy trauma. Anatomic stabilization of these injuries can be challenging and often involves open fixation and arthrodesis. Methods: We present the case of a 22-year-old male who was involved in a high-velocity motorcycle accident with neurological deficit in the lower extremities. Radiographic analysis demonstrated a complete lateral dislocation of L5 vertebral body over the sacrum. The patient was surgically managed with a combined anterior and posterior arthrodesis, posterior decompression, and instrumentation. Results: Successful arthrodesis and spinal alignment was achieved. The patient regained partial neurological function in the lower extremities with an improved Visual Analogue Scale score of 1 and was able to ambulate semi-independently at latest follow-up. Conclusions: A combined anterior and posterior arthrodesis with decompression and instrumentation is an effective method for the treatment of this type of lumbosacral dislocation.

Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique: case report.

The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up. Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

Quantifying Anesthesia Exposure in Growing Rod Treatment for Early Onset Scoliosis.

Background: Growing rod (GR) treatment for early-onset scoliosis requires repeated anesthesia exposure (AE). At a minimum, GR treatment requires AE for diagnostic imaging, index GR surgery, periodic lengthenings, and final fusion. Adjunct procedures and complication-related procedures also increase AE. To our knowledge, this is the first study to quantify AE in GR treatment and to establish preoperative expectations. Methods: A single-center retrospective review of 16 patients who completed GR treatment and underwent final fusion. Duration of all AE related to GR treatment for “standard” care procedures (ie, advanced imaging, index surgery, lengthenings, final fusion) and “associated” care procedures (ie, revisions, adjunctive surgical procedures, wound-related complications) were reviewed. Etiologies were classified per the classification of early-onset scoliosis. Mean total anesthesia time (TAT) was tallied and analyzed for standard care and associated care procedures. Results: There were 5 syndromic, 8 neuromuscular, and 3 idiopathic patients. The mean age at the first AE event related to GR treatment was 7.4 years (range, 3.8 to 11 y). Mean age at the index GR surgery and final fusion was 8.1 years (range, 3.9 to 14.4 y) and 12.8 years (range, 9.7 to 19 y), respectively. The percentage of TAT for each procedural category was 7% for advanced imaging, 14% for index GR, 14% for lengthenings, 21% for final fusion, 27% for revisions, 9% for adjunct surgery, and 9% for wound complications. Standard care procedures accounted for 55% of TAT, whereas associated care procedures accounted for 45%. Conclusions: This study quantified expected duration of AE in GR treatment. Revisions and final fusion contributed most to TAT. Given the recent controversy of repeated AE in young children, efficiency measures should be implemented to reduce AE and avoid duplication without compromising the goals of surgical treatment. Associated care procedures accounted for 45% of the total AE. Level of Evidence: Level IV.

Anterior Column Realignment (ACR): Minimally Invasive Surgery for the Treatment of Adult Sagittal Plane Deformity

Adult sagittal plane alignment is the result of an intricate interaction between the spine and pelvis. The development of a sagittal spine deformity results in a series of compensatory mechanisms including increase in pelvic tilt, hip extensor overutilization, and knee and ankle flexion. When these natural mechanisms fail, patients may develop symptomatic sagittal imbalance, which ultimately affects their function and quality of life.

Progressive early-onset scoliosis in Conradi disease: a 34-year follow-up of surgical management.

Background: Conradi-Hunermann syndrome (CHS) is a rare metabolic syndrome with several orthopaedic problems. Early-onset scoliosis is of great importance because of often rapidly progressive nature and high risk of postoperative complications. Objectives: To report the 34-year follow-up and outcome of a patient with CHS treated with combined anterior and posterior fusion without instrumentation. Methods: All available clinical and radiographs of a female patient with CHS retrospectively reviewed. Overall health status, sagittal and coronal deformity, pulmonary function test, and outcome questionnaires were evaluated. Results: Initial films at the age of 4 months showed a curve of 37 degrees from T6-T11 and a curve of 17 degrees from T11-L2. Thoracic kyphosis was measured at 43 degrees. Standing films at the age of 2 years and 2 months showed progression of both the curves to 50 and 66 degrees, respectively, and a significant spinal imbalance. The kyphosis also progressed to 57 degrees. She underwent a staged anterior inlay graft spinal fusion with autograft and allograft ribs from T8-L1 and posterior in situ fusion from T6-L1 with corticocancellous allograft. Solid radiographic fusion was observed 18 months after surgery. She was 36 years old at her latest follow-up, 34 years after surgery, with neutral clinical coronal and sagittal balance. No significant pain and respiratory complaint at moderate sports and normal daily life activity. “Vital capacity” and “total lung capacity” were 65% and 75%, respectively, of the normal. Thoracic curve of 35 degrees (T6-T11) and right thoracolumbar curve of 53 degrees from T11-L2 with a solid fusion fromT6-L1 with kyphosis measured over the fused area of 40 degrees were observed. Her overall mean Scoliosis Research Society-22 score was 3.68. She is an MBA graduate from a competitive school and currently works full-time. Conclusions: Although the treatment of early-onset scoliosis has significantly evolved over the past 3 decades, the traditional method of anterior release and fusion and staged in-situ posterior fusion posterior fusion with postoperative immobilization showed acceptable deformity correction and maintenance of the pulmonary function over the 34 years.