Peter J. Stasikelis

Scoliotic Curve Patterns in Patients With Chiari I Malformation and/or Syringomyelia

Study Design. A retrospective radiographic review was performed on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. Objectives. To characterize curve patterns and curve features in this population and possibly refine the radiographic indications for magnetic resonance imaging in patients with a normal history and physical examination. Summary of Background Data. A subset of patients with “idiopathic” scoliosis may have an underlying neurologic abnormality. The radiographic indications for magnetic resonance imaging in asymptomatic patients with a normal clinical examination are not well defined. Methods. Data were collected from standing posteroanterior and lateral radiographs. The curve pattern and specific curve features were recorded and compared with historic controls. Thoracic kyphosis and total lumbar lordosis were also measured. Results. Fifty-one percent of patients were male. Ten curve patterns were identified, and, based on our criteria, approximately 50% of patients had an “atypical” pattern (left thoracic, double thoracic, triple, long right thoracic). A subset of those with “typical” patterns (right thoracic, right thoracic/left lumbar) had atypical features including a superior or inferior shift of the apex and/or the upper or lower end vertebrae. The mean kyphosis (T3–T12) was 41.8°. Conclusions. Although the decision to obtain magnetic resonance imaging in a patient with scoliosis should be based on both clinical and radiographic criteria, we suggest that a heightened index of suspicion is warranted with certain curve patterns (left thoracic, double thoracic, triple, and a long right thoracic curve with end vertebra caudal to T12), and with a high or low apex and/or end vertebra, especially in males and patients with a normal to hyperkyphotic thoracic spine.

Outcomes in surgical treatment of "idiopathic-like" scoliosis associated with syringomyelia

Patients with “idiopathic-like” spinal deformities associated with syringomyelia were retrospectively reviewed. Ten patients had surgical stabilization of their curvatures with at least a 2-year follow-up, and an additional five patients were evaluated for deformity pattern with <2 years of follow-up. Paralytic curve patterns, scoliosis associated with spina bifida, congenital scoliosis, or other associated syndromes were discarded. All 10 patients with surgery who were followed for an average of 46 months lost 10° correction above, through, or below the instrumented segments. A total of 50% lost correction through the instrumented segments. Anterior fusion stabilized the instrumented portion of the spine better than posterior instrumentation alone. Eighty percent of the 15 patients had thoracic kyphosis >40°. Only one patient was lordoscoliotic. Syringomyelia deformities tend to be kyphoscoliotic in 80% of cases and behave more like paralytic curvatures postoperatively. MRI is recommended for apparent idiopathic scoliotic curvatures that are kyphoscoliotic and not lordoscoliotic.

Percutaneous Epiphysiodesis of the Lower Extremity: A Comparison of Single- Versus Double-portal Techniques

Background: Percutaneous epiphysiodesis can be achieved using a single-portal or a double-portal technique. This study was performed to demonstrate any differences in outcomes, especially complications, between the 2 techniques. Methods: This was a retrospective review of cases at a single institution from 1983 to 2002 that yielded 336 children, in which 63 qualified for the study with at least 3 years of clinical follow-up. A comparison was performed through clinic chart review and radiographic measurement outcomes, searching for patient satisfaction, surgical time, and complications. Results: Minor complications included superficial infections, hematomas and effusions, whereas major complications included failure to arrest growth, partial arrest with angular deformity, fracture, and joint penetration. The single-portal group had an overall complication rate of 33.3%, with a major complication rate of 20% per patient. The double-portal group had a similar overall complication rate but only a 5.3% major complication rate per patient. There was no significant difference in patient demographics, operative times, or subjective complaints. Conclusions: Many methods of percutaneous epiphysiodesis exist in the literature that report low complication rates that are comparable with the complication rate of the original open procedure. Our study demonstrated a significantly higher rate of complications (both minor and major) compared with results previously reported. Moreover, the use of a single-portal approach increased the possibility of major complication by nearly 4-fold as compared with the use of a double-portal approach that avoids crossing the midline of the physis. Level of Evidence: Therapeutic study, level III.

Surgical corrections in scoliosis: a meta-analysis.

A meta-analysis of the acute correction outcomes in adolescent idiopathic scoliosis is reported. Posterior instrumentation systems generally gave similar coronal plane corrections with average corrections for differing systems ranging from 48% to 67%. There was significant overlap of corrections reported for each of the systems. Anterior instrumentation gave better results with average corrections ranging from 71% to 93%. No instrumentation demonstrated a consistent ability to restore a normal thoracic kyphosis, but all seemed to maintain preoperative kyphosis measures. All systems, including newer multihook systems, showed a small loss of lumbar lordosis postoperatively. The available data demonstrates that no posterior implant produces vertebral derotation.

Fractures in adults at an institution for the developmentally disabled

This is a 2-year prospective observational study of fractures occurring in residents of a live in center for developmentally disabled adults that is designed to identify risk factors that predispose to injury in this group. Fifty-eight individuals sustained 67 fractures during the study period. Only 18 of the 67 (27%) fractures were witnessed by the healthcare staff. Most fractures were diagnosed by subtle findings of erythema or swelling or by a change in the patients behavior. Thirty-three of 332 (10%) community ambulators compared with 25 of 103 (24%) less functional residents incurred fractures. This difference is highly significant. Thirty-one of the 58 (53%) patients who sustained fractures during the study had a history of fracture before the study period. Thus, programs to reduce fractures should focus on residents with previous fractures and those with more severe disabilities.

Epiphyseal changes after proximal femoral osteotomy.

This study was conducted to evaluate the risk factors for epiphyseal changes suggestive of osteonecrosis after proximal femoral osteotomy for hip subluxation associated with cerebral palsy. Forty-eight children with 94 hips were reviewed. Two observers rated the radiographs using a written protocol on two occasions each so that reproducibility of these observations could be assured. Concomitant pelvic osteotomy proved to have the greatest association with risk of epiphyseal changes. These findings, suggestive of osteonecrosis, were present in 7 of 68 (10%) hips that had isolated femoral osteotomy, and in 12 of 26 (46%) hips that had concomitant pelvic osteotomy.

Length changes in tibial osteotomy with angular correction.

Twelve boys, aged 11–17 years, who underwent percutaneus proximal tibial osteotomy with acute angular correction and application of external fixator for unilateral Blounts disease were retrospectively reviewed. Preoperative radiographs were compared with radiographs at healing to evaluate changes in tibial length and overall limb length. Angular correction increased overall limb length by a mean of 1.4 cm (range −0.4 cm to 3.2 cm). This increase was a mean 0.7 cm less than was predicted by adding the preoperative tibial and femoral lengths. This failure to achieve the predicted limb length occurs due to shortening in the tibia and should be considered when planning an osteotomy.

Function of children with myelodysplasia and lower extremity amputations

This is a retrospective study of the functional status of children who underwent a lower extremity amputation for complications of myelodysplasia. With a computerized surgical database, 12 children with myelodysplasia who underwent an amputation at the Boyd level or above at a single childrens referral hospital between 1983 and 2001 were identified. Four patients could not be contacted, but the remaining 8 patients were evaluated through chart review and interview to assess the impact of the amputation on their function. With a mean follow-up time of 9 years (range, 5-15 years), all 6 of the patients with a below-knee or Boyd amputation continued to ambulate using a prosthesis. Most patients occasionally reported having ulcers on their residual limb, but these cases were easily managed and did not result in amputation revisions. The only patient in this series with an above-knee amputation and the only patient with a knee disarticulation were exclusively wheelchair ambulators and no longer owned a prosthesis. This study supports the notion that children with myelodysplasia can have amputations and successfully wear a prosthesis to maintain their ambulation.

Spine behavior caudal to instrumentation in King II and IV curves.

This retrospective review of children surgically treated for King Type II or IV curvature of the spine required a minimum lumbar Cobb angle of 40° and a minimum lumbar inclination (the angle formed between a line through the spinous processes of the three most caudal lumbar vertebrae and a line perpendicular to the floor) of 10°. Twenty children had combined anterior thoracolumbar and posterior instrumentations whereas 20 had only posterior instrumentation. Children who had combined surgery had significantly better corrections of their lumbar Cobb angles. They had a mean correction of 43.3° compared with 26.7° in children with posterior instrumentation only. These superior corrections of the lumbar Cobb angles did not result in significantly better improvements in the lumbar inclinations. Patients who had the combined procedures had a mean improvement of 10.1°, whereas patients who had posterior instrumentation only had a mean improvement of 8.0° in lumbar inclination. Instead of having superior corrections of the lumbar inclinations, the combined surgeries resulted in a significant worsening of the angle between the end plates of the last instrumented vertebra and the next most caudal end plate. In patients who had combined surgery this angle averaged 8.4°, whereas in patients who had posterior instrumentation only this angle averaged 4.1°.

Distraction instrumentation outcomes in scoliosis.

The short-term outcomes of a new distraction technique using a small rod spinal instrumentation system (WRIGHTLOCK) are reported for adolescent idiopathic scoliosis. No caudally directed thoracic hooks were used. Seventy-four children aged 11.7 to 17.5 years who underwent consecutive posterior instrumentations are reviewed. Their curves improved from a mean of 55.6 degrees to 22.7 degrees (average of 59.2% correction). At 2.7 years mean follow-up, coronal curves lost an average of 4.2 degrees correction. Overall, there was a mean increase of 4.4 degrees in kyphosis. Children with the most preoperative hypokyphosis were afforded the greatest gains in kyphosis. Instrumentation resulted in a mean loss of 8.2 degrees lumbar lordosis. These results compare favorably with published results for other multihook systems.