Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Acute angulation at the thoracolumbar junction with segmental subluxation of the spine occurring at the level above an anteriorly hypoplastic vertebra in otherwise normal children is a rare condition described as infantile developmental thoracolumbar kyphosis. Three patient series with total of 18 children have been reported in the literature. We report five children who presented with thoracolumbar kyphosis and discuss the treatment algorithm. We reviewed the medical records and spinal imaging at initial clinical presentation and at minimum two-year follow-up. The mean age at presentation was eight months (two to 12). All five children had L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously in three children kept under monitoring. In contrast, the deformity was progressive in two patients who were treated with bracing. The kyphosis and segmental subluxation corrected at latest follow-up (mean age 52 months; 48 to 60) in all patients with near complete reconstitution of the anomalous vertebra. The deformity and radiological imaging on a young child can cause anxiety to both parents and treating physicians. Diagnostic workup and treatment algorithm in the management of infantile developmental thoracolumbar kyphosis is proposed. Observation is indicated for non-progressive kyphosis and bracing if there is evidence of kyphosis and segmental subluxation deterioration beyond walking age. Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment.

Cite this article: Bone Joint J 2015;97-B:982–7.

Introduction

Growing rods are used in the treatment of early-onset scoliosis. The aim of this technique is to achieve deformity correction while maintaining spinal growth. Gradual stiffening or spontaneous fusion of the spine can interfere with the ability to lengthen. Furthermore, diminished acquired length with serial distraction is common and needs to be evaluated and quantified. The purpose of this prospective study was to measure the forces and amount of distraction over time in patients with early-onset scoliosis treated with growing rods.

We describe the results of a prospective case series to evaluate a technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a u-shaped modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation. 20 patients aged between 9 and 21 years with a pars defect at L5 confirmed on computed tomography (CT) were included. The average age of the patients was 13.9 years. The eligible patient had Grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The average duration of follow-up was 4 years. Clinical assessments for all patients was via the Oswestry disability index (ODI) and visual analogue scores (VAS). At the latest follow-up, 18 of the 20 patients had excellent clinical outcomes with a significant (p<0.001) improvement in their ODI and VAS scores with a mean post-operative ODI score of 8%. Fusion of the pars defect as assessed by CT showed fusion rates of 80%. There were no hardware complications. The strength of the construct obviates the need for post-operative immobilisation.

We describe the clinical results of a technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.

20 patients aged between 9 and 21 years were included in this prospective study. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. Patients had either no or grade I spondylolisthesis. Definitive pseudoarthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity.

A midline incision was used for surgery. The pars interarticularis defect was exposed and filled with autologous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace. The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma and two superficial wound infections which responded to antibiotic treatment. Follow-up was at 6 weeks, 6 months and at 18 months, and 24 months. Clinical assessments for all patients was via the Oswestry disability index (ODI) and visual analogue scores (VAS). At the latest follow-up, 18 out of the 20 patients showed a significant (p<0.05) improvement in their ODI and VAS scores. The mean post-operative ODI score was 8%. All patients had radiographs and CT scans which showed fusion rates of 80% in those patients followed up for a minimum of 24 months. This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index in 18 out of 20 patients studied with a minimum follow-up of 2 years.

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation.

The strength of the construct removes the need for post-operative immobilisation.

Summary: Radiographic and clinical outcomes of anterior thoraco-lumbar and posterior instrumented spinal fusion in patients with double major (AIS) curves are evaluated in this retrospective study. The average thoracic curve was 68 degrees before surgery and 29.2 degrees at follow-up (mean correction 58.3%). The average preoperative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77.5%). Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique with low morbidity in AIS with double curve pattern.

Introduction: Options exist for the surgical treatment of double major AIS curves. With the introduction of multi-level pedicle screw fixation in the thoracic and lumbar spines the role of anterior surgery is being questioned. This series demonstrates the results obtained by anterior thoraco-lumbar and posterior instrumented spinal fusion.

Methods: 28 patients with double major curves who underwent anterior spinal release and instrumented fusion, with staged posterior instrumented spinal fusion between 1999 and 2005 were included for analysis. The minimum follow-up was 2 years after surgery (mean, 5 years; range, 2–8 years). The mean age of patients was 17,3 years (range, 13–21 years). Multiple radiographic parameters were assessed.

Results: Successful selective thoraco-lumbar instrumented fusion and posterior instrumented fusion was performed in 28 consecutive patients with adolescent idiopathic scoliosis. The average thoracic curve was 68 degrees before surgery and 29,2 degrees at final follow-up (mean correction 58,3%). The average pre-operative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77,5%), with good coronal and sagittal balance achieved. Tilt of the lower instrumented vertebra (LIV) improved from 28.2 degrees to 4.6 degrees on last follow-up. Disc angulation below the LIV averaged 6.1 degrees preoperatively and 3.6 degrees on last follow-up. Translation of the LIV from the center sacral vertical line averaged 34.5 mm preoperatively and 13.6 mm on last follow-up.

Discussion: Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique in adolescent idiopathic scoliosis with double curve pattern. These results show that this technique is able to restore normal coronal alignment of the distal unfused lumbar segment and saves fusion levels compared to posterior instrumentation only. Despite the extensive surgery, there is a very low morbidity in this population, with no evidence of pseudarthrosis.

Significance: This represents a large unique series of patients treated for double major curve pattern in adolescent idiopathic scoliosis with low morbidity and excellent balanced corrections in both coronal and sagital planes.

Study Design: Retrospective study with clinical and radiological evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebae (HV).

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 neurological compromise.

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.

Materials and Methods: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. 13 patients had a single posterolateral HV and 2 patients 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. 13 HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine.

Results: The average operating time was procedure was 150 minutes (range, 130 to 210 minutes). The average blood loss 180 mL (range, 100 to 330 mL), equivalent to a mean external blood volume loss of 15% (range, 11 to 24%).

Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) 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 followup.

One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

Key points:

In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result.

Study Design: Retrospective study with clinical and radiological evaluation of 29 patients with congenital scoliosis who underwent 31 short segment anterior instrumented fusions of lateral hemivertebrae.

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 scoliosis in children below the age of 6.

Summary of background data: A variety of treatments have been described in the literature for the treatment of HV. We report the results of a novel technique.

Materials and Methods: Between 1996 and 2005, 29 consecutive patients with 31 lateral HV and progressive scoliosis underwent short segment anterior instrumentation and fusion with preservation of the HV. Mean age at surgery was 2.9 years. Mean follow-up period was 6.3 years.

Results: Preoperative segmental Cobb angle averaging 39°, was corrected to 150 after surgery, being 15º at the last follow up (60% of improvement). Compensatory cranial and caudal curves corrected by approximately 50% and did not change significantly on follow up. The angle of segmental kyphosis averaged 13º before surgery, 12º after surgery, and 12° at follow up. There was 2 wound infection requiring surgical debridment, 1 intraoperative fracture of the vertebral body and 1 case lost correction due to implant failure. All went on to stable bony union. There were no neurologic complications.

Conclusions: Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and to prevent the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion which is of great importance in the growing spine

We describe the clinical results of a new technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.

14 patients aged between 10 and 17 years were included in this study. 7 were males and 7 females. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. All patients had undergone at least 12 months of activity modification, a trial of bracing and physical therapy before surgical options were discussed. None of the patients had spondylolisthesis. Definitive pseudo-arthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity. The pars defect was at L5 in all 14 patients.

A midline incision was used for surgery. The pars intercularis defect was exposed and filled with autolo-gous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace.

The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma. Follow-up was at 6 weeks, 6 months and at 1 year. At the latest follow-up, visual analogue scores ranged between 0 and 4 for all patients, indicating excellent overall pain control. Functional assessments for all patients via the modified Oswestry scores were 0% to 13%, indicating a good overall functional result. All patients had radiographs at follow-up which showed fusion rates of 80% in those patients followed up for 1 year.

This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index.

Tibiotalocalcaneal (TTC) fusion is indicated in rheumatoid patients with combined ankle and subtalar disease, particularly when severe deformity is present. In theory, if bone stock is good, a staged subtalar/triple arthrodesis followed by total ankle replacement (TAR) can be used. This is so rarely the case that the author has no experience of this. TTC fusion is also useful in rheumatoid patients with previous joint sepsis, to salvage a failed TAR and to salvage a non-united ankle fusion. It allows early weight bearing, which is valuable in those patients who have multiple joint, particularly upper limb, involvement.

In our study, 18 patients underwent 21 TTC fusions from August 1988 to September 2002. The average age was 48 years (range 23–90). Nine patients had undergone previous hindfoot procedures, five were smokers, one was diabetic and one had chronic renal failure. Surgery was performed under GA with tourniquet. Patients were reviewed using a modified American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and with regard to their personal satisfaction. Follow up was 18–57 months.

Post-operatively, the oldest patient died due to fulminant sepsis. Seven patients had superficial wound infections but none required re-operation. Fusion was achieved in 18 limbs. Average time to radiological union was 36 weeks (range 9–68), two patients required nail dynamisation. In six cases it was necessary to remove irritating locking screws, either the posterior screw for heel rubbing, or the medial tibial screws for stress riser symptoms. One patient required complete nail removal. There were no amputations.

Fourteen patients were very satisfied, two reasonably so and one not. The average AOFAS pain score (max 40) improved from 11 to 32, and the average AOFAS functional score (max 28) from 4 to 21.

We feel that despite the relatively high complication rate, this technically challenging procedure is a very useful salvage option in these very disabled patients.