Aims. The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Methods. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. Results. All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. Conclusion. Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain. Cite this article: Bone Joint J 2022;104-B(9):1067–1072

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients. Summary of Background Data. All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. Methods. We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardised surgical technique (prospectively collected single surgeon's series). All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. Results. Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range 9-18.3) and mean postoperative follow-up 3.5 years (range 2.8-5). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5° to 21.4° (74.1%). Pelvic obliquity was corrected from mean 24° to 4° (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, ICU stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, ICU stay 8.9 days, and hospital stay 27.4 days. Major complications included one deep infection and one re-operation to remove prominent implants but no deaths, no neurological deficit and no detected pseudarthrosis. Parents' survey demonstrated 100% satisfaction rate. Conclusion. Pedicle screw instrumentation can achieve excellent correction of spinopelvic deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction. Our study has demonstrated that spinal correction using segmental pedicle screw/rod constructs can be performed safely and with lesser major complications and reoperations compared to the traditionally used Unit rod or hybrid instrumentation. The greater degree of deformity correction and lesser rate of complications and reoperations due to non-union, prominent instrumentation or failed pelvic fixation using a pedicle screw compared to the Unit rod technique should be balanced against the increased implant cost

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second. rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates

The aim of this study was to compare the treatment ouctomes of severe idiopathic scoliosis (IS) (>90 degrees) using the staged surgery with initial limited internal distraction and typical IS treated using segmental pedicle screw instrumentation. We hypothesized that staged surgical treatment of severe scoliosis would improve more HRQoL and pulmonary function (PF) as compared with posterior spinal fusion (PSF) for typical IS curves. It was a retrospective review of a consecutive series of 60 IS, severe group (SG) vs. moderate group (MG) with min. 2 years of follow up (FU). The mean preoperative major curve (MC) was 120° and thoracic kyphosis (TK) was 80° for the SG and 54° and 17° for the MG, respectively (p<0.001). The MC was corrected to 58° and TK to 32° for the SG; the MC to 26° and TK to 14°, for the MG, respectively (p<0.001). The mean preoperative AVT was 8.9 cm and improved to 2.8 cm at the final FU for the SG and from 6.5 cm to 2.2 cm at the final FU for the MG (p<0.001). At baseline, the FVC% & FEV1% values were significant different between the two groups (41.5% vs. 83%, p <0.001) & (41.6% vs. 77%, p <0.001). Compared the baseline for SG vs. the values at 2-year FU the FVC % values were (41.5% vs. 66.5%, p <0.001), and the baseline for MG vs. the values at 2-year FU, the FEV1 values were (77% vs. 81%, NS). At last FU, no complications were reported. Gradual traction with complicity of multilevel Ponte's osteotomies and neuromonitoring followed by staged pedicle screws instrumentation in severe IS proved to be a safe and effective method improving spinal deformity (52% correction), PF (improved percentage of predicted forced vital capacity by 49%), and health-related quality and allows to achieve progressive curve correction with no neurologic complications associated to more aggressive one-stage surgeries

Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

Aim:

To determine radiographic variables that predict the need for distal extension of the fusion beyond Cobb-to-Cobb levels in treating thoracolumbar/lumbar (TL/L) scoliosis (Lenke 5) in adolescent patients.

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (. sd. 29, 25° to 141°) and 81° (. sd. 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (. sd. 20; 2° to 87°) and 20° (. sd. 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (. sd. 2.18) and 6.04 hours (. sd. 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (. sd.  2790) and 1785 ml (. sd. 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis

Aims

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.

Aims. It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis. Methods. In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. Results. The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). Conclusion. We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261–267

There are few reports of the treatment of lumbar tuberculous spondylitis using the posterior approach. Between January 1999 and February 2004, 16 patients underwent posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation. Their mean age at surgery was 51 years (28 to 66). The mean follow-up period was 33 months (24 to 48). The clinical outcome was assessed using the Frankel neurological classification and the Kirkaldy-Willis criteria. On the Frankel classification, one patient improved by two grades (C to E), seven by one grade, and eight showed no change. The Kirkaldy-Willis functional outcome was classified as excellent in eight patients, good in five, fair in two and poor in one. Bony union was achieved within one year in 15 patients. The mean pre-operative lordotic angle was 27.8° (9° to 45°) which improved by the final follow-up to 35.8° (28° to 48°). Post-operative complications occurred in four patients, transient root injury in two, a superficial wound infection in one and a deep wound infection in one, in whom the implant was removed. Our results show that a posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation for tuberculous spondylitis through the posterior approach can give satisfactory results

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation. This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up. Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction. Clinical measurement of rib prominence using scoliometer. The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05). This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique

Background. Partial facetectomies with pedicle screw instrumentation is widespread and a well described technique for achieving posterior correction of scoliosis. Newton et al. first described the use of the UBS in the posterior correction of AIS in 2014. The aim of this study was to compare the effectiveness of the UBSPO in achieving posterior correction in Type1 AIS as compared to the traditional partial facetectomies. Aim of this study was to assess the effectiveness of USBPO in achieving posterior correction in Type 1 AIS as compared to partial facetectomies. Methods. A retrospective review of 40 patients with type 1 AIS who had undergone a posterior correction of scoliosis between 2010 and 2016 was performed. Group A (n=20) consisted of consecutive patients that had partial facetectomies while Group B (n=20) consisted of consecutive patients having UBSPO. Both groups were matched for demographic parameters. Pre and post-operative radiographic parameters and operative data in both groups were compared. The Mann-Whitney U test was used for statistical analysis. Results. There was no significant difference between the two groups in terms of age, sex, magnitude of curves, apical rotation and flexibility on the preop imaging. There was a significant difference between the mean postop Cobb angle (21.9° vs 9.8°, p<0.0005), correction (63.04% vs 84.3%, p<0.0005) and postop apical rotation (p = 0.008) in favour of the UBSPO group. At 2-year follow-up there was a statistically significant increase in the cobb angle in the facetectomy group (21.89° (immediate post op) Vs 24.64° P=0.033) and no such difference in the UBSPO group. There was no significant difference between surgical time (p = 0.536) and blood loss (p = 0.380). Conclusion. The use of the UBSPO for posterior release provides more effective correction in the coronal and axial planes than traditional partial facetectomies in type 1 AIS

Introduction. We aimed to determine the midterm effect of pedicle screw instrumentation on sagittal plane alignment, compared with a hybrid alignment, in the treatment of thoracic adolescent idiopathic scoliosis (AIS). Methods. 88 consecutive patients with AIS with a Lenke type 1 curve treated between 1998 and 2003 were analysed. Thoracic hooks were used in 45 patients (group Hy) and thoracic screws alone in 43 patients (group TPS). Preoperative average age (Hy 15·3 years vs TPS 16 years), sex (38 female and seven male vs 37 female and six male), Risser sign (2·9 vs 2·9), main thoracic curve (64° vs 65·5°), and thoracic kyphosis (22·6° vs 21·4°) were similar in both groups. Pearson correlation coefficient and univariate ANOVA were used. Results. At a mean follow-up of 7·3 years (range 5–10), the TPS group had a greater final main thoracic curve correction (Hy 46·4% vs TPS 58·4%; p<0·001), with inferior loss of initial correction (–11·1° vs TPS –1·3°; p<0·0005). Absolute final thoracic kyphosis was similar in both groups (31·4° vs 25·4°; r=0·002; p>0·05), with both groups showing an equally statistically significant amelioration of the sagittal contour (Hy 49·2%; p<0·001 vs TPS 43·4%; p<0·001) (difference between groups p>0·05). We recorded a significant correlation between absolute kyphosis correction (final preoperative) and percentage main thoracic curve initial correction loss in the Hy group (r=0·35, p<0·001). The SRS–30 assessment showed an improvement in self-image and satisfaction, with no significant differences between groups. Conclusions. The previously reported loss of kyphosis after a pedicle screw instrumentation in AIS, when compared with hybrid or hook only implants, should be questioned. At a minimum 5 years of follow-up, sagittal contour in the thoracic spine was not less kyphotic when pedicle screws were compared with hybrid constructs. The higher the loss of initial correction of main thoracic curve, the greater the postoperative absolute kyphosis at T5–T12 level. The clinical relevance of such radiographic differences is still undetectable with present self-assessment methods

Introduction. Posterior spinal arthrodesis with thoracoplasty and an open anterior approach, with respect to a posterior only fusion, have a deleterious effect on pulmonary function for up to 5 years after surgical treatment of adolescent idiopathic scoliosis. We aimed to compare two groups of adolescents surgically treated for their spinal deformity either by posterior segmental fusion alone (PSF) or by posterior spinal fusion and thoracoplasty (PSF+T). We focused on the long-term effects of thoracoplasty on pulmonary function in the surgical treatment of adolescent idiopathic scoliosis. Methods. We compared 40 consecutive adolescent patients surgically treated between 1998 and 2001 by PSF+T with a similar cohort of 40 adolescents treated in the same period by PSF. Inclusion criteria were pedicle screw instrumentation alone and a minimum 5 years of follow-up. A radiographic analysis and a chart review were done, evaluating the pulmonary function tests (PFTs), the SRS-30 score questionnaire, and the Lenke classification system. A radiographic rib-hump (RH) assessment was also undertaken. Results. The entire series was reviewed at an average clinical follow-up of 8·3 years. The two groups did not differ significantly in terms of sex, age (PSF+T 16·3 years vs PSF 15·2 years), Lenke curve type classification, and preoperative Cobb main thoracic (MT) curve magnitude (66° vs 63°); however, final MT percentage correction (53·03% vs 51·35%; p<0·03), RH absolute correction (–2·1 cm vs –1·05; p<0·01), and RH overall percentage correction (55·4% vs 35·4%; p<0·0001) were greater in the PSF+T group than in the PSF group. We recorded no statistical differences between the two groups in PFTs both preoperatively and at last follow-up. Nevertheless, comparing preoperative with final PFTs within each group, only in the PSF group was both forced vital capacity and forced expiratory volume in 1 s significantly improved at final evaluation. At last follow-up visit, the SRS-30 scores did not differ significantly between the two groups (total score 4·1 vs 4·3). Conclusions. Our findings suggest that thoracoplasty did not adversely affect long-term PFTs in patients with adolescent idiopathic scoliosis treated by posterior spinal fusion alone with pedicle screws instrumentation, as already shown in previous reports. A trend towards better coronal plane correction and rib-hump improvement was recorded, although this improvement was not clearly reported in a self-assessment disease-specific questionnaire

Aims. Anchorage of pedicle screw rod instrumentation in the elderly spine with poor bone quality remains challenging. Our study aims to evaluate how the screw bone anchorage is affected by screw design, bone quality, loading conditions, and cementing techniques. Methods. Micro-finite element (µFE) models were created from micro-CT (μCT) scans of vertebrae implanted with two types of pedicle screws (L: Ennovate and R: S. 4. ). Simulations were conducted for a 10 mm radius region of interest (ROI) around each screw and for a full vertebra (FV) where different cementing scenarios were simulated around the screw tips. Stiffness was calculated in pull-out and anterior bending loads. Results. Experimental pull-out strengths were excellently correlated to the µFE pull-out stiffness of the ROI (R. 2. > 0.87) and FV (R. 2. > 0.84) models. No significant difference due to screw design was observed. Cement augmentation increased pull-out stiffness by up to 94% and 48% for L and R screws, respectively, but only increased bending stiffness by up to 6.9% and 1.5%, respectively. Cementing involving only one screw tip resulted in lower stiffness increases in all tested screw designs and loading cases. The stiffening effect of cement augmentation on pull-out and bending stiffness was strongly and negatively correlated to local bone density around the screw (correlation coefficient (R) = -0.95). Conclusion. This combined experimental, µCT and µFE study showed that regional analyses may be sufficient to predict fixation strength in pull-out and that full analyses could show that cement augmentation around pedicle screws increased fixation stiffness in both pull-out and bending, especially for low-density bone. Cite this article: Bone Joint Res 2021;10(12):797–806

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting thoracolumbar/lumbar idiopathic scoliosis in adolescent patients. Summary of Background Data. Thoracolumbar/lumbar scoliosis has been traditionally treated through an anterior approach and instrumented arthrodesis with the aim to include in the fusion the Cobb-to-Cobb levels and preserve distal mobile spinal segments. Posterior instrumentation has been extensively used for thoracic or thoracic and lumbar scoliosis. In the advent of all-pedicle screw constructs there is debate on whether thoracolumbar/lumbar scoliosis is best treated through an anterior or a posterior instrumented arthrodesis. Methods. We reviewed the medical notes and radiographs of 19 consecutive adolescent patients with Lenke 5C idiopathic scoliosis (17 female-2 male, prospectively collected single surgeon's series). We measured the scoliosis, thoracic kyphosis and lumbar lordosis angles, apical vertebral rotation (AVR) and translation (AVT), trunk shift (TS), as well as the lower instrumented vertebra angle (LIVA) both pre-and post-operatively and at minimum 2-year follow-up. SRS 22 data was available for all patients. Results. All patients underwent posterior spinal arthrodesis of the primary thoracolumbar/lumbar curve using all-pedicle screw constructs. Mean age at surgery was 15.1 years. We identified 3 separate groups: Group 1 (9 patients) had a fusion to include the preoperative Cobb-to-Cobb levels of the curve; in Group 2 (8 patients) the fusion extended 1-2 levels distal (all patients) +/− proximal (4 patients) to the end Cobb vertebrae; in Group 3 (2 patients) the fusion extended to one level proximal to the lower end Cobb vertebra. Eight patients had compensatory thoracic curves. Mean Cobb angle before surgery was 60.3° (range: 43-91°). This was corrected by 79% to mean 13° (p<0.001) with no patient losing >2° correction at follow-up. Mean preoperative Cobb levels of the thoracolumbar/lumbar curve were 6.3; mean levels of instrumented fusion were 7 (mean extent of fusion: preoperative Cobb angle + 0.7 levels). Mean preoperative thoracic kyphosis was 34.7° and lumbar lordosis 45.3°. Mean postoperative thoracic kyphosis was 36.6° and lumbar lordosis 43°. Mean theatre time was 3.8 hours, hospital stay 7.5 days and intraoperative blood loss 0.26 blood volumes. There were no neurological complications other than one temporary brachial plexus neuropraxia (recovered before patient discharge from hospital), no wound infections or detected non-union at follow-up. Mean preoperative SRS 22 score was 3.7; this was improved to 4.5 at 2-year follow-up (p=0.01). Pain and self-image demonstrated significant improvement (p=0.02, p=0.001 respectively) with mean satisfaction rate 4.8. Comparison between Groups 1 and 2 showed similar age at surgery but higher preoperative scoliosis in Group 2 (Group 1: 54°/Group 2: 65°, p=0.05). Preoperative AVR, TS and LIVA were similar between the 2 groups (p>0.05). Preoperative AVT was significantly higher in Group 2 (Group 1: 3.3 cm/Group 2: 5 cm, p=0.01). Conclusion. Pedicle screw instrumentation can achieve excellent correction of Lenke 5C idiopathic scoliosis which is maintained at follow-up. This is associated with high patient satisfaction and low complication rates. Greater preoperative AVT and scoliosis angle predicted the need for longer fusion both distally and proximally beyond the end vertebra of the preoperative Cobb angle

The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. . We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score. Cite this article: Bone Joint J 2014;96-B:541–7

Purpose. Retrospective review of growth sparing spinal instrumentation. Methods and results. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants. Conclusion. Dual growth rods are effective at maintaining correction while attaining height for deformities from a variety of aetiologies in paediatric patients. Families need be informed of associated complications and unplanned/multiple surgeries

Introduction. Thoracic pedicle screws have been proven to be safe and effective in the treatment of adolescent idiopathic scoliosis (AIS). However, the effect of the instrumentation alloy has not yet been investigated. We aimed to compare segmental versus non segmental thoracic pedicle screw instrumentation in patients with AIS. Methods. A consecutive series of 143 patients with AIS (Lenke classification 1–4) surgically treated from 1998 to 2005 by means of thoracic pedicle screws were retrospectively reviewed. Considering implant density (number of fixation anchors placed per available anchors sites; segmental =60% [S], non-segmental =60% [NS]) and implant alloy used (titanium [Ti] vs stainless steel [SS]) we divided the cohort into four groups: Ti-S (48 cases); Ti-NS (34 cases); SS-S (35 cases); and SS-NS (26 cases). Groups were similar for preoperative mean age, sex distribution, Risser sign, main thoracic curve, and thoracic kyphosis. Pearson correlation coefficient and univariate analysis of variance were used. Results. At a mean follow-up of 6·2 years (range 3–10) the overall final main thoracic curve correction was a mean of 61·4% (20–89), whereas the implant density within the major curve was 71% (15–100%). We recorded a significant correlation between implant density and percentage major curve correction (r=0·41, p<0·002); when the four groups were compared we noted that the SS-S group showed the greatest average correction (75%), followed by the Ti-S, SS-NS, and Ti-NS groups. We detected no significant differences between SS-S versus Ti-S versus SS-NS (r=0·002, p>0·05; r=0·13, p>0·05; r=0·07, p>0·01, respectively), whereas the Ti-NS group showed a statistically significant inferior percentage correction when compared with all other groups (average 52%; p<0·001). Nevertheless, no significant difference between groups was recorded on the SRS-30 assessment, showing a postoperative improvement in both self-image and satisfaction. Conclusions. When an SS instrumentation is used, non-segmental pedicle screw constructs seem to be equally effective as segmental instrumentations in obtaining satisfactory results in patients with main thoracic AIS. When the implant alloy used is titanium, an implant density of greater than 60% should be guaranteed so as to achieve similar results to those recorded in this study