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Rationale: Congenital scoliosis due to a hemivertebra creates a wedge-shaped deformity, which progresses and causes severe spinal deformities as an individual grows. The treatment of congenital scoliosis focuses on early diagnosis and appropriate surgical management before the development of severe deformity., Patient Concerns: We report the case of a 4-year-old male child with a left thoracolumbar scoliosis of 27° (T10-T12) due to a T11 hemivertebra who was treated by posterior fusion and pedicle screw fixation at the age of 4 years. The implant was removed due to pain secondary to implant prominence after 4 years without definitive revision surgery, which led to significant progression of the scoliosis, to 50°. The indication for posterior vertebral column resection (PVCR) is a congenital spinal deformity with a curve magnitude greater than 30° with fast progression. This includes documented progression of the curve by more than 5° in a 6- month period, failure of conservative treatment, or both., Outcomes: The patient underwent PVCR of the T11 hemivertebra. Nine years after the revision surgery with PVCR, the patient showed satisfactory results and his spine was well balanced., Lessons: This case shows that removal of an implant that was not the only cause of curve progression at a young age may lead to progression of scoliosis and, therefore, should be avoided unless it is absolutely necessary., Conclusion: Congenital scoliosis due to a hemivertebra at a young age could be treated by hemivertebra resection or anterior and posterior epiphysiodesis as definitive surgical treatment. The patient was eventually treated with PVCR, which achieved satisfactory correction without curve progression in a long-term follow-up., Competing Interests: The authors have no conflicts of interest to disclose.

Introduction: Pedicle screw instrumentation in AIS has advantages of rigid fixation, improved deformity correction and a shorter fusion, but needs an exacting technique., Materials and Methods: The author has been using the K-wire method with intraoperative single PA and lateral radiographs, because it is safe, accurate and fast. Pedicle screws are inserted in every segment on the correction side (thoracic concave) and every 2-3 on the supportive side (thoracic convex). After an over-bent rod is inserted on the corrective side, the rod is rotated 90° counterclockwise. This maneuver corrects the coronal and sagittal curves. Then the vertebra is derotated by direct vertebral rotation (DVR) correcting the rotational deformity. The direction of DVR should be opposite to that of the vertebral rotation. A rigid rod has to be used to prevent the rod from straightening out during the rod derotation and DVR. The ideal classification of AIS should address all curve patterns, predicts accurate fusion extent and have good inter/intraobserver reliability. The Suk classification matches the ideal classification is simple and memorable, and has only four structural curve patterns; single thoracic, double thoracic, double major and thoracolumbar/lumbar. Each curve has two types, A and B. When using pedicle screws in thoracic AIS, curves are usually fused from upper neutral to lower neutral vertebra. Identification of the end vertebra and the neutral vertebra is important in deciding the fusion levels and the direction of DVR. In lumbar AIS, fusion is performed from upper neutral vertebra to L3 or L4 depending on its curve types., Conclusions: Rod derotation and DVR using pedicle screw instrumentation give true three dimensional deformity correction in the treatment of AIS. Suk classification with these methods predicts exact fusion extent and is easy to understand and remember.

The pedicle is a power nucleus of the vertebra and offers a secure grip of all 3 columns. Pedicle screw instrumentation has advantages of rigid fixation with improved three-dimensional (3D) correction and it is accepted as a reliable method with a high margin of safety. Accurate placement of the pedicle screws is important to reduce possible irreversible complications. Many methods of screw insertion have been reported. The author has been using the K-wire method coupled with the intraoperative single posteroanterior and lateral radiographs, which is the most safe, accurate and fast method. Identification of the curve patterns and determining the fusion levels are very important. The ideal classification of adolescent idiopathic scoliosis should address the all patterns, predict the extent of accurate fusion and have good inter/intraobserver reliability. My classification system matches with the ideal classification system, and it is simple and easy to learn; and my classification system has only 4 structural curve patterns and each curve has 2 types. Scoliosis is a 3D deformity; the coronal and sagittal curves can be corrected with rod rotation, and rotational deformity has to be corrected with direct vertebral rotation (DVR). Rod derotation and DVR are true methods of 3D deformity correction with shorter fusion and improved correction of both the fused and unfused curves, and this is accomplished using pedicle screw fixation. The direction of DVR is very important and it should be opposite to the direction of the rotational deformity of the vertebra. A rigid rod has to be used to prevent rod bend-out during the derotation and DVR.

Study Design: Retrospective study., Objective: To evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw instrumentation in the treatment of thoracic adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Some spine surgeons recently think more correction of hump deformity using pedicle screws without thoracoplasty. Although thoracoplasty has been conventional treatment of rib hump, there are few papers about the results of pedicle screw instrumentation and concomitant thoracoplasty., Methods: Eighty-seven patients with thoracic AIS (mean age, 14.4 years) treated by pedicle screw instrumentation were retrospectively analyzed after a minimum follow-up of 2 years. Patients were divided into 3 groups; N-T group (no thoracoplasty with iliac bone graft, n = 37), T+N-DVR [thoracoplasty without direct vertebral rotation (DVR), n = 20] and T+DVR group (thoracoplasty with DVR, n = 30). In the T (T+N-DVR and T+DVR) group, 4 to 8 ribs were resected and used for bone graft. Patients were evaluated for deformity correction, balance, pulmonary function, height and angle of rib hump, clinical outcomes (SRS-30), and complications., Results: In the N-T group, the thoracic curve was corrected from 53 degrees to 16 degrees (69% correction), in the T+N-DVR group from 55 degrees to 18 degrees (69%) and in the T+DVR group from 54 degrees to 10 degrees (81%). There was no difference in postoperative spinal balance and pulmonary function among the 3 groups. The correction rates of hump height and angle were 35% and 38% in the N-T group, respectively, 57% and 58% in the T+N-DVR, and 70% and 72% in the T+DVR. The T group showed significantly better correction of rib hump and self-image score in the SRS-30 questionnaire than the N-T group. There were 8 iliac donor site problems in the N-T group and 3 hemothorax in the T group, which had no adverse effect in the final result., Conclusion: Thoracoplasty showed significantly better rib hump correction, satisfactory clinical outcomes without pulmonary function compromise, or iliac bone graft site morbidity in the treatment of thoracic AIS with pedicle screw instrumentation.

Study Design: Radiographic analysis was performed retrospectively. Outcomes and complications were collected prospectively., Objectives: To assess complications after posterior fusion and instrumentation for degenerative lumbar scoliosis, to determine risk factors of complications, and to analyze the clinical outcomes of surgery., Summary of Background Data: The complications after degenerative lumbar scoliosis surgery have reported to be high. Risk factors for developing complications are unknown., Methods: Forty-seven patients (average age, 66.6 years; range, 48-83 years) with degenerative lumbar scoliosis undergoing posterior fusion and instrumentation were analyzed. Seven patients had additional posterior lumbar interbody fusion at the lumbosacral junction. The average number of levels fused was 4.7 +/- 2.2 segments. We evaluated the early perioperative (<3 months after surgery) and late complications., Results: There were 14 early perioperative complications and 18 late complications. There was 1 case of mortality by pulmonary embolism. Early complications included ileus, urinary tract infection, transient delirium, superficial infection, and neurologic deficit. Late complications included adjacent segment diseases, pseudarthrosis, and loosening of screws. Adjacent segment disease developed at the proximal segment in 10 patients and at the distal segment in 5 patients. Pseudarthrosis was noted at the lumbosacral junction in 2 patients. Revision surgery was performed in 7 patients. Older patients (>65 years) had the tendency to increase early complications without statistical difference (P = 0.053). Excessive intraoperative blood loss was the most significant risk factor for the development of early perioperative complications, and number of levels fused was related to blood loss. Operative time and multiple medical comorbidities were not associated with higher complication rate. There were no specific factors related to the development of late complications., Conclusion: The complication rate after posterior fusion and instrumentation for degenerative lumbar scoliosis was 68%. Abundant blood loss was a significant risk factor for early perioperative complications. The improvement of Oswestry disability index was less in patients with late complications.

With the advent of segmental pedicle screw fixation that enables more powerful corrective forces, it is postulated that an additional anterior procedure may be unnecessary even in severe deformities. The purpose of this paper is to evaluate the results of a posterior procedure alone using segmental pedicle screw fixation in severe scoliotic curves over 70 degrees . Thirty-five scoliosis patients treated by pedicle screw fixation and rod derotation were retrospectively analyzed after a minimum follow-up of 2 years (range 2-10.4). The mean age of patients was 15.3 years (range 9.8-34.2). Diagnoses were idiopathic scoliosis in 29, neuromuscular scoliosis in 3 and scoliosis associated with Marfan syndrome in 3. Scoliosis consisted of single thoracic curve in 18, double thoracic in 5 and double major in 12. Twenty-five patients showed a major thoracic curve greater than 70 degrees (range 70-100), and different ten patients showed a major lumbar curve greater than 70 degrees (range 70-105), pre-operatively. The deformity angle, lowest instrumented vertebral tilt (LIVT) and spinal balance were measured. Pre-operatively there were nine patients with coronal decompensation. The pre-operative thoracic curve of 80 +/- 9 degrees with the flexibility of 45 +/- 11% (45 +/- 11 degrees in side-bending film) was corrected to 27 +/- 10 degrees at the most recent follow-up, showing a correction of 66% (53 degrees) and loss of correction of 3.0% (3.7 degrees). The pre-operative lumbar curve of 79 +/- 12 degrees with the flexibility of 62 +/- 14% (30 +/- 11 degrees in side-bending film) was corrected to 33 +/- 14 degrees at the most recent follow-up [59% (46 degrees) curve correction, 3.5% (3.0 degrees) loss of curve correction]. The pre-operative LIVT of 30 +/- 8 degrees was corrected to 11 +/- 6 degrees, showing a correction of 62% (19 degrees). Residual coronal decompensation was observed in three patients postoperatively. Pre-operative thoracic kyphosis of 27 degrees (range 0-82) improved postoperatively to 31 degrees (range 14-53). In conclusion, posterior segmental pedicle screw fixation without anterior release in severe scoliosis had satisfactory deformity correction without significant loss of curve correction. In this series a posterior procedure alone obviated the need for the anterior release and avoided complications related anterior surgery.

Study Design: Retrospective study., Objectives: To evaluate outcomes of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis with a minimum 5-year follow-up., Summary of Background Data: Segmental pedicle screw fixation has been proven to enable true segmental control and greater correction both in coronal and sagittal planes of scoliosis. However, there is no long-term study of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis., Methods: Two hundred and three thoracic idiopathic scoliosis patients with 236 thoracic curves subject to selective thoracic fusion with segmental pedicle screw fixation were analyzed. Mean patient age at the time of operation was 13.8 years (range: 8.9-18)., Results: The preoperative thoracic curve of 51 +/- 12 degrees was corrected to 16 +/- 7 degrees (69% correction, 3% loss of correction) at the most recent follow-up. The noninstrumented lumbar curve of 30 +/- 10 degrees was corrected to 10 +/- 8 degrees (66% correction, 5% loss of correction) at the most recent follow-up. The preoperative thoracic kyphosis of 18 +/- 11 degrees and the lumbar lordosis of 43 +/- 10 degrees were improved to 23 +/- 8 degrees and 46 +/- 9 degrees , respectively, at the most recent follow-up. There was no junctional kyphosis at the most recent follow-up. Coronal decompensation at the most recent follow-up occurred in 10 patients. Postoperative adding-on occurred in 17 patients, who were fused two levels short of the neutral vertebra. Of the 2,867 thoracic pedicle screws inserted in the thoracic level, 43 screws were found to be malpositioned (1.5%), but they did not cause neurologic complications or adversely affect the long-term results., Conclusions: Selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis had satisfactory radiographic and clinical outcomes after surgery and has been well-maintained for minimum 5-year follow-up. It is a safe and effective method for preservation of lumbar motion segments as well as for restoration and maintenance of both coronal and sagittal alignment.

Study Design: A retrospective study was conducted., Objective: To determine the exact distal fusion level in the treatment of single thoracic idiopathic scoliosis (King Types 3 and 4) with segmental pedicle screw fixation., Summary of Background Data: Pedicle screw fixation effectively shortens the distal fusion extent by improved three-dimensional deformity correction. However, the selection of distal fusion extent remains controversial in single thoracic idiopathic scoliosis., Methods: This study analyzed 42 patients with single thoracic adolescent idiopathic scoliosis (32 King 3 patients and 10 King 4 patients) who underwent segmental pedicle screw fixation and had a minimum follow-up period of 2 years (range, 2-6 years). The patients were grouped according to the distal fusion level with reference to the standing neutral rotated vertebra (NV) for comparison of deformity correction and spinal balance using standing radiographs. Failure to restore an adequate trunk balance and progression or extension of the primary curve (adding on) was considered unsatisfactory., Results: Preoperative 50 degrees +/- 11 degrees of thoracic deformity was corrected to 13 degrees +/- 5 degrees, for a curve correction of 74%. Preoperative 23 degrees +/- 7 degrees of lumbar deformity was corrected to 2 degrees +/- 8 degrees, for a curve correction of 93%. Curve correction was not significantly affected by King type or distal fusion level (P > 0.05). Postoperative unsatisfactory results were obtained in 14 patients. When the preoperative NV was the same or one level distal to end vertebra (EV), fusion down to NV was satisfactory (14/14). When the preoperative NV was more than two levels distal to EV, fusion down to one level shorter than NV (NV-1) also was satisfactory (9/9). However, when fusion down to NV-2 or shorter was performed, the chances of adding on were higher (14/19; P < 0.01). Preoperative 17 degrees +/- 8 degrees of thoracic kyphosis was improved to 24 degrees +/- 7 degrees., Conclusions: In single thoracic idiopathic scoliosis, NV is an important factor for the determination of fusion level. When preoperative NV and EV show no more than two-level gap differences, the curve should be fused down to NV. When the gap is more than two levels, fusion down to NV-1 is satisfactory, saving one or two motion segments, as compared with fusion extending to the stable vertebra.

Study Design: A retrospective comparative study.Objective: The aim of this study was to analyze the exact distal fusion level in the treatment of major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) and direct vertebral rotation (DVR) following pedicle screw instrumentation (PSI).Summary Of Background Data: Proper determination of distal fusion level is a very important factor in deformity correction and preservation of motion segments in the treatment of major TL/L AIS.Methods: AIS patients with major TL/L curves (n = 64) treated by PSI with RD and DVR methods with a minimum 2-year follow-up were divided into AL3 (flexible) and BL3 (rigid) according to the flexibility and rotation by preoperative bending radiographs.Results: There was no significant difference in TL/L (major) curve between the AL3 and BL3 groups postoperatively (P = 0.933) and at the last follow-up (P = 0.144). In addition, there was no significant difference in thoracic (minor) and compensatory (caudal) curve postoperatively (thoracic curve: P = 0.828, compensatory curve: P = 0.976); however, there was a significant difference in compensatory (caudal) curve at the last follow-up (P = 0.041). The overall prevalence of unsatisfactory results was 28.1% (18/64 patients), and the prevalence was 15.2% (7/46) in the AL3 group and 61.1% (11/18) in the BL3 group, which was significantly different (P < 0.05).Conclusion: Lowest instrumented vertebra (LIV) would be selected at L3 (EV) when the curve is flexible; L3 crosses CSVL with a rotation of less than grade II in preoperative bending radiographs. However, if the curve is rigid, LIV should be extended to L4 (EV + 1) in order to prevent the adding-on phenomenon in the treatment of major TL/L AIS using RD and DVR following PSI.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective study.Objective: To compare the surgical outcomes of posterior vertebral column resection (PVCR) and its long-term effects on the deformity correction for congenital scoliosis in children less than 18 years of age.Summary Of Background Data: There have been no reports on surgical outcomes that pertain to the timing of surgery for congenital scoliosis in children under age 18 years with long term follow-up.Methods: Forty-five congenital scoliosis patients (N = 45) under age 18 at the time of surgery were treated by PVCR. These cases were retrospectively studied and had a minimum 10-year follow-up. We assigned patients into two groups: Group 1 (N = 19) patients who had surgery before 10 years of age, Group 2 (N = 26) patients who had surgery after 10 years of age.Results: In Group 1, the mean Cobb angle of the main curve was 44° before surgery, 10.2° after surgery, and 14.2° at last follow-up. In Group 2, the mean Cobb angle of the main curve was 48.7° before surgery, 17.2° after surgery, and 20.4° at the last follow-up. The mean operative time was 189 minutes in Group 1 and 245 minutes in Group 2. The mean estimated blood loss (EBL) per kilogram was 52.9 mL/kg in Group 1 and 48.1 mL/kg in Group 2. There were 22 complications for PVCR and the overall prevalence of complications was 48.9%.Conclusion: PVCR is an effective procedure for the management of congenital scoliosis under age 18. PVCR for congenital scoliosis before the age of 10 years had significantly better deformity correction compared with the group after the age of 10 years and did not cause crankshaft phenomenon.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]