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Introduction: Asymmetry in pedicle anatomy is most distinctly noted around the apex of the curve. The correlation of pedicle dysmorphia with apical vertebral rotation (AVR) and coronal Cobb angle (CCA) has not been studied., Objective: To establish whether pedicle dysmorphism is linked to curve magnitude CCA and the AVR in adolescent idiopathic scoliosis (AIS)., Methodology: Preoperative plain whole spine standing radiographs and non-contrast computed tomography (CT) scans of 25 AIS patients that were operated at a single centre from 2013 to 2019 were retrospectively reviewed by 3 independent co-investigators. CCA was noted on the standing radiograph, whereas the AVR was measured on the axial cuts of CT scan. Pedicle morphometric measurements were performed for apical and periapical pedicles. These included apical vertebra (when present), 2 vertebrae above (U1 and U2) and below (B1 and B2) the apex vertebra/disc. The pedicle morphometric measurements were performed on CT scans. We assessed the transverse pedicle diameter, transverse cancellous channel diameter, sagittal pedicle diameter, pedicle length and pedicle axis length. Correlation tests between various pedicle morphometric measurements, AVR and the curve magnitude (Cobb angle) was performed by the Pearson correlation test., Results: The apex of the major curve was in the thoracic spine in 20 patients, thoracolumbar in three patients and in the lumbar spine in two patients. The mean Cobb angle was 61.5 ± 9.3° and the mean AVR was 28.4 ± 17.8°. A positive correlation was noted with the AVR for U1 concave pedicle length (r = 0.45, p = 0.03), pedicle axis length of the U2 concave pedicle (r = 0.6, p = 0.04), transverse pedicle diameter of the convex apical vertebrae (r = 0.82, p = 0.00009) and the convex apical transverse pedicle diameter (r = 0.80, p = 0.002). A negative correlation with the AVR was noted for U2 convex pedicle length (r = - 0.51, p = 0009), transverse cancellous channel diameter of the U2 concave pedicle (r = - 0.42, p = 0.04) and apical concave pedicle (r = - 0.78, p = 0.002) and the sagittal pedicle diameter for the convex pedicle of U2 (r = - 0.45, p = 0.03) and apex(r = - 0.59, p = 0.04). The Cobb angle did not show a significant correlation with any of the pedicle measurements at any of the levels on the convex and the concave sides., Conclusion: Pedicle asymmetry and dysmorphism demonstrate a morphometric association with the apical vertebral rotation than the curve magnitude. The pedicle length and the pedicle axis length increase on the concave apical and periapical region with increase in AVR. The transverse cancellous channel diameter significantly decreases on the concave apical region with the increase in AVR. The sagittal pedicle diameter decreases on the convex side with the increase in AVR., (© 2023. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK)., Methods: The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months., Results: Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group., Conclusion: Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery., Methods: Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared-the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction., Results: At baseline, TK was 29.8° ± 16°, cervical lordosis (CL) was - 1° ± 14°, lumbar lordosis (LL) was - 57.1° ± 21°, C2-C7 sagittal vertical axis (SVA) was 16 ± 14 mm and C7-S1 SVA was - 15 ± 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment-TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. Neither CL nor C2-C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively., Conclusion: There is a high incidence of cervical kyphosis at baseline in AIS patients-more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery-improvement in CL correlates weakly with sagittal correction of the structural curve., (© 2021. Scoliosis Research Society.)

Purpose: To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy., Methods: The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded., Results: The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient., Conclusion: Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction., (© 2021. Scoliosis Research Society.)

Aims: To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach., Methods: Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded., Results: The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient., Conclusion: Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J  2021;103-B(7):1309-1316.

Background: The use of cervical pedicle screws (CPSs) in pediatric subaxial cervical spine has been scarcely reported in the literature. The biomechanical superiority of CPS over other methods of fixation is beneficial in surgery for correcting severe, rigid cervical/cervicothoracic deformity. Our study aims to assess the safety, efficacy, and feasibility of CPS fixation in pediatric subaxial cervical spine without intraoperative navigation., Methods: Eight pediatric patients requiring rigid subaxial cervical spine fixation for complex cervical deformities were operated at a single center between 2014 and 2016. Their hospital records and imaging were retrospectively studied. The feasibility of inserting CPS was assessed by studying pedicle morphometry on preoperative computed tomography (CT) scans. Aberrant vertebral artery anatomy was ruled out using CT angiography. CPS were inserted into selected pedicles without navigation. Postoperative CT scans were studied to look for screw containment within pedicles. Complications were noted and clinicoradiologic follow-up was for a minimum of 36 months., Results: Thirty-seven CPS were inserted in 8 pediatric patients with a mean age of 9.2 years (range: 5 to 13 y). Surgery was done for complex cervical deformities due to various causes-neglected cervical spine trauma (n=3), posttubercular kyphosis (n=2), cervicothoracic scoliosis (n=2), and cervicothoracic osteoblastoma (n=1). The level-wise distribution of the inserted CPS was: C3=4, C4=6, C5=10, C6=10, and C7=7. Postoperative CT scans showed grade-1 medial cortical breach in 5/37 screws and grade-2 medial cortical breach in a single screw (16%). No perioperative complications were noted. At a mean follow-up of 3.6 years (range: 3 to 4.33 y), no patient had implant failure or deformity progression., Conclusions: CPS insertion in pediatric subaxial cervical spine without neuronavigation is safe, feasible, and effective in carefully selected cases. Biomechanical advantages of CPS can be extended to the pediatric subaxial cervical spine., Level of Evidence: Level IV-retrospective cohort., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Posterior vertebral column resection (PVCR) has several advantages over a combined anterior-posterior procedure for management of severe, rigid spinal deformities. The technique, described by Suk et al., has a high complication rate. Modifications of the technique which can reduce this complication rate might make this challenging procedure safer., Purpose: To report the results of PVCR in severe, rigid spinal deformity; to describe a modified technique for PVCR and compare its results with the conventional technique., Study Design: Retrospective cohort., Patient Sample: A total of 38 patients who underwent PVCR for severe, rigid spinal deformities., Outcome Measures: Mean correction of deformity (sagittal and/or coronal), estimated blood loss, operation time, neurological and non-neurological complications, patient-reported outcome score (SRS-22r)., Methods: Thirty-eight patients underwent PVCR for severe, rigid spinal deformities. These patients had a deformity in excess of 90° and a flexibility index <20%. Twenty-one of 38 patients (Group 1) underwent PVCR by the technique reported by Suk et al.; 17 patients (Group 2) underwent a modified PVCR technique. Our technique involves retaining the posterior elements until the other steps of PVCR are completed, which prevents ventral settling and allows for less handling of an already tight spinal cord. The results and complications were compared between the two groups., Results: The mean operating time was 251 minutes and the mean blood loss was 1,251 mL. Mean coronal correction of 50% and a mean sagittal correction of 52.4% were achieved. Intraoperative loss of motor evoked potentials was seen in eight patients while there were two instances of permanent postoperative deficit, both occurring with the conventional PVCR technique. The average operating time, mean correction and blood loss did not differ between the two techniques. There was, however, a reduction in the occurrence of neurological complications with the authors' modified technique., Conclusions: Our retrospective study with a small cohort suggests that the authors' modified technique of PVCR, wherein the posterior elements are preserved until just prior to attempting to correct the deformity, may be safer in terms of neurological complications when compared with the conventional technique. However, larger studies are warranted to conclusively establish this., (Copyright © 2020 Elsevier Inc. All rights reserved.)