Search

Study Design: A retrospective review of pediatric kyphosis patients undergoing a spinal cord-level osteotomy for correction., Objective: To evaluate the prevalence, etiology, timing, and intervention related to loss of spinal cord monitoring data during surgical correction of pediatric kyphosis in the spinal cord region., Summary of Background Data: Although much has been written regarding the risks inherent to scoliosis surgery, there is less literature available regarding the neurologic outcomes of pediatric kyphosis surgery. As more surgeons contemplate posterior-only kyphosis correction with spinal cord-level osteotomies, the importance of maintaining spinal cord neurologic function is paramount., Methods: Forty-two patients with pediatric kyphosis undergoing a posterior-only spinal reconstruction with a spinal cord level osteotomy or posterior-based vertebral column resection performed were reviewed. Patients were categorized by diagnosis, type and incidence of osteotomies, and loss of neurogenic mixed-evoked potential (NMEP) data. Interventions required to regain data and postoperative neurologic outcomes were also reviewed., Results: Of the 42 patients, 9 (21.4%) demonstrated a complete loss of NMEP data sometime during surgery while concomitant somatosensory sensory-evoked potentials (SSEP) remained within acceptable limits of baseline values. All 9 patients had intraoperative intervention including: blood pressure elevation (n = 1), release of corrective forces (n = 2), blood pressure elevation and correction release (n = 3), malalignment/subluxation adjustment (n = 1), further bony decompression (n = 1), or restoration of anterior column height via a titanium cage along with further posterior decompression (n = 1). In all cases, SSEPs were unchanged and NMEPs returned varying from 8 to 20 minutes after loss, with all patients having a normal wake-up test intraoperatively and a normal neurologic examination after surgery., Conclusion: Intraoperative multimodality monitoring with some form of motor tract assessment is a fundamental component of kyphosis correction surgery in the spinal cord region in order to create a safer, optimal environment and to minimize neurologic deficit. The surgeon must be able to trust the information monitoring provides and act on it accordingly.

Study Design: Prospective clinical study of a retrospective database., Objective: To compare the prospective pulmonary function changes following anterior spinal instrumentation and fusion through an open thoracotomy with the same procedure through a thoracoabdominal approach at 2 years follow-up., Summary of Background Data: Open anterior spinal instrumentation and fusion for adolescent idiopathic scoliosis (AIS) has been known to decrease pulmonary function after surgery. However, the differential effect of an open thoracotomy versus thoracoabdominal approach on pulmonary function in AIS is unknown., Methods: Sixty-four AIS patients who underwent an anterior spinal instrumentation and fusion through an open thoracotomy (TC group) for a major main thoracic scoliosis were compared with 55 patients who underwent the same procedure through a thoracoabdominal approach (TA group) for a major thoracolumbar/lumbar (TL/L) scoliosis using pulmonary function tests assessing forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) before surgery and 2 years after surgery. The TC group was divided into 2 groups, TC group with thoracoplasty (1-5 ribs, n = 35) and TC group without thoracoplasty (n = 29)., Results: Preoperative and 2-year postoperative absolute FVC in the TC group averaged 3.05L and 2.74L, respectively (0.31L decrease, P < 0.0001) versus 3.27L and 3.21L, respectively (0.06L decrease, P = 0.15) in the TA group. The TC group demonstrated a significantly larger decrease in absolute FVC at 2 years postoperative (P < 0.0001). Preoperative and 2-year postoperative absolute FEV1 in the TC group averaged 2.56L and 2.35L, respectively (0.21L decrease, P < 0.0001) versus 2.82L and 2.81L, respectively (0.02L decrease, P = 0.67) in the TA group. The TC group demonstrated a significantly larger decrease in absolute FEV1 at 2 years postoperative (P = 0.001). TC patients with thoracoplasty (n = 35) demonstrated a similar average decrease (0.34L) of absolute FVC at 2 years postoperative compared with those without thoracoplasty (0.26L, P = 0.49) and a similar average decrease of absolute FEV1 at 2 years postoperative (0.23L vs. 0.19L without thoracoplasty, P = 0.76)., Conclusion: An open thoracotomy approach for treating a main thoracic curve demonstrated a significant decrease in the absolute pulmonary function tests values at 2 years postoperative while the thoracoabdominal approach for treating a TL/L curve did not.

Study Design: Retrospective radiographic outcomes analysis., Objective: We had 3 hypotheses: 1) a longer fusion; 2) a more proximal instrumented vertebra, and 3) circumferential fusion versus posterior-only fusion would increase the likelihood of adjacent segment disease (ASD)., Summary of Background Data: The literature analyzing risk factors, prevalence, and presentation of patients with ASD is varied and without clear consensus., Methods: A total of 188 patients with minimum 5-year follow-up who had lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative disorders were included. Radiographic ASD was defined by: 1) development of spondylolisthesis >4 mm, 2) segmental kyphosis >10 degrees , 3) complete collapse of disc space, or 4) more than 2 grades worsening of Weiner classification. Clinical ASD was defined as 1) symptomatic spinal stenosis, 2) intractable back pain, or 3) subsequent sagittal or coronal imbalance., Results: Radiographic ASD occurred in 42.6% (80 of 188) of patients. Patients with radiographic ASD had worse Oswestry scores (20.3 vs. 12.5; P = 0.001) at ultimate follow-up than those without ASD. Clinical ASD developed in 30.3% (57 of 188) of patients. Clinical ASD manifested as spinal stenosis (n = 47), instability-type back pain (n = 5), and sagittal or coronal imbalance (n = 5). Age at surgery over 50 years and length of fusion were significant risk factors for the development of ASD in the lumbar spine. Fusion to L1-L3 proximally increased the risk of ASD when compared with L4 and L5. Circumferential fusion versus posterior fusion was not a significant factor in the development of ASD., Conclusion: Patients over the age of 50 were at higher risk of developing clinical ASD than those 50 years old or younger. Length of fusion was a significant risk factor in the development of ASD in the lumbar spine. Fusion up to L1-L3 increased the risk of ASD when compared with L4 and L5. Circumferential fusion, as opposed to posterolateral fusion, was not a statistically significant risk factor for the development of ASD.

Study Design: A retrospective analysis, including prospectively collected patient outcomes data., Objective: To determine the rate of complications and outcomes in patients >or=60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure., Summary of Background Data: As the population ages, an increasing number of older patients are presenting with spinal deformity disorders that may require major reconstructive procedures. Previous studies have reported complication rates as high as 80% in this age group for 1- and 2-level fusion procedures. The prevalence of complications was found to increase with the greater number of levels fused., Methods: Forty-six patients who were 60 years of age or older underwent a thoracic or lumbar arthrodesis procedure consisting of 5 levels or greater. Diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Oswestry Disability Index (ODI) Scores were used to evaluate clinical outcomes., Results: Thirty-eight females and 8 males with a mean age of 67 years (range, 60-85 years) and a mean follow-up of 4.2 years (range, 2-11 years) had complete records. Thirty-six (78%) patients had at least 1 comorbidity. Twenty-nine (63%) patients had at least 1 prior spinal surgery. A mean of 9 levels (range, 5-16 levels) were fused in each patient. The overall complication rate was 37%. The major complication rate was 20%. ODI improved from 49 to 25 for a mean improvement of 24 (49%) (P < 0.0001)., Conclusion: The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (P < 0.05) in predicting the presence of a complication. Patients older than 69 years had more complications. The presence of a comorbidity had no association with complication rates and neither had an effect on final patient reported outcomes, which showed significant improvement (ODI preoperative, 49; postoperative, 25) (P < 0.0001).

Study Design: Retrospective study., Objective: To analyze the causes, prevalence of, and risk factors for sagittal thoracic decompensation in adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1., Summary of Background Data: To our knowledge, no studies on sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1 have been published., Methods: A clinical and radiographic assessment of 99 patients with adult lumbar spinal deformity (average age 56.7 years) who underwent long (> or = 4 vertebrae; range 4-10/average 6.7) spinal instrumentation and fusion (from lower thoracic or upper lumbar spine to L5 or S1) at a single institution between 1985 and 2003 with a minimum 2-year follow-up (average 4.5 years) was performed. We defined sagittal thoracic decompensation as a progressive kyphotic deformity of the thoracic spine without pseudarthrosis after a long lumbar fusion, which subsequently resulted in a C7 plumb relative to the posterior aspect of the L5-S1 disc > or = 8 cm., Results: The prevalence of sagittal thoracic decompensation after long adult lumbar spinal instrumentation and fusion (from distal thoracic or upper lumbar spine) to L5 or S1 was 23% (23/99 cases). The etiologies were 14 acute sharp angular kyphoses and 9 long sweeping kyphoses above the instrumented fusion. Of the 14 sharp angular kyphoses, 10 occurred from severe disc degeneration and 4 were caused by compression fractures at the uppermost instrumented vertebra., Conclusion: Risk factors for sagittal thoracic decompensation developing were sagittal imbalance at 8 weeks postoperatively (> or = 5 cm), smaller lumbar lordosis compared with thoracic kyphosis (< 10 degrees) at 8 weeks postoperatively, preoperative sagittal imbalance (> or = 5 cm), age at surgery (older than 55 years), and associated comorbidities. Sagittal thoracic decompensation adversely affected Scoliosis Research Society 24 outcomes scores.