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Posterior-only surgical correction of adolescent idiopathic scoliosis: an Egyptian experience

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      Abstract

      Introduction: The aim of this prospective case series study is to document safety and effectiveness of high density pedicle screws through posterior only approach with intraoperative wake-up test in correction of adolescent idiopathic scoliosis (AIS).Methods: Between 2011 and 2015, all surgically treated patients for AIS were followed up for a minimum of 2 years. Clinical outcomes were evaluated using scoliosis research society-22 (SRS) questionnaire. All patients were classified according to Lenke classification. Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. All patients underwent an intra-operative wake-up test after deformity correction and a minimum of 80% metal density of implants was used.Results: This study included 50 patients. The mean age at time of surgery was 16.8 years. The mean follow-up period was 38.1 months. The mean correction rate for the coronal Cobb angle of the major curve was 79.12%, while that of the minor curve was 68.9%. The mean thoracic kyphosis angle was 38.4° preoperatively, 29.76° postoperatively and 30.36° at the last follow-up. The mean SRS-22 questionnaire scores improved significantly at the last follow-up (P > 0.001). There were no neurological deficits at the wake-up test. No cases of pseudarthrosis or metal failure were encountered.Conclusion: This is a prospective study of at least 80% metal density pedicle screws technique and intra-operative wake-up test in Egyptian patients with AIS. It proved to be an effective and safe technique in correction of radiological parameters, with no neurological or implant related complications. It allowed excellent scoliotic and kyphotic curves correction with minimal loss of correction. On the whole it led to better quality of life.

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      Free hand pedicle screw placement in the thoracic spine: is it safe?

      A retrospective study. To evaluate the safety of a free hand technique of pedicle screw placement in the thoracic spine at a single institution over a 10-year experience. Thoracic pedicle screw fixation techniques are still controversial for thoracic deformities because of possible complications including neurologic. Three hundred ninety-four consecutive patients who underwent posterior stabilization utilizing 3204 transpedicular thoracic screws by 2 surgeons from 1992 to 2002 were analyzed. The mean age was 27 + 10 years (range 5 + 3-87 + 0 years) at the time of surgery. Etiologic diagnoses were: scoliosis in 273, kyphosis in 53, other spinal disease in 68. Pedicle screws were inserted using a free hand technique similar to that used in the lumbar spine in which anatomic landmarks and specific entry sites were used to guide the surgeon. A 2-mm tip pedicle probe was carefully advanced free hand down the pedicle into the body. Careful palpation of all bony borders (floor and four pedicle walls) was performed before and after tapping. Next, the screw was placed, followed by neurophysiologic (screw stimulation with rectus abdominus muscle recording) and radiographic (anteroposterior and lateral) confirmation. An independent spine surgeon using medical records and roentgenograms taken during treatment and follow-up reviewed all the patients. The number of the screws inserted at each level were as follows (total n = 3204): T1, n = 13; T2, n = 60; T3, n = 192; T4, n = 275; T5, n = 279; T6, n = 240; T7, n = 230; T8, n = 253; T9, n = 259; T10, n = 341; T11, n = 488; T12, n = 572. Five hundred seventy-seven screws inserted into the deformed thoracic spine were randomly evaluated by thoracic computed tomography scan to assess for screw position. Thirty-six screws (6.2%) were inserted with moderate cortical perforation, which meant the central line of the pedicle screw was out of the outer cortex of the pedicle wall and included 10 screws (1.7%) that violated the medial wall. There were no screws (out of the entire study group of 3204) with any neurologic, vascular, or visceral complications with up to 10 years follow-up. The free hand technique of thoracic pedicle screw placement performed in a step-wise, consistent, and compulsive manner is an accurate, reliable, and safe method of insertion to treat a variety of spinal disorders, including spinal deformity.
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        Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis.

        A retrospective matched cohort study. To comprehensively compare the 2-year postoperative results of posterior correction and fusion with segmental pedicle screw instrumentation versus with hybrid (proximal hooks and distal pedicle screws) constructs in adolescent idiopathic scoliosis (AIS) treated at a single institution. Despite the reports of satisfactory correction and maintenance of scoliotic curves by pedicle screw instrumentation, there have been no reports on the comprehensive comparison of AIS treatment after segmental pedicle screw instrumentation versus hybrid instrumentation. A total of 58 AIS patients that underwent posterior fusion with hybrid instrumentation (29) or pedicle screw (29) instrumentation at a single institution were sorted and matched according to four criteria: similar patient age, fusion levels, identical Lenke curve type, and identical operative methods. Patients were compared at 2-year follow-up according to radiographic changes, operative time, intraoperative blood loss, pulmonary function tests, and SRS-24 outcome scores. The two cohorts were well matched. The preoperative major Cobb angle averaged 62 degrees in the screw group and 60 degrees in the hybrid group. Average major curve correction was 70% in the screw group and 56% in the hybrid group (P = 0.001). At 2-year follow-up, major curve correction was 65% and 46%, respectively (P 81% in screw group vs. 85% --> 79% in hybrid group P = 0.08, FEV1; 73% --> 79% in screw group vs. 79% --> 75% in hybrid group, P = 0.006). Postoperative total SRS-24 scores were similar in both groups (hybrid group: 99 vs. screw group: 95) (P = 0.19). There were no neurologic complications related to hybrid or pedicle screw instrumentation. Pedicle screw instrumentation offers a significantly better major curve correction and postoperative pulmonary function values without neurologic problems compared with hybrid constructs. Both instrumentation methods offer similar junctional change, lowest instrumented vertebra, operative time, and postoperative SRS-24 outcome scores in the operative treatment of AIS.
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          Complications of thoracic pedicle screws in scoliosis treatment.

          A retrospective study. To analyze complications with thoracic pedicle screws in scoliosis treatment at our Department over a 3-year period (1999-2001). The use of pedicle screws remains controversial for thoracic scoliosis for fear of complications. A total of 115 consecutive patients who underwent posterior fusion using 1035 transpedicular thoracic screws were reviewed. All patients presented a main thoracic scoliosis with a mean Cobb angle of 75.4 degrees (range, 60 degrees -105 degrees ). For thoracic screw placement, a mini-laminotomy technique was used, inserting a spatula inside the vertebral canal to palpate the borders of the pedicle. Postoperative CT scan was used in 25 patients (21.7%) to study a total of 311 screws, when the screw position was questionable. An independent spine surgeon retrospectively reviewed medical records and radiographs of the patients, at a mean follow-up of 4 years. There were 18 screws misplaced (1.7%) in a total of 13 patients (11.3%). Screw malposition was symptomatic only in 1 patient (pleural effusion and fever) and asymptomatic in the other 12 cases (10.4%). Other complications included intraoperative pedicle fractures in 15 patients (13%), dural tears (without neurologic complications) in 14 cases (12.1%), and superficial wound infections in 2 (1.7%). Another operation for screw removal was performed in 5 patients (4.3%), due to pleural effusion (in 1 case), asymptomatic late lateral loosening of a malpositioned screw (in 1), and the possible future risks related the intrathoracic screw position despite the lack of any symptoms (in 3). Two cases (1.7%) were retreated due to wound infection, without removing instrumentation. There was no loss of correction at follow-up. The thoracic pedicle screw placement in scoliosis patients requires utmost caution. The mini-laminotomy technique was beneficial in increasing safety of the procedure with an acceptable incidence of complications.
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            Author and article information

            Affiliations
            Department of Orthopedic and Trauma Surgery, Assiut University Medical School, 71111 Assiut Egypt
            Author notes
            [* ] Corresponding author: belalelnady83@ 123456gmail.com
            Journal
            SICOT J
            SICOT J
            sicotj
            SICOT-J
            EDP Sciences
            2426-8887
            2017
            11 December 2017
            : 3
            : ( publisher-idID: sicotj/2017/01 )
            29227788
            5725150
            10.1051/sicotj/2017057
            sicotj170101 10.1051/sicotj/2017057
            © The Authors, published by EDP Sciences, 2017

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Counts
            Figures: 4, Tables: 3, Equations: 0, References: 30, Pages: 6
            Categories
            Knee
            Original Article

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