Biomedical subjects

Lawrence G Lenke

Publications and source records attributed to Lawrence G Lenke.

At least 19 recordsLinked to original sources

PubMed2007

The selection of operative versus nonoperative treatment in patients with adult scoliosis.

STUDY DESIGN: Retrospective case-control matched series. OBJECTIVE: The purpose of this study is to define factors that influence the patient and surgeon in the selection of surgical versus nonsurgical treatment for adult scoliosis. SUMMARY OF BACKGROUND DATA: There is no literature that specifically examines why adult scoliosis patients and/or their surgeons choose surgical versus nonsurgical treatment. METHODS: This study analyzes a prospective multicentered database for adult spinal deformity. A logistic regression technique was used to perform case-control matching. A total of 161 matched pairs were compared for radiographic characteristics, questionnaire responses, and standardized outcome measures. RESULTS: Nonsurgical patients had greater preoperative medical risk factors. Surgical patients had larger thoracic (51 degrees vs. 44 degrees, P = 0.006) and thoracolumbar/lumbar curves (55 degrees vs. 43 degrees, P = 0.000). Surgical patients had more frequent leg pain (47% vs. 35%, P = 0.04). They reported a higher mean level of daily back pain (P = 0.008) and more frequent moderate-to-severe back pain over the past 6 months (P = 0.03). There were also significant differences in perception of appearance and social function between the cohorts. CONCLUSIONS: This study emphasizes the complexity of surgical decision making for adult scoliosis patients. It also underscores the importance of patient-based health status measures in evaluating the adult scoliosis patient.

Adolescent↗

PubMed2006

Analysis of patients with nonambulatory neuromuscular scoliosis surgically treated to the pelvis with intraoperative halo-femoral traction.

STUDY DESIGN: Retrospective case-control study. OBJECTIVES: To compare patients treated with and without intraoperative halo-femoral traction to assess neuromuscular spinal deformity correction as well as the safety of the technique. SUMMARY OF BACKGROUND DATA: Optimal sitting balance can be achieved in nonambulatory neuromuscular patients with pelvic obliquity by maneuvering a Galveston-type rod or inserting screws into the iliac wings; however, this is often clinically challenging because of the small, soft bone-stock in the pelvis of these patients. METHODS: A total of 40 patients with nonambulatory neuromuscular scoliosis were treated surgically with a T2 or T3-sacrum instrumented posterior spinal fusion. There were 20 patients (12 who underwent posterior spinal fusion-alone and 8 anterior/posterior spinal fusion) who had intraoperative halo-femoral traction performed unilaterally on the high side iliac wing compared to a control group of 20 patients (15 who underwent posterior spinal fusion-alone and 5 anterior/posterior spinal fusion) operatively treated without halo-femoral traction. Each group had 14 patients with spastic (cerebral palsy) scoliosis, and 6 with flaccid (muscular dystrophy) scoliosis deformities. Minimum follow-up for all patients was 2 years (range 3-12). RESULTS: Preoperative lumbar scoliosis averaged 87 degrees (range 30 degrees-141 degrees) in the halo-femoral traction group and 67 degrees (range 28 degrees-108 degrees) in the control group (P = 0.012). Postoperative lumbar Cobb decreased to 35 degrees (range 15 degrees-60 degrees) in the halo-femoral traction group and 32 degrees (range 4 degrees-66 degrees) in the control group (P = 0.181). Preoperative pelvic obliquity averaged 26 degrees (range 8 degrees-47 degrees) in the halo-femoral traction group and 17 degrees (range 8 degrees-44 degrees) in the control group (P = 0.017); postoperative averaged 6 degrees (range 1 degrees-23 degrees) in the halo-femoral traction group and 7 degrees (range 0 degrees-27 degrees) in the control group. Average pelvic obliquity correction was 78% in the halo-femoral traction group and 52% in the control group (P = 0.001). There were no intraoperative or postoperative halo-femoral traction apparatus-related complications noted (pin cut-out, femoral fractures, pin-sight infections, etc.). CONCLUSIONS: Intraoperative use of halo-femoral traction during the surgical treatment of patients with nonambulatory neuromuscular scoliosis provided significantly improved lumbar curve and pelvic obliquity correction. Intraoperative halo-femoral traction had no associated perioperative complications.

Adolescent↗

PubMed2006

Anterior/posterior spinal instrumentation versus posterior instrumentation alone for the treatment of adolescent idiopathic scoliotic curves more than 90 degrees.

STUDY DESIGN: A retrospective review of patients with adolescent idiopathic scoliosis (AIS), with curves more than 90 degrees treated with either a combined anterior/posterior spinal fusion or a posterior spinal fusion alone. OBJECTIVES: To assess the results of spinal fusion for AIS curves >90 degrees and determine whether the use of a posterior-only approach with an all-pedicle screw construct can decrease the need for anterior release surgery. SUMMARY OF BACKGROUND DATA: Treatment of AIS curves >90 degrees often consists of anterior release and posterior fusion to improve coronal correction and fusion rate. However, the use of pedicle screws has allowed improved coronal curve correction rates even in large curves, which may decrease the need for anterior release surgery. METHODS: A total of 54 consecutive patients with AIS with curves >90 degrees who underwent a spinal fusion procedure at 1 institution between 1987 and 2001, with either a combined anterior/posterior spinal fusion (hooks and screws) or a posterior spinal fusion alone with an all-pedicle screw construct, were included for analysis. All patients had a minimum 2-year follow-up (mean 6.0; range 2.0-14.5), and were analyzed radiographically as well as with pulmonary function tests. Statistical analyses were performed between groups using the Wilcoxon-Mann-Whitney tests. RESULTS: There were 20 patients treated with an anterior/posterior spinal fusion and 34 with a posterior spinal fusion alone. There were no statistically significant differences between the groups for gender, age, number of levels fused, preoperative coronal/sagittal Cobb measurements, coronal curve flexibility, or amount of postoperative coronal Cobb correction. There was less of a negative effect on pulmonary function in the group treated with posterior spinal fusion versus the group treated with a combined anterior/posterior spinal fusion (P < 0.005). There were no complications/reoperations in either group. CONCLUSION: In this patient population with often restrictive preoperative pulmonary function, a posterior-only approach with the use of an all-pedicle screw construct has the advantage of providing the same correction as an anterior/posterior spinal fusion, without the need for entering the thorax and more negatively impacting pulmonary function.

Adolescent↗

PubMed2006

Prospective radiographic and clinical outcomes of dual-rod instrumented anterior spinal fusion in adolescent idiopathic scoliosis: comparison with single-rod constructs.

STUDY DESIGN: Anterior single or dual-rod instrumentation may be performed for the treatment of main thoracic, thoracolumbar, or lumbar adolescent idiopathic scoliosis (AIS) curves. OBJECTIVE: To compare the results of anterior dual-rod instrumentation in single-major AIS curves with our previous experience using single-rod constructs. SUMMARY OF BACKGROUND DATA: Several reports have described the use of anterior single-rod instrumentation for the treatment of AIS curves with acceptable correction rates but with pseudarthroses/implant failures of up to 31%. METHODS: A total of 60 consecutive patients with AIS (12 males and 48 females; average age 15.3 years) with major thoracic (n = 18) or thoracolumbar/lumbar (n = 42) curves were treated with dual-rod instrumented anterior spinal fusion. Follow-up was 2-5 years. Patients were evaluated prospectively with Scoliosis Research Society (SRS) questionnaires. RESULTS: Major thoracic curves were corrected from a mean of 55 degrees to 27 degrees (51% correction), while major thoracolumbar/lumbar curves were corrected from an average of 51 degrees to 17 degrees at latest follow-up (67% correction). No pseudarthroses were identified. With the use of single-rod constructs, a similar amount of coronal correction was obtained for both thoracic (47%) and thoracolumbar/lumbar curves (70%). However, the pseudarthrosis rate for single-rod constructs was 5.5%. The obvious trend toward a lower pseudarthrosis rate in dual-rod (0/60) versus single-rod (5/90) constructs was not statistically significant (P = 0.07). Follow-up SRS questionnaire data for patients with dual-rod instrumentation showed 95% satisfaction, and 93% would choose the same treatment with similar results in the single-rod instrumentation study, 88% patient satisfaction, and 89% choosing the same treatment. Overall SRS scores improved after treatment (P < 0.01). SRS domain scores improved at a significant level for pain (P = 0.05), self-image (P < 0.01), and function (P = 0.01). CONCLUSION: In this largest, to our knowledge, single-center report of dual-rod constructs for patients with AIS, a similar amount of radiographic deformity correction was obtained when compared to single-rod implants. However, the absence of any pseudarthroses in the 60 patients with dual-rod is a distinct advantage.

Adolescent↗

PubMed2006

Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases.

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the incidence of and risk factors for pseudarthrosis in long adult spinal instrumentation and fusion to S1. SUMMARY OF BACKGROUND DATA: Few studies on pseudarthrosis in long adult spinal instrumentation and fusion to S1 exist. METHODS: A clinical and radiographic assessment of 144 adult patients with spinal deformity (average age 52.0 years; range 21.1-77.6) who underwent long (5-17 vertebrae, average 11.9) spinal instrumentation and fusion to the sacrum at a single institution between 1985 and 2002, with a minimum 2-year follow-up (average 3.9; range 2-14) was performed. RESULTS: Of 144 patients, 34 (24%) had pseudarthroses. There were 17 patients who had pseudarthroses at T10-L2 and 15 at L5-S1. A total of 24 patients (71%) presented with multiple levels involved (2-6). Pseudarthrosis was most commonly detected within 4 years postoperatively (31 patients; 94%). Factors that statistically increased the risk of pseudarthrosis were: thoracolumbar kyphosis (T10-L2 > or = 20 degrees vs. < 20 degrees, P < 0.0001); osteoarthritis of the hip joint (P = 0.002); thoracoabdominal approach (vs. paramedian approach, P = 0.009); positive sagittal balance > or = 5 cm at 8 weeks postoperatively (vs. < or = 5 cm, P = 0.012); age at surgery older than 55 years (vs. 55 years or younger, P = 0.019); and incomplete sacropelvic fixation (vs. complete sacropelvic fixation, P = 0.020). Fusion from upper thoracic spine (T2-T5) did not statistically increase the pseudarthrosis rate compared to lower thoracic spine (T9-T12) (P = 0.20). Patients with pseudarthrosis had significantly lower Scoliosis Research Society 24 outcome scores (average score 71/120) than those without (average score 90/120; P < 0.0001) at ultimate follow-up. CONCLUSION: The overall prevalence of pseudarthrosis following long adult spinal deformity instrumentation and fusion to S1 was 24%. Thoracolumbar kyphosis, osteoarthritis of the hip joint, thoracoabdominal approach (vs. paramedian approach), positive sagittal balance > or = 5 cm at 8 weeks postoperatively, older age at surgery (older than 55 years), and incomplete sacropelvic fixation significantly increased the risks of pseudarthrosis to an extent that was statistically significant. Scoliosis Research Society 24 outcomes scores at ultimate follow-up were adversely affected when pseudarthrosis developed.

Adult↗

PubMed2006

Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis.

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.

Adult↗

PubMed2006

An analysis of sagittal spinal alignment following long adult lumbar instrumentation and fusion to L5 or S1: can we predict ideal lumbar lordosis?

STUDY DESIGN: A retrospective study. OBJECTIVE: To determine factors controlling sagittal spinal balance after long adult lumbar instrumentation and fusion from the thoracolumbar spine to L5 or S1. SUMMARY OF BACKGROUND DATA: To our knowledge, no study on postoperative sagittal balance following long adult spinal instrumentation and fusion to L5 or S1 has been published. METHODS: A clinical and radiographic assessment of 80 patients with adult lumbar deformity (average age 53.4 years) who underwent long (average 7.6 vertebrae, 5-11 vertebrae) segmental posterior spinal instrumentation and fusion from the thoracolumbar spine to the L5-S1 (average 4.5 years, 2-15.8-year follow-up) was performed. We defined the optimal sagittal balance (n = 42) group, the distance from C7 plumb to superior posterior endplate of S1 < or = 3.0 cm, and the suboptimal sagittal balance (n = 38) group, the distance from C7 plumb to superior posterior endplate of S1 > 3.0 cm at ultimate follow-up. RESULTS: The optimal sagittal balance group (C7 plumb, average -0.6 +/- 2.5 cm) had the larger average angle differences between lumbar lordosis and thoracic kyphosis (P < 0.0001), preoperative smaller pelvic incidence (P = 0.007), smaller average thoracolumbar junctional angle (T10-L2) increase (P < 0.0001), and bigger lumbar lordosis angle increase (P = 0.014) at ultimate follow-up. Patients with optimal sagittal balance at ultimate follow-up had significantly higher total Scoliosis Research Society 24 outcome scores than those with suboptimal sagittal balance (P = 0.015). Risk factors that were statistically significant for the suboptimal sagittal balance group included pelvic incidence compared with lumbar lordosis (> or = 45 degrees) before surgery (vs. < 45 degrees, P = 0.009), smaller lumbar lordosis compared with thoracic kyphosis (< 20 degrees) at 8 weeks postoperatively (vs. > or = 20 degrees, P = 0.013), and older than 55 years of age at surgery (vs. 55 years or younger, P = 0.024). CONCLUSION: A sagittal Cobb angle difference between lumbar lordosis and thoracic kyphosis of > 20 degrees (higher lumbar lordosis) is advisable in most circumstances to achieve optimal sagittal balance.

Adult↗

PubMed2006

Comparison of pelvic fixation techniques in neuromuscular spinal deformity correction: Galveston rod versus iliac and lumbosacral screws.

STUDY DESIGN: Retrospective radiographic and clinical review. OBJECTIVE: To evaluate the safety and efficacy of iliac screws as a method of pelvic fixation in neuromuscular spinal deformity correction using the Galveston rod technique as a comparison group. SUMMARY OF BACKGROUND DATA: Sacropelvic fixation in patients with neuromuscular spinal deformity has traditionally used Galveston rods placed into the iliac wing. Difficulties with radiographic halos around the rods (loosening), rod contouring, and attaching to lumbar spine anchors have prompted their replacement with iliac screws. METHODS: A minimum 2-year radiographic and clinical follow-up compared 20 patients with the Galveston technique to 20 patients with an iliac screw undergoing posterior spinal fusion (T2/T3-pelvis) for neuromuscular spinal deformity. All patients with the Galveston technique had sublaminar wires for their lumbar anchors, while the majority of patients with an iliac screw technique had at least 2 lumbar and/or sacral screws placed in addition to the iliac screws. RESULTS: There were no significant differences between the 2 groups in preoperative, postoperative, and latest follow-up (mean 3.1 years) measurements for coronal Cobb measures, coronal and sagittal C7 plumblines, and T1 offset. Pelvic obliquity was similar in both groups preoperatively (22 degrees) but at latest follow-up was statistically improved in the patients with an iliac screw (4.4 degrees) versus those with the Galveston technique (7.3 degrees) (P = 0.04). There were 13 patients with the Galveston technique versus 6 with an iliac screw who had radiolucent halos more than 2 mm around the pelvic anchor devices at latest follow-up (P < 0.05). The Galveston technique group had 4 broken rods and 2 reoperations, while the iliac screw group had 1 broken screw and no reoperations. CONCLUSIONS: Using iliac screws for pelvic fixation in neuromuscular spinal deformity affords equivalent maintenance of pelvic obliquity and scoliosis correction compared to the Galveston technique. Furthermore, the iliac screw technique avoids complex, lumbosacral 3-dimensional rod bends and yields minimal implant complications.

Adolescent↗

PubMed2006

Comparison of Scheuermann kyphosis correction by posterior-only thoracic pedicle screw fixation versus combined anterior/posterior fusion.

STUDY DESIGN: Retrospective comparison review. OBJECTIVE: Compare posterior-only treatment results with segmental thoracic pedicle screw constructs versus combined anterior/posterior fusion in patients with Scheuermann kyphosis. SUMMARY OF BACKGROUND DATA: Traditionally, operative Scheuermann kyphosis has been treated with combined anterior/posterior spinal fusion, with the anterior portion being performed via an open thoracotomy or a video-assisted thoracoscopic approach. METHODS: There were 18 patients with Scheuermann kyphosis who underwent a posterior-only thoracic pedicle screw (P/TPS) fusion and 21 who underwent an anterior/posterior fusion who were followed for a 2-year minimum. The 2 groups were well matched according to average age (anterior/posterior fusion 18.0 degrees and P/TPS 17.3 degrees; P = 0.60), maximum preoperative kyphosis (anterior/posterior fusion 89.1 degrees and P/TPS 84.4 degrees; P = 0.21), flexibility index (anterior/posterior fusion 0.408 degrees and P/TPS 0.407 degrees; P > 0.99), and posterior fusion levels (anterior/posterior fusion 12.1 degrees and P/TPS 12.2 degrees; P = 0.95). Of 21 patients with anterior/posterior fusions, zero versus 12 of 18 (67%) patients in the P/TPS group underwent apical Smith-Petersen osteotomies. Fixation in the anterior/posterior fusion group was achieved with hybrid hook/screw constructs. Posterior fixation in the P/TPS group was performed using segmental thoracic pedicle screw constructs. Both groups had posterior iliac bone autografting. Operating time and blood loss were noted, and radiographs were evaluated before surgery, after surgery, and at final follow-up. At final follow up, Scoliosis Research Society-30 questionnaire data and complications were recorded. RESULTS: At surgery, operating time and blood loss were significantly less in the P/TPS group (P = 0.009 and P = 0.05, respectively). The mean residual kyphosis of the P/TPS group averaged 38.2 degrees after surgery and 40.4 degrees at final follow-up versus anterior/posterior fusion group (51.9 degrees and 58.0 degrees, P < 0.001 and P = 0.001, respectively). Even without an anterior release, kyphosis correction in the P/TPS group averaged 54.2% after surgery and 51.8% at final follow-up versus the anterior/posterior fusion group (41.2% and 38.5%, P = 0.001 and P < 0.001, respectively). Scoliosis Research Society-30 outcome scores at final follow-up were comparable between the 2 groups (P/TPS = 120 and anterior/posterior fusion = 128; P = 0.14). The anterior/posterior fusion group had 8/21 (38%) patients with complications, including paraplegia in 1, proximal junctional kyphosis in 1, proximal hook pullout in 1, and infection in 2. The P/TPS group had no complications (P = 0.003). CONCLUSIONS: With less operating time and intraoperative blood loss, posterior-only Scheuermann kyphosis treatment with thoracic pedicle screws achieved and maintained better correction, and had significantly less complications than with circumferential fusion.

Adolescent↗

PubMed2006

Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective, case-control. OBJECTIVE: Evaluate the utility of preoperative autologous blood donation (PABD) for surgical treatment of adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Recent data have highlighted overuse of PABD in elective surgery; however, PABD is a major blood conservation strategy for AIS surgery. METHODS: Medical records of 123 patients treated for AIS between June 1995 and November 2004 were reviewed. Patients were divided into PABD (n = 104) and nondonors (NPABD; n = 19). RESULTS: No differences existed between PABD and NPABD for age, major curve size, or operative procedures. Average PABD preoperative hematocrit was lower than NPABD (37.8 vs. 40.2; P < 0.005). PABD patients were 9 times more likely to be transfused than NPABD, and 3 times more likely to be transfused for each unit donated. There was a 25% transfusion risk reduction for each percent preoperative hematocrit increase. Minimum one autologous unit was not transfused in 32 patients (31%). Twenty-nine PABD patients (28%) were transfused for hematocrit >30. Fifty-three PABD patients (51%) wasted at least one unit or were transfused for hematocrit >30. CONCLUSIONS: The majority of PABD patients (51%) wasted minimum one autologous unit or were transfused at a high hematocrit (>30). More precise PABD guidelines are needed to limit unnecessary transfusion and wasted resources.

Adolescent↗

PubMed2006

Selective posterior thoracic fusions for adolescent idiopathic scoliosis: comparison of hooks versus pedicle screws.

STUDY DESIGN: A retrospective review of adolescent idiopathic scoliosis (AIS) patients with major thoracic-compensatory lumbar C modifier curves treated with a selective posterior fusion using an all-hook construct versus pedicle screw construct. OBJECTIVES: To compare the clinical and radiographic results of selective posterior thoracic fusion using hooks versus pedicle screws in patients with major thoracic-compensatory lumbar C modifier AIS curves. SUMMARY OF BACKGROUND DATA: Although spontaneous lumbar curve correction often occurs following a selective thoracic spinal fusion, there are few reports that focus on selective posterior thoracic spinal fusion in the presence of a lumbar C modifier curve. METHODS: Sixty-six consecutive patients with major thoracic-compensatory lumbar C modifier AIS curves underwent selective posterior thoracic fusion to T12 or L1 at a single institution (1987-2001). Hooks were used for instrumentation in 32 patients and pedicle screws were used in 34 patients. Patients were evaluated at a minimum 2-year follow-up. To test for differences between groups analysis of covariance (ANCOVA) was used. RESULTS: There was no statistical difference between the preoperative thoracic and lumbar Cobb values for the hook group versus the pedicle screw group. The amount of correction obtained surgically of the thoracic Cobb and the amount of spontaneous lumbar Cobb correction were significantly greater in the pedicle screw group (P < 0.001). The incidence of postoperative coronal decompensation, with a greater than 20 mm shift to the left of the C7 plumbline, was higher in the hook group (13 patients) as compared with the pedicle screw Group 4 patients (P < 0.005). There were no complications or reoperations in either group. CONCLUSION: Selective thoracic fusion of main thoracic-compensatory lumbar C modifier AIS curves with pedicle screws allowed for better thoracic correction and less postoperative coronal decompensation than seen with hooks.

Adolescent↗

PubMed2006

Comparison of the lowest instrumented, stable, and lower end vertebrae in "single overhang" thoracic adolescent idiopathic scoliosis: anterior versus posterior spinal fusion.

STUDY DESIGN: A retrospective multicenter study. OBJECTIVE: To investigate the relationship between the lowest instrumented, stable, and lower end vertebrae in patients with "single overhang" thoracic (main thoracic) curves treated with anterior or posterior spinal fusion. SUMMARY OF BACKGROUND DATA: Previous studies have shown "saving" fusion levels with anterior spinal fusion, as opposed to posterior spinal fusion; however, to our knowledge, none of these studies evaluated the relative position to the lower end vertebra to compare study groups accurately. For clarification, "single overhang" includes Lenke 1A and 1B curves. For these thoracic curves, the lumbar curve does not cross the midline. MATERIALS AND METHODS: A retrospective multicenter study of adolescent idiopathic scoliosis was performed to identify specifically patients with "single overhang" thoracic (Lenke 1A and 1B) curves with more than a 2-year follow-up. To analyze relative fusion levels, the differences were computed as follows: (1) the difference between the vertebra position for the stable vertebra of the main thoracic (MT) curve and the lowest instrumented vertebra, as noted on postoperative radiographs, or [equation: see text] (2) the difference between the vertebra position for the lower end vertebra of the main thoracic (MT) curve and the lowest instrumented vertebra, as noted on postoperative radiographs, or [equation: see text]. RESULTS: A total of 298 "single overhang" thoracic curves (148 Lenke 1A, 150 Lenke 1B) were identified, of which 293 had either an anterior spinal fusion or posterior spinal fusion; 5 patients underwent a combined anterior-posterior spinal fusion. Anterior spinal fusion was performed in 70 patients (23.9%) and posterior spinal fusion in 223 (76.1%). While comparing the lowest instrumented vertebra to the stable vertebra with anterior spinal fusion, the lowest instrumented vertebra was identified either at the level of the stable vertebra or above in 97% of 1A/B curves (P < 0.001). Using posterior spinal fusion techniques, the lowest instrumented vertebra was identified either at the stable vertebra or above in 65% of the 1A/B curves (P < 0.05). CONCLUSIONS: These data confirm that anterior spinal fusion techniques result in a mean shorter fusion of 1.5 vertebral segments/patient when compared to posterior spinal fusion techniques with respect to the position of the lowest instrumented and stable vertebrae for "single overhang" thoracic (Lenke 1A/B) curves. However, because this is a retrospective multicenter study over 10 years, it represents various posterior spinal fusion techniques that do not include all pedicle screw constructs.

Adolescent↗

PubMed2006

Traumatic noncontiguous double fracture-dislocation of the lumbosacral spine.

BACKGROUND CONTEXT: To our knowledge, the presence of noncontiguous fracture-dislocation of the lumbosacral spine occurring at two levels has not been reported. The etiology, evaluation, and treatment of the unusual injury is presented. PURPOSE: To notify spinal traumatologists about the possibility of this unusual injury. STUDY DESIGN: A case report of an unusual noncontiguous double fracture-dislocation of the lumbosacral spine. METHODS: A 26-year-old man was involved in a motor vehicle accident where his car fell over a bridge and plummeted approximately 300 feet before hitting the ground. The patient was transported to a major medical center where he was found to be conscious, and amazingly, his only major injury was fracture-dislocations of L2-L3 and L5-S1. His preoperative neurologic status showed a partial paraparesis to all motor groups of the lower extremities bilaterally. RESULTS: The patient underwent a posterior reduction, instrumentation, and fusion from L1 to S1 with autogenous bone graft and segmental pedicle screw instrumentation. One week postoperatively, he underwent an anterior spinal fusion of L5/S1. Postoperatively, his neurologic status improved allowing him to be ambulatory, with a normal lumbosacral alignment being well-maintained. CONCLUSIONS: Noncontiguous double fracture-dislocation of the lumbosacral spine is an unusual injury, which results from a very high-energy trauma. Prompt recognition of the injuries, reduction of the fracture-dislocations, and posterior stabilization is recommended for neural decompression, spinal alignment, and long-term stabilization.

Accidents, Traffic↗

PubMed2006

Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity.

STUDY DESIGN: Clinical radiographic and outcomes investigation. OBJECTIVE: To investigate clinical and radiographic outcomes for lumbosacral fusion (in patients with spinal deformity) using a combination of bilateral sacral and iliac screws with a minimum 5-year follow-up. SUMMARY OF BACKGROUND DATA: To our knowledge, long-term results (>5 years of follow-up) of bilateral S1 screw/bilateral iliac screw fixation have never been published or presented. MATERIALS AND METHODS: A total of 67 patients (from an initial consecutive cohort of 81) undergoing lumbosacral fusion with bilateral sacral and iliac screws with a minimum follow-up of 5 years (range 5-10 + 5, average 6 + 3) were analyzed for radiographic outcome and clinical course by an outcome questionnaire (administered at ultimate follow-up) analysis. Patients were divided into 2 groups: group 1, 34 patients with mostly high-grade spondylolisthesis; and group 2, 33 with adult scoliosis fused mostly from the thoracic spine to the sacrum. A true anteroposterior pelvis film was obtained in all patients to assess for sacroiliac joint arthritis, as were standard spine radiographs. Patients were administered Oswestry and directed buttock pain questionnaires at latest follow-up. RESULTS: There were no cases of sacral screw failure (i.e., screw loosening, partial screw pullout, or fracture of the sacral screw). There were 5 cases of nonunion at L5-S1. Of the 5 cases, 3 did not have anterior column support at L5-S1. Four of the 5 cases were revised, and, subsequently, 3 achieved union. Iliac screws were removed electively on 1 or both sides in 23 of the patients after 2 years postoperatively because of prominence. There were 7 cases of iliac screw breakage. Iliac screw halos were observed in 29 patients. No sacroiliac osteoarthritis was observed on the true anteroposterior pelvis films. At ultimate follow-up, average visual analog painscale (0-10) score to assess buttock pain was 2.4, and average Oswestry score was 20.1. CONCLUSIONS: For high-grade spondylolisthesis and long adult deformity fusions to the sacrum, a montage of bilateral S1 screws and iliac screws were effective in protecting the sacral screws from failure. Pseudarthrosis at L5-S1 was manifested by rod breakage at that level. We saw no evidence of a long-term effect of the iliac screws predisposing the sacroiliac joints to degeneration at follow-up ranging from 5 to 10 years.

Adolescent↗

PubMed2006

Comparative analysis of pedicle screw versus hybrid instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective matched cohort study. OBJECTIVE: 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. SUMMARY OF BACKGROUND DATA: 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. MATERIALS AND METHODS: 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. RESULTS: 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 < 0.001). At 2-year follow-up, thoracic sagittal Cobb angle changes between T5 and T12 were 9.0 degrees decrease in the screw group and 2.4 degrees decrease in the hybrid group compared with preoperative (P = 0.024). There were no differences in the lowest instrumented vertebra below the lower end vertebra (P = 0.56), operative time (P = 0.14), and average estimated blood loss (P = 0.54). Two years following surgery, the screw group demonstrated improved percent predicted pulmonary function values compared with that of the hybrid group (FVC; 81% --> 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. CONCLUSION: 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.

Adolescent↗

PubMed2006

Thoracic and thoracolumbar idiopathic deformity.

Idiopathic scoliosis in adolescents and adults presents many challenges to the spinal surgeon. Preoperative planning, intraoperative technique, and postoperative management all contribute to the ultimate outcome. Avoiding complications in the treatment of idiopathic scoliosis depends on a thorough knowledge of the fundamental principles of spinal deformity evaluation and treatment.

Adolescent↗

PubMed2006

Blood loss minimization and blood salvage techniques for complex spinal surgery.

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.

Antifibrinolytic Agents↗

PubMed2006

Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up.

BACKGROUND: In a previous prospective, randomized, controlled, double-blinded study on the effect of nerve root blocks on the need for operative treatment of lumbar radicular pain, we found that injections of corticosteroids were more effective than bupivacaine for up to thirteen to twenty-eight months. We performed a minimum five-year followup of those patients who had avoided surgery. METHODS: All of the patients were considered to be operative candidates by the treating surgeon, and all had initially requested operative intervention. They had then been randomized to be treated with a selective nerve-root block with either bupivacaine or bupivacaine and betamethasone. Both the treating physician and the patient were blinded to the type of medication. Of fifty-five randomized patients, twenty-nine avoided an operation in the original study. Twenty-one of those twenty-nine patients were reevaluated with a follow-up questionnaire at a minimum of five years after the initial block. RESULTS: Seventeen of the twenty-one patients still had not had operative intervention. There was no difference between the group treated with bupivacaine alone and the group treated with bupivacaine and betamethasone with regard to the avoidance of surgery for five years. At the five-year follow-up evaluation, all of the patients who had avoided operative treatment had significant decreases in neurological symptoms and back pain compared with the baseline values. CONCLUSIONS: The majority of patients with lumbar radicular pain who avoid an operation for at least one year after receiving a nerve root injection with bupivacaine alone or in combination with betamethasone will continue to avoid operative intervention for a minimum of five years.

Follow-Up Studies↗