Posterior Minimally Invasive Surgery for the Treatment of Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) represents the most frequent indication for scoliosis surgery at the pediatric age. The current gold standard for the surgical treatment of AIS is spinal instrumentation and fusion through an open approach. Despite reproducible good outcomes, this standard approach necessitates significant soft-tissue disruption and extensive paravertebral muscle detachment. It is consequently associated with long-lasting paravertebral muscle injury and denervation, leading to persistent atrophy and decreased trunk extension muscle strength. Minimally invasive surgery (MIS) techniques have been increasingly used over the last two decades for the treatment of lumbar degenerative disorders and thoracolumbar fractures in the adult patient population. Over the last decade, MIS techniques have also been increasingly reported for the treatment of adult spinal deformity. These less invasive techniques have been shown to be useful tools for the treatment of adult spine deformity, with reduced complication rates when compared with conventional open techniques. But they also appear to be less effective for correction of severe and/or fixed sagittal and/or coronal plane deformities. Adolescent spine deformity is generally considered less rigid than adult, thus theoretically more amenable to standalone MIS techniques. The pediatric spine, because of its inherent flexibility and ability to fuse, is theoretically ideal for MIS. Given the positive results obtained with MIS to treat adult spine pathologies, including deformities, the next logical step is the application of less invasive surgical techniques to the treatment of spine deformity at the pediatric age, and in particular AIS. During the nineties, a first attempt to propose an MIS treatment for AIS has been made with the development of thoracoscopic anterior spinal fusion and instrumentation (TASF) for AIS. This technically demanding procedure, with an acceptable complication rate, including during the learning curve, is however restricted for thoracic curves, and offers similar good or excellent results for these patients when compared to the gold standard (open posterior spine fusion). Due to an expanded degree of correction and reduced risk of instrumentation failure associated with modern posterior technique, most spine surgeons, including the proponents of this technique, have currently converted almost entirely to the open posterior approach for the treatment of thoracic AIS. In order to try to decrease the approach-related morbidity associated with the conventional posterior approach, a MIS technique for posterior spinal fusion, using 3 skin incisions and muscle splitting approach, has been recently proposed for AIS. The limited available data suggest that the use of posterior MIS technique for AIS is associated with deformity correction and complication rates equivalent to open posterior spinal fusion, with potential benefits related to a less traumatizing exposure, with low blood loss and a diminished length of hospital stay. However these encouraging results are obtained at the expense of a prolonged surgical time, which could be related, at least partially, to a learning curve effect. The longer-term safety of this procedure needs to be documented in larger studies with long-term follow-up, before recommending its routine use. The impact of some surgical strategies, like dual attending surgeon to try to lessen operative time, and intraoperative traction to address stiff curves, also needs to be better precised

Casting in infantile idiopathic scoliosis as a temporising measure: A systematic review and meta-analysis

Objective: Treatment of infantile idiopathic scoliosis remains vague. Because implantation of temporary telescopic devices carries a high risk of complications, interest in the older technique of serial casting is growing as a temporising measure before invasive procedures. The goal of this review was to meta-analyse studies examining the effect and safety of casting in infantile idiopathic scoliosis.Methods: Two reviewers independently searched for relevant studies in PubMed and Embase databases through November 2018. The studies included were limited to infantile idiopathic scoliosis patients who underwent casting, had a mean Cobb angle of 20 or more and written in English. The methodological quality of the chosen studies was assessed. The primary outcome was the difference in Cobb angle means from before and after casting. The secondary outcome was adverse events of casting. Heterogeneity was explored and a funnel plot was drawn.Results: Of the 366 studies screened, 10 studies were included in the meta-analysis (243 subjects) and all were non-randomised. The casting was consistently associated with a reduction in the mean Cobb angle. The pooled mean difference was 24.85° (95% confidence interval: 19.25 to 30.46, p Conclusion: Casting seems to be effective and safe in decreasing Cobb angle even in high curve magnitudes. In older patients, casting showed less Cobb angle correction.</p

Scoliose idiopathique de l'adolescent : critères diagnostiques et prise en charge

The rapid growth of the spine during the pubertal spurt requires greater vigilance for the pediatrician at the annual check during this period to detect the occurrence of scoliosis. Before confirming the diagnosis of idiopathic scoliosis, it is imperative to exclude a secondary cause with appropriate history and clinical examination, and in selective cases with additional testing. Any scoliosis detected during growth should be considered potentially progressive and sent to a specialist if it is equal to or exceeds 20° on the X-rays. Radiological changes of more than 5° during a 6 months interval must also motivate an appointment with a specialist. Regular clinical and radiological surveillance, every 6 months, remains imperative to confirm or deny this risk of progression and decide on treatment

Treatment of congenital thoracic scoliosis with associated rib fusions using VEPTR expansion thoracostomy: a surgical technique

Untreated growing patients with congenital scoliosis and fused ribs will develop finally thoracic insufficiency syndrome. The technique of expansion thoracoplasty with implantation of a vertical expandable prosthetic titanium rib (VEPTR) was introduced initially to treat these children

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications

Tibial aplasia-hypoplasia and ectrodactyly in monozygotic twins with a discordant phenotype

Tibial hemimelia with ectrodactyly is reported for the first time in monozygotic female twins with a positive family history for limb anomalies. This very rare autosomal dominant condition is known to be associated with a highly variable phenotype, as illustrated by the distinct clinical presentations, despite identical genotype

Proximal Interphalangeal Hyperextension Injuries in Children: The Development of a Clinical Decision Guide

Objective: To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers.Study design: Consecutive patients age : location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed.Results: The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found.Conclusion: Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.</p