Special article: Update on the magnetically controlled growing rod: tips and pitfalls

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Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It

BACKGROUND: The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes. METHODS: The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed. RESULTS: Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = -0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery. CONCLUSIONS: Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

A Detailed Comparative Analysis of Anterior Versus Posterior Approach to Lenke 5C Curves

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves. SUMMARY OF BACKGROUND DATA: Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves. METHODS: A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches. RESULTS: A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P < 0.001), but PSIF resulted in significantly less disc angulation below lowest instrumented vertebrae (ASIF: 3.4°, PSIF: 1.7°; P = 0.011), greater lumbar lordosis (P < 0.001), and greater % correction of lumbar prominence (P = 0.017). CONCLUSION: The amount of correction achieved was similar between ASIF and PSIF. ASIF resulted in shorter fusions (average 1.6 levels) compared with PSIF. This was at the expense of increased disc angulation below the lowest instrumented vertebrae, less lumbar lordosis, and a lower % correction of the lumbar prominence than PSIF

Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies

Study design: Retrospective. Objectives: To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Summary of background data: Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes. Methods: GPI �graduates� with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications. Results: 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p ' 0.01) and remained unchanged through a final follow-up. Final major curve was ' 40° in 9 patients (35), 40°�60° in 11 patients (42), and ' 60° in 6 patients (23). None worsened throughout treatment. Mean T1�T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p ' 0.01). T1�T12 height increased in all patients and was ultimately ' 18 cm in 10 patients (38), 18�22 cm in 10 patients (38), and ' 22 cm in 6 patients (23). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46) experienced � 3 complications; four patients (15) experienced none. Conclusion: We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population. Level of evidence: Therapeutic-III. © 2020, Scoliosis Research Society