Diagnosis and treatment are evolving in all fields related to the spine, and this evolution is particularly notable in spinal deformities since the last two decades.Recently, even genetic factors of adolescent idiopathic scoliosis (AIS) have been identified, providing new insights into the pathogenesis.It seems that we can even dream of an ideal treatment without any surgery for idiopathic scoliosis.The present focus, "evolution in diagnosis and treatment of scoliosis", is a cornerstone of all scoliosis specialists in the world and I am extremely proud to have top-ranking experts in the field.The first article by Dr. Fong and Prof. Luk is an overview of the new evidence on the use of school screening for AIS based on a large-scale cohort.Their impressive conclusion is that screening is not only beneficial to patients requiring clinical monitoring but also provides a platform for a better understanding of the natural history of idiopathic scoliosis.The same authors also introduce "Fulcrum bending radiograph and its applications", with a focus on scoliosis management.They show that fulcrum bending has advantages over other kinds of flexibility radiographs.Dr. Kabirian and Prof. Akbarnia present an update of surgical treatment of early onset scoliosis (EOS).The concept of "Growth-Guidance" and the dual growing rods technique are explained in detail.The primary goals of any treatment in EOS are to control the progression of the deformity and allow for spinal growth until skeletal maturity, but also to increase the capacity of the thorax allowing lung growth.Complications in the course of surgical treatment of EOS patients are very common mainly due to associated co-morbidities and repeated surgery.Thus, this is a long and multidisciplinary process.Dr. Kawakami et al. report on thoracic insufficiency syndrome of 70 patients with congenital scoliosis (CS) with rib anomalies (RA).Progression of scoliosis in these patients occurred in early phase of growth periods and significantly related with types/location of RA and type of vertebral anomalies.The results suggest the timing of early intervention is critical in this pathology.Recent advances in surgical treatment of AIS are well illustrated by Prof. Lenke.A well-balanced spine in the coronal and sagittal planes, and a solid spinal fusion at the instrumented levels can be achieved with up-to-date instrumentation optimising safety and the shortest fusion length.On the other hand, surgical strategies for adult/elderly thoracolumbar and lumbar spinal deformities are described by Dr. Taneichi.He emphasizes that the minimum necessary surgery should be selected on the basis of the deformity pattern in degenerative spine deformities.Finally, Prof. Dubousset gives a thorough summary of his principles in scoliosis treatment whatever the patient's age.He begins with the concept of "cone of economy" that explains compensatory mechanisms of the spine.Then he insists on the role of the 4 th dimension: "time" when considering surgical intervention for scoliosis in whatever age: developmental ("ascending" scoliosis) and degenerative ("descending" scoliosis).He also advocates a harmonious and balanced spine, sparing the lumbar level as much as possible, with even an incomplete reduction enabling the major function of the spine, compensation.The take-away message being: "Treat the patient, not the X-rays" (John Cobb).The recent evolution of diagnosis and treatment of scoliosis owes a lot to all the leading figures in the field.The authors in this edition outshine among their counterparts.I am confident our readers will gain outstanding knowledge on the diagnosis, approaches, techniques, and above all the philosophy!I hope you will enjoy each contribution.¼
PP239 Development of alginate-based hydrogels/ cryogels by gelation under pressure AA Barros, S Quraishi, M Martins, RS p, P Gurikov, I Smirnova, ARC Duarte and RL Reis 3B’s Research Group – Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, 4806-909 Taipas, Guimar~ aes, Portugal; ICVS/3B’s – PT Government Associate Laboratory, Braga/ Guimar~ aes, Portugal; Hamburg University of Technology, Institute of Thermal Separation Processes, Eißendorfer Straße 38, 21073 Hamburg, Germany
Assessing flexibility of the deformity has become an integral part of scoliosis management. The fulcrum bending radiograph has advantages over other kinds of flexibility radiographs. It is useful for assessing the flexibility of scoliosis deformity, comparing the efficacy of scoliosis correction with different instruments or surgical strategies, predicting the amount of scoliosis correction with surgery, determining the fusion levels and predicting spontaneous coupling correction of sagittal and rotational spinal deformities. This article focuses on the development and applications of this technique for scoliosis management.
Since the days of the ancient Pharaohs, leakage of cerebrospinal fluid has been known to have potentially fatal consequences and should not be underestimated.The purpose of this special supplement is to draw spinal surgeons' attention to the clinical history, investigation and treatment of CSF leaks.Brisby et al. focus on CSF leakage during or after elective surgery for spinal disc disease.They point out that the reported incidence is as high as 16% in elective surgery, and dural tears are more common in elderly patients, lumbar surgery, ossification of the posterior longitudinal ligament, and when surgeons are less experienced.Massicotte and George add to this list of risk factors for CSF leakage, including the connective tissue disorders such as Marfans and Ehlers Danlos syndromes.In their article they define the terms: durotomy, CSF leak, pseudomeningocoele, and duro-cutaneous fistula.Choi highlights that not all CSF leaks are complications of surgery or due to surgeon error.During surgery for spinal tumours for example, often the dura is purposely resected for complete tumour clearance.These wide resections of dura can be a challenge to repair, and pre-operative planning is essential to prevent complications.Surgeons should remember that operations for spinal tumours usually aim to improve quality of life and relieve symptoms; these goals can be easily negated by the complications of CSF leakage.Depreitere et al. comment that most dural tears are noticed at the time of surgery, and therefore immediate and adequate primary closure of the CSF leak is important.Although there are many commercial products, glues and sealants available, the most efficient method for stopping a CSF leak is by accurate closure by primary suture.There is no clear consensus on when or whether to use an intrathecal lumbar CSF drain, a superficial wound drain, or no drain at all.Some authors advocate lumbar CSF drainage to allow the primary closure to heal adequately, whereas others suggest that lumbar drainage itself can add to the complications of low CSF pressure and infection.This debate will continue until scientific evidence from randomised trials becomes available.Styliaras et al. discuss the difficulties in diagnosis and management of CSF leaks after penetrating injuries caused by knives and bullets.For many, the escape of CSF through an open skin wound may be controlled by 96 hours of bed-rest, and a contained meningocoele in a closed injury may be observed by follow-up imaging in many circumstances.High velocity and impact battlefield injuries represent a more serious problem where the effects of the blast and multiple organ involvement are a priority.Each chapter contains a very useful list of references to help the serious reader to enquire further.Choi, Singh and Wang provide clinical examples -so often we learn more easily by following examples of patient management, rather than from tables and flowcharts.There is some repetition in the detail of these chapters, particularly in the diagnosis and treatment of CSF leakage, but this is intentional for two reasons: firstly to reinforce the message of this special supplement, and secondly, there is no gold-standard, evidence-based method for dealing with CSF leaks, and one-size certainly does not fit all.The reader will see that there are some common threads in the management plans discussed, and some differences in opinion, which will together allow the reader to formulate their own opinion on how to avoid, detect, and treat this potential complication.Our overall aim is to alert all spinal surgeons to this uncommon but important complication of open and minimally invasive surgery.Early diagnosis is paramount, and repair requires good microsurgical technique.¼
Surgical strategies for degenerative thoracolumbar/lumbar spinal deformity in patients over 60 years of age were discussed in this article. Clinical outcomes of posterior spinal fusion (PSF) in 27 consecutive patients over 60 years of age were reviewed. The correction rate of scoliosis was significantly higher in PSF with intervertebral release (IVR) than in non-IVR. Whereas, bending correction index of kyphosis was significantly better in 3-column spinal osteotomy (3CO) than in non-3CO. Although PSF with IVR or 3CO is a major invasive procedure, rigid and imbalanced deformities in the elderly were effectively corrected without severe complications. Degenerative thoracolumbar/lumbar deformities can be classified into 4 particular patterns according to global balance and rigidity of the curve. Our recommended surgical strategies for each pattern of the deformity are demonstrated.
Among the complex of craniocervical junction disorders Chiari malformation is one of the most frequent targets of neurosurgical treatments. Hydrocephalus associated with Chiari malformation is related to CSF flow obstruction and is treatable by neuroendoscopic third ventriculostomy(ETV). However the impact of ETV on CSF flow is more widespread and changes of the other pathological findings in Chiari malformation - tonsilar dystopia and syringomyelia are described. The aim of the study is to describe the efficacy of ETV as a part of complex therapy of Chiari patients.
The evaluation, classification and surgical treatment of adolescent idiopathic scoliosis (AIS) continues to evolve. There is a deeper understanding of the 3-dimensional nature of the deformity and the techniques used to realign the spinal column into a more physiologic position with spinal instrumentation and implants prior to performing a spinal fusion. The posterior approach utilizing pedicle screw implants and various forms of derotation techniques have become quite popular and multicenter analysis of the operative results are commonly performed. Inherent to the current treatment is an emphasis on safety, optimal correction and treatment methods emphasizing less invasive approaches with non-fusion technologies. This review will provide a synopsis of the changes in the past decade in the operative care of AIS patients.
This review provides an overview of the new evidence on the use of school screening for adolescent idiopathic scoliosis (AIS), in response to the concerns of the United States Preventive Services Task Force. School scoliosis screening, if carefully designed and planned, can effectively detect AIS patients with significant curvature. A tandem use of screening methods in addition to the conventional forward bending test may improve screening effectiveness. School scoliosis screening continues to be an effective platform for early conservative treatment of AIS.
Study design Retrospective study. Objectives To evaluate progression of various types of congenital scoliosis (CS) with rib anomalies (RA) during the various stages of the growth period, and to assess severity of progression in order to make a strategic planning of expansion thoracoplasty. Summary of background data VEPTR is approved for the treatment of patients with TIS in more than 30 countries. However, there is no consensus on the surgical indications, or the age or time when VEPTR surgery should be performed. Furthermore, there is no study related to natural history of congenital scoliosis with rib anomalies except two reports that are not sufficient to indicate risk factors of progression during the growth period. Methods Based on a survey of CS and RA via questionnaires, 70 patients (32 males and 38 females with an average age of 2.6 years at the first visit.) matched the inclusion criteria: CS with RA, no procedures that could influence natural history during follow-up periods, repeated plain X-ray check-ups with at least two years interval during growth periods. Average follow-up (F/U) time was 5.4 years (2–14). Plain X-ray images of 70 patients were divided into three age groups: infantile (0–5,6), juvenile (5–10,11), and adolescent (11,12-). Each X-ray image was evaluated in terms of laterality, range and type of RA, severity of scoliosis, type of CS, thoracic height ratio, SAL, and associated anomalies. Results 54 of the 70 patients had unilateral rib anomalies. Rib anomalies included rib fusion in 52, mixed type (fusion and defect) in 8, rib proximity in 6, and rib defect in 4. Vertebral anomalies included formation failure in 1, segmentation failure in 16 and mixed type in 53. The magnitude of scoliosis was 46.9° at the first visit and 65.7° at the final F/U. Scoliosis progressed at the rate of 4.6°/year in 70, 3.6°/year in bilateral RA involvement and 4.9°/year in unilateral. Scoliosis progressed with the rate of 4.6°/year in 70, 3.6°/year in bilateral RA involvement and 4.9°/year in unilateral. Scoliosis progressed most severely during infantile period with the rate of 5.0°/year, followed by adolescent of 3.8°/year and juvenile of 2.3°/year. Patients with rib defect or unilateral unsegmented bar showed higher progression rates (10.7°/year and 7.0°/year) during infantile period. According to the relationship between SAL and scoliosis, four grades in severity of progression (most severe, severe, moderate, mild) were set up with the cut-off value of 70%, 85% of SAL and 45°, 85° of scoliosis for making the strategic planning of ET. Those grades were significantly related with types and location of RA and types of vertebral anomalies. Conclusions Progression of scoliosis was analysed in 70 patients with CS & RA. Congenital scoliosis with rib anomalies progressed most rapidly during the early infantile period (7.8°/year), followed by the late infantile period (5.0°/year), and the adolescent period (3.8°/year). Progression of scoliosis in patients with CS and RA occurred in early phase of growth periods and significantly related with types and location of RA as well as type of vertebral anomalies. The results of this study surely suggest the timing of ET for the patients with CS and RA.
Surgery for spine tumours can be challenging, and due to the increased complexity of surgery, the dura may be transgressed either for purposeful resection of tumour margins or by inadvertent breach whilst removing extradural tumour. If leakage of CSF occurs, this may affect the patient’s quality of life, at a time when maintaining function and good outcome is paramount. Surgical planning should aim to minimise the risk of CSF leakage, but if dural breach does occur, the defect should be repaired by using sutures, dural patch techniques and application of tissue adhesives. We outline and illustrate the methods of dural closure that can be used to prevent leakage of CSF during surgery for spine tumours.
Progressive Early-Onset Scoliosis (EOS) is one of the most challenging problems in pediatric orthopaedics. Extensive research efforts are underway to understand different aspects of natural history, diagnostic measures and treatment options.
Chronic CSF leak is a complication of spinal surgery. Multiple terms are used in the context of abnormal flow of CSF at the spinal level and clarification is needed. Differences between durotomy, duro-cutaneous fistula and pseudo-meningocele are important and must therefore be better appreciated. Clinical significance can be found in the incidence of this problem which can plague patients and frustrate clinicians. By providing a comprehensive review of the pathophysiology, a logical treatment algorithm can be suggested for assisting treating physicians.
Penetrating Spinal Cord Injuries are often complicated by Cerebrospinal Fluid (CSF) leaks, which can be diagnosed either at initial presentation, or present themselves in a delayed fashion. Symptoms are usually non-specific and include positional headaches, nausea, vomiting, vertigo, and may even include hypotension, cranial nerve palsies, and in severe cases, meningitis. Imaging to detect CSF leaks include: plain radiographs, CT and MRI, CT-myelogram, radionuclide cisternograms, MRI with intrathecal gadolinium. Initial treatment of CSF leaks is conservative, including bedrest, hydration/overhydration, and medications such as caffeine and theophylline. Although overall treatment protocols are controversial, there seems to be a consensus that if a CSF leak persists for over 96 hours, it should be surgically treated, as it would inevitably increase the risks of pseudomeningocele formation and meningitis. Surgical options include a blood/fibrin patch, the placement of a lumbar drain, and ultimately surgical exploration and primary closure of the dural defect.
