Adult spinal deformity (ASD) is characterized by three-dimensional abnormalities of the thoracic or thoracolumbar spine that exerts significant impacts on the health-related quality of life (HRQoL). With the important effects that deformity of the sagittal plane exerts on the HRQoL, there have been paradigm shifts in ASD evaluation and management. Loss of lumbar lordosis is recognized as a key driver of ASD followed by reducing kyphosis, pelvic retroversion, and knee flexion. The Scoliosis Research Society (SRS)- Schwab classification reflects the sagittal spinopelvic parameters that correlate pain and disability in ASD patients. Although the SRS-Schwab classification provides a realignment target framework for surgeons, a structured patient-specific systemic approach is crucial for the process of decision-making. ASD management should be focused on restoring age-specific harmonious alignment and should consider the comorbidities and risk factors of each patient to prevent catastrophic complications and enhance the HRQoL.

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Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

A giant spinal arachnoid cyst is an unusual cause of progressive epidural compressive syndrome. The authors describe 4 cases of a "complex" subtype of this lesion and discuss aspects of surgical management. The patients presented with progressive spastic paraparesis and were found to harbor extensive spinal extradural arachnoid cysts with multiple septations and significant paraspinal extensions. Extensive laminotomy and excision of the cyst along with its extensions were performed in all cases. Compared with previously indexed cases of surgically managed extensive spinal extradural arachnoid cysts, the cases reported here are unique because of their complex nature. Curative treatment consists of radical excision inclusive of the paraspinal extensions as well as closure of a dural defect, if found. A laminotomy or laminoplasty should be performed to avoid postoperative instability related to the extensive exposure. Extended follow-up and instrumentation may be required in select cases.

Management of complex giant spinal arachnoid cysts presenting with myelopathy

Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

/pdf/proximal-junctional-kyphosis-in-adult-spinal-deformity-2u4ino1sh6.pdf

Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies.

Military hospitals in Iraq and Afghanistan treated children with traumatic injuries during the recent conflicts. Diagnostic imaging is an integral component of trauma management; however, few published data exist on its use in the wartime pediatric population. The authors describe the emergency department (ED) utilization of radiology resources for pediatric trauma patients in Iraq and Afghanistan. We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients admitted to military fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We retrieved ED data on ultrasound (US), radiographic and computed tomography (CT) studies. During the study period, there were 3,439 pediatric encounters, which represented 8.0% of all military hospital trauma admissions. ED providers obtained a total of 12,376 imaging studies on 2,920 (84.9%) children. Of the 12,376 imaging studies, 1,341 (10.8%) were US, 4,868 (39.3%) were radiographic and 6,167 (49.8%) were CT exams. Most children undergoing radiographic evaluation were boys (77.8%) and located in Afghanistan (70.4%), and they sustained penetrating injuries (68.0%). Children who underwent imaging had higher composite injury severity scores in comparison to those who did not undergo imaging (10 versus 9). Military health care providers frequently utilized radiographic studies in the evaluation of pediatric trauma casualties in Iraq and Afghanistan. Deployed military hospitals that treat children would benefit from dedicated pediatric-specific imaging training and protocols.

Emergency department imaging of pediatric trauma patients during combat operations in Iraq and Afghanistan

Study Design:Systematic reviewObjectives:Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-known complications after long-segment fusions in the thoracolumbar spine ...

https://journals.sagepub.com/doi/pdf/10.1177/2192568220939902

A Systematic Review of Treatment Strategies for the Prevention of Junctional Complications After Long-Segment Fusions in the Osteoporotic Spine:

To evaluate the incidence of mechanical complications in patients with adult spine deformity (ASD) treated by restoring the normal shape according to the Roussouly classification. This is a retrospective multicentric study with a minimum follow-up of 2 years. Patients operated on with fusion for ASD (minimum performed fusion: L2 to sacrum) were included. Patients with a history of previous spinal fusion of more than three levels were excluded. Spinal and pelvic parameters were measured on the preoperative and the immediate postoperative follow-up. All mechanical complications were recorded. A total of 290 patients met the criteria of inclusion with a minimum follow-up of 2 years. Mechanical complications occurred in 30.4% of the cohort. The most common complication was PJK with an incidence of 18% while nonunion or instrumentation failure (rod breakage, implant failure) occurred in 12.4%. 66% of the patients were restored to the normal shape according to the Roussouly classification based on their PI and had a mechanical complication rate of 22.5%, whereas the remaining 34% of patients had a complication rate of 46.8% (p < 0.001). The relative risk for developing a mechanical complication if the algorithm was not met was 3 (CI 1.5–4.3; p < 0.001) In the recent literature, there are no clear guidelines for ASD correction. Restoring the sagittal spinal contour to the normal shapes of Roussouly according to the PI could serve as a guideline for ASD treatment. Ignoring this algorithm has a threefold risk of increased mechanical complications. We recommend this algorithm for treatment of ASD. IV cross-sectional observational study. These slides can be retrieved under Electronic Supplementary Material.

/pdf/mechanical-complications-in-adult-spinal-deformity-and-the-23r2g3mief.pdf

Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study.

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

https://online.boneandjoint.org.uk/doi/pdf/10.1007/s11832-008-0092-2

Pediatric cervical spine instability

Introduction The vertical position of the thoracic pad is a subject of controversy in brace design. Traditional recommendations dictate a maximal force applied at the level of the apical rib, about 2 levels below the apical vertebra. We sought to evaluate the optimal vertical position of the brace thoracic pad using fulcrum bending radiographs. Hypothesis A lateral force applied at the apical vertebra of a thoracic curve is more efficient at correcting coronal deformity than a force placed the apical rib. Patients and methods In this prospective study, we recruited patients presenting with adolescent idiopathic scoliosis (AIS) and Risser stage 0-2 over a period of 12 months. Patients with a history of spine or thoracic surgery were excluded. Two fulcrum bending radiographs were performed for each patient: one with the center of the fulcrum placed under the most lateral part of the apical rib and another with the fulcrum centered below the apical vertebra. Cobb angles were measured on each fulcrum radiograph and compared using a paired t test. Results Fifty-two patients were included, with a mean age of 12.4 years and mean thoracic Cobb angle of 39.4˚. Placing a fulcrum under the apical vertebra reduced the Cobb angle to a mean of 11.5˚, which was significantly lower than a fulcrum placed under the apical rib (14.3˚, p = 0.001). This corresponded to a 20% relative loss in the absolute correction angle when placing the fulcrum under the apical rib. The difference between the 2 Cobb angles was not significantly correlated to patient age (p = 0.896) or curve apex (p = 0.813). Discussion This is the first clinical study addressing the vertical position of the thoracic pad in braces for AIS. A lateral force applied at the level of the apical vertebra was significantly more efficient at reducing thoracic curve deformities than one applied at the apical rib. Our results provide clinical support to finite element studies that refute traditional recommendations of brace design, advocating for a revision of these guidelines to optimize non-operative treatment of AIS. Level of evidence II, prospective comparative study.

Optimizing the vertical position of the brace thoracic pad: Apical rib or apical vertebra?

Resume Introduction La position verticale de la main d’appui thoracique fait objet de controverse dans la confection des corsets. Les recommandations traditionnelles placent la force maximale au niveau de la cote-sommet, soit 2 niveaux en-dessous de la vertebre-sommet. Nous avons voulu evaluer la position optimale de la main d’appui thoracique au sein d’un corset par une etude clinique basee sur les radiographies sur billot. Hypothese Une force laterale appliquee au niveau de la vertebre-sommet d’une courbure thoracique est plus efficace pour corriger la deformation frontale qu’une force appliquee au niveau de la cote-sommet. Materiel et methode Dans cette etude prospective, nous avons recrute des patients se presentant pour scoliose idiopathique de l’adolescent avec un stade Risser 0–2 sur une periode de 12 mois. Les patients ayant une histoire de chirurgie rachidienne ou thoracique ont ete exclus. Deux cliches radiographiques sur billot furent obtenus pour chaque patient : l’un avec le centre du billot place en-dessous de la cote-sommet et l’autre avec le billot centre sous la vertebre-sommet. Les angles de Cobb furent mesures sur chaque cliche et ensuite compares en utilisant un test de Student avec appariement. Resultats Cinquante-deux patients furent inclus avec un âge moyen de 12,4 ans et un angle de Cobb moyen de 37,5° pour la courbure thoracique. La mise en place d’un billot sous la vertebre-sommet a reduit l’angle de Cobb a une moyenne de 11,5, une valeur significativement inferieure au billot place sous la cote-sommet (14,3, p = 0,001). Ceci correspond a une perte relative de 20 % de l’angle de correction lorsque le billot est place sous la cote-sommet. La difference entre les 2 angles de Cobb ne fut pas significativement correlee a l’âge du patient (p = 0,896) ou a l’apex de la courbure thoracique (p = 0,896). Discussion Ceci est la premiere etude clinique adressant la position verticale de la main d’appui thoracique dans les corsets pour scoliose idiopathique de l’adolescent. Une force laterale appliquee en regard de la vertebre-sommet fut significativement plus efficace pour reduire une courbure thoracique qu’une force appliquee a la cote-sommet. Nos resultats soutiennent les etudes de modelisation en elements finis qui remettent en cause les recommandations traditionnelles pour la confection de corsets et preconisent ainsi la revision de ces recommendantions afin d’optimiser le traitement orthopedique de la scoliose idiopathique de l’adolescent. Niveau d’evidence II, etude prospective comparative.

Iconographies supplémentaires de l'article : Optimisation de la position verticale de la main d’appui thoracique du corset : côte-sommet ou vertèbre-sommet ?

Gabi Kreichati

Papers

Mechanical complications in adult spinal deformity and the effect of restoring the spinal shapes according to the Roussouly classification: a multicentric study.

Pediatric cervical spine instability

Optimizing the vertical position of the brace thoracic pad: Apical rib or apical vertebra?

Iconographies supplémentaires de l'article : Optimisation de la position verticale de la main d’appui thoracique du corset : côte-sommet ou vertèbre-sommet ?

Optimisation de la position verticale de la main d’appui thoracique du corset : côte-sommet ou vertèbre-sommet ?