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7:52 Surgical correction of sagittal deformity in Scheuermann kyphosis
Proceedings of the NASS 17th Annual Meeting / The Spine Journal 2 (2002) 47S–128S Disclosures: No disclosures. Conflict of interest: No conflicts. PII: S1529-9430(02)00296-6
7:46 Treatment recommendations for idiopathic scoliosis: an assessment of the Lenke classification Rolando Puno, MD1, Ki-Chan An, MD1, Raquel Puno, MD1, Ashley Jacob, Sung-Soo Chung, MD1; 1Leatherman Spine Center, Louisville, KY, USA Purpose of study: To determine the usefulness of the treatment recommendation criteria given by the Lenke classification for treatment of idiopathic scoliosis. Methods used: One hundred eighty-three patients with idiopathic scoliosis and with a minimum follow-up period of 24 months were included in the study and classified according to the Lenke system. Among these patients, 135 patients were treated with fusion and instrumentation in accordance with the Lenke recommendations and are described as Group 1. The 48 patients whose treatments do not follow the recommendation of the Lenke system constitute Group 2. These two groups were compared in regard to the correction of the Cobb angle and the trunk shift after surgery in order to establish the effectiveness and reliability of the treatment recommendations described by Lenke. Summary of findings: Type 1 primary thoracic curve: There was no difference between the results from the group with selective thoracic fusion (Group 1) and from the group with both thoracic and lumbar curves fused (Group 2). Type 2 double thoracic scoliosis: The correction of the upper thoracic curve, the first thoracic vertebral tilt and left shoulder elevation were better in the group with both thoracic curves fused (Group 1) than in the group with midthoracic fusion (Group 2). Type 3 double major scoliosis: The lumbar curve correction was better in the group with both thoracic and lumber curves fused (Group 1) than in the group with selective thoracic fusion (Group 2), and decompensation occurred more frequently in Group 2. Type 4 triple major scoliosis: Because there were only two patients with this type of curve, no analysis was completed. Type 5 thoracolumbar or lumbar curve: There was no difference between the results from the group with selective thoracolumbar or lumbar fusion (Group 1) and the group with thoracic and lumbar curves fused (Group 2). Type 6 double major scoliosis with larger lumbar curve: The thoracic curve correction was better in the group with both curves fused (Group 1) than in the group with only the lumbar curve fused (Group 2). Relationship between findings and existing knowledge: Recent studies [1,2] have proven that the Lenke system regarding curve classification is relatively efficient and consistent. However, before this study, the recommendations regarding the selection of fusion levels had yet to be established as reliable. In our evaluation, we were able to achieve better clinical and radiological results when following the treatment recommendations proposed by Lenke than when the treatment did not coincide with that of Lenke. Therefore, based on our findings, Lenke classification seems to be a valuable tool in the selection of fusion levels. Overall significance of findings: In the surgical treatment of spinal deformity, the importance of adequate curve correction, maintenance of trunk balance and saving motion segments cannot be overemphasized. This study proved that by following the recommendations of Lenke, these goals can be achieved. Additionally, our results show that the use of these treatment recommendations helps surgeons avoid unnecessary fusion of the lumbar or thoracic spine in certain curve types. Disclosures: No disclosures. Conflict of interest: No conflicts. PII: S1529-9430(02)00297-8
7:52 Surgical correction of sagittal deformity in Scheuermann kyphosis Dilip K. Sengupta, MD1, S.H. Mehdian, FRCS1, Michael P. Grevitt, FRCS1; 1University Hospital Nottingham, Nottingham, United Kingdom
61S
Purpose of study: Surgically treated Scheuermann kyphosis cases have been reviewed to evaluate the factors affecting the degree of correction, loss of correction and proximal and distal junctional kyphosis. Methods used: Thirty-nine cases (24 male, 15 female) of Scheuermann kyphosis, treated surgically to relieve persistent pain or progressive deformity, during 1992 to 1999, were reviewed. Median age at operation was 18 years (14 to 53 years). Mean preoperative kyphosis (Cobb angle) was 81 (65-115). The apex of the curve was at T8 or higher in 20 cases and at T9 or lower in 19 cases. Flexible curves, which bend down to below 45 on hyperextension bending X-ray (n12) had one-stage posterior surgery only, using segmental instrumentation. Rigid curves (greater than 45 on bending films) had either thoracoscopic anterior release (n17) or open anterior release (n10), followed by antero-posterior (AP) instrumentation. Summary of findings: Mean follow-up was 45 months (26 to 140 months). The mean direct postoperative kyphosis was 47.2 degrees (38 to 75 degrees), and mean loss of correction at final follow-up was 9.3 degrees (0 to 17 degrees). Kyphosis correction achieved at final follow-up ranged from 39% after posterior-only surgery, to 42% after thoracoscopic AP surgery and 48% after open AP surgery. Mean loss of correction was 12 degrees after posterior-only surgery, 9.5 degrees after thoracoscopic AP surgery and 6 degrees after open AP surgery. Four cases of open AP surgery had additional anterior structural support with cages, before posterior instrumentation. A mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 18 years (n21) had significantly better kyphosis correction than the older age group (p.05). Four cases (10%) developed distal junctional kyphosis resulting from fusion short of the first lordotic segment. All of them had the apex below T9. Six cases (15%) developed proximal junctional kyphosis; all of them had the apex above T6. Complications included infection (four), pneumothorax (one), heamothorax (one), instrumentation failure (four cases); three cases had persistent back pain. Relationship between findings and existing knowledge: No correlation between the four different types of curves described in the literature (upper, middle, lower and whole thoracic) and the outcome was found in this study. Overall significance of findings: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann kyphosis. Anterior structural support prevents loss of correction. Proximal junctional kyphosis is more common in higher curves, and distal junctional kyphosis is more common in lower curves. Correction is better achieved in younger patients but is not influenced by the location of the curve. Disclosures: Device or drug: pedicle screws and rods. Status: approved. Conflict of interest: No conflicts. PII: S1529-9430(02)00298-X
7:58 Sagittal morphology and equilibrium of pelvis and spine in normals Pierre Roussouly, MD1, Ensor Transfeldt, MD1, James Schwender, MD1, Eric Bethonnaud, PhD1, Johannes Dimnet, MD1; 1Twin Cities Spine Center, Minneapolis, MN, USA Purposes of study: Most studies published on sagittal spinal balance have focused on the cervical, thoracic, lumbar and sacral spine without evaluating its relationship to the pelvis and femoral heads. Measures of sagittal balance of 148 asymptomatic volunteers from two countries have been studied. The purpose of this study was to evaluate the relationship between the measures of pelvic equilibrium and lumbar lordosis. Methods used: Volunteers were required to have had no previous spinal surgery, no low back pain, no lower limb length inequality and no scoliotic deformity. A 72-inch, standing lateral X-ray of the spine, pelvis and proximal femurs of each subject was obtained while the subject stood on a force plate, in a standardized position, knees in extension. The force plate provided the ground coordinates of the central axis of gravity (CAG). Each X-ray was digitized, and morphological and positional data of spine and pelvis were measured using custom software. Spinal measures collected in-
7:46 Treatment recommendations for idiopathic scoliosis: an assessment of the Lenke classification Rolando Puno, MD1, Ki-Chan An, MD1, Raquel Puno, MD1, Ashley Jacob, Sung-Soo Chung, MD1; 1Leatherman Spine Center, Louisville, KY, USA Purpose of study: To determine the usefulness of the treatment recommendation criteria given by the Lenke classification for treatment of idiopathic scoliosis. Methods used: One hundred eighty-three patients with idiopathic scoliosis and with a minimum follow-up period of 24 months were included in the study and classified according to the Lenke system. Among these patients, 135 patients were treated with fusion and instrumentation in accordance with the Lenke recommendations and are described as Group 1. The 48 patients whose treatments do not follow the recommendation of the Lenke system constitute Group 2. These two groups were compared in regard to the correction of the Cobb angle and the trunk shift after surgery in order to establish the effectiveness and reliability of the treatment recommendations described by Lenke. Summary of findings: Type 1 primary thoracic curve: There was no difference between the results from the group with selective thoracic fusion (Group 1) and from the group with both thoracic and lumbar curves fused (Group 2). Type 2 double thoracic scoliosis: The correction of the upper thoracic curve, the first thoracic vertebral tilt and left shoulder elevation were better in the group with both thoracic curves fused (Group 1) than in the group with midthoracic fusion (Group 2). Type 3 double major scoliosis: The lumbar curve correction was better in the group with both thoracic and lumber curves fused (Group 1) than in the group with selective thoracic fusion (Group 2), and decompensation occurred more frequently in Group 2. Type 4 triple major scoliosis: Because there were only two patients with this type of curve, no analysis was completed. Type 5 thoracolumbar or lumbar curve: There was no difference between the results from the group with selective thoracolumbar or lumbar fusion (Group 1) and the group with thoracic and lumbar curves fused (Group 2). Type 6 double major scoliosis with larger lumbar curve: The thoracic curve correction was better in the group with both curves fused (Group 1) than in the group with only the lumbar curve fused (Group 2). Relationship between findings and existing knowledge: Recent studies [1,2] have proven that the Lenke system regarding curve classification is relatively efficient and consistent. However, before this study, the recommendations regarding the selection of fusion levels had yet to be established as reliable. In our evaluation, we were able to achieve better clinical and radiological results when following the treatment recommendations proposed by Lenke than when the treatment did not coincide with that of Lenke. Therefore, based on our findings, Lenke classification seems to be a valuable tool in the selection of fusion levels. Overall significance of findings: In the surgical treatment of spinal deformity, the importance of adequate curve correction, maintenance of trunk balance and saving motion segments cannot be overemphasized. This study proved that by following the recommendations of Lenke, these goals can be achieved. Additionally, our results show that the use of these treatment recommendations helps surgeons avoid unnecessary fusion of the lumbar or thoracic spine in certain curve types. Disclosures: No disclosures. Conflict of interest: No conflicts. PII: S1529-9430(02)00297-8
7:52 Surgical correction of sagittal deformity in Scheuermann kyphosis Dilip K. Sengupta, MD1, S.H. Mehdian, FRCS1, Michael P. Grevitt, FRCS1; 1University Hospital Nottingham, Nottingham, United Kingdom
61S
Purpose of study: Surgically treated Scheuermann kyphosis cases have been reviewed to evaluate the factors affecting the degree of correction, loss of correction and proximal and distal junctional kyphosis. Methods used: Thirty-nine cases (24 male, 15 female) of Scheuermann kyphosis, treated surgically to relieve persistent pain or progressive deformity, during 1992 to 1999, were reviewed. Median age at operation was 18 years (14 to 53 years). Mean preoperative kyphosis (Cobb angle) was 81 (65-115). The apex of the curve was at T8 or higher in 20 cases and at T9 or lower in 19 cases. Flexible curves, which bend down to below 45 on hyperextension bending X-ray (n12) had one-stage posterior surgery only, using segmental instrumentation. Rigid curves (greater than 45 on bending films) had either thoracoscopic anterior release (n17) or open anterior release (n10), followed by antero-posterior (AP) instrumentation. Summary of findings: Mean follow-up was 45 months (26 to 140 months). The mean direct postoperative kyphosis was 47.2 degrees (38 to 75 degrees), and mean loss of correction at final follow-up was 9.3 degrees (0 to 17 degrees). Kyphosis correction achieved at final follow-up ranged from 39% after posterior-only surgery, to 42% after thoracoscopic AP surgery and 48% after open AP surgery. Mean loss of correction was 12 degrees after posterior-only surgery, 9.5 degrees after thoracoscopic AP surgery and 6 degrees after open AP surgery. Four cases of open AP surgery had additional anterior structural support with cages, before posterior instrumentation. A mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 18 years (n21) had significantly better kyphosis correction than the older age group (p.05). Four cases (10%) developed distal junctional kyphosis resulting from fusion short of the first lordotic segment. All of them had the apex below T9. Six cases (15%) developed proximal junctional kyphosis; all of them had the apex above T6. Complications included infection (four), pneumothorax (one), heamothorax (one), instrumentation failure (four cases); three cases had persistent back pain. Relationship between findings and existing knowledge: No correlation between the four different types of curves described in the literature (upper, middle, lower and whole thoracic) and the outcome was found in this study. Overall significance of findings: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann kyphosis. Anterior structural support prevents loss of correction. Proximal junctional kyphosis is more common in higher curves, and distal junctional kyphosis is more common in lower curves. Correction is better achieved in younger patients but is not influenced by the location of the curve. Disclosures: Device or drug: pedicle screws and rods. Status: approved. Conflict of interest: No conflicts. PII: S1529-9430(02)00298-X
7:58 Sagittal morphology and equilibrium of pelvis and spine in normals Pierre Roussouly, MD1, Ensor Transfeldt, MD1, James Schwender, MD1, Eric Bethonnaud, PhD1, Johannes Dimnet, MD1; 1Twin Cities Spine Center, Minneapolis, MN, USA Purposes of study: Most studies published on sagittal spinal balance have focused on the cervical, thoracic, lumbar and sacral spine without evaluating its relationship to the pelvis and femoral heads. Measures of sagittal balance of 148 asymptomatic volunteers from two countries have been studied. The purpose of this study was to evaluate the relationship between the measures of pelvic equilibrium and lumbar lordosis. Methods used: Volunteers were required to have had no previous spinal surgery, no low back pain, no lower limb length inequality and no scoliotic deformity. A 72-inch, standing lateral X-ray of the spine, pelvis and proximal femurs of each subject was obtained while the subject stood on a force plate, in a standardized position, knees in extension. The force plate provided the ground coordinates of the central axis of gravity (CAG). Each X-ray was digitized, and morphological and positional data of spine and pelvis were measured using custom software. Spinal measures collected in-