Spinal deformities the essentials 2th

Heary_FM 04/26/2014 12:51:10 Page Heary_FM 04/26/2014 12:51:10 Page Heary_FM 04/26/2014 12:51:10 Page Spinal Deformities The Essentials Second Edition Robert F Heary, MD Professor Department of Neurological Surgery Director, Spine Research Laboratory Rutgers, The State University of New Jersey Newark, New Jersey Todd J Albert, MD Richard H Rothman Professor and Chair Department of Orthopaedics Professor of Neurosurgery Thomas Jefferson University and Hospitals President, The Rothman Institute Philadelphia, Pennsylvania Thieme New York  Stuttgart  Delhi  Rio de Janeiro Heary_FM 04/26/2014 12:51:10 Page Thieme Medical Publishers, Inc 333 Seventh Ave New York, NY 10001 Executive Editor: Kay Conerly Managing Editor: Judith Tomat Editorial Assistant: Haley Paskalides Senior Vice President, Editorial and Electronic Product Development: Cornelia Schulze Production Editor: Mason Brown International Production Director: Andreas Schabert Vice President, Finance and Accounts: Sarah Vanderbilt President: Brian D Scanlan Library of Congress Cataloging-in-Publication Data Spinal deformities : the essentials / [edited by] Robert F Heary, Todd J Albert – Second edition p ; cm Preceded by Spinal deformities / Robert F Heary, Todd J Albert c2007 Includes bibliographical references ISBN 978-1-60406-411-7 (alk paper) – ISBN 978-1-60406412-4 (eISBN) I Heary, Robert F., editor of compilation II Albert, Todd J., editor of compilation [DNLM: Spinal Curvatures–surgery Spinal Injuries–surgery Spine–surgery WE 735] RD594.3 617.4'820441–dc23 2014002450 Important note: Medical knowledge is ever-changing As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may be required The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information Readers are encouraged to confirm the information contained herein with other sources For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain Copyright © 2014 by Thieme Medical Publishers, Inc Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA, 1-800-782-3488, customerservice@thieme.com Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany, +49 [0]711 8931 421, customerservice@thieme.de Thieme Publishers Delhi A-12, Second Floor, Sector -2, NOIDA -201301, Uttar Pradesh, India +91 120 45 566 00, customerservice@thieme.in Thieme Publishers Rio, Thieme Publicaỗừes Ltda Argentina Building 16th oor, Ala A, 228 Praia Botafogo Rio de Janeiro 22250-040 Brazil, +55 21 3736-3631 Cover design: Thieme Publishing Group Typesetting by Thomson Digital, India Printed in by Printed in TBD 54321 ISBN 978-1-60406-411-7 eISBN 978-1-60406-412-4 This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage Heary_FM 04/26/2014 12:51:10 Page I would like to dedicate this book to my wife Cara and my children Declan, Maren, and Conor They provide so much joy to me and support for all projects Without their energies, it would not be possible to find the motivation to complete an endeavor such as this Robert F Heary, MD To my wife Barbara for always being my biggest supporter, my best cheerleader, my trusted advisor, and my special love Todd J Albert, MD Heary_FM 04/26/2014 12:51:11 Page Acknowledgments I would like to recognize and thank all of the neurosurgical residents who have worked so hard in our training program over the past seven years Their energy and enthusiasm are limitless, and their unending commitment to providing the highest quality of care makes the performance of these complex, reconstructive spine surgeries safe and effective I would like to specifically thank Remon S Bebawee, BS, who is a future physician, who put an unbelievable amount of time and energy into helping expedite the review process for this textbook to help it come to fruition Robert F Heary, MD vi To the spine fellows who have worked so hard to master the science and art of spinal deformity and surgery for spinal disorders Todd J Albert, MD | 26.04.14 - 12:52 Contents Acknowledgments vi Foreword xv Preface xvi Contributors xvii Principles of Spinal Deformities 1 The History and Overview of Spinal Deformity Robert F Heary and Remon S Bebawee 1.1 The History of Spinal Deformity 1.7 Postoperative Considerations 10 1.2 Overview of Spinal Deformity 1.8 Results and Complications 10 1.3 Spinal Deformity Terms and Principles 1.9 Future Developments 11 1.4 Evaluation of the Patient with a Spinal Deformity 1.10 Conclusion 12 References 12 14 1.5 Indications for Adult Spinal Deformity Surgery 1.6 Operative Treatments Measuring Value in Spinal Deformity Care Paul C Celestre, Leah Y Carreon, and Steven D Glassman 2.1 2.2 2.3 The Importance of Health Care Economics 14 Outcome Measures in Spinal Deformity Surgery 14 QALYs, ICER, and Value in Health Care Decision Making 15 2.5 Value in Spinal Deformity Care 16 2.6 Conclusion 17 References 17 Intraoperative Neuromonitoring in Spinal Deformity Surgery 18 Minimum Clinically Important Difference and Substantial Clinical Benefit 2.4 15 Daniel M Schwartz, Vidya M Bhalodia, and Anthony K Sestokas 3.1 Introduction 3.2 Neurophysiological Monitoring Techniques 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 Somatosensory Evoked Potentials Transcranial Electric Motor Evoked Potentials The H-Reflex Electromyography Stimulated Electromyography The Transpsoas Approach 18 18 3.3 3.4 The Role of IONM in Monitoring Patient Positioning 22 Pathophysiology of Evoked Potential and Electromyography Changes 22 Effects of Anesthetics on Neurophysiological Signals 24 Conclusion 27 References 27 18 3.5 19 19 20 21 21 3.6 vii | 26.04.14 - 12:52 Contents Anatomy and Evaluation of Spinal Alignment 29 Charles Kuntz IV 4.1 Introduction 29 4.2 Clinical and Radiographic Evaluation of Deformity 29 4.2.1 Sagittal Alignment Angles and Displacements Regional Spinal Alignment Pelvic Alignment Global Spinal Alignment 32 34 34 34 Conclusion 34 References 34 Anatomical Variants with Spinal Deformity 36 Coronal Alignment Angles and Displacements Regional Spinal Alignment Pelvic Alignment Global Spinal Alignment 31 32 32 32 4.3 Christopher M Bono and Andrew J Schoenfeld 5.1 Introduction 36 5.5 Spinous Processes 39 5.2 Vertebral Body 36 5.6 Facet Joints and Pars Interarticularis 39 5.2.1 5.2.2 36 5.7 Spinal Cord 40 37 37 5.8 Vascular Structures 41 5.2.3 Idiopathic Scoliosis Congenital/Dysplastic and Isthmic Spondylolysis and Spondylolisthesis Scheuermann Kyphosis 5.3 Ribs 38 5.8.1 5.8.2 Aorta Segmental Vessels 41 41 5.4 Pedicles 38 References 42 The Importance of the Sacrum and Pelvis in Deformity Evaluation and Treatment 43 Frank J Schwab, Jeffrey H Weinreb, and Virginie Lafage 6.1 Introduction 43 6.2 Pelvic Radiographic Parameters and Compensation 43 6.3 Evaluation 44 45 6.5 Treatment 47 6.6 Conclusion 47 References 47 6.4 Classification The Lenke Classification System for Adolescent Idiopathic Scoliosis 49 Jeffrey L Gum, Lawrence G Lenke, and Shay Bess 7.1 Introduction 49 7.2 Radiographic Measurements 49 7.3 Classification Schemes for Adolescent Idiopathic Scoliosis 49 7.4 Lenke AIS Classification System 50 7.5 Operative Treatment of AIS According to Curve Types 7.5.1 7.5.2 7.5.3 7.5.4 7.5.5 7.5.6 7.6 viii 54 Type 1: Main Thoracic Curves Type 2: Double Thoracic Curves Type 3: Double Major Curves Type 4: Triple Major Curves Type 5: Thoracolumbar/Lumbar Curves Type 6: Thoracolumbar/Lumbar–Main Thoracic Curves 54 55 56 56 56 Conclusion 56 References 58 56 | 26.04.14 - 00:17 Treatment of Spinal Deformities kyphotic correction maintained at years after a posterior decompression with instrumentation and fusion of one segment above and below the level of deformity.61 Oner et al noted that MRI findings of endplate comminution and vertebral body involvement portended a poor prognosis in thoracolumbar spinal fracture patients treated conservatively.30 They observed that the recurrence of kyphotic deformity in operatively treated patients could be reliably predicted when posterior longitudinal ligamentous complex disruption was present with endplate comminution and vertebral body involvement on preoperative imaging evaluation 26.8.6 Complications The late onset of neurologic worsening after posttraumatic deformity progression is fortunately rare.62,63 This complication is greater in the surgical management of posttraumatic spinal deformity Factors like instrumentation misplacement due to complex anatomical distortion, or more commonly, spinal cord tethering from deformity correction, may explain the increased rate of neurologic injury Intraoperative spinal cord monitoring is extremely useful in the early detection of changes in neurologic function during surgical manipulation.62,63 Patients treated surgically for posttraumatic deformity are often debilitated and chronically colonized by bacteria because of delayed mobilization and prolonged hospitalization Furthermore, depending on their postinjury neurologic status, these patients may have open decubiti, leading to an increased rate of infection with any type of surgical intervention Postoperative infections in these frequently debilitated polytrauma patients often result from less virulent bacteria In patients who have had spinal cord injury with lower extremity paralysis and a neurogenic bladder, prolonged inpatient admissions or delay in surgical intervention increases the risk of polymicrobial infections due to urinary tract colonization or line sepsis Adequate nutrition with parenteral supplementation, early mobilization, removal of indwelling lines and catheters as early as possible, proper hygiene, and local wound care may help decrease the incidence of spinal wound infections 26.9 Conclusion Traumatic injury to the spinal cord and vertebral column is a devastating injury that is fraught with potential complications, including the potential for posttraumatic spinal deformity Successful management of a posttraumatic spinal deformity requires a thorough understanding of the three-dimensional nature of the deformity and the alterations of normal spinal anatomy that are frequently noted in this group of patients In addition, a clear understanding of the injury mechanism and the resultant deficiencies of the bony and soft-tissue structures is paramount in the selection of an appropriate treatment regimen Failure to appreciate potentially unstable injury patterns may result in inadequate immobilization or delay in operative treatment The treatment of a posttraumatic deformity should adhere to basic biomechanical principles of deformity surgery, including achieving spinal balance and obtaining spinal fusion An anterior, posterior, or a combined surgical approach may be necessary, depending on the degree and type of spinal deformity Care must be taken when manipulating the spinal column 228 so that pre-existing spinal cord damage is not further aggravated Nevertheless, surgical management of posttraumatic deformity is an arduous undertaking A strict attention to detail and preoperative planning are mandatory to ensure a successful outcome with restoration of spinal stability References [1] Vaccaro AR, Jacoby SM Thoracolumbar fractures and dislocations In: Fardon DF, Garfin SR, eds Orthopedic Knowledge Update: Spine Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002:263–278 [2] Gertzbein SD Scoliosis Research Society Multicenter spine fracture study Spine 1992; 17: 528–540 [3] Reinhold M, Knop C, Beisse R et al Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery Eur Spine J 2010; 19: 1657–1676 [4] Vaccaro AR, Silber JS Post-traumatic spinal deformity Spine 2001; 26 Suppl: S111–S118 [5] Abel R, Gerner HJ, Smit C, Meiners T Residual deformity of the spinal canal in patients with traumatic paraplegia and secondary changes of the spinal cord Spinal Cord 1999; 37: 14–19 [6] Been HD, Poolman RW, Ubags LH Clinical outcome and radiographic results after surgical treatment of post-traumatic thoracolumbar kyphosis following simple type A fractures Eur Spine J 2004; 13: 101–107 [7] Spinal cord injury: facts and figures at a glance J Spinal Cord Med 2001; 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An in vivo animal model Spine 1999; 24: 2139–2146 [20] Bohlman HH, Kirkpatrick JS, Delamarter RB, Leventhal M Anterior decompression for late pain and paralysis after fractures of the thoracolumbar spine Clin Orthop Relat Res 1994; 300: 24–29 [21] Polly DW, Klemme WR, Shawen S Management options for the treatment of posttraumatic thoracic kypohosis Semin Spine Surg 2002; 12: 110–116 [22] Qiu Y, Zhu ZZ, Lü JY, Wang B, Li WG, Zhu LH Clinical manifestations and significance of post-traumatic thoracolumbar syringomyelia Chin J Traumatol 2004; 7: 52–55 [23] Batzdorf U, Klekamp J, Johnson JP A critical appraisal of syrinx cavity shunting procedures J Neurosurg 1998; 89: 382–388 [24] Bernhardt M Normal spinal anatomy: normal sagittal plane alignment In: Bridwell KH, DeWald RL, eds The Textbook of Spinal Surgery Philadelphia, PA: Lippincott-Raven; 1997:185–191 [25] DeSmet AA Radiographic evaluation In: Radiology of Spinal Curvature St Louis, MO: Mosby; 1985:23 | 26.04.14 - 00:17 Prevention and Treatment of Posttraumatic Deformity of the Thoracolumbar Spine [26] Curati WL, Kingsley DP, Kendall BE, Moseley IF MRI in chronic spinal cord trauma Neuroradiology 1992; 35: 30–35 [27] Lee TT, Alameda GJ, Gromelski EB, Green BA Outcome after surgical treatment of progressive posttraumatic cystic myelopathy J Neurosurg 2000; 92 Suppl: 149–154 [28] Rechtine GR, Cahill D, Chrin AM Treatment of thoracolumbar trauma: comparison of complications of operative versus nonoperative treatment J Spinal Disord 1999; 12: 406–409 [29] Resch H, Rabl M, Klampfer H, Ritter E, Povacz P [Surgical vs conservative treatment of fractures of the thoracolumbar transition] Unfallchirurg 2000; 103: 281–288 [30] Oner FC, van Gils AP, Faber JA, Dhert WJ, Verbout AJ Some complications of common treatment schemes of thoracolumbar spine fractures can be predicted with magnetic resonance imaging: prospective study of 53 patients with 71 fractures Spine 2002; 27: 629–636 [31] Vaccaro AR, Blam OG Adult spine trauma In: Koval KJ, ed Orthopaedic Knowledge Update Rosemont, IL: American Academy of Orthopedic Surgeons; 2002:593–607 [32] Shaffrey CI, Shaffrey ME, Whitehill R, Nockels RP Surgical treatment of thoracolumbar fractures Neurosurg Clin N Am 1997; 8: 519–540 [33] Seljeskog EL Thoracolumbar injuries Clin Neurosurg 1983; 30: 626–641 [34] Saboe LA, Reid DC, Davis LA, Warren SA, Grace MG Spine trauma and associated injuries J Trauma 1991; 31: 43–48 [35] Wang XY, Dai LY, Xu HZ, Chi YL Kyphosis recurrence after posterior shortsegment fixation in thoracolumbar burst fractures J Neurosurg Spine 2008; 8: 246–254 [36] Kerttula LI, Serlo WS, Tervonen OA, Pääkkö EL, Vanharanta HV Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study Spine 2000; 25: 1104–1108 [37] Lancourt JE, Dickson JH, Carter RE Paralytic spinal deformity following traumatic spinal-cord injury in children and adolescents J Bone Joint Surg Am 1981; 63: 47–53 [38] Denis F Spinal instability as defined by the three-column spine concept in acute spinal trauma Clin Orthop Relat Res 1984; 189: 65–76 [39] Gelb D, Ludwig S, Karp JE et al Successful treatment of thoracolumbar fractures with short-segment pedicle instrumentation J Spinal Disord Tech 2010; 23: 293–301 [40] Jindal N, Sankhala SS, Bachhal V The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial J Bone Joint Surg Br 2012; 94: 1101–1106 [41] Guven O, Kocaoglu B, Bezer M, Aydin N, Nalbantoglu U The use of screw at the fracture level in the treatment of thoracolumbar burst fractures J Spinal Disord Tech 2009; 22: 417–421 [42] Kostuik JP, Matsusaki H Anterior stabilization, instrumentation, and decompression for post-traumatic kyphosis Spine 1989; 14: 379–386 [43] Knop C, Fabian HF, Bastian L, Blauth M Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting Spine 2001; 26: 88–99 [44] Moreland DB, Egnatchik JG, Bennett GJ Cotrel-Dubousset instrumentation for the treatment of thoracolumbar fractures Neurosurgery 1990; 27: 69–73 [45] McBride GG, Greenberg D Treatment of Charcot spinal arthropathy following traumatic paraplegia J Spinal Disord 1991; 4: 212–220 [46] Standaert C, Cardenas DD, Anderson P Charcot spine as a late complication of traumatic spinal cord injury Arch Phys Med Rehabil 1997; 78: 221–225 [47] Sobel JW, Bohlman HH, Freehafer AA Charcot’s arthropathy of the spine following spinal cord injury A report of five cases J Bone Joint Surg Am 1985; 67: 771–776 [48] Roberson JR, Whitesides TE Surgical reconstruction of late post-traumatic thoracolumbar kyphosis Spine 1985; 10: 307–312 [49] Steib JP, Mezghani S, Charles YP, Mitulescu A Double approach in thoracolumbar malunions Eur Spine J 2010; 19 Suppl 1: S48–S51 [50] Bohlman HH, Freehafer A, Dejak J The results of treatment of acute injuries of the upper thoracic spine with paralysis J Bone Joint Surg Am 1985; 67: 360–369 [51] Transfeldt EE, White D, Bradford DS, Roche B Delayed anterior decompression in patients with spinal cord and cauda equina injuries of the thoracolumbar spine Spine 1990; 15: 953–957 [52] Haiyun Y, Rui G, Shucai D et al Three-column reconstruction through single posterior approach for the treatment of unstable thoracolumbar fracture Spine 2010; 35: E295–E302 [53] El-Sharkawi MM, Koptan WM, El-Miligui YH, Said GZ Comparison between pedicle subtraction osteotomy and anterior corpectomy and plating for correcting post-traumatic kyphosis: a multicenter study Eur Spine J 2011; 20: 1434–1440 [54] Zhang X, Zhang X, Zhang Y, Wang Z, Wang Y Modified posterior closing wedge osteotomy for the treatment of posttraumatic thoracolumbar kyphosis J Trauma 2011; 71: 209–216 [55] Anderson PA Late anterior decompression of thoracolumbar spine fractures Semin Spine Surg 1990; 2: 54–62 [56] Bradford DS, McBride GG Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits Clin Orthop Relat Res 1987; 218: 201–216 [57] Vlach O, Bayer M [Sequelae of injuries of the thoracolumbar spine and indications for surgery] Acta Chir Orthop Traumatol Cech 1991; 58: 174–177 [58] Willén J, Dahllöf AG, Nordwall A Paraplegia in unstable thoracolumbar injuries A study of conservative and operative treatment regarding neurological improvement and rehabilitation Scand J Rehabil Med Suppl 1983; 9: 195–205 [59] Keene JS, Wackwitz DL, Drummond DS, Breed AL Compression-distraction instrumentation of unstable thoracolumbar fractures: anatomic results obtained with each type of injury and method of instrumentation Spine 1986; 11: 895–902 [60] Lehmer SM, Keppler L, Biscup RS, Enker P, Miller SD, Steffee AD Posterior transvertebral osteotomy for adult thoracolumbar kyphosis Spine 1994; 19: 2060–2067 [61] Wu SS, Hwa SY, Lin LC, Pai WM, Chen PQ, Au MK Management of rigid posttraumatic kyphosis Spine 1996; 21: 2260–2266, discussion 2267 [62] Clohisy JC, Akbarnia BA, Bucholz RD, Burkus JK, Backer RJ Neurologic recovery associated with anterior decompression of spine fractures at the thoracolumbar junction (T12-L1) Spine 1992; 17 Suppl: S325–S330 [63] Chapman JR, Anderson PA Thoracolumbar spine fractures with neurologic deficit Orthop Clin North Am 1994; 25: 595–612 229 | 26.04.14 - 00:17 Treatment of Spinal Deformities 27 Bracing and Nonoperative Treatment of Spinal Deformity Christopher M Bono and Andrew J Schoenfeld The Essentials ● ● ● ● ● ● ● Poor compliance with brace wear may be the most important factor in determining the success of nonoperative management in adolescent idiopathic scoliosis Prognostic factors influencing success in the nonoperative management of adolescent idiopathic scoliosis include curve magnitude, skeletal maturity, gender, obesity, and compliance with brace wear The results of part-time bracing are generally inferior to full-time (23 h/d) wear However, lumbar curves, thoracolumbar curves, and curves measuring less than 35 degrees in magnitude may be amenable to a trial of part-time bracing Superior results using brace treatment in Scheuermann kyphosis can be anticipated in patients with smaller curves (< 60 degrees), younger age, more flexible deformities, and enhanced compliance with brace wear Orthotic use does not appear to substantially impact the healing of spondylolytic defects, prevent the development of isthmic spondylolisthesis, or halt slip progression Younger patients, individuals treated early in the clinical course, and those with Fujii acute-stage spondylolysis may be the most likely to benefit from brace wear Patients with spastic cerebral palsy and those with flexible neuromuscular curves may be the most amenable to orthotic management, although true clinical efficacy is not well supported in the literature 27.1 Introduction The nonoperative management of spinal deformities is one of the defining and most enduring principles of the orthopedic discipline, extending back to the work of Nicholas Andry, and before that to Hippocrates Over the course of the last century, several methods have been utilized to impact spinal deformity, including serial casting, bracing, sequential and sustained spinal traction, electrical stimulation, spinal manipulation, and stretching.1–6 Of these techniques, however, only bracing and casting have been shown to be clinically efficacious from a scientific perspective.1,3,4 The indications for bracing, as well as the ultimate intent of the intervention, vary according to the condition being treated For example, the goal in bracing adolescent idiopathic scoliosis is to arrest curve progression and prevent deformity.1 In neuromuscular scoliosis, the aim is to preserve or restore functionality.7 In the setting of isthmic spondylolysis, bracing may be used as a means to facilitate the healing of a pars fracture, although its intent in the case of spondylolisthesis is largely to provide symptomatic relief of back pain.8 For the express purpose of directing treatment or identifying the need for bracing, modern classification systems utilized for 230 spinal deformity are not particularly helpful For example, although adolescent idiopathic scoliotic curves in the range of 25 to 30 degrees are typically treated with a brace, the commonly used Lenke classification2 does not influence this recommendation An exception to this may be the Fujii classification9 for isthmic spondylolysis, in which acute-stage defects may be more amenable to successful brace management than endstage terminal lesions.8 In this chapter, we provide an overview of the available treatment methods, indications for use, and published outcomes of nonoperative management of spinal deformity A focus is placed on bracing, which not only is a cornerstone of conservative management in spinal deformities, but also maintains the most established record of success in the peer-reviewed literature when compared to other nonoperative modalities 27.2 Patient Evaluation The initial evaluation of a patient with spinal deformity by a specialist is highly influenced by the nature of the deformity, the underlying condition responsible for its occurrence, and any other associated abnormalities that may be present in conjunction All patients should receive a thorough intake history, with the parents being interviewed as necessary, to determine the approximate origin of the deformity, the length of time the deformity has been present, and how rapidly the deformity has progressed—if it has progressed at all The potential for remaining growth is determined by questions regarding observed growth spurts, current Tanner development stage, and menstrual history in girls.1 The evaluation of developmental milestones plays an important role in the assessment of children with neuromuscular conditions, but the presence of increased spasticity or “clumsiness” on the part of a previously normal child may herald intraspinal anomalies, such as a tethered spinal cord or syringomyelia In the setting of congenital scoliotides or neuromuscular curves, an in-depth determination should be made regarding the presence of other medical conditions, as well as an assessment of cognitive and social functioning.7,10 Congenital spinal conditions are associated with cardiac malformations in 12% of cases, whereas genitourinary defects may be present in as many as 20%.10 A family history of spinal deformity and/or the presence of deformities in siblings should also be assessed In the case of kyphosis or spondylolysis/listhesis, the presence of antecedent trauma must be ascertained Participation in activities that can precipitate stress fractures in the pars interarticularis, such as competitive weightlifting, wrestling, and gymnastics, may be screened in addition The physical examination includes an intensive neurologic examination, with assessment of reflexes, the presence of upper motor neuron signs, such as abnormal reflexes and clonus, or spasticity, observation of gait pattern, and the evaluation of dermatomal or mytotomal deficits Provocative maneuvers, | 26.04.14 - 00:17 Bracing and Nonoperative Treatment of Spinal Deformity including hyperextension at the lumbosacral junction, can reproduce pain in the setting of spondylolysis, whereas the Adams forward flexion test is the characteristic screening technique for scoliosis Direct manipulation of a patient with spinal deformity during the physical examination can also provide some input with regard to the degree of curve flexibility 27.3 Radiographic Assessment All patients with scoliosis or spinal kyphosis should receive standing full-length spine films, to include anteroposterior and lateral studies In nonambulatory patients, such as those with congenital, juvenile, or neuromuscular scoliosis, seated and/or supine films can be obtained Patients with apex-left thoracic curves and those with neurologic abnormalities by history or exam must be further evaluated using magnetic resonance imaging (MRI) Individuals with spondylolysis or spondylolisthesis are initially evaluated by a plain radiographic series of the lumbar spine and lumbosacral junction, including oblique views capable of identifying the pathognomonic defect in the “neck of the Scotty dog.” Computed tomographic (CT) studies may be employed as an adjunct to better define osseous anatomy or declare a lytic pars defect if one cannot be identified with reasonable certainty on plain film Computed tomography should be used sparingly, however, particularly in children, because of the associated radiation exposure In the past, nuclear imaging studies (e.g., technetium 99 bone scan) were utilized to identify “reactive” pars defects that were deemed more amenable to brace treatment because of an associated heightened potential for healing Nuclear imaging has largely been supplanted by MRI due to the latter’s ability to define soft-tissue structures and its lack of ionizing radiation Increased uptake in the region of the pars defect on T1- and T2weighted MRI is indicative of an active process akin to the “hot” lesions previously recognized on bone scans 27.4 Indications for Nonoperative Management 27.4.1 Adolescent Idiopathic Scoliosis Scoliotic curves exceeding 10 degrees, especially in children with substantial growth remaining, must be closely observed with physical examination and radiographic imaging every to 12 months until skeletal maturity is attained.1 Progressive curves, and those in the range of 20 to 30 degrees, should be assessed at even shorter intervals, preferably three times a year In the skeletally immature patient, accepted indications for bracing are 30 degrees of scoliosis at initial presentation or radiographically documented curve progression greater than 10 degrees to where the curve now exceeds 25 degrees.1 Brace treatment is the only nonoperative intervention for adolescent idiopathic scoliosis shown to be effective at limiting curve progression and/or obviating the need for surgical correction through evidence-based examination of the literature.1,3,4,11–20 Other nonoperative interventions, such as spinal manipulation, traction, or electrical stimulation, cannot be supported due to lack of scientific evidence documenting their efficacy.1,5,6,19 27.4.2 Scheuermann Kyphosis Because of persistent limitations in understanding the etiology of the condition as well as its natural history, indications for bracing in Scheuermann kyphosis remain poorly defined.21–23 Most studies have not been able to definitively demonstrate that brace management is capable of correcting kyphotic deformity in Scheuermann kyphosis.22 Nonetheless, skeletally immature patients with flexible kyphoses in the range of 45 to 75 degrees are generally considered acceptable candidates for bracing Curves that cannot be corrected to less than 50 degrees in a brace, rigid curves, problematic curves in skeletally mature patients, and those exceeding 75 degrees most likely necessitate surgical intervention.22,23 27.4.3 Isthmic Spondylolysis and Spondylolisthesis At present, no universally accepted guidelines exist for the treatment of isthmic spondylolysis or spondylolisthesis using orthoses.8 In the setting of spondylolysis, some authors contend that symptomatic reduction and the healing of pars defects occurs not through brace use, but by the activity restriction that goes along with orthotic management.8 There is no evidence that presently indicates that orthotic use, as opposed to other nonoperative interventions, is more effective at healing spondyloytic defects, preventing the onset of spondylolisthesis, or halting slip progression.8 Bracing may be a useful adjunct in facilitating activity restriction in patients with spondylolysis and/or spondylolisthesis and can also be helpful in providing symptomatic relief during pain exacerbations.24,25 27.4.4 Neuromuscular Scoliosis The goals of nonoperative management in the setting of neuromuscular scoliosis are to prevent trunk collapse, decrease pelvic obliquity, and stabilize the curve angle.7 Delay of surgical intervention may also be considered a relative indication; however, many individuals with neuromuscular scoliosis will require surgery, and orthotic management has never been shown to be an effective means of preventing curve progression in neuromuscular disorders or to be capable of obviating the need for surgery.26 Well-accepted indications for the start of brace management not exist at present, although many authors define curves exceeding 25 degrees as viable candidates for surgery.7,26 Kotwicki and Jozwiak proposed that early-onset, flexible curves, particularly in patients with spastic cerebral palsy, should be targeted for bracing.7 Although the use of botulinum toxin in spastic paraspinal musculature has some proven efficacy in the relief of back pain, this treatment has no role in the management of neuromuscular scoliosis.7 27.5 Treatment Options and Published Outcomes 27.5.1 Treatment Options Orthoses used in the treatment of scoliosis control coronal aspects of the curve through pressure on the rib cage and/or 231 | 26.04.14 - 00:17 Treatment of Spinal Deformities iliac wings.27 Sagittal deformity is corrected through forces applied to the sternum, anterior iliac spines, and spinous processes.28 Proximal thoracic curves may necessitate additional control through the use of mandibular pads, although these must be used with caution because of an associated concern for dental dysplasia.10 The amount of corrective force applied through the brace has been shown to have a direct correlation with the degree of deformity correction.27 Much of this force, however, is dissipated through the paraspinal soft tissues and is not directly exerted on the vertebrae involved in the deformity A number of brace options are available to the spine specialist engaged in the treatment of patients with spinal deformities In most instances, a custom orthotic must be developed in close collaboration with an experienced orthotist The type of brace utilized should be tailored to the patient’s specific needs, manner of deformity, underlying condition(s), and curve severity The primary goal of brace manipulation is to position the spinal column in a corrected or overcorrected position through 3point bending moments, and to maintain the new position while the patient continues to grow.1,27 For this to be achieved, the candidate for bracing must have a flexible spine and the capacity to tolerate brace wear, which is dose-dependent in efficacy (e.g., the more the brace is worn, the greater impact it will have on correcting the deformity).18 Fig 27.2 The Wilmington brace was developed in an attempt to improve the cosmetic appeal and wear compliance of the brace It is custom-molded from a single piece of plastic Charleston Brace Custom-molded, underarm, thoracolumbar sacral orthoses (TLSO) that effect overcorrection of scoliotic curves (▶ Fig 27.1) This is a part-time brace, generally worn at night.1,29 Providence Brace Similar to the Charleston, the Providence brace is an acrylic orthotic that uses overcorrection to impact scoliotic deformities The brace can be used in all single and double major curves, but its efficacy in curves exceeding 35 degrees has not been conclusively shown.1,13,27 This brace is worn only at night Wilmington Brace The Wilmington brace is a TLSO, fashioned from a single piece of plastic (▶ Fig 27.2) with the intent of improving wear compliance The Wilmington is most commonly employed in the treatment of adolescent idiopathic scoliosis and is a full-time brace, worn from 12 to 23 hours per day.10 Milwaukee Brace The Milwaukee brace was the first orthosis employed in the modern treatment of adolescent idiopathic scoliosis It is typically used in proximal thoracic or double major curves.1,3 It is also frequently employed in the management of Scheuermann kyphosis22,30 and neuromuscular scoliotides.7 The Milwaukee’s custom-fit vest sits on the iliac crests and the anterior and posterior superior iliac spines, while corrective forces are applied to the ribs, sternum, and spinous processes (▶ Fig 27.3) Longitudinal uprights immobilize the proximal thoracic region and cervicothoracic junction through connections to pads that engage the occiput and mandible The brace is worn 23 hours per day Because of comfort and appearance, patient compliance is a particular concern when the Milwaukee brace is prescribed Boston Brace Fig 27.1 The Charleston brace is a custom-made underarm thoracolumbar sacral orthosis 232 The Boston brace is an underarm TLSO (▶ Fig 27.4) used in the treatment of scoliosis It was developed at Harvard Medical School and Children’s Hospital Boston in the 1970s with the intent of creating a more comfortable and patient-friendly | 26.04.14 - 00:17 Bracing and Nonoperative Treatment of Spinal Deformity Fig 27.3 The Milwaukee brace includes a form-fitting apron that rests upon subcutaneous pelvic bony protuberances and longitudinal uprights that support occipital and mandibular pads alternative to the Milwaukee orthosis.1 The Boston brace is a full-time brace and can be used in the treatment of all forms of scoliosis, including curves arising from neuromuscular conditions.31 For curves with an apex above the level of T10, however, an additional Milwaukee-like superstructure is required.1 Suspension Trunk Orthosis This brace is used solely in patients with neuromuscular curves associated with flaccid trunk muscle paralysis (e.g., spinal muscular atrophy and certain cases of myelomenigocele) who are also nonambulatory.7 The use of this brace redistributes portions of the patient’s body weight to the thoracic region and also creates a stable base to assist in seated posture Fig 27.4 The Boston brace was the first underarm brace introduced to treat scoliosis 27.5.2 Outcomes Adolescent Idiopathic Scoliosis Among all spinal deformity conditions, the literature is most robust with respect to the effective use of bracing in the management of adolescent idiopathic scoliosis.1,3,4,11–20 Although electrical stimulation was once a popular method of treating scoliosis, several published studies have documented its inability to alter the natural history of this condition.5,6 Nonetheless, no high-quality level I evidence is available that demonstrates the advantage of spinal orthoses over observation or other nonoperative measures to prevent curve progression, cosmetic deformity or to avoid the need for surgery in scoliosis.1 Jewett Hyperextension Brace The Jewett brace is not custom made but is adjustable to patient dimensions through a strap and buckle system In terms of treating deformity, it may be effective in managing mild hyperkyphosis and can be employed in the treatment of Scheuermann kyphosis It is considered a part-time brace (▶ Fig 27.5) DuPont Kyphosis Brace This brace is designed specifically to treat individuals with Scheuermann kyphosis.23 The advantage of this brace over other models is that it may be worn underneath normal clothing Antilordotic Lumbosacral Brace This modified Boston TLSO maintains the lower lumbar spine in a flexed posture to relieve shear stresses on the pars interarticularis in the setting of isthmic spondylolysis It may be worn full-time or part-time Although this brace is theorized to enhance healing of pars defects, the clinical efficacy of this brace has not been demonstrated.8 Fig 27.5 The Jewett hyperextension brace utilizes an open design that delivers posterior forces through the sternum and anterior pelvis and an anterior force through a dorsal thoracic pad 233 | 26.04.14 - 00:17 Treatment of Spinal Deformities The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), however, has gone a long way toward ameliorating the current situation in terms of providing scientific evidence in support of brace wear.1 Other works of lesser-quality evidence have established the comparative effectiveness of bracing, as compared to observation alone, in arresting curve progression A prospective, nonrandomized study conducted by Nachemson and Peterson4 showed that brace use prevented curve progression of degrees or more in 74% of patients, compared to 34% in those treated with observation alone In a retrospective review of over 1,700 cases of adolescent idiopathic scoliosis treated with a Milwaukee brace or observation, Lonstein and Winter concluded that orthotic management was more effective at preventing progression and avoiding surgery in curves with a magnitude of 20 to 39 degrees.3 In works focusing on patients with larger curves, several studies have reported satisfactory outcomes and avoidance of surgery, as long as patients remained compliant with brace use.16,18,20 A ready example of this premise is the work of Wiley et al,20 a retrospective review of outcomes among 50 patients with curves in the range of 35 to 45 degrees treated with a Boston brace Only 8% of patients compliant with brace use failed orthotic treatment (curve progression > degrees).20 Thirty-six percent of individuals in the semicompliant (brace wear 12–18 h/d) and 92% of the noncompliant group exhibited curve progression Katz and Durrani documented like findings in patients with curves exceeding 35 degrees.16 In this analysis, 61% of the cohort exhibited no curve progression, while 31% necessitated surgical intervention.16 In a more recent prospective investigation, Katz et al reported a 50% success rate in adolescent patients treated with a Boston brace.18 In this prognostic effort, success was highly correlated to the extent of brace wear (82% of those who wore the brace more than 12 h/d had a successful outcome) and the extent of skeletal maturity.18 Specifically, as longer periods of brace wear were required for individuals with open triradiate cartilage, successful outcomes were more likely to occur in patients with closed triradiate cartilage and more advanced Risser stage.18 Other prognostic research has indicated superior outcomes among female patients, a finding directly attributed to compliance with brace wear.32 Night-time bracing with the Charleston or Providence brace has been shown to be effective for individuals with curves measuring less than 35 degrees.1,13,29 Trivedi and Thomson reported a 60% success rate with use of the Charleston brace29 and similar results for the Providence brace were reported by D’Amato’s group in a prospective investigation.13 In this analysis of 102 patients, 74% had no evidence of curve progression.13 Lumbar and thoracolumbar curves may be more amenable to night-time bracing than other varieties of scoliosis.1 In terms of comparative effectiveness, several conflicting reports exist in the literature.11,15,17,19 These are likely inhibited, to a certain extent, by patient heterogeneity and different determinations regarding the criteria for “success.”1 Full-time bracing is generally well accepted as more efficacious than part-time bracing, due to a dose-dependent effect.1 However, Allington and Bowen reported that no statistically significant difference in curve progression could be appreciated in individuals treated with a Wilmington brace for 23 hours a day, as compared to those who wore the brace part-time.11 It should be 234 recognized, however, that these findings may be confounded by compliance with brace wear (e.g., the patients prescribed fulltime wear were only using the brace about as much as those recommended part-time wear).1,18 To be considered “effective,” Schiller et al set a standard that an orthosis should prevent more than degrees of curve progression in 70% of compliant patients.1 Using these stringent criteria in a systematic review, the authors maintained that no brace could be deemed more effective than any other in terms of limiting curve progression or influencing the need for surgical intervention.1 With respect to unconventional forms of bracing, such as short-segment bracing33 or nonrigid orthoses,34 the literature is still immature at this time Although some provisional reports regarding these techniques33,34 are attractive, the lack of longterm follow-up and high-quality scientific evidence limits the capacity to make recommendations for their use Scheuermann Kyphosis The evidence base in support of the efficacy of orthotic management in Scheuermann kyphosis is very limited.21–23,30,35,36 At the present time, no high-quality evidence exists that is capable of predicting situations in which bracing will be effective, prevent progression, or result in the avoidance of surgery.22 Younger age at the time of treatment, flexible curves, curves less than 60 degrees, and compliance with brace wear appear to be factors predictive of successful outcome.22 Sachs and co-workers reported that 63% of Scheuermann patients treated with a Milwaukee brace were able to achieve some degree of correction.30 A greater kyphosis angle at the time of treatment was associated with a greater degree of correction Approximately 70% of patients were able to maintain correction at 5-year follow-up.30 However, in a long-term observational study, Farsetti and colleagues found that all Scheuermann curves eventually returned to pretreatment parameters at a minimum, irrespective of the degree of correction attained.36 In a more recent study, Riddle et al documented satisfactory results in a small series of patients treated with the DuPont kyphosis brace.23 In this investigation, 73% of those managed with the brace demonstrated improvement or no progression in the degree of kyphosis Patients were followed until skeletal maturity, but long-term observations of this cohort were not reported.22,23 Isthmic Spondylolysis and Spondylolisthesis There are a limited number of studies that examine the effectiveness of brace use in the treatment of spondylolysis and spondylolisthesis.8,24,25,37 Although efficacy in terms of pain relief is well established, no evidence exists to support the contention that orthotic wear potentiates healing in pars defects or prevents slip development or progression.8 Steiner and Micheli reported satisfactory outcomes with the use of an antilordotic lumbosacral orthosis.25 Among 67 individuals, 78% of those treated with the brace were found to have a good or excellent outcome at an average of 2.5-year follow-up However, in a similar work published by Seitsalo,37 treatment consisted of only activity restriction and strengthening exercises in most patients and was reported to be successful in 88% In this series of 72 patients, only five were treated with a brace.37 | 26.04.14 - 00:17 Bracing and Nonoperative Treatment of Spinal Deformity The recent meta-analysis conducted by Klein and colleagues concluded that the available literature could not support the claim that bracing maintains an advantage over activity modification in terms of clinical improvement in spondylolysis or spondylolisthesis.8 Moreover, no evidence exists supporting orthotic use as a means to facilitate the healing of pars defects Although a combination of bracing, activity restriction, and physical therapy exercises does seem to provide acceptable short-term symptomatic relief, the evidence base is poor in support of nonoperative management impacting spondylolysis, preventing the development of isthmic spondylolisthesis, or halting slip progression in listhetic segments.8,37 Younger patients, individuals who sought treatment earlier in the clinical course, and those with Fujii acute-stage spondylolysis9 are most likely to benefit from orthotic management.8 Neuromuscular Scoliosis Bracing has never been considered an effective means of preventing the need for surgery or halting curve progression in the setting of neuromuscular curves.7,26 Rather, Kotwicki and Jozwiak postulated that the goals of orthotic management in neuromuscular scoliotides were to (1) prevent trunk collapse, (2) maintain trunk balance, and (3) preserve sitting stability.7 The use of a brace prior to surgical intervention may also simplify the ultimate surgical procedure in patients with neurogenic disorders Patients with spastic cerebral palsy and those with flexible curves are considered more amenable to brace treatment, although true clinical efficacy is not well supported in the literature.7,31 Olafsson and colleagues were able to prevent curve progression in only 25% of neuromuscular scoliosis patients treated with a Boston brace.31 Terjesen et al reported more optimistic outcomes,38 yet the larger corpus of research conducted by Miller’s group at the DuPont Institute indicates a lack of clinical efficacy if avoidance of surgery is considered to be the main endpoint.26 Similarly, several works maintain that braces are ineffective in managing scoliotic curves in patients with neurogenic conditions resulting in flaccid trunk paralysis (e.g., familial dysautonomia, Friedrich ataxia, and spinal muscular atrophy).39–41 Orthoses may be useful in the prevention of spinal deformity in older children (age > 14 years) who have sustained a spinal cord injury.42 27.6 Complications The most common complication associated with brace wear is discomfort and muscle soreness Overall, in patients with idiopathic scoliosis, Scheuermann kyphosis, and isthmic spondylolysis/spondylolisthesis, the use of orthoses is generally well tolerated The application of Milwaukee-type braces, particularly in younger children, has been associated with dental and mandibular dysplasia, however A greater risk with orthotic wear is present in patients with neuromuscular disorders, especially when individuals lack protective sensation in the lower abdomen, lumbar region, iliac prominences, and ischial tuberosities.7 In these settings, there is a real potential for soft-tissue ischemia and the development of pressure ulcers References [1] Weinstein SL, Dolan LA, Wright JG, Dobbs MB Effects of bracing in adolescents with idiopathic scoliosis N Engl J Med 2013; 369: 1512–1521 [2] Lenke LG, Betz RR, Harms J et al Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis J Bone Joint Surg Am 2001; 83-A: 1169–1181 [3] Lonstein JE, Winter RB The Milwaukee brace for the treatment of adolescent idiopathic scoliosis A review of one thousand and twenty patients J Bone Joint Surg Am 1994; 76: 1207–1221 [4] Nachemson AL, Peterson LE Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society J Bone Joint Surg Am 1995; 77: 815–822 [5] Bertrand SL, Drvaric DM, Lange N et al Electrical stimulation for idiopathic scoliosis Clin Orthop Relat Res 1992; 276: 176–181 [6] Durham JW, Moskowitz A, Whitney J Surface electrical stimulation versus brace in treatment of idiopathic scoliosis Spine 1990; 15: 888–892 [7] Kotwicki T, Jozwiak M Conservative management of neuromuscular scoliosis: personal experience and review of literature Disabil Rehabil 2008; 30: 792–798 [8] Klein G, Mehlman CT, McCarty M Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of observational studies J Pediatr Orthop 2009; 29: 146–156 [9] Fujii K, Katoh S, Sairyo K, Ikata T, Yasui N Union of defects in the pars interarticularis of the lumbar spine in children and adolescents The radiological outcome after conservative treatment J Bone Joint Surg Br 2004; 86: 225–231 [10] Winter R, Lonstein J, Boachie-Adjei O Congenital spinal deformity In: Pritchard D, ed Instructional Course Lectures Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996: 117–127 [11] Allington NJ, Bowen JR Adolescent idiopathic scoliosis: treatment with the Wilmington brace A comparison of full-time and part-time use J Bone Joint Surg Am 1996; 78: 1056–1062 [12] Bowen JR, Keeler KA, Pelegie S Adolescent idiopathic scoliosis managed by a nighttime bending brace Orthopedics 2001; 24: 967–970 [13] D’Amato CR, Griggs S, McCoy B Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis Spine 2001; 26: 2006–2012 [14] Goldberg CJ, Dowling FE, Hall JE, Emans JB A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls Spine 1993; 18: 902–908 [15] Howard A, Wright JG, Hedden D A comparative study of TLSO, Charleston, and Milwaukee braces for idiopathic scoliosis Spine 1998; 23: 2404–2411 [16] Katz DE, Durrani AA Factors that influence outcome in bracing large curves in patients with adolescent idiopathic scoliosis Spine 2001; 26: 2354–2361 [17] Katz DE, Richards BS, Browne RH, Herring JA A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis Spine 1997; 22: 1302–1312 [18] Katz DE, Herring JA, Browne RH, Kelly DM, Birch JG Brace wear control of curve progression in adolescent idiopathic scoliosis J Bone Joint Surg Am 2010; 92: 1343–1352 [19] Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau D A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis J Bone Joint Surg Am 1997; 79: 664–674 [20] Wiley JW, Thomson JD, Mitchell TM, Smith BG, Banta JV Effectiveness of the Boston brace in treatment of large curves in adolescent idiopathic scoliosis Spine 2000; 25: 2326–2332 [21] Lowe TG, Kasten MD An analysis of sagittal curves and balance after CotrelDubousset instrumentation for kyphosis secondary to Scheuermann’s disease A review of 32 patients Spine 1994; 19: 1680–1685 [22] Lowe TG, Line BG Evidence based medicine: analysis of Scheuermann kyphosis Spine 2007; 32 Suppl: S115–S119 [23] Riddle EC, Bowen JR, Shah SA, Moran EF, Lawall H The duPont kyphosis brace for the treatment of adolescent Scheuermann kyphosis J South Orthop Assoc 2003; 12: 135–140 [24] d’Hemecourt PA, Zurakowski D, Kriemler S, Micheli LJ Spondylolysis: returning the athlete to sports participation with brace treatment Orthopedics 2002; 25: 653–657 [25] Steiner ME, Micheli LJ Treatment of symptomatic spondylolysis and spondylolisthesis with the modified Boston brace Spine 1985; 10: 937–943 235 | 26.04.14 - 00:17 Treatment of Spinal Deformities [26] Miller A, Temple TH, Miller F Impact of orthoses on the rate of scoliosis progression in children with cerebral palsy J Pediatr Orthop 1996; 16: 332–335 [27] Chase AP, Bader DL, Houghton GR The biomechanical effectiveness of the Boston brace in the management of adolescent idiopathic scoliosis Spine 1989; 14: 636–642 [28] Colbert AP, Craig C Scoliosis management in Duchenne muscular dystrophy: prospective study of modified Jewett hyperextension brace Arch Phys Med Rehabil 1987; 68: 302–304 [29] Trivedi JM, Thomson JD Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis J Pediatr Orthop 2001; 21: 277–280 [30] Sachs B, Bradford D, Winter R, Lonstein J, Moe J, Willson S Scheuermann kyphosis Follow-up of Milwaukee-brace treatment J Bone Joint Surg Am 1987; 69: 50–57 [31] Olafsson Y, Saraste H, Al-Dabbagh Z Brace treatment in neuromuscular spine deformity J Pediatr Orthop 1999; 19: 376–379 [32] Karol LA Effectiveness of bracing in male patients with idiopathic scoliosis Spine 2001; 26: 2001–2005 [33] van Rhijn LW, Veraart BE, Plasmans CM Application of a lumbar brace for thoracic and double thoracic lumbar scoliosis: a comparative study J Pediatr Orthop B 2003; 12: 178–182 236 [34] Coillard C, Leroux MA, Zabjek KF, Rivard CH SpineCor—a non-rigid brace for the treatment of idiopathic scoliosis: post-treatment results Eur Spine J 2003; 12: 141–148 [35] Platero D, Luna JD, Pedraza V Juvenile kyphosis: effects of different variables on conservative treatment outcome Acta Orthop Belg 1997; 63: 194–201 [36] Farsetti P, Tudisco C, Caterini R, Ippolito E Juvenile and idiopathic kyphosis Long-term follow-up of 20 cases Arch Orthop Trauma Surg 1991; 110: 165–168 [37] Seitsalo S Operative and conservative treatment of moderate spondylolisthesis in young patients J Bone Joint Surg Br 1990; 72: 908–913 [38] Terjesen T, Lange JE, Steen H Treatment of scoliosis with spinal bracing in quadriplegic cerebral palsy Dev Med Child Neurol 2000; 42: 448–454 [39] Hayek S, Laplaza FJ, Axelrod FB, Burke SW Spinal deformity in familial dysautonomia Prevalence, and results of bracing J Bone Joint Surg Am 2000; 82-A: 1558–1562 [40] Cady RB, Bobechko WP Incidence, natural history, and treatment of scoliosis in Friedreich’s ataxia J Pediatr Orthop 1984; 4: 673–676 [41] Müller EB, Nordwall A Brace treatment of scoliosis in children with myelomeningocele Spine 1994; 19: 151–155 [42] Brown JC, Swank SM, Matta J, Barras DM Late spinal deformity in quadriplegic children and adolescents J Pediatr Orthop 1984; 4: 456–461 | 26.04.14 - 00:17 Index Index A Adolescent idiopathic scoliosis, see Scoliosis, adolescent idiopathic Adult degenerative scoliosis, see Scoliosis, de novo degenerative Adult idiopathic scoliosis, see Scoliosis, adult idiopathic AESOP device 183 Alignment, spinal – anatomy in 29, 30, 31–33 – assessment of 60, 60, 61–62 – global 32, 33, 34 – in asymptomatic individuals 30 – pelvic 34 – regional 34 Anatomical variants, with spinal deformity 36, 37–41 Anatomy, in spinal alignment 29, 30, 31–33 Anesthesia, neurophysiological signals and 24, 25–26 Angle(s) – C1-C2 34 – C2-C7 34 – cervicothoracic junction 30, 32, 34 – chin-brow to vertical 30, 32, 34 – Cobb 5, 6, 50 – coronal alignment 31, 31 – head tilt 30, 32 – interpupillary 30, 31, 32 – lumbar 30 – lumbosacral junction 30, 34 – main thoracic 30, 50 – occipitocervical junction 30, 34 – of trunk inclination 32 – proximal thoracic 30, 32, 50 – shoulder tilt 31, 32 – thoracolumbar 30, 32, 50 – thoracolumbar junction 30, 34 Ankylosing spondylitis 196 – See also Sagittal malalignment Anterior spinal fusion (ASF), see Combined anterior and posterior arthrodesis – contraindications for 127 – for neuromuscular scoliosis 116, 117, 118, 122, 122 – for thoracic scoliosis 126 – indications for 126 – open technique 127 – posterior versus 136 – progressive sagittal kyphosis and 129 – pulmonary function and 129 – spontaneous correction of lumbar and proximal thoracic curves with 128 – thoracoscopic 127, 128 Anterior spinal instrumentation – contraindications for 127 – for adolescent idiopathic scoliosis 83 – for thoracic scoliosis 126 – indications for 126 – open technique 127 – thoracoscopic 127, 128 Antilordotic lumbosacral brace 233 – See also Orthoses Aorta, anatomical variants of, in spinal deformity 41, 41 Apical vertebral rotation (AVR) 30, 32 Apical vertebral translation (AVT) 32, 69 Arthrodesis, see Anterior spinal fusion (ASF), Combined anterior and posterior arthrodesis, Lateral interbody fusion, Posterior spinal fusion (PSF) ASF, see Anterior spinal fusion (ASF) AVR, see Apical vertebral rotation (AVR) AVT, see Apical vertebral translation (AVT) B BMP, see Bone morphogenic proteins (BMPs) Bone morphogenic proteins (BMPs) 11 Boston brace 232, 233 – See also Orthoses Braces, see Nonoperative management, Orthoses – Boston 232, 233 –– See also Orthoses – Charleston 232, 232 – DuPont kyphosis 233 – Jewett hyperextension 233, 233 – Milwaukee 97, 168, 232, 233 – Providence 232 – Wilmington 232, 232 C C1-C2 angle 34 C2-C7 angle 34 Casting, serial, for early-onset scoliosis 106 – See also Nonoperative management CBVA, see Chin-brow to vertical angle (CBVA) Central sacral vertical line (CSVL) 5, 6, 32 Cerebral palsy, neuromuscular scoliosis in 113, 113, 114, 114–117, 120, 124 Cervical coronal curves 32 Cervical lordosis – defined 34 – in asymptomatic individuals 30 Cervical sagittal alignment 61 Cervicothoracic junction angles 30, 32, 34 Cervicothoracic lumbosacral orthosis (CTLSO) 97, 97 – See also Milwaukee brace Charcot spine, in posttraumatic thoracolumbar spinal deformity 225 Charleston brace 232, 232 Chin-brow to vertical angle (CBVA) 30, 32, 34 Clinical evaluation, see Patient evaluation Cobalt chromium 179 Cobb angle 5, 6, 50 Combined anterior and posterior arthrodesis – complications with 155 – for congenital scoliosis 98, 99 – in adult deformities 152 – in pediatric patients 152, 153 – indications for 151 – patient evaluation in 151 – postoperative care in 155 – radiographic assessment in 151 – staging of 153 – surgical techniques in 153, 154 Combined anterior and posterior hemiepiphyseodesis and hemiarthrodesis, for congenital scoliosis 98, 99 Complex spinal deformity – anterior-posterior vertebral osteotomy in 72 – coronal 199 – coronal balance in 72, 73 – defined 195 – in posttraumatic thoracolumbar spinal deformity 224 – multiplanar 199 – multiple osteotomies for 199 – outcomes with 202 – patient evaluation in 195 – posterior vertebral osteotomy in 72, 73 – preoperative planning for 195 – sagittal malalignment in 196 –– eggshell osteotomy for 198 –– indications for surgical treatment of 196 –– pedicle subtraction osteotomy for 198, 198 –– Smith-Petersen osteotomy for 197, 197 –– surgical techniques for 197 – vertebral column resection for 72, 73, 199 –– posterior 200, 201 Complications 10 – in adult scoliosis surgery 193 – in combined anterior-posterior surgery 155 – in complex deformity surgery 202 – in early-onset scoliosis surgery 109 – in lateral interbody fusion 148 –– minimally invasive 178 – in osteotomies 202 – in posterior spinal fusion 141 – in posttraumatic thoracolumbar spinal deformity 228 – in revision surgery in adults 211 – in spondylolisthesis surgery 220 – with orthoses 235 Computed tomography (CT) 9, 76, 223 – See also Imaging Computed tomography-based imageguided surgery 181 Cone of economy 43, 43, 59, 59 Congenital scoliosis, see Scoliosis, congenital Congenital spondylolysis, see Spondylolysis, congenital/dysplastic Conservative management – See also Nonoperative management Coronal alignment angles and displacements 31, 31 Coronal balance – clinical evaluation of 67, 68 – in adolescent idiopathic scoliosis 68, 69 – in adult idiopathic scoliosis 70 – in complex severe multiplanar deformities 72, 73 – in congenital scoliosis 72, 72 – in de novo degenerative scoliosis 71, 71 – radiographic evaluation of 67, 68–69 – revision surgery for 209, 209, 210 Coronal plane deformity principles 67, 68–69, 71–73 Cosmesis, adult scoliosis and 189 Crankshaft phenomenon 98, 99, 120, 127 CSVL, see Central sacral vertical line (CSVL) CT, see Computed tomography (CT) CTLSO, see Cervicothoracic lumbosacral orthosis (CTLSO) Curve(s) – apex of 50 – cervical coronal 32 – compensatory – double major –– in Lenke classification 51, 52 –– operative treatment of 55, 56 – double thoracic –– in Lenke classification 51, 52 –– operative treatment of 54, 55 – flexibility of, surgical management and 82 – in Lenke classification 51 – lumbar 32 –– in Lenke classification 51 –– operative treatment of 56, 56, 57 – lumbosacral coronal 32 – lumbosacral fractional 70 – main thoracic –– defined 32 –– in Lenke classification 51, 52 –– operative treatment of 53, 54 – nonstructural – occipitocervical 32 – structural – thoracolumbar/lumbar –– in adult idiopathic scoliosis 70 –– in Lenke classification 51 –– operative treatment of 56, 56, 57 – thoracolumbar/lumbar-main thoracic –– in Lenke classification 51 –– operative treatment of 56, 57 – triple major –– in Lenke classification 51 –– operative treatment of 55, 56 CyberKnife 183 D da Vinci system 183, 184 De novo degenerative scoliosis, see Scoliosis, de novo degenerative Degenerative scoliosis, see Scoliosis, de novo degenerative DEXA, see Dual-energy X-ray absorptiometry (DEXA) Dextroscoliosis 5, 6, – See also Scoliosis Diskography, in adult scoliosis 189 Distal adjacent segment disease, revision surgery for 210 Dual-energy X-ray absorptiometry (DEXA) 9, 77, 206 – See also Imaging 237 | 26.04.14 - 00:17 Index Duchenne muscular dystrophy, neuromuscular scoliosis in 113, 116, 118, 121, 121 DuPont kyphosis brace 233 Dysplastic spondylolysis, see Spondylolysis, congenital/dysplastic Dystonia 113 E Early Onset Scoliosis 24-Item Questionnaire (EOSQ-24) 109 Early-onset scoliosis, see Scoliosis, early-onset Economics, health care 14 Eggshell osteotomy, see Osteotomy(ies), eggshell Electrical stimulation 11, 231, 233 Electromyography (EMG) 20, 21 – See also Intraoperative neuromonitoring (IONM) – pathophysiology of changes in 22 – stimulated 21, 22, 23 – transpsoas approach for 21 Enteral nutrition 10 EOSQ-24, see Early-onset scoliosis Evaluation, see Imaging, Patient evaluation Evoked potentials – anesthetic effects and 24, 25–26 – pathophysiology of changes in 22 – somatosensory 18, 19–20 – transcranial electric motor 19, 19, 20, 20–21, 23 Examination, see Patient evaluation F Facet blocks, in adult scoliosis 189 Facet joints, anatomical variants of, in spinal deformity 39 Familial dysautonomia 113 Fixed deformities – flexible versus 75, 76–78, 80–81, 83–85 – pedicle subtraction osteotomy for 80 – Smith-Petersen osteotomy for 80, 81 – vertebral column resection for 80 Flatback syndrome 6, 84, 85 Flexible versus fixed spinal deformity 75, 76–78, 80–81, 83–85 Fluoroscopy-based image-guided surgery 180, 180, 181 Friedreich ataxia 113, 119 G Genetics – in congenital scoliosis 94 – in Scheuermann kyphosis 166 Global spinal alignment 32, 33 Growing rods – breakage of 109 – complication minimization with 109 – for early-onset scoliosis 106, 109 – for Marfan syndrome 108 – for neuromuscular scoliosis 116, 117 – magnetically-controlled 110 Guided-growth techniques, for earlyonset scoliosis 108 238 H H-reflex 19, 20 Head tilt angle 30, 32 Health care economics 14 Health-Related Quality of Life (HRQOL) assessment 9, 14 Hemiarthrodesis, combined anterior and posterior, for congenital scoliosis 99 Hemiepiphyseodesis, combined anterior and posterior, for congenital scoliosis 98, 99 Hemivertebra – excision and fusion, for congenital scoliosis 98, 100 – in congenital scoliosis pathology 94, 94, 96, 96 – in posterior vertebral column resection 200 Hip axis (HA) 34 Hippocratic ladder History, of spinal deformity 2, Hyperalimentation 10 I ICER, see Incremental cost effectiveness ratio (ICER) IGS, see Image-guided surgery (IGS) Image-guided surgery (IGS) – computed tomography-based 181 – fluoroscopy-based 180, 180, 181 Imaging 9, 29 – flexible versus fixed deformity in 76, 76, 77–78 – in adult degenerative scoliosis 144, 144 – in adult scoliosis 188, 188 – in combined anterior-posterior surgery 151 – in coronal balance evaluation 67, 68–69 – in early-onset scoliosis evaluation 105, 105 – in Lenke classification system 49 – in nonoperative management evaluation 231 – in posttraumatic thoracolumbar spinal deformity 223 – in Scheuermann kyphosis 167 – in spondylolisthesis 214 Incremental cost effectiveness ratio (ICER) 16 Indications, for adult spinal deformity surgery Infection – revision surgery due to 206 – surgical site, with growth rods for early-onset scoliosis 109 Injury, see Posttraumatic deformity of thoracolumbar spine, Spinal cord injury Interpupillary angle (IPA) 30, 31, 32 Interpupillary line 32 Intraoperative neuromonitoring (IONM) 18, 19–21, 22, 23, 25–26 – anesthetic effects and 24, 25–26 – in osteotomies 201 – in revision surgery 211 – patient positioning and 22 IONM, see Intraoperative neuromonitoring (IONM) IPA, see Interpupillary angle (IPA) Isthmic spondylolysis, see Spondylolysis, isthmic J Jewett hyperextension brace 233, 233 Juvenile idiopathic scoliosis, see Scoliosis, early-onset, Scoliosis, juvenile idiopathic Lumbar lordosis – as sacropelvic parameter – normal 8, 30, 45 Lumbosacral coronal curve 32 Lumbosacral junction angle 30, 34 Lumbosacral lordosis – defined 34 – in asymptomatic individuals 30 Lung development, early-onset scoliosis and 104 Lung function, anterior spinal fusion and 129 K King classification system 49 Kyphosis – anterior spinal fusion and progressive sagittal 129 – as sacropelvic parameter – in posttraumatic thoracolumbar spinal deformity 223, 225, 226–227 – main thoracic 30 – normal 8, 30 – proximal junctional 11, 141 – proximal thoracic 30 – Scheuermann 84 –– anatomical variants in 37, 38 –– anatomy in 163 –– atypical 167, 168 –– clinical findings in 166 –– differential diagnosis of 167 –– etiology of 166 –– genetics in 166 –– incidence of 166 –– natural history of 166 –– nonoperative treatment of 168, 231, 234 –– orthoses for 168 –– pathogenesis of 166 –– pathomechanics of 164, 165 –– radiographic findings in 167 –– surgical treatment of 168, 169–171, 176 –– treatment of 84 – thoracic –– as sacropelvic parameter –– assessment of 60, 61 –– defined 34 –– main 30 –– normal 8, 30, 45 –– proximal 30 L Lateral interbody fusion – case subsidence with 148 – complications with 148, 178 – for adult degenerative scoliosis 146, 146–147, 147, 148 – minimally invasive 158, 158, 177, 178 – outcomes with 147–148 Lenke classification system 49, 51, 51– 52 Levoscoliosis – See also Scoliosis Lordosis – cervical 30, 34 – in posttraumatic thoracolumbar spinal deformity 224, 227 – lumbar 7–8, 30, 45 – lumbosacral 30, 34 Lumbar angle 30, 32 M Magnetic resonance imaging (MRI) 9, 77 – See also Imaging – in combined anterior-posterior surgery 151 – in early-onset scoliosis 105 – in posttraumatic thoracolumbar spinal deformity 223 Magnetically-controlled growing rods (MCGR) 110 – See also Milwaukee brace Main thoracic angle 30, 50 Main thoracic curves – defined 32 – in Lenke classification 51, 52 – operative treatment of 53, 54 Marchetti-Bartolozzi classification, for spondylolisthesis 213 Marfan syndrome, growing rods for 108 MCGR, see Magnetically-controlled growing rods (MCGR) McGregor line 34 MCID, see Minimum Clinically Important Difference (MCID) Milwaukee brace 97, 168, 232, 233 Minimally invasive surgery (MIS) 11 – See also Thoracoscopic anterior spinal fusion and instrumentation – for lateral interbody fusion 158, 158, 177, 178 – for pedicle subtraction osteotomy 161, 162 – for screw placement 178, 179 – for spondylolisthesis 218 – for transforaminal interbody fusion 159, 160–161 – in adult scoliosis 192 Minimum Clinically Important Difference (MCID) 15, 15 MIS, see Minimally invasive surgery (MIS) Monitoring, see Intraoperative neuromonitoring (IONM) MRI, see Magnetic resonance imaging (MRI) Multiplanar spinal deformity, see Complex spinal deformity Myelography Myelokyphosis 122, 123–124 Myelomeningocele, neuromuscular dystrophy in 113, 113, 114, 117– 119, 121, 122–123 N Natural history – of congenital scoliosis 95 | 26.04.14 - 00:17 Index – of early-onset scoliosis 103 – of Scheuermann kyphosis 166 – of spinal deformity 87, 88–89 Neuromonitoring, see Intraoperative neuromonitoring (IONM) Nonoperative management, see Orthoses – indications for 231 – of adolescent idiopathic scoliosis 231, 233 – of congenital scoliosis 96 – of early-onset scoliosis 106 – of isthmic spondylolysis 231, 234 – of neuromuscular scoliosis 116, 231, 235 – of Scheuermann kyphosis 168, 231, 234 – of spondylolisthesis 231, 234 – patient evaluation in 230 – radiographic assessment in 231 Nutrition, see Hyperalimentation – enteral 10 – total parenteral 202 O Obese patients 116, 188, 215 Occipitocervical curves 32 Occipitocervical junction angle 30, 34 ODI, see Oswestry Disability Index (ODI) Orthoses, see Nonoperative management – complications with 235 – for congenital scoliosis 97, 97 – for early-onset scoliosis 106 – for neuromuscular scoliosis 116 – for Scheuermann kyphosis 168 – suspension trunk 233 Osteotomy(ies) – anterior-posterior vertebral, in complex severe multiplanar deformities 72 – classification of 195, 195 – complications with 202 – eggshell, for sagittal malalignment 198 – for complex spinal deformities 195 – general considerations with 201 – intraoperative monitoring with 201 – multiple, for complex spinal deformity 199 – pedicle subtraction –– for fixed deformities 80 –– minimally invasive 161, 162 – posterior vertebral, in complex severe multiplanar deformities 72, 73 – Smith-Petersen –– for fixed deformities 80, 81 –– for sagittal malalignment 197, 197 Oswestry Disability Index (ODI) 14 Outcomes 10 – in complex deformities 202 – in early-onset scoliosis 108 – in posttraumatic thoracolumbar spinal deformity 227 – measures for 14 – with lateral interbody fusion 147– 148 – with posterior spinal fusion 140, 141 – with vertebral body stapling 130 – with vertebral body tethering 132 P Pars interarticularis – anatomical variants of, in spinal deformity 39 – direct repair of, for spondylolisthesis 216, 217 Patient evaluation 8, 29 – in adult degenerative scoliosis 143 – in adult scoliosis 187 – in combined anterior-posterior surgery 151 – in complex spinal deformity 195 – in congenital scoliosis 94 – in early-onset scoliosis 105 – in nonoperative management 230 – in posttraumatic thoracolumbar spinal deformity 223 – in revision surgery in adults 205 – in spondylolisthesis 214 – of coronal balance 67, 68 – spinal alignment in 29, 30, 31–33 Patient positioning, intraoperative neuromonitoring and 22 Pedicle screws – for adolescent idiopathic scoliosis 83 –– See also Anterior spinal fusion, Posterior spinal fusion (PSF) – percutaneous placement of 178, 179 – surgical anatomy with 136 – uniplanar 179 Pedicle subtraction osteotomy, see Osteotomy(ies), pedicle subtraction Pedicles – anatomical variants of, in spinal deformity 38, 39 – transverse diameter of 136 Pelvic alignment 30, 32, 34 Pelvic incidence (PI) 61 – as sacropelvic parameter – defined 43 – in pelvic alignment 34 – normal Pelvic obliquity 30 Pelvic tilt (PT) 62 – age and – as sacropelvic parameter – defined 43 – health-related quality of life and – in pelvic alignment 34 – normal 45 Pelvis, fusion including 119 Percutaneous screw placement 178, 179 Physical examination, see Patient evaluation PI, see Pelvic incidence (PI) PJK, see Proximal junctional kyphosis (PJK) Plain radiography – See also Imaging Plumb lines 6, 68 Polio, neuromuscular scoliosis in 112, 113 Posterior segmental instrumentation (PSSI), for neuromuscular scoliosis 116, 116, 118 Posterior spinal arthrodesis, see Posterior spinal fusion (PSF) Posterior spinal fusion (PSF), see Combined anterior and posterior arthrodesis, Pedicle screws – anterior versus 136 – complications with 141 – for congenital scoliosis 97 – for neuromuscular scoliosis 116, 116, 118, 122, 122 – for Scheuermann kyphosis 170 – results with 140, 141 – surgical technique for 137, 137, 138– 140 Posterior vertebral column resection 200, 201 – See also Vertebral column resection (VCR) Postoperative considerations 10 Posttraumatic deformity of thoracolumbar spine, see Spinal cord injury anatomy in 222 biomechanics in 222 causes of 224 Charcot spine in 225 classification of 223 clinical presentation of 223 combined deformity in 224 complications in 228 epidemiology of 222 hardware failure in 225 in coronal plane 224 in sagittal plane 223 instability in 224, 225 kyphotic deformity in 223, 225, 226–227 – lordotic deformity in 224, 227 – outcomes in 227 – pseudarthrosis in 225 – radiographic evaluation of 223 – scoliotic deformity in 224, 227 – surgical treatment of 225 – translational deformity in 224, 227 Providence brace 232 Proximal adjacent segment disease, revision surgery for 210, 211 Proximal junctional kyphosis (PJK) 11, 141 Proximal thoracic angle 30, 32, 50 Proximal thoracic kyphosis 30 PSF, see Posterior spinal fusion (PSF) PSSI, see Posterior segmental instrumentation (PSSI) PT, see Pelvic tilt (PT) – – – – – – – – – – – – – – Q QALY, see Quality-adjusted life year (QALY) Quality-adjusted life year (QALY) 15 R Radiography, see Imaging Radiosurgery 183 Results, see Outcomes Rett syndrome 114 Revision surgery, in adult scoliosis – complications in 211 – for combined imbalance 209, 210 – for coronal imbalance 209, 209, 210 – for distal adjacent segment disease 210 – for implant failure 207 – for infection 206 – for proximal adjacent segment disease 210, 211 – for pseudarthrosis 207 – for sagittal imbalance 201, 207, 208, 209, 209 – indications for 206 – overview of 192 – patient evaluation for 205 – perioperative management in 206 – radiographic assessment in 205 – treatment options in 206 Rib(s) – anatomical variants of, in spinal deformity 38, 38 – vertical expandable prosthetic titanium –– for early-onset scoliosis 108 –– for neuromuscular scoliosis 116, 118, 118 Robotic spine surgery 182, 184 S Sacral slope (SS) 7, 34, 44, 44, 45, 62 Sacropelvic parameters – importance of 43 – normal – overview of Sagittal imbalance, revision surgery for 201, 207, 209 Sagittal malalignment 196 – eggshell osteotomy for 198 – etiology of 196 – in posttraumatic thoracolumbar spinal deformity 223 – indications for surgical treatment of 196 – pedicle subtraction osteotomy for 198, 198 – Smith-Petersen osteotomy for 197, 197 – surgical techniques for 197 Sagittal plane deformity principles 59, 59, 60–62, 65 Sagittal spinal balance 30 Sagittal spinopelvic alignment – clinical correlations of 63 – surgical planning and treatment for 63 Sagittal vertical axis (SVA) 7, 60, 60, 62 SCB, see Substantial clinical benefit (SCB) Scheuermann kyphosis, see Kyphosis, Scheuermann Scoliosis, see Curve(s) – adolescent idiopathic –– anatomical variants in 36 –– anterior spinal instrumentation for 83 –– classification of 45, 49 –– combined anterior-posterior surgery for 152, 153 –– coronal balance in 68, 69 –– curve flexibility in 82 –– function and 186 –– natural history of 87 –– nonoperative management of 231, 233 –– pedicle screws for 83 –– postskeletal maturity 89 –– preskeletal maturity 88 –– prevalence of 87 –– progression of 88–89 –– thoracic major curves in 70 – adult –– complications in 193 239 | 26.04.14 - 00:17 –– –– –– –– –– –– –– –– –– –– cosmesis and 189 diskography in 189 facet blocks in 189 fusion levels in 191 fusions to sacrum in 191, 192 history in 187 in asymptomatic patients 189 in symptomatic patients 189 incidence of 186 intraoperative management with 192 –– minimally invasive surgery for 192 –– neural decompression in 191 –– nonsurgical treatment of 189 –– patient evaluation in 187 –– physical examination in 187 –– postoperative care for 192 –– radiographic assessment in 188, 188 –– revision surgery in ––– complications in 211 ––– for combined imbalance 209, 210 ––– for coronal imbalance 209, 209, 210 ––– for distal adjacent segment disease 210 ––– for implant failure 207 ––– for infection 206 ––– for proximal adjacent segment disease 210, 211 ––– for pseudarthrosis 207 ––– for sagittal imbalance 201, 207, 208, 209, 209 ––– indications for 206 ––– overview of 192 ––– patient evaluation for 205 ––– perioperative management in 206 ––– radiographic assessment in 205 ––– treatment options in 206 –– surgical treatment of 189, 190, 192 – adult idiopathic –– anatomical variants in 36 –– combined anterior-posterior surgery for 152 –– coronal balance in 70 –– degenerative versus 143 –– lumbosacral fractional curves in 70 –– rigidity of 84 –– thoracolumbar/lumbar major curves in 70 – complex, see Complex spinal deformity – congenital –– classification 94 –– combined anterior and posterior arthrodesis for 98, 99 –– combined anterior and posterior hemiepiphyseodesis and hemiarthrodesis for 98, 99 –– coronal balance in 72, 72 –– genetics in 94 –– hemivertebra excision and fusion for 98, 100 –– natural history of 95 –– nonoperative treatment of 96 –– observation for 96 –– orthoses for 97, 97 –– patient evaluation in 94 –– posterior spinal arthrodesis for 97 –– surgical treatment of 97, 99–101 –– terminology 94 –– thoracic expansion surgery for 100, 101 240 –– vertebral column resection for 101 – de novo degenerative –– classification of 143–144 –– coronal balance in 71, 71 –– decompression for 145 –– indications for surgical management of 145 –– lateral interbody fusion for 146, 146–147, 147, 148 –– nonsurgical treatment of 145 –– patient evaluation in 143 –– radiographic assessment of 144, 144 –– rigidity of 84 –– treatment options for 145 – early-onset –– classification of 103, 103, 103, 104 –– clinical evaluation of 105 –– complications in 109 –– growing rods for 106, 109 –– guided-growth techniques for 108 –– lung development and 104 –– natural history of 103 –– nonoperative treatment of 106 –– outcome measures in 108 –– radiographic evaluation of 105, 105 –– spine development and 104 –– surgical treatment of 106, 107 –– vertical expandable prosthetic titanium rib for 108 – in posttraumatic thoracolumbar spinal deformity 224, 227 – juvenile idiopathic, natural history of 87 – neuromuscular –– acquired 114 –– anterior spinal fusion for 116, 117, 118, 122, 122 –– classification of 114 –– developmental 114 –– growing rods for 116, 117 –– in cerebral palsy 113, 113, 114, 114–117, 120, 124 –– in Duchenne muscular dystrophy 113, 116, 118, 121, 121 –– in myelomeningocele 113, 113, 114, 117–119, 121, 122–123 –– in polio 112, 113 –– in spinal cord injury 113–114, 114, 117, 121, 121, 122 –– myelokyphosis and 122, 123–124 –– nonoperative treatment of 116, 231, 235 –– posterior segmental instrumentation for 116, 116, 118 –– posterior spinal fusion for 116, 116, 118, 122, 122 –– rigidity in 84, 84 –– surgical treatment of 116, 116, 117–124 –– vertebral body stapling for 116, 118, 118 –– vertical expandable prosthetic titanium rib for 116, 118, 118 – paralytic 84 – thoracic, anterior spinal fusion for 126 Scoliosis Research Society-22 R (SRS22R) 14 Segmental vessels, anatomical variants of, in spinal deformity 41, 41 Serial casting, for early-onset scoliosis 106 SF-36, see Short-Form 36 Physical Component Summary (SF-36 PCS) Shilla growth guidance system, for early-onset scoliosis 108 Short-Form 36 Physical Component Summary (SF-36 PCS) 14 Shoulder tilt angle (ShTA) 31, 32 ShTA, see Shoulder tilt angle (ShTA) Skeletal maturity Smith-Petersen osteotomy, see Osteotomy(ies), Smith-Petersen Smoking Somatosensory evoked potentials (SSEPs) 18, 19–20 – See also Evoked potentials SPI, see Spinopelvic inclination (SPI) Spinal alignment, see Alignment, spinal Spinal cord injury, neuromuscular scoliosis with 113–114, 114, 117, 121, 121, 122 – See also Posttraumatic deformity of thoracolumbar spine Spinal cord, anatomical variants of, in spinal deformity 40, 40, 41 Spinal deformity, see Complex spinal deformity, Scoliosis – history of 2, – indications for surgical management of – natural history of 87, 88–89 – overview of – patient evaluation in – principles – terms – value in care for 16 Spinal development, early-onset scoliosis and 104 Spinal fusion, see Anterior spinal fusion, Combined anterior and posterior arthrodesis, Lateral interbody fusion, Posterior spinal fusion (PSF) Spinopelvic inclination (SPI) 60, 60 Spinopelvic parameters 79 Spinous processes, anatomical variants of, in spinal deformity 39, 39 Spondylolisthesis – classification of 213, 213 – complications with 220 – indications for surgical management of 215 – minimally invasive techniques for 218 – nonoperative management of 231, 234 – pars repair for 216, 217 – patient evaluation in 214 – progression of 214 – radiographic assessment of 214 – spinal fusion for –– high-grade 218, 219 –– low-grade 217 – treatment options for 215 Spondylolysis – congenital/dysplastic, anatomical variants in 37, 37 – isthmic –– anatomical variants in 37 –– nonoperative management of 231, 234 SRS-22R, see Scoliosis Research Society22R (SRS-22R) SS, see Sacral slope (SS) SSEPs, see Somatosensory evoked potentials (SSEPs) SSI, see Surgical site infection (SSI) Stapling, see Vertebral body stapling (VBS) Stimulated electromyography (stEMG) 21, 22, 23 Substantial clinical benefit (SCB) 15, 15 Surgical site infection (SSI), with growth rods for early-onset scoliosis 109 Surgical-assist devices 183 Suspension trunk orthosis 233 SVA, see Sagittal vertical axis (SVA) T tceMEPs, see Transcranial electric motor evoked potentials (tceMEPs) Teleoperators 183 Terminology Thoracic expansion surgery, for congenital scoliosis 100, 101 Thoracic kyphosis (TK) – as sacropelvic parameter – assessment of 60, 61 – defined 34 – main 30 – normal 8, 30, 45 – proximal 30 Thoracolumbar angle 30, 32, 50 Thoracolumbar junction angle – defined 34 – in asymptomatic individuals 30 Thoracoscopic anterior spinal fusion and instrumentation 127, 128, 175, 176–177 Thromboembolic stockings 10 TK, see Thoracic kyphosis (TK) Total parenteral nutrition (TPN) 202 TPN, see Total parenteral nutrition (TPN) Transcranial electric motor evoked potentials (tceMEPs) 19, 19, 20, 20–21, 23 – See also Evoked potentials Transforaminal interbody fusion, minimally invasive 159, 160–161 Transpedicular instrumentation, see Pedicle screws Trauma, neuromuscular scoliosis with 113–114, 114, 117, 121, 121, 122 – See also Posttraumatic deformity of thoracolumbar spine V Value, in spinal deformity care 14 Variants, anatomical, with spinal deformity 36, 37–41 Vascular anatomical variants, in spinal deformity 41, 41 VBS, see Vertebral body stapling (VBS) VCR, see Vertebral column resection (VCR) VEPTR, see Vertical expandable prosthetic titanium rib (VEPTR) Vertebra(e) – end, defined 5, 5, 32 – neutral, defined 5, – stable, defined 6, | 26.04.14 - 00:17 Index Vertebral body stapling (VBS) – for neuromuscular scoliosis 116, 118, 118 – indications for 130 – results with 130 – surgical technique for 130 Vertebral body tethering 131 – indications for 131 – results with 132 – surgical technique for 131 Vertebral body, anatomical variants of, in spinal deformity 36, 37–38 Vertebral column resection (VCR) – for complex severe multiplanar deformities 72, 73, 195, 199 – for congenital scoliosis 101 – for fixed deformities 80 – posterior 200, 201 Vertebrectomy, see Vertebral column resection (VCR) Vertical expandable prosthetic titanium rib (VEPTR) – for early-onset scoliosis 108 – for neuromuscular scoliosis 116, 118, 118 Wilmington brace 232, 232 Wiltse-Newmann classification, for spondylolisthesis 213 X W Weight loss 9, 188, 215 X-ray, see Imaging, Plain radiography 241 | 26.04.14 - 00:17