Utilization of thoracic pedicle screws is controversial, especially in the treatment of scoliosis. We present a case of a 15-year-old girl seen 6 months after her initial surgery for scoliosis done elsewhere. She complained of persistent epigastric pain, tremor of the right foot at rest, and abnormal feelings in her legs. Clinical examination revealed mild weakness in the right lower extremity, a loss of thermoalgic discrimination, and a forward imbalance. A CT scan revealed at T8 and T10 that the right pedicle screws were misplaced by 4 mm in the spinal canal. At the time of the revision surgery the somatosensory evoked potentials (SSEP) returned to normal after screw removal. The clinical symptoms resolved 1 month after the revision. The authors conclude that after pedicle instrumentation at the thoracic level a spinal cord compression should be looked for in case of subtle neurologic findings such as persistent abdominal pain, mild lower extremity weakness, tremor at rest, thermoalgic discrimination loss, or unexplained imbalance.
The results of surgical treatment of vertebral metastases were evaluated from a retrospective review of a consecutive series of 100 patients, with special reference to anatomoclinical aspects and functional outcome. The primary tumour in most cases was lung, breast, or prostate; it was unknown in 11 cases. Diagnosis of the metastasis occurred 4-86 months after that of the primary tumour (lung metastasis: 4 months; breast metastasis: 86 months; prostatic metastasis: 22 months). Patients complained of vertebral pain in 96 cases and/or radicular pain in 43 cases. Intractable pain was observed in lung metastasis in particular. All patients received analgesics, and 57 received morphinics. Walking was impossible for 50 patients. Thirty-eight patients presented with neurologic deficit; neurologic status varied according to the primary tumour. Treatment included anterior surgery in 58 patients, posterior surgery in 33 patients, and combined surgery in 9 patients. Mean duration of hospitalisation was 12 days. No patient was admitted to the intensive care unit. Mean follow-up was 13.5 months. Eighty-nine patients were dead at follow-up, with an average survival of 10 months. Mean survival time was 7 months for patients with lung metastasis, 12 months for those with breast metastasis and 24 months for those with prostatic metastasis. Ten patients were still alive at follow-up (mean follow-up period 45 months, range 17-72 months). Analgesics were stopped for 62 patients following discharge from hospital. Morphinics had to be continued in seven patients. Thirty-five patients out of 50 (70%) recovered walking capacity. Neurologic status improved in 30 out of 38 patients. Although duration of survival was limited, surgery proved to be beneficial in providing a significant and early improvement in the functional status of more than 80% of patients. A precise evaluation of preoperative pain is necessary. Pain is dependent upon the bony lesion, the primary tumour, and the tumoral topography, which defines the surgical approach.
This is a prospective study comparing the short-and long-term three-dimensional (3D) changes in shape, length and balance of the spine after spinal instrumentation and fusion in a group of adolescents with idiopathic scoliosis. The objective of the study was to evaluate the stability over time of the postoperative changes of the spine after instrumentation with multi rod, hook and screw instrumentation systems. Thirty adolescents (average age: 14.5 ± 1.6 years) undergoing surgery by a posterior approach had computerized 3D reconstructions of the spine done at an average of 3 days preoperatively (stage I), and 2 months (stage II) and 2,5 years (stage III) after surgery, using a digital multi-planar radiographic technique. Stages I, II and III were compared using various geometrical parameters of spinal length, curve severity, and orientation. Significant improvement of curve magnitude between stages I and II was documented in the frontal plane for thoracic and lumbar curves, as well as in the orientation of the plane of maximum deformity, which was significantly shifted towards the sagittal plane in thoracic curves. However, there was a significant loss of this correction between stages II and III. Slight changes were noted in apical vertebral rotation, in thoracic kyphosis and in lumbar lordosis. Spinal length and height were significantly increased at stage II, but at long-term follow-up spinal length continued to increase while spinal height remained similar. These results indicate that although a significant 3D correction can be obtained after posterior instrumentation and fusion, a significant loss of correction and an increase in spinal length occur in the years following surgery, suggesting that a crankshaft phenomenon may be an important factor altering the long-term 3D correction after posterior instrumentation of the spine for idiopathic scoliosis.
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