Floccari, Lorena V.

Background: The purpose of this study was to compare the Vickers physiolysis procedure with osteotomy for correction of digital clinodactyly and determine which method provides better correction at final follow-up or whether the patient’s age, preoperative angulation, or presence of syndactyly affects final outcomes. Methods: All patients of skeletal immaturity who underwent surgical correction of clinodactyly were evaluated with clinical examination and radiographs to determine the percentage and absolute change in the degree of clinodactyly pre- versus postoperatively, in addition to stratification based on the degree of deformity, age, and presence of syndactyly. Results: Vickers’ physiolysis and osteotomy were undertaken in 30 and 11 digits, respectively. The angulation significantly improved from 43.0° to 23.9°, with a 46.2% correction of deformity in the Vickers group at 46.3 months. The angulation decreased from 39.2° to 22.4° in the osteotomy group, with a 55.3% correction of deformity at 55.3 months. There was better correction in those with isolated clinodactyly compared with those with concomitant syndactyly and better percentage of correction in patients with lesser deformity in the Vickers group. There were more reoperations in the osteotomy group. Conclusions: The use of osteotomy may lead to more revision cases, whereas the Vickers procedure has minimal complications and need for revision. The Vickers physiolysis procedure is more effective in those with angulation <55°.

Background: Adjacent segment pathology is a known complication after spinal fusion, but little has been reported on junctional failure. A series of adolescent patients presented with acute distal junctional failure (DJF). We sought to determine any common features of these patients to develop a prevention strategy. Methods: A retrospective review was conducted of pediatric patients who developed DJF after instrumented spinal fusion performed at 2 institutions from 1999 to 2013. Patients with proximal junctional failure or junctional kyphosis without failure were excluded. Results: Fifteen subjects were identified with mean follow-up of 38 months. Distal failure occurred a mean of 60 days after index surgery, with history of minor trauma in 4 patients. Failures included 3-column Chance fracture (11) or instrumentation failure (4). Thirteen patients presented with back pain and/or acute kyphosis, whereas 2 asymptomatic patients presented with healed fractures. Two patients also developed new onset of severe lower extremity neurological deficit after fracture, which improved but never resolved after revision. A total of 13/15 subjects required revision surgery, typically within 1 week. Complications associated with revision surgery were encountered in 8 patients (62%). Major complications that required return to the operating room included 2 deep infections, 2 instrumentation failures, and dense lower extremity paralysis that improved after medial screw revision and decompression. At final follow-up, 10 patients are asymptomatic, 2 have persistent neurological deficit, 2 have chronic pain, and 1 has altered gait with gait aid requirement. Conclusions: This study analyzes a heterogenous cohort of spinal fusion patients who developed DJF from 3-column Chance fracture or instrumentation failure. Revision surgery is typically required, but has a high complication rate and can result in severe neurological deficit, highlighting the morbidity of this complication. It is unclear whether level of the lowest instrumented vertebra contributes to DJF. Increased awareness of junctional failure in children may prompt additional studies to further characterize risk factors and preventative strategies. Level of Evidence: Level IV—study-type case series.

Background: In pediatric patients, pedicle screws are malpositioned 5% to 15% of the time. Complications associated with malpositioned screws are infrequently reported in the literature. We present a series of adolescent idiopathic scoliosis (AIS) patients who presented in a delayed manner with positional headache and chronic dural leak adjacent to the pedicle screw tract. Methods: Scoliosis databases at 2 centers were reviewed, and cases of delayed positional headaches following posterior spinal fusion for AIS were identified. Demographic and clinical data were collected. Results: Of 322 patients, 4 patients presented with positional headaches at a mean of 12.8 weeks following posterior spinal fusion surgery for AIS, with an interval time to diagnosis of 5 months. Computed tomographic myelogram demonstrated severe pedicle screw malposition in 1 patient, and minimal malposition in 3 patients (<2 mm violation). The patients had delayed presentation with positional headaches secondary to dural leak. All patients successfully underwent revision surgery with repair of the dural leak. At the time of latest follow-up, all patients are asymptomatic. Conclusions: Pedicle screw malposition can result in dural leaks. Patients may present in a delayed manner with positional headaches and an acquired Chiari malformation. Clinical suspicion should prompt imaging of the brain or cervical spine followed by computed tomographic myelogram to determine site of leak. This is a rare complication from pedicle screw malposition. Levels of Evidence: Level IV—case series.

Background: Up to 10% of free-hand pedicle screws are malpositioned, and 1 in 300 patients may undergo return to surgery for revision of malpositioned screws. The indications for revision of asymptomatic malpositioned screws have not been carefully examined in the literature. We sought to evaluate the threshold among spinal deformity surgeons for revision of malpositioned screws. Methods: Twelve experienced spine surgeons reviewed x-ray and computed tomographic images of 32 malpositioned pedicle screws with variable degrees of anterior, medial, and lateral breeches. The surgeons were asked whether based on the image they would revise the screw: (1) intraoperatively before rod placement; (2) intraoperatively after rod placement; (3) in clinic with an asymptomatic patient. For each scenario, we assumed stable neuromonitoring and no neurological changes. Agreement and multirater κ was calculated. Results: There was good agreement as to which screws were malpositioned (80% agreement, κ=0.703). After the rod was placed or postoperatively (scenarios 2 and 3), surgeons less frequently recommended screw revision, and there was greater variability among the surgeons’ recommendations. For return to surgery from clinic for asymptomatic screw revision, % agreement was only 65% (κ=0.477). The majority recommended revision surgery for screws which approached the dura (10/12) or the aorta (7/12 surgeons). Half of the surgeons recommended revision surgery for an asymptomatic screw if the entire screw diameter was in the canal. Revision surgery was not recommended for asymptomatic patients with screws partially violating the canal (<½ the screw diameter), malpositioned laterally in the rib head, or with small anterior cortical violations remote from a vascular structure. Conclusions: There is significant variability of opinion among surgeons regarding which malpositioned screws can be safely observed in an asymptomatic patient. Given the frequency of malpositioned screws and morbidity of surgical return to surgery, more long-term data are needed to develop practice guidelines for determining which screws require revision surgery. Level of Evidence: Level III—retrospective comparative study.