CURVE PROGRESSION AFTER ANTERIOR SURGICAL CORRECTION OF SCOLIOSIS: TWO CASES REPORT

Nguyen Thanh Nhan*, Do Tran Khanh, Vo Quang Dinh Nam, Huynh Manh Nhi, Vu Viet Chinh Paediatric Orthopedic Department Hospital for Traumatology and Orthopaedics Ho Chi Minh City Vietnam
* MD, Paediatric Orthopaedic Department, Medical University

BACKGROUND
Peter O. Newton, Dennis R. Wenger The indications for surgical correction of scoliosis: - Curve magnitude - Clinical deformity - Risk for progression - Skeletal maturity, and curve pattern. - Thoracic curves of Cobb angle > 40 to 50 degrees in skeletally immature patients whereas surgical correction is reserved for curves of 50 degrees or more in mature patients (lower risk of progression). - Trunk deformity (rotation) and trunk balance are important factors in deciding when to advise surgical correction.

BACKGROUND
Peter O. Newton, Dennis R. Wenger Anterior instrumentation and fusion generally include those with a single structural deformity (thoracic, thoracolumbar or lumbar curves, Lenke 1A B C, 5 C).

BACKGROUND
Lee S. Segal and Kelly L. Vanderhave Anterior instrumentation is indicated for primary thoracic curves and thoracolumbar curves, with the goal to save two or more levels compared with that predicted for posterior Fusion levels tend to extend from the proximal to the distal end vertebrae measured in the Cobb angle.

BACKGROUND
The potential advantages Avoiding disruption of the posterior extensor musculature Decreased risk of junctional problems Superior long-term correction of the compensatory noninstrumented curves with less postoperative coronal decompensation Improved ability to derotate the spine in the transverse plane Better correction of thoracic hypokyphosis

BACKGROUND
The contraindications for anterior approach - Significant preoperative kyphosis (>400), - Curves greater than 800 - Impaired respiratory function (vital capacity < 50%) - And double or triple structural curves.

BACKGROUND
Historical problems with anterior instrumentation Rod breakage Pull-out of the proximal screw Pseudoarthrosis Kyphosis. These problems have been addressed with the use of larger rods, structural grafts and spacers to provide anterior column reconstruction, and maintaining lordosis for thoracolumbar curves.

PURPOSE
To review the indications for anterior surgical correction of scoliosis. To evaluate used constructs. To analyze the causes of progression of scoliosis.

MATERIALS AND METHODS

Retrospective study 10/2003 - 3/2009 151 patients:
Male. 37.75% Female. 62.25%

57 male, 94 female

CAUSES OF SCOLIOSIS
78 cases idiopathic scoliosis 53 cases congenital scoliosis 20 cases miscellaneous scoliosis
51.65% 35.09%

13.24%

idiopathic scoliosis

congenital scoliosis

miscellious scoliosis

SURGERY OF IDOPATHIC SCOLIOSIS

1. POSTERIOR INSTRUMENTATION (69 cases) 5 cases Harrington rods without fusion 4 cases Harrington rods with sublaminar wires 1 case hooks only 20 cases hybrid constructs with segmental translation pedicle screws and hooks ( 4 cases used 3 rods ) 39 cases all pedicle screws 2. ANTERIOR SURGERY TECHNIQUES (9 cases) 9 cases with an anterior single-rod construct / 2 cases revision due to progressive scoliosis

METHODS
2/9 cases of anterior surgical correction of scoliosis. Thoraco lumbar approach, discs discectomy, vertebral screw with one single rod Moss Miami. The results of correction are evaluated by Cobb angle. Post-Op, wearing brace in 3 6 months. Progressive scoliosis > 500: posterior CD instrumentation.

RESULTS
Time follow up (12, 30 months) First correction results: Percentage corrected (63%, 76%). Curve progressed (Cobb angle: 260 560, 200 520) Posterior CD instrumentation. Percentage corrected (82%, 35%), trunk balance, no complications.

Case 1: Pt Nguyen Vu C 1993, Male, 14 YO. Cobb angle T10-L4: 700, Bending: 580 King 1 - Lenke 5CN

PreOp: Cobb angle T10 L4: 700

PostOp: Cobb angle T10 L4: 260 (percentage corrected: 63%)

1 year later, curve progressed, Cobb angel T10 L4: 560

X ray PostOp: Cobb angle T10 L4: 100 (percentage corrected 82%)

Case 2: Pt Vu Thanh N, 1991, Male, 15 YO. Cobb angle T9-L2: 840, Bending: 420 King 2 Lenke 4BN

PreOp: Cobb angle T9 L2: 840.

PostOp: Cobb angle T9 L2: 200 (percentage corrected: 76%)

30 ms later, curve progressed, Cobb angle T8 L2: 520

PostOp: Cobb angle T8 L2: 340 (percentage corrected 35%)

DISCUSSION
1. Surgery indication: Case 1 (King 1, Lenke 5CN), anterior instrumentation indication is exact. Case 2 (King 2, Lenke 4BN), anterior instrumentation indication is wrong because of triple structural curve, Cobb angle > 800 (840).

DISCUSSION
2. Anterior constructs gave good correction results (63%, 76%) but both are not enough long because of not reaching the proximal end and distal end vertebrae of Cobb angle. We wish to do longer but the approach not enough long Choosing the approach in anterior surgery must be exact, long enough to gain effective construct . Case 1 need to put 2 levels higher. Anterior instrumentation should only indicated for type of short single structural curve, thoraco-lumbar or low thoracic. .

DISCUSSION
3. Patient must wear brace enough time to have good fusion. Need to closely follow up to detect progressive curve. 4. Adolescent patient (14, 15 YO, Risser V), still have potential progressive scoliosis. Why? 5. Have the problems in posterior instrumentation in patient with anterior instrumentation? Put pedicle screws. Have any interaction between different kinds of metal?

CONCLUSION
Anterior spinal instrumentation gave good correction, but need to indicate exactly. Instruments need enough strong and long (from the proximal end to distal end vertebrae of the Cobb angle). Need to programe follow up the curve. Posterior correction instrumentation may be a good option.