The Growing Spine (eBook)

The Growing Spine 2
Dedication 4
Foreword I 6
Foreword II 8
Foreword III 10
Preface 11
Contents 13
Contributors 17
Section I:General 24
1: Embryology and Anatomy:Spine/Spinal Cord 25
1.1 Introduction 25
1.2 Early Development 25
1.3 Somite Formationand Differentiation 27
1.4 Central Nervous SystemDevelopment 29
1.5 Peripheral Extension of the CNS Formation of the PeripheralNervous System31
1.6 Vertebral Ossifi cation 31
1.7 Conclusion 34
References 34
2:Normal Growth of the Spine and Thorax 35
2.1 Growth Holds the Basics 35
2.2 Biometric Measurements 36
2.2.1 Standing Height 36
2.2.2 Sitting Height 37
2.2.3 Subischial Limb Length 37
2.2.4 Arm Span 37
2.2.5 Weight 39
2.2.6 The Multiplying Coeffi cient 41
2.3 Chronology 41
2.3.1 Intrauterine Development 41
2.3.2 From Birth to 5 Years 41
2.3.3 From 5 Years to Beginningof Puberty 42
2.3.4 Puberty: A Turning Point 42
2.3.5 Secondary Sexual Characteristics 44
2.3.6 Pubertal Diagram and Peak HeightVelocity (Figs. 2.7–2.10) 45
2.4 Estimation of Skeletal Maturity 46
2.5 The Concept of Risser sign isMisleading (Figs. 2.13, 2.14) 47
2.6 Growth of the Trunk 49
2.6.1 Growth in the Spinal Column 49
2.6.2 Cervical Spine 50
2.6.3 T1–S1 Segment (Figs. 2.15, 2.16) 50
2.6.4 Thoracic Spine T1–T12(Figs. 2.19, 2.20) 50
2.6.5 Lumbar Spine (L1–L5) 50
2.6.6 The Thoracic Growth is the FourthDimension of the Spine [20] 51
2.6.7 Scoliosis and Puberty 55
2.6.8 The Scoliotic Risk 57
2.6.9 Growth in the Paralytic Child 58
2.7 Lessons Learned from Growth 58
2.8 The Growing Spine:from the Normal to Abnormal 59
2.8.1 The Pathologic Spine is Dominatedby the Crankshaft Phenomenon 59
2.8.2 Growth DisturbancesAfter Spinal Arthrodesis 59
2.9 From Birth to 5 Years of Age,the Spine-Rib-Lung Complex 60
2.9.1 A Thorough Pediatric Evaluationis a Priority 60
2.9.2 From Five to Puberty,a Quiescent Period 61
2.9.3 What we Know, Where we are,and Which Way to Follow? 62
References 62
3:Biomechanics in the Growing Spine 65
3.1 Background 65
3.2 Biomechanical Considerationsfor Instrumenting the GrowingSpine 66
3.3 Conclusions 68
References 69
4:Genetics 71
4.1 Basic Genetics 71
4.2 The Chromosome and DNA 71
4.3 Genetic Polymorphismsand Their Relation to Diseases 73
4.4 Types of Disease 74
4.5 Disease Gene Mapping 74
4.6 Linkage Analysison Familial Subjects 75
4.7 Case–Control Association Studieson Population-Based Subjects 76
4.8 Genetic Mutationsto Spinal Abnormalities 77
4.9 Genetics of Idiopathic Scoliosis 78
References 80
Section II:Evaluation of the Growing Child 82
5:Clinical Examination 83
5.1 Introduction 83
5.2 Medical History 83
5.2.1 Birth History 83
5.2.2 Family History 83
5.2.3 Spinal Deformity History 83
5.3 Physical Examination 84
5.3.1 Overall Health and Reviewof Systems 84
5.3.2 Neurological Status 84
5.3.3 Mental Status 84
5.3.4 Pain Status 84
5.3.5 Musculoskeletal Statusand Examination of the Thorax 84
5.4 Diagnostic Laboratory Testing 86
5.5 Diagnostic Imaging 86
5.5.1 Radiographs 86
5.5.2 Magnetic Resonance Imaging (MRI) 86
5.5.3 Computed Tomography (CT) 87
5.6 Developing a ComprehensiveTreatment Plan 87
5.6.1 Postoperative Examination 87
References 87
6:Comorbidities Associatedwith Early Onset Scoliosis 88
6.1 Introduction 88
6.2 Organ System Comorbidities 88
6.2.1 Neural Axis 88
6.2.1.1 Idiopathic Scoliosis 89
6.2.1.2 Congenital Scoliosis 89
6.2.1.3 Marfan Syndrome 90
6.2.1.4 Neurofi bromatosis 90
6.2.1.5 Neuromuscular andMyelomeningocele Scoliosis 92
6.3 Cardiac 92
6.3.1 Idiopathic Scoliosis 92
6.3.2 Congenital Scoliosis 92
6.3.3 Neuromuscular Scoliosis 93
6.3.4 Marfan Syndrome 93
6.3.5 Congenital Heart Disease 93
6.4 Urogenital 94
6.4.1 Congenital Scoliosis 94
6.4.2 Neuromuscular Scoliosis 94
6.5 Musculoskeletal 95
6.5.1 Idiopathic Scoliosis 95
6.5.2 Congenital Scoliosis 95
6.5.3 Neuromuscular Scoliosis 95
6.5.4 Marfan Syndrome 95
6.5.5 Neurofi bromatosis 95
6.6 Gastrointestinal 96
6.7 Cutaneous 96
6.8 Pain and Disability 96
References 96
7:Thoracic Insuffi ciency Syndrome (TIS) 98
7.1 Introduction 98
7.2 Lung and Chest Wall Mechanics 99
7.2.1 Gas Exchange 102
7.2.2 Lung Function Asymmetry 102
7.2.3 Respiratory Muscle Function 103
7.3 Pulmonary Hypertension 104
7.4 Nutritional Statusas a Pulmonary Assessment 104
References 104
8:Imaging of the Growing Spine 106
8.1 Introduction 106
8.2 Plain Radiography 106
8.3 The EOS System 108
8.4 Computed Tomography (CT Scans) 108
8.5 Unique Applications of Using CTScans in the Growing Spine 110
8.6 Magnetic Resonance Imaging (MRI) 113
References 114
9:Back Pain in Children 115
9.1 Epidemiology of Back Painin Children 115
9.2 Age 116
9.3 Gender 116
9.4 Anthropometric Factors 117
9.5 Spinal Posture 117
9.6 Spinal Mobility 118
9.7 Muscle Strength 119
9.8 Leisure Time and Sporting Activities 119
9.9 Back Pain and Co-Morbidity 120
9.10 Disc Pathologies as CausativeFactors for Low Back Painin Adolescents 120
9.11 Summary 122
References 122
10:Pediatric Spinal Infections 124
10.1 Pediatric Spinal Infections 124
10.1.1 Discitis 124
10.1.1.1 Pathophysiology 124
10.1.1.2 History and Physical Examination 125
10.1.1.3 Laboratory Workup 125
10.1.1.4 Imaging Studies 125
10.1.1.5 Biopsy 126
10.1.1.6 Management 126
10.1.2 Vertebral Osteomyelitis 126
10.1.2.1 Pathophysiology 126
10.1.2.2 History and Physical Examination 127
10.1.2.3 Laboratory Workup 127
10.1.2.4 Imaging Studies 127
10.1.2.5 Management 128
10.1.3 Tuberculosis of the Spine 128
10.1.3.1 Pathophysiology 128
10.1.3.2 History and Physical Examination 128
10.1.3.3 Laboratory Workup 128
10.1.3.4 Imaging Studies 129
10.1.3.5 Management 129
10.1.4.1 Other Pathogens Involvedin Spondylodiscitis 130
10.1.5 Postoperative Infections 131
10.1.5.1 Pathophysiology 131
10.1.5.2 Clinical Diagnosis and LaboratoryWorkup 132
10.1.5.3 Imaging Studies 132
10.1.5.4 Management and Prevention 132
References 133
11:Management of Spine Tumorsin Young Children 136
11.1 Evaluation 136
11.1.1 Clinical Presentation 136
11.1.2 Imaging Studies 137
11.1.3 Staging 137
11.1.3.1 Oncological Staging 137
Benign Tumors 137
Malignant Tumors 137
11.1.3.2 Surgical Staging 137
11.1.4 Biopsy 138
11.2 Surgical Treatment of SpinalTumors 138
11.3 Specifi c Spinal Column Tumors 140
11.3.1 Benign Tumors 140
11.3.1.1 Eosinophilic Granuloma (LangerhansCell Histiocytosis) 140
11.3.1.2 Osteoid Osteoma and Osteoblastoma 142
11.3.1.3 Aneurysmal Bone Cyst 142
11.3.1.4 Hemangioma 144
11.3.1.5 Osteochondroma 144
11.3.1.6 Other Benign Tumors 145
11.3.2 Malignant Tumors 145
11.3.2.1 Osteosarcoma 145
11.3.2.2 Ewing’s Sarcoma 146
11.3.2.3 Leukemia 146
11.3.2.4 Other Malignant and MetastaticLesions 146
11.4 Summary 146
References 148
12:Pediatric Spine Trauma 151
12.1 Introduction 151
12.2 Cervical Spine Trauma 152
12.2.1 Epidemiology 152
12.3 Cervical Spine Anatomy 152
12.3.1 Clinical Evaluation 153
12.3.2 Radiologic Evaluation 154
12.4 Specifi c Injury Patterns 154
12.4.1 Atlanto-Occipital Dislocations 154
12.4.2 Fractures of the Atlas 157
12.4.3 Odontoid Fractures 157
12.4.4 Hangman’s Fracture 158
12.4.5 Atlanto-axial Subluxation 159
12.4.6 Spinal Cord Injury WithoutRadiographic Abnormalities 159
12.5 Cervical Spine Injuries Outcomes 160
12.6 Thoracolumbar Fractures 161
12.6.1 Epidemiology 161
12.6.2 Anatomy 161
12.6.3 Mechanisms of Injury 161
12.6.4 Clinical Evaluation 162
12.6.5 Radiographic Evaluation 162
12.6.5.1 Management 163
12.6.6 Outcome Studies for Thoracicand Lumbar Spine Traumain Pediatric Patients 163
12.7 Conclusion 164
References 164
13:The Growing Spine and Sports 167
13. 1 Introduction 167
13.1.1 Cervical Spine Injuries 167
13.1.2 Back Pain in the Pediatric Athlete 168
13.1.2.1 Introduction 168
13.1.2.2 Evaluation 168
13.1.3 Stress Fractures 169
13.1.4 Spodylolysis/Spondylolisthesis 170
13.1.4.1 Pathophysiolgy 171
13.1.4.2 Clinical Presentation 171
13.1.4.3 Imaging 172
13.1.4.4 Management 173
13.1.5 Pedicle Fractures 173
13.1.6 Other Causes of Back Painin the Adolescent Athlete 174
13.1.6.1 Disc Herniation 174
13.1.6.2 Lumbar Scheuermann’s Disease 174
13.1.6.3 Muscle Strain 174
13.1.6.4 Vertebral ApophysealAvulsion Fractures 175
13.1.7 Return to SportsAfter Spine Surgery 175
13.1.7.1 Special Olympics and the DisabledAthlete 176
References 177
14:Spinal Deformity in Metabolic Diseases 179
14.1 General Concepts 179
14.1.1 Soft Bone and Spinal Deformity 179
14.1.2 Scoliosis 179
14.1.3 Kyphosis 179
14.1.4 Spondylolysisand Spondylolisthesis 180
14.1.5 Basilar Invagination 180
14.1.6 Poor Bone Purchase 180
14.2 Rickets and Rickets-LikeSyndromes 180
14.2.1 Rickets 180
14.3 Hypophosphatasia 181
14.4 Lowe’s Syndrome 181
14.5 Osteogenesis Imperfecta 182
14.6 Storage Diseases 189
14.7 Juvenile Osteoporosis 189
14.8 Anorexia Nervosa 189
References 190
15:Spinal Manifestationsof the Skeletal Dysplasias 193
15.1 Introduction 193
15.2 Spinal Pathology Associatedwith Skeletal Dysplasias 193
15.2.1 Atlantoaxial Instabilityand Odontoid Hypoplasia 193
15.2.2 Cervical Kyphosis 194
15.2.3 Thoracic and ThoracolumbarKyphosis 194
15.2.4 Scoliosis 194
15.2.5 Foramen Magnum Stenosis 195
15.2.6 Spinal Stenosis 195
15.3 Classifi cation of Dysplasias 195
15.3.1 Achondroplasia 195
15.3.2 Diastrophic Dysplasia 198
15.3.3 Pseudoachondroplasia 198
15.3.4 Dysplasias Secondaryto Mutations in CollagenSynthesis 199
15.3.5 Mucopolysaccharidoses 200
15.3.6 Other Skeletal Dysplasias 200
15.4 Conclusions 201
References 201
16:Syndromic Spinal Deformitiesin the Growing Child 203
16.1 Introduction 203
16.2 General Principles of SyndromicDeformity Management 203
16.2.1 Role of NonoperativeManagement 203
16.2.2 Comprehensive Imaging 204
16.2.3 Medical Considerations 204
16.2.4 Operative and PostoperativeManagement 204
16.3 Specifi c Syndromes 205
16.3.1 Marfan Syndrome 205
16.3.2 Loeys–Dietz Syndrome 207
16.3.3 Shprintzen–Goldberg Syndrome 207
16.3.4 Ehlers–Danlos Syndrome 209
16.3.5 Prader–Willi Syndrome 209
16.3.6 Rett Syndrome 209
16.3.7 Down Syndrome 211
16.4 Conclusions 211
References 211
Section III:Spinal Deformities in the Growing Child 213
17:Idiopathic Scoliosis: Infantile and Juvenile 214
17.1 Introduction 214
17.2 Natural History 215
17.2.1 Growth and Development 215
17.2.2 Epidemiology 215
17.2.3 Prognosis 215
17.2.4 Etiology 216
17.3 Clinical Evaluation 217
17.3.1 History 217
17.3.2 Physical Examination 217
17.4 Diagnostic Testing 218
17.4.1 Radiologic Evaluation 218
17.4.2 The Role of Advanced Imagingand Neural Axis Abnormalities 219
17.5 Management Themes (Fig. 17.2) 219
17.5.1 Selecting Surgical Candidates 219
17.5.2 Surgical Treatment: HistoricPerspective 221
17.5.3 Current Approaches to SurgicalManagement 222
17.5.4 Distraction-Based Growing Rods 223
17.5.5 Growth Directed Surgery 224
17.6 On the Horizon and Conclusion 225
References 225
18:Congenital Scoliosis 228
18.1 Introduction 228
18.2 Etiology 228
18.3 Classifi cation 229
18.4 Natural History 230
18.5 Patient Evaluation 230
18.6 Imaging 231
18.7 Associated Anomalies 231
18.8 Treatment Alternatives 232
18.8.1 Observation 232
18.8.2 Bracing 233
18.8.3 Growth Inhibition 233
18.8.4 Growth Modulation 233
18.8.5 Growth Preservation/Stimulation 233
18.8.6 Reconstruction 233
References 241
19:Treatment of Spinal Deformityin Cerebral Palsy 243
19.1 Introduction 243
19.2 Clinical Presentationand Evaluation 244
19.3 Nonoperative Care 246
19.4 Operative Care 246
19.5 Preoperativeand Perioperative Concerns 248
19.6 Surgical Technique 249
19.7 Postoperative Care 252
19.8 Complications 252
19.9 Outcomes 252
References 252
20:Myelodysplasia 254
20.1 Myelodysplasia 254
20.2 Classifi cation 255
20.3 Incidence, Etiology 256
20.4 Prenatal Diagnosis 257
20.5 In Utero Surgery 258
20.6 Associated Abnormalities:Factors Responsible forProgressive Spinal Deformities 258
20.6.1 Arnold–Chiari Malformation 258
20.6.2 Hydrocephalus 258
20.6.3 Tethered Spinal Cord 259
20.7 Other Associated Abnormalities 259
20.7.1 Latex Allergy 259
20.7.2 Short Stature andPrecocious Puberty 260
20.8 Spinal Deformity 260
20.8.1 Scoliosis 261
20.8.1.1 Orthotic Treatment 261
20.8.1.2 Surgical Indications,Complications, and Planning 261
20.8.1.3 Preoperative Evaluation 263
20.8.1.4 Surgery 264
Combined Anterior Posterior Instrumentationand Fusion 264
Anterior Only and Posterior OnlyInstrumentation and Fusion 266
20.8.1.5 Posterior Instrumentation Techniques 272
20.8.1.6 Growth Preserving Instrumentation 274
20.8.2 Congenital Kyphosis 276
References 276
21:Spinal Dysraphism 281
21.1 Open Spinal Dysraphism(Myelomeningocele) (also seeChapter 20) 282
21.1.1 Pathogenesis 282
21.1.2 Etiology and Epidemiology 283
21.1.3 Presentation 283
21.1.4 Surgical Treatment 284
21.2 Closed (Occult) Spinal Dysraphism 285
21.2.1 Pathogenesis 286
21.2.2 Diastematomyelia (SCMs) 286
21.2.3 Spinal Lipoma(Lipomyelomeningocele) 286
21.2.3.1 Thick/Fatty Filum 287
21.2.3.2 Spinal Dermal Sinus 288
21.2.4 Epidemiology 288
21.2.5 Presentation 288
21.2.6 Treatment 289
References 290
22:Other Neuromuscular Diseases 292
22.1 Duchenne’s Muscular Dystrophy 292
22.1.1 Spinal Deformity 292
22.1.2 Medical Considerations 293
22.1.3 Nonsurgical Managementof Scoliosis 293
22.1.4 Surgical Managementof Scoliosis 294
22.1.5 Long-term Outcomes 297
22.1.6 Conclusion 297
22.2 Spinal Muscular Atrophy 297
22.2.1 Classifi cation 297
22.2.1.1 Type I, Acute Werdnig–HoffmanDisease 297
22.2.1.2 Type II, Chronic Werdnig–HoffmanDisease 297
22.2.1.3 Type III, Kugelberg–Welander Disease 298
22.2.1.4 Functional Classifi cation 298
22.2.2 Diagnosis 298
22.2.3 Spinal Deformity 298
22.2.4 Nonsurgical Managementof Scoliosis 299
22.2.5 Surgical Managementof Scoliosis 299
22.2.6 Long-Term Outcomes 301
22.2.7 Conclusions 301
22.3 Arthrogryposis 301
22.3.1 Spinal Deformity 302
22.4 Poliomyelitis Scoliosis 302
22.4.1 Spinal Deformity 302
22.5 Rett Syndrome 303
22.5.1 Spinal Deformity 303
22.6 Friedreich’s Ataxia 304
22.6.1 Spinal Deformity 304
22.7 Congenital Myopathies 305
22.7.1 Spinal Deformity 305
References 305
23:Neurofi bromatosis 310
23.1 Introduction 310
23.2 Epidemiology and Genetics 310
23.3 Clinical Features 311
23.4 Spinal Abnormalities 311
23.4.1 Spinal Deformities 311
23.4.2 Dural Ectasia 312
23.5 Cervical Spine Abnormalities 313
23.6 Thoracic/Thoracolumbar SpinalAbnormalities 314
23.6.1 Non-Dystrophic Scoliosis 314
23.6.2 Dystrophic Scoliosis 314
23.7 Natural History 314
23.8 Treatment 318
23.8.1 Trapdoor Procedure 324
23.9 Growing Rod Instrumentation 324
23.10 Other Spinal Deformities 324
23.10.1 Kyphosis 324
23.10.2 Spondylolisthesis 325
23.11 Conclusion 325
References 325
24:Sagittal Plane Deformitiesin Growing Children 327
24.1 Introduction 327
24.2 Scheuermann’s Kyphosis 328
24.2.1 Etiology 328
24.2.2 Symptoms 328
24.2.4 Operation 328
24.3 Congenital Kyphosis 328
24.4 Myelodysplasia 329
24.4.1 Treatment 330
24.4.1.1 Nonsurgical 330
24.4.1.2 Operation 330
24.5 Post-Infectious Kyphosis 330
24.5.1 Treatment 331
24.5.1.1 Conservative 331
24.5.1.2 Operation 331
24.6 Post-Traumatic Kyphosis 332
24.7 Osteoporosis and HereditaryDisorders 332
24.7.1 Treatment 332
24.8 Iatrogenous Kyphosis 332
24.8.1 Surgery 333
24.9 Hyperlordosis 333
24.9.1 Treatment 333
24.9.2 Operation 333
References 334
25:Spondylolisthesis 335
25.1 Introduction 335
25.1.1 Defi nitions 336
25.1.2 Etiology 336
25.1.3 Classifi cation 336
25.1.4 Epidemiology 337
25.1.5 Natural History and Riskof Progression 338
25.2 Clinical Presentation 338
25.2.1 Symptoms 338
25.2.2 Physical Examination 338
25.3 Imaging 340
25.3.1 Plain Radiographs 340
25.3.2 Functional Radiographs 340
25.3.3 Computed Tomography (CT) 341
25.3.4 Magnetic ResonanceImaging (MRI) 342
25.3.5 Single-Photon Emission ComputedTomography (SPECT) 342
25.4 Treatment 342
25.4.1 Observation 343
25.4.2 Nonoperative Treatment 343
25.4.3 Operative Treatment 343
25.4.3.1 Spondylolysis and Low-GradeSlip (£50%) 344
25.4.3.2 High-Grade Slip (> 50%)
25.4.3.3 Spondyloptosis 356
25.4.4 Spondylolisthesis in VeryYoung Children 358
25.4.5 Exotic Spondylolisthesis 361
References 363
Section IV:Management of Spinal Deformity in theGrowing Child: Non-Surgical 368
26:Casting for Early Onset Scoliosis 369
26.1 Infl uence of Age and Etiology 370
26.2 Technique of Casting 370
References 372
27:Orthotic Management for Infantileand Juvenile Scoliosis 373
27.1 Introduction 373
27.2 Evidence for Effi cacy of Bracingin Early Onset Idiopathic Scoliosis 379
27.3 Decision-Making in OrthoticTreatment of Early OnsetIdiopathic Scoliosis 380
27.4 Bracing Techniques 384
27.5 Current and Future Developments 385
References 387
28:Halo-Gravity Traction 390
28.1 Introduction 390
28.2 Indications 390
28.3 Technique 392
28.4 Complications 395
28.5 Current Results 397
References 398
29:Crankshaft Phenomena Following SpinalFusion in the Growing Child 399
29.1 Introduction 399
29.2 The Problems of CorrectiveFusion with Instrumentationin Idiopathic Scoliosis 399
29.2.1 Halting of Further LongitudinalSpinal Growth 399
29.2.2 Loss of Correction 400
29.2.3 Prediction and Preventionof Crankshaft Phenomenon 400
29.3 Spinal Fusion with or WithoutInstrumentation in CongenitalScoliosis 401
29.4 Crankshaft Phenomenonin Congenital Scoliosis 402
References 402
30:Convex Growth Arrestfor Congenital Scoliosis 404
30.1 Background 404
30.2 Classical Indicationsand Contraindications 405
30.3 Techniques 405
30.4 Results 405
30.5 Problems 406
30.6 Proposed Solutionsand Modifi cations 406
30.7 Conclusion 408
References 409
31:Kyphectomy in Myelomeningocele 410
31.1 Background 410
31.2 Medical/Neurosurgical Issues 410
31.3 Perioperative Management 411
31.4 Surgical Strategies: General 411
31.5 Surgical Technique Specific 412
31.5.1 Vertebral Resection KyphectomyTechnique 412
31.5.2 Subtraction (Decancellation)Kyphectomy Technique 413
31.5.3 Results 413
31.6 Summary 414
References 415
32:Hemivertebrectomy 416
32.1 Background 416
32.2 Hemivertebra Resection Concept 417
32.2.1 Biological Concept 417
32.2.1.1 First Part is the Resectionof the Posterior Aspects of the HV 417
32.2.1.2 Second Part is the Resectionof the Anterior Aspects of the HV 417
32.2.2 Stability Concept 419
32.2.2.1 Primary Stability 419
32.2.2.2 Secondary Stability 419
32.3 Our Personal Technique 420
32.3.1 Preoperative Evaluation 420
32.3.2 Technique 420
32.3.3 Results 420
32.4 Discussion 420
References 429
33:Vertebral Osteotomy 431
33.1 Introduction 431
33.2 Single Osteotomy 431
33.3 Multiple Osteotomies 433
33.4 Use of Spinal Instrumentation 433
33.5 Rib Osteotomies 434
33.5.1 Rib Osteotomies at the Concavity 434
33.5.2 Osteotomies of the Ribsat the Convexity 434
References 434
34:Vertebral Resection 435
34.1 Introduction 435
34.2 Evaluation 436
34.3 Management 437
34.4 Surgical Procedure 438
34.4.1 Surgical Technique 439
34.4.2 Postoperative Management 440
34.4.3 Documentation 440
34.5 Discussion 441
34.6 Summary 443
References 443
35:Single Growing Rods 445
35.1 Introduction 445
35.2 Surgical Techniquefor Single Growing RODS 445
35.2.1 Intraoperative 445
35.2.2 Postoperative Management 447
35.2.3 Defi nitive Fusion 447
35.3 Current Results 448
35.4 Controversies 449
35.5 Conclusions 450
References 450
36:Dual Growing Rods 452
36.1 Introduction 452
36.2 Background 452
36.3 Indications 454
36.4 Technique 456
36.4.1 Initial Dual Rod Procedure 456
36.4.2 Technique of PreparingFoundations 456
36.4.3 Insertion of Dual Rodsand Anchors 459
36.5 Lengthenings 459
36.5.1 Lengthening Outsidethe Tandem Connector 459
36.6 Final Fusion 460
36.6.1 Spinal Cord Monitoring 461
36.7 Complications (Fig. 36.7a–g) 462
36.7.1 How to Avoid Complications 466
36.8 Results 466
36.9 Discussion 469
36.10 Growing Spine Study Group 469
36.11 Future Direction 470
References 470
37:VEPTR Expansion Thoracoplasty 472
37.1 Introduction 472
37.1.1 Thoracic Insuffi ciency Syndrome:Anatomic Basis 472
37.1.2 Volume Depletion Deformitiesof the Thorax 473
37.1.3 FDA Indications for VEPTRExpansion Thoracoplasty 473
37.2 VEPTR Preoperative Assessment 475
37.2.1 Clinical Examination 475
37.2.2 Imaging Studies 475
37.2.3 Specifi c Cardiopulmonary Studies 476
37.3 VEPTR Expansion ThoracoplastyTreatment Strategies 477
37.4 Surgical Technique 477
37.4.1 The General VEPTR ImplantationSurgical Approach 477
37.5 VEPTR Expansion Procedures 479
37.6 VEPTR Replacement Procedures 480
37.7 Specifi c VEPTR Surgical Strategies 480
37.7.1 Type I Volume DepletionDeformity: Rib Absenceand Scoliosis 480
37.7.2 Type II Volume DepletionDeformity: Fused Ribsand Scoliosis 482
37.7.3 Type II Volume DepletionDeformity: Myelomeningocele 483
37.7.4 Type IIIb/ II Volume DepletionDeformity: Early Onset Scoliosis 484
37.7.5 Type IIIa Volume DepletionDeformity: Jarcho-Levin Syndrome 485
37.8 Minimizing Complications 486
37.8.1 Overall Complication Rates 486
37.8.2 VEPTR Device Complications 486
37.8.3 Prevention of Complications 487
37.8.4 Treatment of Complications 488
References 488
38:Revision Spine Surgeryin the Growing Child 490
38.1 Overview 490
38.2 Clinical Presentation, Evaluationand Diagnosis 491
38.3 Goals for Treatmentand Surgical Considerations 494
38.3.1 Smith-Petersen Osteotomy 494
38.3.2 Pedicle Substraction Osteotomy 494
38.3.3 Vertebral Column Resection 495
38.4 Author’s Experience 495
38.5 Summary 499
References 499
39:Anesthesia and PostoperativeManagement of Spinal DeformitySurgery in Growing Children 501
39.1 Introduction 501
39.2 Spinal Cord Blood Flowand Regulation 501
39.3 Anesthesia Management 502
39.3.1 Preoperative Evaluation 502
39.3.2 Cardiopulmonary Involvement 503
39.3.3 Conduct of Anesthesia 504
39.3.4 One-Lung Ventilation (OLV) 506
39.4 Neurological Risk and Spinal CordMonitoring 507
39.4.1 Intraoperative Managementof Neurological Insult 508
39.5 Anesthesia Techniquesin Blood Conservation 508
39.5.1 Positioning and Ventilation 509
39.5.2 Preoperative AutologousBlood Donation and AcuteNormovolemic Hemodilution 509
39.5.3 Controlled Hypotension 510
39.5.4 Hemostatic Drugs 511
39.5.5 Antifi brinolytics 511
39.6 Postoperative Care 511
39.6.1 Central Nervous System 511
39.7 Summary 513
References 513
40:Intraoperative NeurophysiologicalMonitoring During Corrective SpineSurgery in the Growing Child 516
40.1 Introduction 516
40.2 What Neural Structuresand Pathways Are at Risk? 516
40.3 Neuromonitoring Modalities 518
40.3.1 Transcranial Electric MotorEvoked Potentials 518
40.3.2 The Hoffman Refl ex 519
40.3.3 Neurogenic-Evoked PotentialsAre Sensory Not Motor 521
40.3.4 Monitoring Spinal Nerve Roots 521
40.3.5 Monitoring the Brachial Plexus 521
40.3.6 Anesthesia Considerations 523
40.3.7 Hemodynamic Considerations 524
40.4 Conclusions 524
References 524
41:Nursing Care 526
41.1 Overview 526
41.2 Family Education 526
41.3 Nonoperative Care 527
41.3.1 Bracing 527
41.3.2 Casting 528
41.4 Operative Care 529
41.5 Complications 529
41.6 Preoperative Teaching 529
41.6.1 Growing Rods 529
41.6.2 VEPTR 531
41.7 Preoperative Planning(All Techniques) 531
41.7.1 Preoperative Testing: InitialSurgery 531
41.7.2 Preoperative Testing: LengtheningProcedures 532
41.8 Perioperative Care 532
41.8.1 Growing Rods: Initialand Complex Revision Surgery 532
41.8.2 VEPTR: Initial and ComplexRevision Surgery 532
41.8.3 Growing Rods: LengtheningProcedures 532
41.8.4 VEPTR: Lengthening Procedures 533
41.9 Postoperative Care 533
41.9.1 Growing Rods: Initial Surgery 533
41.9.2 VEPTR: Initial Surgery 533
41.9.3 Growing Rods: PostLengthening Care 534
41.9.4 VEPTR: Post Lengthening Care 534
41.9.5 Growing Rods: PostFinal Fusion Care 534
41.10 Future Treatment: Evolutionfrom Knowledge 534
References 535
42:Long-Term Effects of InstrumentedFusion in Growing Children 536
42.1 Introduction 536
42.2 Patient Characteristics 536
42.2.1 Infantile Idiopathic Scoliosis 537
42.2.2 Juvenile Idiopathic Scoliosis 537
42.2.3 Congenital Spinal Deformities 539
42.2.4 Genetic Syndromes 540
42.2.5 Neuromuscular Disorders 540
42.2.6 Salvage Procedures 540
42.3 Conclusion 546
References 546
43:Outcomes in Children with EarlyOnset Scoliosis 547
43.1 Introduction 547
43.2 Framework for Measurement 549
43.3 Available Endpointsand Measures of Outcome 549
43.3.1 Radiographic Measures 549
43.3.2 Natural History of EarlyOnset Scoliosis 550
43.4 Lung Function 550
43.4.1 What Do We Know Aboutthe Outcomes of Treatment? 551
43.4.1.1 Negative Effects of Early Fusion 551
43.4.1.2 Outcomes in Patients Treatedwith “Growing Rods” 551
43.4.1.3 VEPTR and Expansion Thoracoplastyin Children with Fused Ribs 551
43.4.1.4 Growth Modulation: VertebralStapling and the Shilla Technique 551
43.4.2 Opportunities for Future Progress 552
43.5 Conclusion 552
References 552
44:Current Research in Growth Modulationand Future Outlook 554
44.1 Introduction 554
44.2 Biologic Growth Modulation 554
44.2.1 Hemiepiphyseodesis 554
44.2.2 Rib Shortening/Lengthening 554
44.2.3 Vertebral NeurocentralSynchondrosis Asymmetry 555
44.3 Asymmetric Vertebral Growth 555
44.4 Spinal Growth ModulationTechniques 556
44.4.1 Anterior Vertebral Staples 556
44.4.2 Anterolateral Spinal Tethering 558
44.5 Posterior Spinal GrowthModulation Techniques 559
44.5.1 Posterior Spinal Tether 559
44.5.2 Shape-Memory MetalInstrumentation 559
44.5.3 Expandable SpinalInstrumentation 559
44.6 Vertical Expandable ProstheticTitanium Rib 562
44.7 Conclusions 564
References 565
45:Non-Fusion Anterior Stapling 567
45.1 Introduction 567
45.2 Historical Overview 568
45.3 Basic Science Overview 568
45.4 Clinical Outcomes 569
45.5 Clinical and Technical Overview 569
45.5.1 Indications and Contraindications 569
45.5.2 Technical Overview 570
45.5.3 Postoperative Care 573
45.5.4 Complications 573
45.6 Summary 573
References 574
46:Spinal External Fixation 576
46.1 Introduction 576
46.2 Indications 576
46.3 Operative Technique (ExternalFixator Application) 576
46.4 Lengthening Procedure 577
46.5 Postoperative Care 577
46.6 Operative Technique (Removalof the External Fixatorand Posterior Fusionwith Instrumentation) 578
46.7 Complications 578
46.8 Conclusions 578
References 581
47:Magnetic Powered Extensible Rodfor Thorax or Spine 582
47.1 Introduction 582
47.2 Technical Specifi cations 582
47.2.1 Technique of Lengthening 582
47.2.2 Characteristics of the Rod 583
47.3 Surgical Instructions 583
47.3.1 Rib Fixation 583
47.3.2 Spinal Fixation 583
47.4 Lengthening Mode 584
47.5 Preliminary Results 584
47.6 Clinical Cases 584
47.6.1 Case 1 584
47.6.2 Case 2 584
47.7 Discussion 588
References 588
48:Growth Guided Instrumentation: ShillaProcedure 589
48.1 Introduction 589
48.2 Historical Perspective 589
48.3 Experimental Background 590
48.4 Method 590
48.4.1 The Implant Design 590
48.4.2 Surgical Technique 591
48.4.2.1 Preoperative Planning 591
48.5 Clinical Experience 594
48.6 Summary 594
49:Hybrid Distraction-Based Growing Rods 597
49.1 Introduction 597
49.2 Indications 599
49.3 Contraindications 600
49.4 Thorocotomy GenerallyUnnecessary 600
49.5 Surgical Technique 600
49.5.1 Unilateral or Bilateral Rods 603
49.6 Complications 603
49.7 The Special Case of CervicothoracicCongenital Scoliosis 605
References 607
50:Basic Science and FutureClinical Perspective 608
References 609
Index 611