H. Gökhan DEMİRKIRAN, İbrahim AKEL, Güney YILMAZ, MEHMET AYVAZ, Ahmet ALANAY, Muharrem YAZICI

Long-segment posterior instrumentation and fusion with freeze-dried allograft in congenital scoliosis

Amaç: Çalışmanın amacı konjenital skolyozlu hastalarda uzun segment posterior enstrümantasyon ve allogreft uygulamasının füzyon elde etmede etkinliğinin değerlendirilmesi idi. Çalışma planı: Konjenital skolyoz nedeniyle uzun segment posterior enstrümantasyon (>6 seviye) ve donmuş-kurutulmuş allogreft uygulanmış, en az 24 ay takip süresi olan 21 hasta incelendi. Altı hasta anterior girişimler nedeniyle çalışmadan çıkarıldı. Konjenital skolyozlu, posterior enstrümantasyon ve allogreft uygulanan 15 hasta (13 kız, 2 erkek; ortalama yaş: 12.2±3, dağılım: 7-17 yıl) retrospektif olarak değerlendirildi. Ortalama takip süresi 30.9±9.4 (dağılım: 24-48) ay idi. Posterior füzyon işlemi sırasında altı hastaya intraspinal anomalilerinin düzeltimi ya da daha önce geçirdiği posterior cerrahiler nedeniyle laminektomi uygulandı. Hastaların omurga grafileri ameliyat öncesi, sonrası ve son takipte değerlendirildi. Füzyonu değerlendirmek için Bridwell ve ark.’nın sınıflandırması kullanıldı. Bulgular: İki hasta ‘füzyon yok’, 4 hasta ‘olası füzyon’, 9 hasta ‘kesin füzyon’ olarak değerlendirildi. Ana eğrilik ortalama 68±18.6 dereceden 39.3±12.2’ye düzeltildi (p

Konjenital skolyozlu hastalarda uzun segment posterior enstrümantasyon ve donmuş-kurutulmuş allogreft uygulaması

Objective: The aim of this study was to evaluate the effectiveness of long-segment posterior instrumentation and allograft application in obtaining fusion in congenital scoliosis. Methods: Twenty-one patients with congenital scoliosis who were treated with long-segment posterior instrumentation (>6 levels) and freeze-dried allograft and followed up for more than 24 months were reviewed. Six patients were excluded from the study due to anterior procedures. Fifteen patients with congenital scoliosis (13 females, 2 males; mean age: 12.2±3 years, range: 7-17 years) were retrospectively reviewed. Mean follow-up time was 30.9±9.4 (range: 24 to 48) months. Six patients had laminectomy either due to previous posterior surgeries or to address intraspinal pathologies during the posterior fusion procedure. Preoperative, postoperative and final follow-up anteroposterior and lateral spine X-rays were reviewed. Fusion was graded according to the classification reported by Bridwell et al. Results: Two patients were graded as ‘no fusion’ (pseudarthrosis), four patients as ‘probably fused’, and nine patients as ‘definitely fused’. The major curve was corrected from an average of 68±18.6 to 39.3±12.2 degrees (p<0.001). Mean correction lost in the major curve was an average of 4.5±5.2 degrees in the latest follow-up. There was significant correction in the compensatory curve (preoperative 37.9±13.2 degrees, postoperative 20.2±6.6 degrees; p=0.001). Preoperative and postoperative global thoracic kyphosis were 39.5±13.3 and 32.3±7.9 degrees, respectively (p=0.018). Preoperative and postoperative global lumbar lordosis was 36.3±7.4 and 36.1±8.9 degrees, respectively (p=0.883). Successful fusion was detected in %86.7 of patients in the final follow-up. Conclusion: The usage of allograft alone to achieve fusion increases the rates of pseudarthrosis while additional anterior procedure decreases the pseudarthrosis rate in patients with congenital scoliosis that require long-segment posterior instrumentation. Further studies should be performed to assess the efficacy of the usage of polysegment pedicle screw instrumentation

___

1. McMaster MJ, K Ohtsuka. The natural history of congenital scoliosis. A study of two hundred and fifty-one patients. J Bone Joint Surg Am 1982;64:1128-47.
2. Kerry RM, Masri BA, Garbuz DS, Czitrom A, Duncan CP. The biology of bone grafting. Instr Course Lect 1999;48:645- 52.
3. Laurie SW, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone. Plast Reconstr Surg 1984;73:933-8.
4. Kurz LT, Garfin SR, Booth RE Jr. Harvesting autogenous iliac bone grafts. A review of complications and techniques. Spine 1989;14:1324-31.
5. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989;3:192-5.
6. Jones KC, Andrish J, Kuivila T, Gurd A. Radiographic out- comes using freeze-dried cancellous allograft bone for poste- rior spinal fusion in pediatric idiopathic scoliosis. J Pediatr Orthop 2002;22:285-9.
7. Price CT, Connolly JF, Carantzas AC, Ilyas I. Comparison of bone grafts for posterior spinal fusion in adolescent idiopath- ic scoliosis. Spine 2003;28:793-8.
8. Aurori BF, Weierman RJ, Lowell HA, Nadel CI, Parsons JR. Pseudarthrosis after spinal fusion for scoliosis. A comparison of autogeneic and allogeneic bone grafts. Clin Orthop Relat Res 1985;(199):153-8.
9. Fabry G. Allograft versus autograft bone in idiopathic scolio- sis surgery: a multivariate statistical analysis. J Pediatr Orthop 1991;11:465-8.
10. Dodd CA, Fergusson CM, Freedman L, Houghton GR, Thomas D. Allograft versus autograft bone in scoliosis sur- gery. J Bone Joint Surg Br 1988;70:431-4.
11. Grogan DP, Kalen V, Ross TI, Guidera KJ, Pugh LI. Use of allograft bone for posterior spinal fusion in idiopathic scolio- sis. Clin Orthop Relat Res 1999;(369):273-8.
12. Knapp DR Jr, Jones ET, Blanco JS, Flynn JC, Price CT. Allograft bone in spinal fusion for adolescent idiopathic scol- iosis. J Spinal Disord Tech 2005;18 Suppl:S73-6.
13. McCarthy RE, Peek RD, Morrissy RT, Hough AJ Jr. Allograft bone in spinal fusion for paralytic scoliosis. J Bone Joint Surg Am 1986;68:370-5.
14. Yazici M, Asher MA. Freeze-dried allograft for posterior spinal fusion in patients with neuromuscular spinal deformi- ties. Spine 1997;22:1467-71.
15. Bridwell KH, O'Brien MF, Lenke LG, Baldus C, Blanke K. Posterior spinal fusion supplemented with only allograft bone in paralytic scoliosis. Does it work? Spine 1994;19:2658-66.
16. Vauzelle C, Stagnara P, Jouvinroux P. Functional monitoring of spinal cord activity during spinal surgery. Clin Orthop Relat Res 1973;(93):173-8.
17. Pang D. Split cord malformation: Part 2: Clinical syndrome. Neurosurgery 1992;31:481-500.
18. Hedequist DJ, Hall JE, Emans JB, The safety and efficacy of spinal instrumentation in children with congenital spine deformities. Spine 2004;29:2081-7.
19. McMaster MJ, Singh H. The surgical management of con- genital kyphosis and kyphoscoliosis. Spine 2001;26:2146-55.
20. Winter RB, Moe JH. The results of spinal arthrodesis for con- genital spinal deformity in patients younger than five years old. J Bone Joint Surg Am 1982;64:419-32.
21. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and func- tional assessment. Clin Orthop Relat Res 1997;(339):76-81.
22. Skaggs DL, Samuelson MA, Hale JM, Kay RM, Tolo VT. Complications of posterior iliac crest bone grafting in spine surgery in children. Spine 2000;25:2400-2.
23. Youdas JW, Wood MB, Cahalan TD, Chao EY. A quantita- tive analysis of donor site morbidity after vascularized fibula transfer. J Orthop Res 1988;6:621-9.
24. Kessler P, Thorwarth M, Bloch-Birkholz A, Nkenke E, Neukam FW. Harvesting of bone from the iliac crest – com- parison of the anterior and posterior sites. Br J Oral Maxillofac Surg 2005;43:51-6.
25. Blanco JS, Sears CJ. Allograft bone use during instrumenta- tion and fusion in the treatment of adolescent idiopathic scol- iosis. Spine 1997;22:1338-42.
26. Winter RB, Moe JH, Lonstein JE. Posterior spinal arthrode- sis for congenital scoliosis. An analysis of the cases of two hun- dred and ninety patients, five to nineteen years old. J Bone Joint Surg Am 1984;66:1188-97.
27. Hedequist D, Yeon H, Emans J. The use of allograft as a bone graft substitute in patients with congenital spine deformities. J Pediatr Orthop 2007;27:686-9.