A biomechanical analysis of growing rods used in the management of early onset scoliosis

INTRODUCTION Managing spinal deformities in young children is challenging, particularly early onset scoliosis (EOS). Surgical intervention is often required if EOS has been unresponsive to conservative treatment particularly with rapidly progressive curves. An emerging treatment option for EOS is fusionless scoliosis surgery. Similar to bracing, this surgical option potentially harnesses growth, motion and function of the spine along with correcting spinal deformity. Dual growing rods are one such fusionless treatment, which aims to modulate growth of the vertebrae. The aim of this study was to ascertain the extent to which semiconstrained growing rods (Medtronic, Sofamor, Danek, Memphis, TN) with a telescopic sleeve component, reduce rotational constraint on the spine compared with standard "constrained / rigid" rods and hence potentially provide a more physiological mechanical environment for the growing spine. METHODS Six 40-60kg English Large White porcine spines served as a model for the paediatric human spine. Each spine was dissected into a 7 level thoracolumbar multi-segment unit (MSU), removing all non-ligamentous soft tissues and leaving 3cm of ribs either side. Pure nondestructive axial rotation moments of ±4Nm at a constant rotation rate of 8deg.s-1 were applied to the mounted MSU spines using a biaxial Instron testing machine. Displacement of each vertebral level was captured using a 3D motion tracking system (Optotrak 3020, Northern Digital Inc, Waterloo, ON). Each spine was tested in an un-instrumented state first and then with appropriately sized semi-constrained growing rods and rigid rods in alternating sequence. The rods were secured by multi-axial pedicle screws (Medtronic CD Horizon) at levels 2 and 6 of the construct. The range of motion (ROM), neutral zone (NZ) size and stiffness (Nm.deg-1) were calculated from the Instron load-displacement data and intervertebral ROM was calculated through a MATLAB algorithm from Optotrak data. RESULTS Irrespective of the order of testing, rigid rods significantly reduced the total ROM compared with semi-constrained rods (p<0.05) with in a significantly stiffer spine for both left and right axial rotation (p<0.05). Analysing the intervertebral motion within the instrumented levels 2-6, rigid rods showed reduced ROM compared with semi-constrained growing rods and compared with un-instrumented motion segments. CONCLUSION Semi-constrained growing rods maintain similar stiffness in axial rotation to un-instrumented spines, while dual rigid rods significantly reduce axial rotation. Clinically the effect of semi-constrained growing rods as observed in this study is that they would be expected to allow growth via the telescopic rod components while maintaining the axial flexibility of the spine, which may reduce occurrence of the crankshaft phenomenon.

A biomechanical analysis of growing rods used in the management of early onset scoliosis

INTRODUCTION Managing spinal deformities in young children is challenging, particularly early-onset scoliosis (EOS). Any progressive spinal deformity particularly in early life presents significant health risks for the child and a challenge for the treating surgeon. Surgical intervention is often required if EOS has been unresponsive to conservative treatment particularly with rapidly progressive curves. An emerging treatment option particularly for EOS is fusionless scoliosis surgery. Similar to bracing this surgical option potentially harnesses growth, motion and function of the spine along with correcting spinal deformity. Dual growing rods is one such fusionless treatment, which aims to modulate growth of the vertebrae. The aim of this study was to ascertain the extent to which semi-constrained growing rods (Medtronic, Memphis, TN) with a telescopic sleeve component, reduce rotational constraint on the spine compared with standard rigid rods and hence potentially provide a more physiological mechanical environment for the growing spine. METHODS Six 40-60kg English Large White porcine spines served as a model for the paediatric human spine. Each spine was dissected into 7 level thoracolumbar multi-segment unit (MSU) spines, removing all non-ligamentous soft tissues. Appropriately sized semi-constrained growing rods and rigid rods were secured by multi-axial screws (Medtronic) prior to testing in alternating sequences for each spine. Pure nondestructive moments of +/4Nm at a constant rotation rate of 8deg/s was applied to the mounted MSU spines. Displacement of each level was captured using an Optotrak (Northern Digital Inc, Waterloo, ON). The range of motion (ROM), neutral zone (NZ) size and stiffness (Nm/deg) were calculated from the Instron load-displacement data and intervertebral ROM was calculated through a MATLAB algorithm from Optotrak data. RESULTS Irrespective of sequence order rigid rods significantly reduced the total ROM (deg) than compared to semi-constrained rods (p<0.05) and resulted in a significantly stiffer (Nm/deg) spine for both left and right axial rotation testing (p<0.05). Analysing the intervertebral motion within the instrumented levels, rigid rods showed reduced ROM (Deg) than compared to semi-constrained growing rods and the un-instrumented (UN-IN) test sequences. CONCLUSION The semi-constrained growing rods maintained rotation similar to UN-IN spines while the rigid rods showed significantly reduced axial rotation across all instrumented levels. Clinically the effect of semi-constrained growing rods evaluated in this study is that they will allow growth via the telescopic rod components while maintaining the axial rotation ability of the spine, which may also reduce the occurrence of the crankshaft phenomenon.

Radiographic outcomes over time after endoscopic anterior scoliosis correction

A prospective, consecutive series of 106 patients receiving endoscopic anterior scoliosis correction. The aim was to analyse changes in radiographic parameters and rib hump in the two years following surgery. Endoscopic anterior scoliosis correction is a level sparing approach, therefore it is important to assess the amount of decompensation which occurs after surgery. All patients received a single anterior rod and vertebral body screws using a standard compression technique. Cleared disc spaces were packed with either mulched femoral head allograft or rib head/iliac crest autograft. Radiographic parameters (major, instrumented, minor Cobb, T5-T12 kyphosis) and rib hump were measured at 2,6,12 and 24 months after surgery. Paired t-tests and Wilcoxon signed ranks tests were used to assess the statistical significant of changes between adjacent time intervals.----- Results: Mean loss of major curve correction from 2 to 24 months after surgery was 4 degrees. Mean loss of rib hump correction was 1.4 degrees. Mean sagittal kyphosis increased from 27 degrees at 2 months to 30.6 degrees at 24 months. Rod fractures and screw-related complications resulted in several degrees less correction than patients without complications, but overall there was no clinically significant decompensation following complications. The study concluded that there are small changes in deformity measures after endoscopic anterior scoliosis surgery, which are statistically significant but not clinically significant.

A new measure to quantify chest wall deformity in scoliosis patients : does rib hump measurement correlate with anterior chest wall deformity post surgery?

The primary aims of scoliosis surgery are to halt the progression of the deformity, and to reduce its severity (cosmesis). Currently, deformity correction is measured in terms of posterior parameters (Cobb angles and rib hump), even though the cosmetic concern for most patients is anterior chest wall deformity. In this study, we propose a new measure for assessing anterior chest wall deformity and examine the correlation between rib hump and the new measure. 22 sets of CT scans were retrieved from the QUT/Mater Paediatric Spinal Research Database. The Image J software (NIH) was used to manipulate formatted CT scans into 3-dimensional anterior chest wall reconstructions. A ‘chest wall angle’ was then measured in relation to the first sacral vertebral body. The chest wall angle was found to be a reliable tool in the analysis of chest wall deformity. No correlation was found between the new measure and rib hump angle. Since rib hump has been shown to correlate with vertebral rotation on CT, this suggests that there maybe no correlation between anterior and posterior deformity measures. While most surgical procedures will adequately address the coronal imbalance & posterior rib hump elements of scoliosis, they do not reliably alter the anterior chest wall shape. This implies that anterior chest wall deformity is to a large degree an intrinsic deformity, not directly related to vertebral rotation.

The anatomical and biomechanical consequences of anterior vertebral stapling for the fusionless correction of scoliosis

Fusionless scoliosis surgery is an emerging treatment for idiopathic scoliosis as it offers theoretical advantages over current forms of treatment. Anterior vertebral stapling using a nitinol staple is one such treatment. Despite increasing interest in this technique, little is known about the effects on the spine following insertion, or the mechanism of action of the staple. The aims of this study were threefold; (1) to measure changes in the bending stiffness of a single motion segment following staple insertion, (2) to describe the forces that occur within the staple during spinal movement, and (3) to describe the anatomical changes that occur following staple insertion. Results suggest that staple insertion consistently decreased stiffness in all directions of motion. An explanation for the finding may be found in the outcomes of the strain gauge testing and micro-CT scan. The strain gauge testing showed that once inserted, the staple tips applied a baseline compressive force to the surrounding trabecular bone and vertebral end-plate. This finding would be consistent with the current belief that the clinical effect of the staples is via unilateral compression of the physis. Interestingly however, as each specimen progressed through the five cycles of each test, the baseline load on the staple tips gradually decreased, implying that the force at the staple tip-bone interface was decreasing. We believe that this was likely occurring as a result of structural damage to the trabecular bone and vertebral end-plate by the staple effectively causing ‘loosening’ of the staple. This hypothesis is further supported by the findings of the micro-CT scan. The pictures depict significant trabecular bone and physeal injury around the staple blades. These results suggest that the current hypothesis that stapling modulates growth through physeal compression may be incorrect, but rather the effect occurs through mechanical disruption of the vertebral growth plate.

Effect of bone graft type on fusion rates following endoscopic anterior scoliosis correction

Bone graft is generally considered fundamental in achieving solid fusion in scoliosis correction and pseudarthrosis following instrumentation may predispose to implant failure. In endoscopic anterior-instrumented scoliosis surgery, autologous rib or iliac crest graft has been utilised traditionally but both techniques increase operative duration and cause donor site morbidity. Allograft bone and bone- morphogenetic-protein alternatives may improve fusion rates but this remains controversial. This study's objective was to compare two-year postoperative fusion rates in a series of patients who underwent endoscopic anterior instrumentation for thoracic scoliosis utilising various bone graft types. Significantly better rates of fusion occurred in endoscopic anterior instrumented scoliosis correction using femoral allograft compared to autologous rib-heads and iliac crest graft. This may be partly explained by the difficulty obtaining sufficient quantities of autologous graft. Lower fusion rates in the autologous graft group appeared to predispose to rod fracture although the clinical consequence of implant failure is uncertain.

Computed tomography evaluation of axial vertebral derotation in endoscopic anterior instrumentation for adolescent idiopathic scoliosis

Thoracoscopic instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS) has clinical benefits that include reduced pulmonary morbidity, postoperative pain, and improved cosmesis. However, quantitative data on radiological improvement of vertebral rotation using this method is lacking. This study’s objectives were to measure preoperative and postoperative axial vertebral rotational deformity at the curve apex in endoscopically-treated anterior-instrumented scoliosis patients using CT, and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction. This is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares favourably with historically published figures of 24% for patients with posterior all-hook-rod constructs. CT measurements correlated significantly to the clinical outcome of rib hump deformity correction.

The relationship between deformity correction and clinical outcomes after thoracoscopic scoliosis surgery

Surgical treatment of scoliosis is quantitatively assessed in the clinic using radiographic measures of deformity correction, as well as the rib hump, but it is important to understand the extent to which these quantitative measures correlate with self-reported improvements in patients’ quality of life following surgery. The purpose of this prospective study was to evaluate the relationship between clinical outcomes of thoracoscopic anterior scoliosis surgery and deformity correction using the Scoliosis Research Society questionnaire (SRS-24). Patients undergoing thoracoscopic anterior scoliosis correction report good SRS scores which are comparable to those reported in previous studies for both open and thoracoscopic scoliosis correction procedures. Major Cobb correction is a significant predictor of patient satisfaction when comparing subgroups of patients with the highest and lowest major curve corrections.

Computer simulation in spine biomechanics : An application in adolescent idiopathic scoliosis

Scoliosis is a spinal deformity, involving a side-to-side curvature of the spine in the coronal plane as well as a rotation of the spinal column in the transverse plane. The coronal curvature is measured using a Cobb angle. If the deformity is severe, treatment for scoliosis may require surgical intervention whereby a rod is attached to the spinal column to correct the abnormal curvature. In order to provide surgeons with an improved ability to predict the likely outcomes following surgery, techniques to create patient-specific finite element models (FEM) of scoliosis patients treated at the Mater Children’s Hospital (MCH) in Brisbane are being developed and validated. This paper presents a comparison of the simulated and clinical data for a scoliosis patient treated at MCH.

The measurement of applied forces during anterior single rod correction of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is the most common form of spinal deformity in paediatrics, prevalent in approximately 2-4% of the general population. While it is a complex three-dimensional deformity, it is clinically characterised by an abnormal lateral curvature of the spine. The treatment for severe deformity is surgical correction with the use of structural implants. Anterior single rod correction employs a solid rod connected to the anterior spine via vertebral body screws. Correction is achieved by applying compression between adjacent vertebral body screws, before locking each screw onto the rod. Biomechanical complication rates have been reported as high as 20.8%, and include rod breakage, screw pull-out and loss of correction. Currently, the corrective forces applied to the spine are unknown. These forces are important variables to consider in understanding the biomechanics of scoliosis correction. The purpose of this study was to measure these forces intra-operatively during anterior single rod AIS correction.