A 12-year-old female presents with a left thoracic rib prominence. back muscle stretching and reduced weight in the backpack. This is an AAOS Self Assessment Exam (SAE) question. In patients with adolescent idiopathic scoliosis, bracing is indicated in which of the following conditions: Cervical radiculopathy is a clinical condition characterized by unilateral arm pain, numbness and tingling in a dermatomal distribution in the hand, and weakness in specific muscle groups associated with a single cervical nerve root. Galveston Rod Preparation, Placement of wires, hooks or pedicle screws. Continue full-time bracing until skeletal maturity. Mullender, M., et al., A Dutch guideline for the treatment of scoliosis in neuromuscular disorders. Karlin, The relationship between preoperative nutritional status and complications after an operation for scoliosis in patients who have cerebral palsy. Physical exam shows absent abdominal reflexes in the upper and lower quadrants on the left side, but present on the right. After a complete history and physical, you order PA thoracolumbar radiograph, which is seen in figure A. The 'Risser sign' is one of the most commonly used markers for skeletal maturation and growth potential in patients with adolescent idiopathic scoliosis. teardrop view, remove pedicle probe/awl and probe tract with ball tip to confirm osseous channel and measure tract, for adults a minimum diameter of 8.5mm is typical and this may be appropriate for older teenagers, for younger children a smaller diameter may be necessary, place screw and confirm position with AP and teardrop fluoroscopic images, if orientation of pelvis/imaging is unclear, one can dissect along outer table, then, place finger in depression of sciatic notch to confirm direction of tract, make a separate fascial incision over the PSIS. An isolated long-segment instrumented posterior spinal fusion is considered in which of the following clinical situations? decreased pulmonary function in the future, to undergo an MRI to rule out any underlying neurologic pathology, as this is an abnormal curve, an increased risk of chronic back pain over her lifetime, this curve magnitude has the highest curve progression rate without operative intervention, (OBQ04.144) Everyone's spine has subtle natural curves. She has 5 of 5 motor strength in all muscles groups in her lower extremities and symmetric patellar and Achilles reflexes. Continue nocturnal bracing until skeletal maturity. These curves can't be corrected simply by learning to stand up straight. an alternative method is to dissect from midline and enter the medial wall of the iliac crest, expose the outer table to visualize trajectory (from PSIS to sciatic notch), use a rongeur just lateral to the PSIS to expose cancellous bone, use a lenke probe/awl to create a tract between the inner and outer wall of the iliac wing aiming toward the anterior inferior iliac spine (AIIS) taking care to avoid the sciatic notch, probe tract with ball trip probe to confirm osseous channel and measure length of tract, place screw in tract and confirm position with c arm fluoroscopy, create channel from the PSIS to the lateral ilium by using progressively larger probes, this channel should pass just superior to the sciatic notch, once the channel is made, insert a rod (5.5 mm in smaller children) to a depth of 6-7 cm, Verify bony walls intact and measure depth of channel, probe the channel to ensure that the bony walls are intact and measure the depth of the channel for later Galveston Rod Placement, use bone wax to plug the hole at the PSIS to prevent blood from oozing before final rod placement, remove the facets with a rongeur, osteotome, burr or bone scalpel, start at the L5-S1 articulation and proceed cephalad to the level below the planned upper instrumented vertebrae, remove a window of ligamentum flavum at each interspinous region if planning wire passage, use gelfoam soaked in thrombin when needed to control local bleeding, if needed for additional deformity correction a ponte osteotomy can be performed by removing the facet in its entirety with a combination of a Kerrison rongeur and burr, Identify the pedicle starting point and use a high speed cortical burr to mark starting point and penetrate cortical surface, Insert lenke pedicle probe into the pedicle with the tip pointing laterally at the identified starting point and advance to 20mm or alternatively a 2.0 mm drill bit can be used, Probe the tract using a flexible sounding probe (ball tip probe) to palpate the superior, inferior, medial and lateral walls and the endpoint (floor), If no breeches are appreciated face Lenke probe medially and advance to anterior cortex or alternatively a 3.2 mm drill bit can be used, Place the pedicle screw slowly in the orientation of the tract that was created, Stimulate screws: if less than 6-8mA reevaluate screw position, Confirm position of screws with AP and lateral C-arm fluoroscopy, For additional details on pedicle screw placement see technique for idiopathic scoliosis, contour 16 gauge double wires to allow sublaminar passage, wire should be bent with a radius of curvature that approximates the width of the lamina, keep gentle pressure anteriorly to make sure you are not to deep and inadvertently damaging the cord, conversely do not push so hard on the undersurface of the lamina that the tip is caught and the wire is levered into the spinal cord, pull tip through until ends are of similar lengths, then can cut to separate the double wire, separate the wires placing one wire on each side of the spine, it is important to roll rather than push when placing sublaminar wires, add 5-10cm depending upon size and flexibility of the curve, If using SAI screws, the rod will need a sharp bend at lumbosacral junction (around 70 degrees), use hand benders to bend the rod at 90 degrees at the marked location, place the short end of the rod in the slot at the end of the Galveston Rod benders, have an assistant hold the long end of the rod parallel to the operating room table top, this should be held vertical to this plane, place a rod bender on the short end of the rod to bend the end 90 degrees to a position perpendicular to the operating room table, bend the kyphosis into the upper rod for appropriate sagittal plane alignment, bend the second rod so that it mirrors the shape of the first rod, insert the rod on either side of the scoliosis, Spread the sublaminar wire apart usually with the distal wire limb passing laterally, place a surgical towel over the wires of the second side to prevent confusion, after the wires have been spread insert the initial Galveston rod into the iliac wing and tamp into place at the PSIS, Prepare the rods for insertion add the depth of the iliac crest channel and the offset distance from the PSIS to the midpoint of the L5 lamina make a mark at the distance from the end of the straight rod, After placement examine the lateral iliac wing to ensure that the rod didn't penetrate laterally during insertion, It is better to use a softer/more flexible rod or do additional contouring for less correction than to pull out anchors, After rod is seated additional bending with in situ or L-benders can be performed to optimize correction, If using SAI screws can align rods with SAI screws and pedicle screws directly, If using iliac screws then will need a connector to attach to rods, can consider connecting the concave and convex rods via a connector for added rigidity, especially with weak bone, use serial reducers to load share on multiple fixation points, The T square of Tolo can be very helpful in intraoperatively assessing that pelvic obliquity is improved and sitting balance has been achieved, tighten the sublaminar wires starting at L5, sequentially tighten the wires on the side to L1 or L2, place downward pressure with rod pusher on the rod as a counterforce to the wire tightening to minimize the chance of wire pull through, contour the upper end of the rod in the kyphotic position to minimize the risk of pullout of the upper Implants, hold manually in place with a rod pusher while the 2 most cephalad sublaminar wires are tightened, Insert the concave side rod into the upper spinal implants, Hold the rod into place while the upper two sublaminar wires on the side are tightened, tighten the remaining sublaminar wires on the concave side, once all the have been tightened cut the twisted wire at a level that leaves them about 1 to 1.5 cm in length, consider placement of one additional cross link to stabilize the upper end of the instrumentation at the midthoracic level, bend the wire ends and tamp down to prevent dorsal protrusion, Sublaminar wires or bands can also be used to supplement screws especially with weak bone to avoid screw pullout, The wires or bands can be used to do provisional reduction and then rod can be seated in screws, decorticate the exposed bony areas through the region of intended fusion with rongeurs and a power burr, irrigate spine with saline (author's preference is to use a 3L bag of irrigation with castile soap), author's preference is to add vancomycin powder- mixing half of it with the bone graft and sprinkling half of it above the fascia once closed, place hemovac drain under fascia if there is enough bleeding/multiple osteotomies to raise concern for hematoma formation, need water tight closure and need to decrease dead space for hematoma, many of these children have conditions associated with slow or poor wound healing, if risk of dehiscence is high, consider reinforcing with use of additional nonabsorbable suture (3-0 nylon), Author's preference is to use waterproof layer at base to prevent soiling reaching the incision in patients who are developmentally delayed or have impaired sensation/inability to communicate when they have soiled the dressing, changes dressing when soiled or based on attending preference, review postoperative radiographs and identifies mal-positioned pedicle screws, loss of fixation and overall correction. 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