Ballert Orthopedic :: Newsletters and Articles

Adolescent Idiopathic Scoliosis: Treatment via Selective Anterior Thoracic Instrumentation and Fusion
by Steven Mardjetko, MD

Steven Mardjetko, MD
Vol. 5, No. 3 October 2000

From time to time Ballert invites a noted expert in the field to contribute to Ballert Briefs. This month’s contributor is Dr. Steven Mardjetko, whose biography appears on the back page. Mardjetko relates an interesting case study involving the use of a custom-molded TLSO in the treatment of scoliosis.

Case Presentation. A. R. is a 15-year-old female who presents with a double major scoliosis. Right thoracic curve measures 65°, left lumbar curve measures 58°. Significant structural changes were identified in the right thoracic curve. The left lumbar curve demonstrated significant flexibility on side bending.

Surgical Procedure: Options for treatment include standard posterior stabilization and fusion extending from T4 to L4. A second and more attractive option would include a selective thoracic curve. A secondary correction of the lumbar curve may be expected based on previous experience gained in Europe and in Japan.

The patient underwent surgical intervention which included right thoracotomy, removal of the discs from T6 to T11, in sertion of screws, and correction with a 5 mm rod utilizng the Moss-Miami system. Fusion cages were utilized at the lower segment to maintain appropriate alignment at this level. A thoracoplasty was performed. This involves removal of short segments of rib to alleviate the rib hump.

Preoperative

Preoperative Requirements. Autologous blood donation (2-3 units) with concurrent supplemental Ferrous Sulfate and MVI. Also required were current spinal x-rays, screening blood, and urine tests, AP and lateral chest x-rays, and pulmonary function tests.

Anticipated Postoperative Course. One night in the Pediatric Intensive Care Unit. Five days in the hospital. Three or four weeks off from school. Patient would be required to wear a custom molded TLSO when out of bed for approximately four months. No gym or sports would be allowed for six months. Usually patients are off of all narcotic pain medication after four weeks. Most patients resume all normal activities by six months postop.

Postoperative

Discussion. Postoperative radiographs reveal a substantial correction of the right thoracic curve and a spontaneous improvement of the lumbar curve.  The development of the selective anterior thoracic technique can be credited to Dr. Klaus Zielke, from Germany. The current surgical procedure is similar to that used by Dr. Zielke. Advances in spinal instrumentation appear to have improved fusion rates and sagittal spinal alignment.

The selective thoracic fusion may be performed from the posterior approach but problems with coronal plane decomprensation have been reported.

The selective anterior thoracic fusion technique offers a major long-term benefit to the patient and the lumbar spine remains un-fused. This should allow for greater spinal mobility and should decrease the long-term risk of accelerated spinal degeneration adjacent to instrumentation extening into the lumbar spine.

Suggested References:

Bridwell KH, McAllister JW, Betz RR, et al. Coronal decompensation produced by Cotrel-Dubousset "derotation" maneuver for idiopathic right thoracic scoliosis. Spine 1994;16:769.

Hammerberg KW, Rodts MF, DeWald RL. Zielke instrumenation. Orthopedics 1988;11:1365-1371.

Kamimura M, Ebara S, Kinoshita T, et al. Angerior Surgbery with Short Fusion Using the Zielke Procedure for Thoracic Scoliosis: Focus on the Correction of Compensatory Curves. J Spinal Disord. 1999;6:451-60.

Lenke LG, Betz RR, Bridwell KH, et al. Spontaneous lumbar coronal correction after selective anterior or posterior thoracic fusion in adolescent idiopathic scoliosis. Spine 1999;16:1663-71.

Zielke K, Stunkat R, Beaujean F. Ventrale derotations-spondylodesis. Arch Orthop Unfallchir. 1976;5:598-604.

Steven Mardjetko, MD
Dr. Mardjetko, FAAP, is an orthopaedic spine surgeon with a professional interest in pediatric spinal deformity.

Mardjetko went to medical school and was a resident at the University of Illinois. He completed fellowship programs in spinal surgery and pediatric orthopedics.

Mardjetko is currently an Assistant Professor at Rush Presbyterian St. Luke’s Medical Center, Department of Orthopedics. Currently, Dr. Mardjetko is in private practice at Illinois Bone and Joint Institute, Ltd., and is a consultant at Shriner’s Hospital for Children where he sees patients and performs surgery.

The author of articles for journals and textbooks on the subjects of spinal disorders and their surgical treatment, Dr. Mardjetko is active in a number of professional organizations, including the North American Spine Society, the Scoliosis Research Society and the American Academy of Pediatrics, and has served on the Editorial Advisory Board of Spine Journal.

Dr. Mardjetko can be contacted at:

Illinois Bone & Joint Institute, Ltd.
1875 Dempster, Suite 301
Park Ridge, IL 60068

Or:

150 N. River Rd., Suite 100
Des Plaines, IL 60016
Phone: 847-375-3000
Fax: 847-391-6140