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Case series. Serie de casos. To describe the results of surgical treatment of Scheuermann's disease by the posterior approach. A descriptive, retrospective, longitudinal study in which patients with Scheuermann's disease, treated surgically by the posterior approach at the Hospital de Traumatologia y Ortopedia [Hospital for Traumatology and Orthopedics] "Lomas Verdes" IMSS. The Cobb method was used to measure the kyphosis in all the patients, of T5-T The surgical technique used was vertebral shortening by the Ponte osteotomy technique, at the apex of the deformity, accompanied by transpedicular instrumentation and posterior arthrodesis.
Five patients were included; three men and two women, with an average age of Blood loss was ml, with a surgery time of 3 hours. Three patients were submitted to neurophysiological monitoring. No neurological lesion was found. There was no loss of correction at 6 months of evolution. The vertebral shortening technique with posterior instrumentation eliminates the use of the anterior approach to release the anterior longitudinal ligament.
Osteotomies by the Ponte technique make the spine more flexible, and together with pedicular instrumentation, correct the deformity and preserve the correction over time.
Scheuermann's disease, also known as juvenile kyphosis, is a structural vertebral deformity that causes hyperkyphosis at the thoracolumbar level, due to the development of vertebral wedging during adolescence. Its exact etiology is not known, but a hereditary correlation has been found. Although the normal range of thoracic kyphosis varies, the Scoliosis Research Society defines the normal range as degrees of kyphosis between T5 and T Wenger 4 describes two types of juvenile kyphosis: the classic thoracic form, type 1, and the atypical thoracolumbar form, type 2.
In type 1 juvenile kyphosis, the apex is usually between T1 and T8, and there are three or more vertebrae wedged more than 5 degrees. Type 2 thoracolumbar form has more irregularities, such as a decrease in the intervertebral spaces and anterior Schmorl's nodes.
The usual symptom is dorsal or lumbar pain, which is particularly exacerbated by exercise, certain prolonged postures, or lifting heavy objects. The aesthetic deformity is another factor that prompts the patient to seek medical attention, although this is often delayed because the parents initially believes the problem to be postural. The pathophysiology consists of a modification of the epiphyseal growth phenomenon of the vertebral body, with molecular factors collagen, proteoglycans that eventually manifest as morphological changes.
The history of the disease is usually benign. There are cases of angles of more than degrees, when cardiopulmonary changes are present. The treatment objectives are to prevent progression, correct the deformity, alleviate the pain, and improve the patient's appearance. The management is dictated by the patient's age, the degree of deformity, and the symptoms.
Treatment of kyphosis of less than 50 degrees is based on observation, to determine the progression of the deformity until the skeleton is mature.
When the angle is greater, there is substantial growth remaining, and the vertebral deformity is flexible, a back brace is usually indicated. The criteria for indication of surgical management are: directly related neurological changes, kyphosis of more than 70 degrees, rapid progression of the curve, and pain that does not respond to conservative treatment.
The technique of vertebral shortening by Ponte osteotomy also known as Smith-Petersen osteotomy at the apex of the deformity, together with transpedicular instrumentation and posterior arthrodesis, has also been described, with good results and few complications.
The aim of this study is to analyze the results of 5 patients with Scheuermann's Disease treated surgically with single management via the posterior approach, in our hospital. It is an observational, descriptive and retrospective study Case series carried out in the period to , with a total of 12 patients diagnosed with Scheuermann's disease, who underwent surgery during the study period. Clinical and radiological data were recorded for each patient, together with preoperative and intraoperative data, and postoperative data for a period of 6 months, which is why only these cases were included in this review.
The Cobb method was used to measure the kyphosis before and after surgery. Radiographic studies were performed during hospitalization, after the surgery, and in the 3- to 6-year follow-up. All the patients were submitted to the same surgical technique. To increase the flexibility of the deformity, Ponte type osteotomies were carried out. This technique involves removal of the facet joints and interspinal ligaments and the ligamentum flavum in the posterior spine, to accentuate the lordosis, creating flexibility, and avoiding what was previously done by performing release of the anterior longitudinal ligament by a second approach.
The osteotomies were performed in all cases, at the apical level of 3 to 6 levels, depending on each case. Posterior instrumentation was performed using the system of transpedicular screws and titanium rods. For the arthrodesis, an autologous bone graft was used, plus tricalcium phosphate. Figure 1 A postoperative back brace was not used. Walking was indicated between 3 and 5 days after surgery. The patients were subsequently discharged to their homes.
Figure 1. A Placement of screws prior to the Ponte osteotomies. B Ponte osteotomy. C Final result of the instrumentation. The variables age, sex, symptoms, associated pathology, Wenger 4 classification, initial Cobb angle intra-observer measurement , Cobb angle after surgery, degrees corrected, and percentage degree of same, surgery time, surgical bleeding, and complications at 6 months were analyzed infection, loss of anchorage, neurological damage, wound dehiscence.
Of the 12 patients with Scheuermann's disease, five were operated on; two women and three men, with an average age of Four patients had associated symptoms, particularly pain lumbago and dorsal lumbago.
Table 1. Describes the results obtained for the 5 patients, describing the variables analyzed and the surgical results. The patients were classified according to Wenger's classification. Three patients had type 1, the thoracic form, and two patients had type 2, the thoracolumbar form.
The mean initial angle was The mean postoperative angle was The mean correction was Figure 2. Relationship between initial correction vs. The mean surgery time was min with mean surgical bleeding of ml In three of our patients, a neuromonitor was used during the surgery. None of our patients presented complications during or after the surgery, or at the 6-month follow-up.
Figure 3. Clinical case of patient with Scheuermann's disease managed with single posterior approach, before and after surgery. A comparison was carried out using the Student's t test for statistical analysis, comparing our results with those of a study by Hosman et al. Table 2. Student t statistical analyses, comparing our results with those of the study by Hosman et al.
Hartley's f test for equality of variance. Scheuermann's disease has been treated in different ways, and the treatment option we propose is the vertebral shortening technique with posterior instrumentation, which avoids the anterior approach for release of the anterior longitudinal ligament. Ponte osteotomies increase the flexibility of the spine and together with the pedicular instrumentation, are able to correct the deformity and maintain it over time. Our results indicate that surgical correction of juvenile kyphosis using this technique results in few complications, satisfactory angular correction, and acceptable surgical times, days of hospitalization and intra-operative bleeding.
The management of corrective surgery of the spine requires the definition of evidence as to which is the best treatment option, particularly in diseases with low incidence involving high-risk procedures for the patient.
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It occurs in 0. Its exact etiology is not known, but a hereditary cor- relation has been found. Although the normal range of thoracic kyphosis varies, the Sco- liosis Research Society defines the normal range as degrees of kyphosis between T5 and T In type 1 juvenile kyphosis, the apex is usually between T1 and T8, and there are three or more vertebrae wedged more than 5 degrees.