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SPINE Volume 29, Number 16, pp 1789–1794
©2004, Lippincott Williams & Wilkins, Inc.
Scheuermann Kyphosis: Safe and Effective Surgical
Treatment Using Multisegmental Instrumentation
Moe Lim, MD, Daniel W. Green, MD, Jason E. Billinghurst, MD, Russel C. Huang, MD,
Bernard A. Rawlins, MD, Roger F. Widmann, MD, Stephen W. Burke, MD, and Oheneba Boachie-Adjei, MD
Study Design. A retrospective review was conducted
on 23 consecutive patients who underwent surgical correction of Scheuermann kyphosis using modern multisegmental instrumentation.
Objective. To evaluate Scheuermann kyphosis correction and complication rates.
Summary of Background Data. The surgical treatment
of Scheuermann kyphosis remains a topic of debate. The
literature of the 70s and 80s on the surgical management
of this disorder using Harrington instrumentation demonstrated that operative correction is quite effective but associated with significant complications. This literature,
however, may be less applicable to current clinical situations. The use of modern multisegmental instrumentation
and increased awareness of potential complications may
decrease the risks of current operative treatment.
Methods. Hospital charts, office charts, and radiographs on 23 consecutive patients who underwent operative treatment using multisegmental instrumentation for
Scheuermann kyphosis were reviewed to identify complications of surgery. Complications were classified as minor, major, or life threatening.
Results. The mean follow-up was 38 months (range
10 –123 months). Preoperative kyphosis ranged from 63°
to 104° with an average of 83°. Twenty of the 23 patients
(87%) underwent combined anterior release/arthrodesis
with posterior arthrodesis/multisegmental instrumentation. The remaining 3 patients underwent posterior arthrodesis/multisegmental instrumentation. Postoperative
total kyphosis ranged from 32° to 67° with an average of
46°. At final follow-up, the total kyphosis ranged from 37°
to 75° with an average of 51°. Overall, we had 43% minor
complications, 17% major complications, and 0% lifethreatening complications.
Conclusions. Surgical correction of Scheuermann kyphosis can be performed safely and effectively using
modern multisegmental instrumentation.
Key words: Scheuermann kyphosis, complications,
deformity, spine fusion. Spine 2004;29:1789 –1794
Scheuermann disease is defined as thoracic kyphosis
greater than 45° with greater than 5° of anterior wedging
in 3 consecutive vertebrae. It is the most common cause
of severe thoracic kyphosis in adolescence with reported
prevalence of 1% to 8%.1 The etiology of the deformity
From the Hospital for Special Surgery, New York, New York.
Acknowledgment date: April 28, 2003. First revision date: September
6, 2003. Acceptance date: October 2, 2003.
The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication.
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Daniel W. Green, MD,
Hospital for Special Surgery, 535 East 70th Street, New York, NY
10021, USA; E-mail: [email protected]
has been attributed to defective end plates, juvenile osteoporosis, or mechanical causes but remains largely unknown. Patients primarily present with deformity and/or
pain. Before 1993, aggressive treatment was justified by
several studies that suggested an ominous natural history. In their series, Ponte et al demonstrated that all
curves ⬎45° progressed during the adolescent growth
spurt and continued to increase after the age of 30.2
Sorensen reported a 50% incidence of pain during the
adolescent growth spurt.3 Bradford et al reported a
higher incidence of disabling thoracic and lumbar back
pain in untreated adults.4,5 The authors noted the often
unremitting and incapacitating nature of the pain and
the unacceptable appearance of the deformity.
Treatment using a Milwaukee brace was shown to be
effective to relieve pain and correct curves less than 74° in
skeletally immature patients.6 This indication for brace
treatment remains generally accepted. The surgical treatment of patients with Scheuermann kyphosis, however,
remains more controversial. In 1993, Murray et al published their study on the natural history of untreated
Scheuermann disease on patients with an average age of
53 years and an average kyphosis of 71°.7 They found
that these patients were more likely to have thoracic
pain, had higher pain intensity readings, were more
likely to work in sedentary jobs, and were more likely to
be unmarried. However, their symptoms did not interfere with their activities of daily living, and they had no
preoccupation with their physical appearance. Operative
treatment at that time was shown to be effective for pain
and deformity correction but fraught with complications. Death, pulmonary emboli, gastrointestinal obstruction, neurologic injury, device failure, loss of correction, reoperation, infection, pseudarthrosis, and pain
were all not uncommon.5,8 –11 After weighing the natural
history against the risks of operation, Murray et al suggested a review of the use of operative treatment for
Scheuermann disease. The reports of operative treatment
available at that time, however, primarily involved patients treated using Harrington instrumentation.5,8 –11
With the advent of modern multisegmental instrumentation and increased awareness of the potential complications, it may now be possible to undertake operative
treatment with greater safety. The present report aims to
evaluate our institution’s experience with operative
treatment of Scheuermann kyphosis using multisegmental instrumentation, with a particular focus on
complications.
1789
1790 Spine • Volume 29 • Number 16 • 2004
Table 1. Results of Treatment
Fusion Levels
Patient No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Average
Age (yrs)/
Gender
Initial Kyphosis (°)
Anterior
Posterior
Follow-up (mos)
Postop Total Kyphosis (°)
Final Total Kyphosis (°)
17 M
20 F
21 M
21 F
36 F
18 M
17 M
35 F
13 M
14 F
14 F
16 M
26 F
15 M
17 M
19 M
14 F
17 F
14 F
14 M
15 M
17 M
21 M
19
70
96
87
90
67
84
95
85
83
76
63
82
75
97
88
77
74
73
74
104
100
77
87
83
T5–T11
T5–T11
T11–L2
NA
NA
T5–T11
T5–T11
T6–T11
T4–T11
T4–T10
T4–T11
T4–T10
NA
T5–T10
T6–T11
T4–T10
T5–T11
T4–L1
T10–L2
T4–T11
T5–T10
T3–T11
T10–L2
T2–L2
T3–L2
T4–L2
T2–L1
T3–L1
T3–L3
T2–L2
T2–L2
T4–L3
T3–L1
T3–L2
T4–L2
T2–L1
T3–L1
T3–L1
T2–L2
T2–L1
T2–L2
T4–L2
T4–L2
T2–L2
T2–L2
T4–L3
24
10
59
50
35
24
52
60
12
26
25
44
48
66
123
18
60
12
23
10
24
36
33
38
32
52
53
39
40
46
51
57
42
44
35
42
50
62
44
44
40
45
65
67
45
28
46
46
39
65
58
50
49
58
48
59
37
48
54
40
48
65
49
42
43
50
75
67
39
40
49
51
NA ⫽ not applicable.
Materials and Methods
Twenty-six consecutive patients underwent operative treatment using modern multisegmental instrumentation for
Scheuermann kyphosis at our institution from 1986 to 1999.
Inpatient charts, office charts, and radiographs were available
for 23 patients. These records were carefully reviewed with an
emphasis on identifying complications of surgery. Twelve
(52%) patients were male and 11 (48%) were female. Their
ages ranged from 13 to 36, with an average of 19 years. Follow-up ranged from 10 to 123 months, with an average of 38
months. Six patients had less than a 2-year follow-up. All but 1
patient complained of unacceptable deformity. Fifteen of the
23 patients also complained of pain that was attributable to the
thoracic kyphosis by physical examination. None of the 23
patients had neurologic deficits.
Preoperative radiographs were reviewed. Thoracic kyphosis
was determined by the Cobb method on the standing lateral
view. Scoliosis was similarly determined on the standing anteroposterior (AP) view. All patients met the criteria for diagnosis of Scheuermann disease: kyphosis greater than 45° accompanied by greater than 5° of wedging on 3 consecutive
vertebrae. Endplate irregularities and/or Schmorl nodes were
noted on all patients. Preoperative kyphosis ranged from 63° to
104° with an average of 83° (Table 1). Preoperative scoliosis
ranged from 0° to 39°, with an average of 11°. Eleven patients
had scoliosis greater than 10°. Only 1 patient had a scoliosis
greater than 20° (patient 9 with 39°) (Figure 1).
Four different attending surgeons performed the surgeries.
Twenty of the 23 patients (87%) underwent combined anterior
release/arthrodesis with posterior arthrodesis/multisegmental
instrumentation. Seventeen of these were performed on the
same day, whereas 3 were staged with an average of 10 days in
between. The remaining 3 patients underwent posterior arthrodesis/multisegmental instrumentation. ISOLA instrumenta-
tion was used in 14 patients and Cotrel-Dubousset in 9 patients. Two patients underwent halofemoral traction, one for
14 days before surgery (patient 9) and the other in the intervening time between the anterior and posterior procedures (patient 12).
Before surgery, all patients were evaluated and cleared by a
pediatrician or medical internist from our institution. Autologous blood donation, hypotensive anesthesia, and cell-saver
were utilized. Pneumatic compression boots or antiembolism
stockings were applied before the induction of anesthesia. Neurologic monitoring included somatosensory-evoked potentials
and wake-up tests after the anterior release and after the corrective maneuver.
A left-sided thoracotomy or a thoracoabdominal approach
was used for the anterior procedure except when a concomitant
scoliotic deformity was present. In this case, the convex side of
the scoliotic curve was selected. Anterior releases, including
sectioning of the anterior longitudinal ligament and discectomies of all levels adjacent to wedged vertebrae and/or all levels
within the Cobb curve, were performed. Rib autograft and/or
cancellous allograft were used as bone graft. Usually 5 to 6
periapical discs were removed (average 5.9 discs, range 3–10).
In cases of long round kyphosis (as in patients 18 and 22), more
discs were taken. In cases of sharp kyphosis with areas of significant wedging (as in patients 3, 19, and 23), anterior releases
were limited to the involved levels. After the anterior procedure, a chest tube was inserted. Care was taken to create a long
subcutaneous tunnel over 2 to 3 ribs.
The patients were then repositioned and reprepped for the
posterior procedure. Posteriorly, fusion was carried to the most
cephalad level involved in the kyphosis using multiple fixation
points or claw constructs. Fusion was performed to T2 in 10
patients, to T3 in 7 patients, and to T4 in 6 patients. The
spinous process of the most proximal level was preserved to
Surgical Correction of Scheuermann Kyphosis • Lim et al 1791
Figure 1. (A) Preoperative lateral radiograph of a 17-year-old
patient with 95° Scheuermann’s
kyphosis. (B) Postoperative lateral radiograph demonstrating
correction to 48°.
save the interspinous ligaments. Caudally, a pedicle screw
foundation composed of 4 to 6 screws or a hook/claw construct
was used. Pedicle screws were used in 13 patients and hook/
claws were used in 10 patients. The fusion was extended distally to the body below the first lordotic disc as determined on
a lateral standing radiograph. Seven patients were fused to L1,
13 patients to L2, and 3 patients to L3. After posterior instrumentation, rib autograft, iliac crest autograft, and/or cancellous allograft were applied. Subfascial and subcutaneous
drains were placed.
After surgery, the patients were monitored in an intensive
care unit and transferred to the floor when medically stable. A
multidisciplinary team including the orthopedics attending, pediatrics/medical attending, orthopedic residents, pediatric residents, a physical therapist, an occupational therapist, and a
nurse practitioner followed the patients daily. Prophylactic antibiotics were used routinely for 48 hours after surgery. Pneumatic compression boots or stockings were maintained to prevent thromboembolic events. No casts were used. A
thoracolumbosacral orthosis was used at the discretion of the
attending surgeon if the instrumentation construct and/or the
bone quality were felt to be suboptimal. In our series, 4 patients
were braced for 3 to 6 months after surgery. Aggressive mobilization was achieved by twice-daily physical therapy. The patients were advanced to standing and ambulation as tolerated
with a walker, usually beginning on the second postoperative
day.
Results
The estimated blood loss for the posterior fusions averaged 1350 cc (range 400 –1800 cc). The estimated blood
loss for the combined anterior/posterior fusions aver-
aged 1800 cc (range 600 –3030 cc). The average length of
hospital stay was 11 days.
At final follow-up, 6 patients complained of persistent
pain. All 6 had pain before surgery. In all cases, the pain
was either occasional or mild and required no medications. In 4 patients, the pain was thoracic but poorly
localized. In 1 patient, the pain was localized to prominent instrumentation near the apex of the kyphosis. This
pain was not severe enough for the patient to desire removal of the device. The last 1 of the 6 patients complained of intermittent lumbar pain only with lifting or
bending. Nine of the 15 patients (60%) with preoperative pain had complete relief.
Postoperative scoliosis ranged from 0° to 11° with an
average of 4°. Only 1 patient had a scoliosis greater than
10°.
Postoperative total kyphosis ranged from 32° to 67°
with an average of 46°. This represents an average correction of 37°. At final follow-up, the total kyphosis
ranged from 37° to 75° with an average of 51° (Table 1).
This represents a final average correction of 32°.
Proximal junctional kyphosis over 10° was seen in 3
patients (13%, in patients 11, 14, and 19). Only 1 of
these patients had junctional kyphosis over 20° (patient
19). The development of 35° of proximal junctional kyphosis in this patient was most likely related to the short
proximal fusion to T4. Patients 11 and 14 were fused to
T3. No cases of junctional kyphosis were observed in
patients fused to T2. All 3 patients had less than 50%
1792 Spine • Volume 29 • Number 16 • 2004
Table 2. Literature Review
Complications
Series
Points
Approach
Bradford et al, 1975
Taylor et al, 1979
Speck and Chopin,
1986
Bradford et al, 1980
Herndon et al, 1981
DeJonge et al, 2001
22
27
61
HSS 2003
23
PSF
PSF
54 PSF
7 A/PSF
A/PSF
A/PSF
2 A/PSF
6 PSF
20 A/PSF
3 PSF
24
13
8
Follow-up
(mos)
Instrumentation
Preop
Kyphosis (°)
Final
Kyphosis (°)
Minor
Major
Life Threatening
35
28
56
21 Harrington
Harrington
Harrington
70
72
77
47
46
41
27%
30%
21%
18%
7%
7%
5%
7%
2%
39
29
72
72
35
44
Harrington
Harrington
CD
CD
CD, ISOLA
ISOLA
77
78
97
82
84
77
47
46
54
46
52
53
29%
38%
0%
38%
23%
25%
17%
8%
0%
50%
0%
20%
0%
0%
0%
PSF ⫽ posterior spinal fusion; A/PSF ⫽ anterior/posterior spinal fusion; CD ⫽ Cotrel-Dubousset.
correction of the deformity. No cases of distal junctional
kyphosis were seen. At the latest follow-up, none of these
patients had pain attributable to the proximal junctional
kyphosis.
Complications
The most common complications were pulmonary.
There were 7 pleural effusions and 2 pneumothoraces in
8 patients (39%). All 8 of these patients had a combined
anterior/posterior arthrodesis. Two of the patients with
pleural effusions required treatment, 1 with a diuretic
and 1 with a chest tube. Both treatments were effective.
The other effusions and pneumothoraces were observed
and had resolved by the time of discharge.
One patient (4%) had persistent serous drainage from
his posterior iliac crest bone graft harvest site. Drainage
stopped by postoperative day 5, and the wound healed
without further sequelae. There were no cases of superficial or deep wound infections. There were no cases of
skin breakdown from the use of the postoperative brace.
One patient (4%) developed bilateral upper extremity
numbness and weakness after surgery. This was attributed to intraoperative positioning and resolved
spontaneously.
Three reoperations (13%) were required for loss of
fixation of instrumentation. In patient 2, the most proximal supralaminar hook at T3 dislodged on postoperative day 11. The fusion construct was extended cephalad
to T1 without further sequelae. In patient 20, the caudal
sublaminar hook at L2 became dislodged 4 months after
surgery, also requiring extension of instrumentation and
fusion. Patient 19 had a sharp preoperative kyphosis
from T10 to L2. Subsequently, a limited anterior release
was performed through these levels. Posterior fusion was
performed from T4 –L2 with claw constructs proximally
and pedicle screws distally. Radiographs before discharge revealed that the caudal pedicle screw at L2 had
pulled out. The patient was subsequently revised by caudal extension of the fusion to L3 using pedicle screws.
We do not believe that the limited anterior release led to
the need for revision. Rather, the distal extent of her
fusion was only to L2, although her first lordotic disc was
at L2–L3. The failure to extend her fusion beyond that
disc is a more likely cause of the need for revision. Although the latest follow-up on these 3 patients is short,
they all had solid fusions and were pain free.
All the above complications occurred in the 20 patients who had combined anterior posterior approaches.
There were no complications in the 3 patients who had
only a posterior approach. Overall, there were no cases
of intraoperative fractures. There were no cases of device
breakage. There were no cases of pseudarthrosis by the
time of latest follow-up. There were no cardiac, gastrointestinal, renal, or urologic complications. There were
no clinically apparent thromboembolic events.
Our complications were then classified as minor, major, or life threatening and compared to prior surgical
series. Minor complications were defined as those requiring little to no treatment. Examples of minor complications include superficial wound infection treated by antibiotics, pleural effusion treated by diuretics or by
observation alone, intraoperative transverse process
fractures that led to no clinical sequelae, ileus treated by
a nasogastric tube and intravenous fluids, psychiatric difficulties in halofemoral traction, and transient neurologic deficit related to patient positioning. A major complication was defined by the need for prolonged or
surgical treatment. Examples of major complications include deep venous thrombosis, deep infections requiring
irrigation and drainage and/or device removal, skin
breakdown requiring plastic surgery, pulmonary effusion or pneumothorax requiring a chest tube, junctional
kyphosis requiring further surgery, pseudarthrosis requiring further surgery, device failure or prominence requiring further surgery, and intraoperative fractures
with clinical sequelae. Life-threatening complications include pulmonary embolism, hemothorax requiring thoracic surgery, gastrointestinal obstruction requiring abdominal surgery, neurologic deficits requiring further
surgery, and death. In our series, we had overall 43%
minor, 17% major, and 0% life-threatening complications. Complication rates from previously published surgical series were then also classified accordingly (Table
2). The series that did not provide adequate information
on their complications or used neither standard Har-
Surgical Correction of Scheuermann Kyphosis • Lim et al 1793
rington nor modern multisegmental instrumentation
were excluded from our analysis.12–19
Discussion
The surgical treatment of Scheuermann kyphosis remains a topic of debate. In the late 1970s, several studies
established the effectiveness of surgical intervention in
correcting the deformity and relieving the pain associated with Scheuermann kyphosis.5,8,9,11,18 Bradford et
al8 reviewed 22 patients who underwent posterior spine
fusion with Harrington instrumentation for average preoperative kyphosis of 70°. At the mean follow-up of 35
months, the average kyphosis was corrected to 47°. All
the patients with thoracic back pain had relief after operation and all the patients were satisfied with the deformity correction. Herndon et al11 performed combined
anterior posterior spine fusion with Harrington instrumentation on 13 patients with an average preoperative
kyphosis of 78°. At the mean follow-up of 29 months,
the average kyphosis was 46°. Twelve of the 13 patients
had good pain relief and were happy with their cosmetic
results.
Although these and similar studies showed that surgery with Harrington instrumentation was effective, they
also demonstrated that surgery often led to serious and
life-threatening complications. Taylor et al9 performed
posterior spine fusion with Harrington instrumentation
on 27 patients with a mean preoperative curve of 72°.
The mean final kyphosis at the average 28-month follow
up was 52°. Their minor complications included 1 intraoperative laminar fracture, 3 wound hematomas, 3 upper gastrointestinal obstructions treated by nasogastric
tube and intravenous fluids, and 1 transient paresthesias
attributed to intraoperative positioning. Their major
complications included 2 instrumentation failures that
required further surgery. Their life-threatening complications included 1 tension pneumothorax and 1 upper
gastrointestinal obstruction requiring hyperalimentation
for 10 weeks. Overall, they had 30% minor complications, 7% major complications, and 7% life-threatening
complications.
Bradford et al5 examined 24 patients who underwent
combined anterior/posterior spine fusion with Harrington instrumentation for a mean kyphosis of 77°. After a mean follow-up of 39 months, the average kyphosis
was corrected to 47°. Their minor complications included 4 pressure sores treated nonoperatively, 1 painful
prominent device treated conservatively, 1 pericardial
effusion that resolved spontaneously, and 1 intercostal
neuroma. Their major complications included 1 deep infection, 1 pseudarthrosis requiring bone grafting, 1 junctional kyphosis requiring extension of fusion, 1 pressure
sore requiring plastic surgery, 2 painful devices requiring
removal, and 3 partial wound dehiscences requiring repair. Their life-threatening complications included 2 patients with pulmonary emboli, 1 duodenal obstruction
requiring exploratory laparotomy, and the same patient
with persistent hemothorax requiring pleural decortica-
tion. Overall, their minor complication rate was 29%,
major complication rate 38%, and life-threatening complication rate 17%. Despite these high rates of serious
complications, surgical intervention was justified by the
prevailing belief at that time that Scheuermann kyphosis
led to progressive deformity with concomitant cardiopulmonary failure and severe back pain.
In 1993, Murray et al7 reported their natural history
study that refuted this belief. They examined 67 patients
who were treated conservatively for Scheuermann kyphosis and compared them to normal controls. Their
average follow-up was 32 years after diagnosis was made
by Sorensen’s criteria. They found that although these
patients had more pain, their symptoms did not interfere
with their work or activities of daily living, and they had
no preoccupation with their physical appearance. Only
patients with kyphosis greater than 100° with the apex
above T8 were found to have restrictive lung disease.
This study suggested a less ominous natural history of
Scheuermann kyphosis. In light of these findings, Murray
et al suggested a re-examination of the use of operative
treatment.
The operative series available at the time of Murray et
al’s study, however, consisted mostly of patients instrumented with Harrington rods. The problems with Harrington instrumentation include the need for postoperative cast immobilization for 6 to 9 months, technical
difficulty in insertion of the instrumentation, and frequent failure of the rod or the hook– bone interface.
These problems may have contributed to the high complications rates of operative treatment. In the late 1980s,
modern multisegmental instrumentation systems became
widely available. We believe that the use of the modern
multisegmental rod, hook, and screw instrumentation
and the heightened awareness of potential complications
have increased the safety in the surgical treatment of
Scheuermann kyphosis. This report evaluates our institution’s experience with operative treatment of Scheuermann kyphosis using modern multisegmental instrumentation, with a particular emphasis on complications. Our
average preoperative kyphosis of 83° was corrected to
51° at final average follow-up of 38 months. Our minor
complications included 6 pleural effusions, 2 pneumothoraces, 1 wound with serous drainage, and 1 transient
upper extremity neurologic deficit secondary to intraoperative positioning. Our major complications included 1
pleural effusion requiring placement of a chest tube and 3
reoperations for loss of fixation of instrumentation. We
had no life-threatening complications. Overall, we had
43% minor complications, 17% major complications,
and 0% life-threatening complications. Our most common complication was pleural effusions, most of which
were asymptomatic and resolved without treatment.
The decision for undertaking operative treatment of
Scheuermann kyphosis is ultimately an individual one
between the surgeon and the patient. Potential benefits of
the treatment in relieving pain and improving physical
appearance and self-esteem, and their related social im-
1794 Spine • Volume 29 • Number 16 • 2004
plications are weighed against the potential complications of treatment. Our surgical series demonstrates that
the current complications with the use of modern multisegmental instrumentation may not be as morbid as once
observed when Harrington instrumentation was used.
Our current indications for operative treatment of
Scheuermann kyphosis include skeletally mature patients with significant kyphosis who find their appearance unacceptable and/or experience pain refractory to
conservative management. Anterior release is indicated
in rigid thoracic kyphosis that is greater than 50 days on
hypertension radiographs and in rigid thoracolumbar
kyphosis greater than 20 days on bending radiographs.
Release and discectomies of all levels adjacent to wedged
vertebrae and/or all levels involved in the Cobb curve
should be performed. Sharp kyphosis with focal areas of
wedging may require fewer levels of release than longer
round kyphosis. Posteriorly, fusion should be carried to
the most cephalad level involved in the kyphosis using
multiple fixation points or claw constructs. To avoid
junctional kyphosis, we recommend proximal fusion to
T2. Caudally, we recommend fusion beyond the first lordotic disc (usually to L2 or L3) using a pedicle screw
foundation composed of 4 to 6 screws. After surgery, a
multidisciplinary team approach is crucial in minimizing
medical complications.
In conclusion, this series demonstrates that surgical
correction of Scheuermann kyphosis using modern multisegmental instrumentation can be performed effectively
and safely without life-threatening complications.
Key Point
Surgical correction of Scheuermann kyphosis
can be performed safely and effectively using modern multisegmental instrumentation.
●
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