SPINE Volume 28, Number 8, pp 799–805
©2003, Lippincott Williams & Wilkins, Inc.
The Efficacy of Convex Hemiepiphysiodesis in Patients
With Iatrogenic Posterior Element Deficiency Resulting
from Diastematomyelia Excision
Akin Uzumcugil, MD,* Akin Cil, MD,* Muharrem Yazici, MD,* Emre Acaroglu, MD,*
Ahmet Alanay, MD,* Nejat Akalan, MD,† Pınar Ozisik, MD,† and Adil Surat, MD*
Study Design. Retrospective analysis was performed.
Objective. To investigate the safety and efficacy of
anterior and posterior hemiepiphysiodesis in patients
with iatrogenic posterior element deficiency.
Summary of Background Data. Anterior and posterior
convex hemiepiphysiodesis is a well-accepted treatment
method for severe and progressive congenital scoliosis
in young children. Many patients with congenital spinal
deformities have intraspinal pathologies that require
neurosurgical intervention with laminectomy. The effi-
cacy of this method has not been studied in these pa-
tient populations.
Methods. Between 1990 and 2001, among 82 patients
with congenital spinal deformity, 38 were treated with
convex epiphysiodesis. This study included 18 of these
patients (2 males and 16 females) who underwent di-
astematomyelia excision and had at least 2 years of fol-
low-up evaluation. Diastematomyelia excision was per-
formed before the orthopedic procedure in 8 patients and
at the same anesthetic setting sequentially in 10 patients.
The mean age at the time of the fusion was 20 months
(range, 6 – 60 months), and the average follow-up period
was 39 months (range, 24 –120 months).
Results. The mean Cobb angle was 54° (range, 31–90°)
before surgery and 48° (range, 30 – 84°) at the final fol-
low-up assessment. Any increase of more than 6° was
accepted as progression. Eight patients (44%) had a true
epiphysiodesis effect: 58° (range, 40 –90°) before sur-
gery and 39° (range, 30 –70°) at follow-up evaluation.
Eight patients (44%) had a fusion effect: 49° (range,
31– 68°) before surgery and 50° (range, 37–74°) at fol-
low-up assessment. Two patients (12%) had a postop-
erative progression of deformity: 63°(range, 54 –72°)
before surgery and 75° (range, 65– 84°) at follow-up
evaluation.
Conclusions. Convex epiphysiodesis is an effective
method for patients with midline laminectomy defect as
those with intact posterior elements. Because the facet
joints and transverse processes usually are unaffected,
the presence of midline defect does not diminish the
From the Departments of *Orthopaedics and †Neurosurgery, Hacet-
tepe University, Ankara, Turkey.
Acknowledgment date: June 11, 2002.
First revision date: August 9, 2002.
Acceptance date: September 30, 2002.
Device status/drug statement: The submitted manuscript does not con-
tain information about medical devices or drugs.
Conflict of interest: 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 article.
Address reprint requests to Muharrem Yazici, MD, Department of
Orthopaedics, Hacettepe University, Sihhiye, Ankara, 06100 Turkey.
E-mail: yazioglu@hacettepe.edu.tr.
efficacy of the technique. [Key words: congenital, convex
hemiepiphysiodesis, diastematomyelia, intraspinal pa-
thology, scoliosis, surgery, treatment] Spine 2003;28:
799 – 805
The longitudinal growth imbalance of anomalous verte-
bra forms the basis of congenital scoliosis. Imbalance
originates from normal or nearly normal growth of the
convex side with respect to the concave side, which has
little, if any, growth potential. Convex anterior and pos-
terior hemiepiphysiodesis has been a well-accepted treat-
ment method for stopping the progression or even re-
versing the deformity associated with congenital
scoliosis, provided there is proper adherence to the pre-
requisites.1–7 The ideal patient has a pure scoliotic curve
without major kyphosis or lordosis, a progressive curve
with a magnitude less than 70°, a curve length consisting
of five segments or fewer, an age less than 5 years, no
cervical spine involvement, and no unilateral unseg-
mented bar as the etiology of the curve.5,7 Occasionally,
the classic indications have been stretched in terms of age
at surgery, magnitude of the curve, and etiology with
successful outcomes.1,3,6
There is a high likelihood of associated anomalies
both inside and outside the spinal column in congenital
scoliosis because the developments of the spinal cord and
vertebral column are closely associated. Diastematomy-
elia, one of the probable coexisting congenital malfor-
mations of the neural axis, is reported to have an inci-
dence of 1.8% to 16% in patients with congenital
scoliosis.8 –11 Diastematomyelia is a sagittal division of a
spinal cord or cauda equina segment with a fibrocarti-
laginous or bone spur that protrudes from the posterior
midline portion of one or more vertebral bodies.11–14 To
avoid creating a neural deficit or increasing the preexist-
ing neural deficit, laminectomy to remove the bone spur
is indicated for patients with diastematomyelia before
any procedure for correction of the vertebral column
that might cause traction on the spinal cord.9,11–15
For an effective posterior fusion, availability of poste-
rior elements is an important advantage. One of the rea-
sons for the increased pseudarthrosis rate associated
with posterior fusion in spina bifida ranging from 42%
to 76% is thought to originate from inadequate bed for
bone grafts.16 –18 The efficacy of convex growth arrest,
which is directly proportional to the quantity and
799
800 Spine • Volume 28 • Number 8 • 2003
strength of the posterior fusion mass, in patients with
iatrogenic posterior element deficiency is unknown.
The purpose of this study was to investigate the safety
and efficacy of convex anterior and posterior he-
miepiphysiodesis in patients with iatrogenic posterior el-
ement deficiency.
Methods
Between 1990 and 2000, among 82 consecutive patients with
the diagnosis of congenital scoliosis, 38 were treated with con-
vex growth arrest at our institution. Inclusion criteria specify a
diagnosis of congenital scoliosis without significant kyphosis
or lordosis, a curve magnitude greater than 50° or a docu-
mented progression or a pattern known to be progres-
sive,10,19,20 and concomitant diastematomyelia. Excision of di-
astematomyelia and the convex growth arrest should have been
performed before the age of 5 years. The patients with pure
cervical congenital scoliosis and those with myelomeningocele
were not included. A total of 18 patients (16 females and 2
males) fulfilled the criteria. Their mean age at the time of con-
vex growth arrest was 20 months (range, 6 – 60 months), and
the average follow-up period was 39 months (range, 24 –120
months).
Congenital vertebral anomalies were diagnosed on the su-
pine anteroposterior and lateral spine radiographs. The sites of
vertebral anomalies and resultant sites of curvatures were
noted. Deformities were classified according to Winter et al20
as unsegmented bar with or without contralateral hemiverte-
bra, block vertebra, hemivertebra, wedge vertebra, or complex
congenital deformities. Additional vertebral anomalies at other
levels that did not contribute to the spinal deformity were not
recorded. Cobb angles21,22 were measured on the anteroposte-
rior radiographs of the spine at the initial visit and at the fol-
low-up visits every 6 months. As a result, any increase more
than 6° was accepted as a progression.22 All patients with con-
genital scoliosis underwent CT myelography or MRI to rule
out possible concomitant intraspinal anomaly before the sur-
gery.8,15,23,24 Diastematomyelia was diagnosed in 6 of the pa-
tients using CT myelography and 12 of the patients using MRI.
The levels of spurs and other intraspinal anomalies, if any, were
recorded.
Ten of the patients sequentially underwent surgery with
neurosurgeons in a single anesthetic setting. Spur excision was
performed via laminectomy, followed by posterior convex he-
miepiphysiodesis. Anterior convex hemiepiphysiodesis was
performed 1 week to 10 days later. In the remaining eight
patients, laminectomy and spur excision had been performed
10 days to 5.5 months before the single-anesthetic sequential
anterior and posterior convex hemiepiphysiodesis. During the
neurosurgical part of the operation, spur excision was per-
formed first, then dural tube reconstructed. In some cases, re-
construction was required to extend laminectomy one or more
levels above. Four patients had concomitant dermal sinuses,
which were excised. The operative technique used for convex
growth arrest was identical to that described by Winter et al,7
except for the trough on the lateral side of the vertebral bodies
that accommodates the autogenous rib graft, which was not
used in these patients. Posterior elements at the convex side,
including the remnants of the laminae, facet joints, and trans-
verse processes were exposed subperiosteally. Inferior articular
processes were excised, and articular cartilages were removed.
After decortication, ample bone grafting was used. During the
anterior part of the surgery, half of the convex side disc and
endplates was removed. The corresponding spaces were filled
with chip grafts obtained from the ribs. If one rib was not
sufficient to fill in these spaces, an additional rib was taken.
Determined by the presenting anomaly, arthrodesis generally
extended at least one level above and one level below the anom-
alous segments posteriorly and along the full length of the curve
anteriorly. Supplemental instrumentation was not used. A
body cast was applied 4 to 7 days after the operation and
removed at a minimum of 4 months (range, 4 – 6 months).
Results
The profile of the patients is presented in Table 1. In this
study, 18 patients with congenital scoliosis and concom-
itant diastematomyelia underwent spur excision and an-
terior and posterior convex hemiepiphysiodesis and
hemiarthrodesis.
The primary symptoms manifested in the children
were spinal deformity in 14 patients, foot deformity in 2
patients, gait disturbance in 1 patient, and back pain and
hairy patch in 1 patient. Cutaneous abnormalities over-
lying the spine were present in 10 patients (56%). These
included hairy patches in five patients, dermal sinuses in
four patients (2 also had hairy patches), hyperpigmented
nevus in one patient, sacral dimple in one patient. Four
patients (22%) had neurologic abnormalities including
paraparesis in two patients, mild left lower extremity
paresis and urinary incontinence in one patient, and
weakness of foot intrinsics in one patient. Sensory and
motor testing was difficult in this age population, so
some additional patients may have had sensory or motor
problems. Three patients (17%) had foot deformities in-
cluding clubfeet in two children and calcaneovalgus de-
formity in one child. One child had acetabular dysplasia,
and one child had a horseshoe-shaped kidney.
Ten of the patients had complex vertebral anomalies;
four patients had unilateral unsegmented bar and con-
tralateral hemivertebra; one patient had unilateral un-
segmented bar, and three patients had hemivertebra.
Eight patients (44%) had lumbar spurs; four (22%)pa-
tients had thoracic spurs; and seven patients (39%) had
thoracolumbar spurs. Among the 18 patients, only 1 pa-
tient (6%) had double spurs. Eleven of the spurs were
located at or near the apex of the curve formed by con-
genital vertebral anomalies. In 7 of the 18 patients, the
spur was located one or more level below the curve. To
reconstruct the dural tube in three of the patients and to
excise the dermal sinuses in four of the patients, laminec-
tomy was extended to the curve, resulting in posterior
element deficiency within the fusion area. On the aver-
age, three laminas (range, 2–5) had to be removed for
excision of the spur or dural tube reconstruction. Spina
bifida occulta was seen in almost all of the patients.
However, in some patients, it was extensive, involving
several vertebrae, whereas in others, it was small. Eleven
patients had rib anomalies including fusion on the con-
cave side.
 The Efficacy of Convex Hemiepiphysiodesis • Uzumcugil et al 801

Table 1. Patient Profiles

Age at Level of Neurologic
Case Sex Anomaly Level of Curve Surgery (months) Diastematomyella Manifestations

1 F Complex T11–L4 10 L3 No
2 F UB⫹H T6–L1 13 T10 No
3 M Complex T8–L2 9 L3 Bilateral weak foot
intrinsics
4 F Complex T1–L3 60 T6 Left weakness,
urinary
incontinence
5 F UB⫹H T8–T12 11 L1 No
6 F H T5–T12 7 L4 No
7 F H T7–L1 18 T11–L1 No
8 M Complex T6–T10 9 T12–L1 No
9 F UB⫹H T4–L2 24 T10–12 No
10 F Complex T2–T8 24 T12–L1 No
11 F Complex T8–L5 24 L2 Paraparesis
12 F UB T5–T12 36 T5–7 No
13 F Complex T5–L2 20 DUAL (T11–12 No
and L1–2)
14 F UB⫹H T4–T8 21 L2 Paraparesis
15 F Complex T9–L2 6 T9 No
16 F Complex T4–T10 12 T12 No
17 F Complex T7–T12 14 L1 No
18 F H T12–L5 42 L3 No
UB ⫽ Unsegmented bar, H ⫽ Hemivertebra

The indications for the surgery were documented pro- Discussion

gression in 7 patients and magnitude of the curve (⬎50°)
at admission in 11 patients.
The mean Cobb angle was 54° (range, 31–90°) before
surgery and 48° (range, 30 – 84°) at the final follow-up
assessment. Because more than 6° difference is accepted
as a change in curve magnitude, the patients fell into
three groups. Eight patients (44%) had a true epiphys-
iodesis effect, with an average curve magnitude of 58°
(range, 40 –90°) before surgery and 39° (range, 30 –70°)
at follow-up evaluation (Figure 1 A and B). Eight pa-
tients (44%) had a fusion effect, with an average curve
magnitude of 49° (range, 31– 68°) before surgery and
50° (range, 37–74°) at follow-up evaluation (Figure 2 A
and B). Two patients (12%) had a progressive deformity
with an average curve magnitude of 63° (range, 54 –72°)
before surgery and 75° (range, 65– 84°) at follow-up
evaluation (Table 2, Figure 3 A and B). The behavior of
the compensatory curves followed that of the treated
primary curves. Sagittal alignments within the operated
segments were not observed to change.
Three patients had a curve magnitude exceeding 70°
(cases 6, 9, and 13), which constituted an extended indi-
cation of the procedure. Two of these patients had a true
epiphysiodesis effect, and one patient had progression.
Five patients had unilateral unsegmented bars (cases 2, 5,
9, 12, and 14), four of which also had contralateral hemi-
vertebra constituting an extended indication as well. One
of these patients had progression; two had a true
epiphysiodesis effect; and two had fusion effects.
No complications occurred during spur removal or
convex growth arrest. In none of the patients the neuro-
logic deficit progress or a new neurologic deficit occur
after the operation.
The delineation of the natural history and the difficulties
in correcting the rigid curves of the congenital scoliosis
have led spine surgeons to attempt stopping the defor-
mity before it becomes severe.1–7,15,19,20,25 For patients
with congenital scoliotic deformity that becomes evident
before the age of 5 years, there are some treatment op-
tions including hemivertebra excision, posterior fusion,
and convex growth arrest.
Hemivertebral excision seems to be the ideal treat-
ment of choice because it results in acute and presumable
correction in one stage. However, it has some significant
disadvantages. Klemme et al26 reported six children with
an average age of 19 months (range, 13–33 months) who
had undergone hemivertebra excision. In their series, the
duration of surgery averaged 435 minutes, and the blood
loss averaged 362 mL. In another study, hemivertebra
excision was demonstrated to have higher risks than
other procedures with regard to neurologic injury.27 The
main indication for excision is the hemivertebra at lum-
bar level (preferably at L3 or L4), which causes signifi-
cant decompensation that cannot be corrected by other
means.25,28,29
Winter and Moe30 reported their results from poste-
rior fusion in 32 patients with congenital scoliosis who
were younger than 5 years. Of the 32 patients, 12
(37.5%) were shown to demonstrate bending of fusion
mass even after the fusion was solid. Winter and Moe30
attributed this to weak fusion mass, and others attrib-
uted it to crankshaft effect produced by anterior spinal
growth in the presence of posterior tether created by the
solid fusion mass.31,32
802 Spine • Volume 28 • Number 8 • 2003
Figure 1. A 35-month-old girl (case 5) with an unsegmented bar (thick arrow) and contralateral multiple hemivertebrae (thin arrows)
concomitant with rib fusions. The Cobb angle was 56° before surgery (A) and 38° at a 2-year follow-up assessment (B).
To negate late bending, convex growth arrest both
anteriorly and posteriorly had been considered a remedy
for this small age population of patients.1–7 Although a
number of series have reported the outcome of convex
growth arrest, the great majority of the patients in these
studies were not followed until skeletal maturity (Table
3). The reported epiphysiodesis effect ranges from 20%
to 77%. The fusion effect reportedly is 17% to 70%, and
progression after this procedure reportedly is 6% to
21%.1,3,5–7 Recently, transpedicular anterior and pos-
terior convex growth arrest had been reported with
success comparable to that for classic convex growth
arrest3 (Table 3).
In this series, 18 patients with congenital scoliosis and
diastematomyelia underwent spur excision and convex
anterior and posterior hemiepiphysiodesis at an average
age of 20 months and were followed for a minimum of 2
years. Among these patients, 44% had epiphysiodesis
effect; 44% had fusion effect; and 12% deteriorated. The
88% success rate is comparable with that of the afore-
mentioned studies on convex growth arrest. However,
some questions still need to be answered, such as why
some patients responded well to the treatment and
others did not. With a limited number of patients in
this study, statistically significant correlations could
not be drawn between the type or location of the de-
formity or the age group that underwent surgery and
the response to treatment. Also, in the literature, this
issue is not highlighted.1–7
The treatment of unilateral unsegmented bar with
convex growth arrest was reported to be useless because
it was believed to be impossible for the concavity of the
curve to grow.7,29 Winter6 operated on two patients with
unilateral unsegmented bar and obtained a fusion effect
in both patients. Andrew and Piggott1 operated on three
patients with unsegmented bar, two of which also had
contralateral hemivertebra, and achieved an epiphys-
iodesis effect in two patients and a fusion effect in one
patient. Keller et al3 operated on seven curves with uni-
lateral unsegmented bar, and obtained fusion in five, but
two patients progressed. In the current series, five pa-
tients had unilateral unsegmented bar, four of whom had
contralateral hemivertebra. An epiphysiodesis effect was
obtained in two patients and a fusion effect in two pa-
tients, whereas one patient experienced progression. As
the operation extends above and below the bar, there still
is some possibility of correction, with growth, or at least
a fusion effect, to be obtained.1
A curve magnitude less than 70° was reported to be
one of the prerequisites for a successful convex growth
arrest.7 Winter6 operated on two patients with a curve
magnitude exceeding 70° and obtained a fusion effect in
 The Efficacy of Convex Hemiepiphysiodesis • Uzumcugil et al 803

Figure 2. An 18-month-old girl (case 7). The curve was stabilized at 24 months after surgery. The Cobb angle was 40° before surgery (A)
and 42° at the final follow-up assessment (B).

both. Andrew and Piggott1 operated on one patient and a contralateral hemivertebra complicating the situation,
obtained a true epiphysiodesis effect. Keller et al3 oper- experienced progression. Although the number of pa-
ated on one patient with more than 70° of curve magni- tients treated was limited in the current study and in the
tude and obtained a fusion effect. The current authors literature, the authors think that whenever the other pre-
obtained two true epiphysiodesis effects, whereas one requisites of convex growth arrest are fulfilled in a pa-
patient, who also had a unilateral unsegmented bar with tient, the curve magnitude exceeding 70° can be of sec-
ondary importance.
Table 2. Patient Cobb Angles Although none of the 4 patients with neurologic def-
icit had progression and no neurologic deficits were iden-
Cobb angle(°) Age at Follow-up tified in the remaining 14 patients, it was decided to
follow-up time
Case Sex Preoperative Follow-up (months) (months)
remove the spurs. One of the objectives was to prevent
possible neural deterioration in patients with a deficit (4
1 F 31 37 34 24 patients).9,11–15 Neural deficit progression was seen pre-
2 F 68 74 73 60
3 M 58 63 33 24
dominantly in patients before the age of 5 years.9 Pro-
4 F 60 49 100 40 gression of neural symptoms was reported for 70% of
5 F 56 38 35 24 the patients at the subsequent follow-up assessment.14
6 F 90 70 57 50
7 F 40 42 42 24
Another objective was to prevent possible development
8 M 55 55 33 24 of neural abnormality in patients who were neurologi-
9 F 72 84 51 27 cally normal (14 patients).9,11–15 The last but most im-
10 F 54 65 144 120
11 F 45 32 48 24 portant objective was to prevent neural complications
12 F 54 60 96 60 during prospective and gradual curve correction after
13 F 74 30 80 80 convex growth arrest.9,11–15 McMaster9 advised re-
14 F 40 32 57 36
15 F 46 32 30 24 moval of intraspinal anomaly as a prophylactic measure
16 F 45 40 45 33 in all children younger than 6 years with a congenital
17 F 53 30 38 24 scoliosis regardless of their neural status. Excision of the
18 F 39 33 66 24
spur did not result in a dramatic improvement in neuro-
804 Spine • Volume 28 • Number 8 • 2003

Figure 3. A 2-year-old girl (case 10). At the 10-year follow-up assessment, a curve progression of 11° was observed. A, Preoperative
radiograph. B, Follow-up anteroposterior radiographs.

logic status, but at least none of the patients were made
worse. This also was a common finding in the literature
reporting on diastematomyelia excision.9,11–13 The pa-
tients with neural lesions comprised 22% of the patients
of the current study. This is a significantly lower inci-
dence than the reported 50% to 89% neural deficit
among patients with diastematomyelia in the litera-
ture.9,11–14 This may be the result of diagnosing and
treating the patients at an early age.
The presence of iatrogenic laminectomy defect, al-
though theoretically thought to decrease the bony sur-
face available for an effective solid fusion posteriorly,
was found to have no negative effect on the outcome in
the patients treated with convex growth arrest. This
could result from the integrity of the facet joints and
transverse processes, which were not resected during re-
moval of the spur.28
Convex growth arrest is a safe procedure that generally
does not result in serious complications except for wound
or chest infections and traction neuropraxias of the inter-
costal or thigh cutaneous nerves.1–7 The patients in the cur-
rent study had no major or minor complications.
In conclusion, convex epiphysiodesis is as effective for
treating patients with midline laminectomy defects as for
treating patients with intact posterior elements. How-
ever, for a better analysis of the results from this tech-

Table 3. Previously Reported Outcomes of Convex Growth Arrest

Number of Age at Follow-up Epiphysiodesis
Study Patients Surgery Period Effect Fusion Effect Progression

Winter [29] 10 3 yr. 10 mo. 2 yr. 9 mo. 2 (20%) 7 (70%) 1 (10%)

Andrew [1] 13 5 yr. 10 mo. 4 yr. 4 mo. 6 (46%) 6 (46%) 1 (8%)
Winter [31] 13 3 yr. 6 mo. 6 yr. 6 mo. 5 (38%) 7 (54%) 1 (8%)
Keller [13] 16 4 yr. 8 mo. 4 yr. 8 mo. 7 (37%) 8 (42%) 4 (21%)
Thompson [25] 30 6 yr. 4 mo. 8 yr. 10 mo. 23 (77%) 5 (17%) 2 (6%)
Present Series 18 1 yr. 8 mo. 3 yr. 3 mo. 8 (44%) 8 (44%) 2 (12%)
 The Efficacy of Convex Hemiepiphysiodesis • Uzumcugil et al 805
nique, the patients should be followed until skeletal
maturity.
Key Points
● A retrospective review was conducted for 18 pa-
tients with congenital scoliosis and diastematomy-
elia who underwent spur excision and anterior and
posterior convex growth arrest and were followed
up for a minimum of 2 years.
● Convex hemiepiphysiodesis is as effective for
treating patients with midline laminectomy defects
as it for treating patients with intact posterior
elements.
● For a better analysis of the results, these patients
should be followed up until skeletal maturity.
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