Commentary.

Dear Editor, I read with great interest the case report from Silverstein and colleagues [1] about the surgical technique used to correct a congenital kyphosis in Uganda. Having been involved in the care of spinal deformities in developing countries for the last 7 years, I would like to comment on this interesting case. First, I commend the authors for performing such a procedure (pedicle subtraction osteotomy [PSO] at the cord level) with this nice immediate postoperative result. Performing complex spine surgery in such environment requires specific talents that range from extraordinary personal relationship skills (built over the years with the local surgical team), to very skilled surgeons used to perform such techniques of PSO at this level. However, a few points need to be clarified. Diagnosis The diagnosis from the x-rays available appears to show a congenital kyphosis type 2 with lack of segmentation. Besides there seems to be multiple levels of defect of segmentation on the x-rays as it seems that the level T12– L1 and L1–L2 are fused anteriorly as well. The curve measured 65°, as indicated by the authors. Such a defect of segmentation will very likely progress in a 10-year-old girl who is most likely premenarchal; thus, I agree with the need to correct the deformity. Her neurological picture is intriguing and I think this should be emphasized in the text as I am not aware of such a case causing myelopathy at such a young age as opposed to type I congenital kyphosis (defect of formation), which is notorious for neurologi-cal complications if not stabilized. In the articles by McMaster and Singh [2] and Winter et al [3], all neurological complications from congenital kyphosis were observed in type 1 or 3 (mixed types) and none from type 2 [4]. Therefore, I have some serious doubts as to this congenital kyphosis causing neurological symptoms in this case. It is unfortunate that no MRI was available to rule out other causes of myelopathy or gait disturbance. If Silverstein et al [1] believed that kyphosis was responsible for myelopathy then a simple myelogram with a lateral shoot through x-rays could have been helpful. Spinal cord monitoring In the last 10 years it has become state of the art to perform spinal deformity correction with spinal cord monitoring (SCM). Performing spinal deformity surgery without SCM is obviously possible and one can use the Stagnara wake up as the only …