大重量Halo-股骨髁上牵引辅助一期后路手术治疗重度僵硬型非特发性脊柱侧凸的临床疗效

[目的]探讨大重量Halo-股骨髁上牵引辅助一期后路手术治疗重度僵硬型非特发性脊柱侧凸的可行性及临床疗效。[方法]2007年1月²012年2月本院实施587例脊柱侧弯矫形术,对其中行Halo-股骨髁上牵引治疗且临床资料完整的35例重度僵硬型非特发性脊柱侧凸患者进行回顾性分析。[结果]随访142012年2月本院实施587例脊柱侧弯矫形术,对其中行Halo-股骨髁上牵引治疗且临床资料完整的35例重度僵硬型非特发性脊柱侧凸患者进行回顾性分析。[结果]随访14⁷2个月(平均42个月)。Halo-股骨髁上牵引治疗结束后侧凸Cobb角平均(49±11)°,与术前冠状面Cobb角相比,差异具有统计学意义;侧凸纠正率达平均(40.9±9.3)%。后路矫形术后侧凸Cobb角与术前冠状面Cobb角相比,差异具有统计学意义;侧凸矫正率为平均(52.6±8.2)%。术后矢状面后凸Cobb角为(34±10)°,与术前矢状面后凸Cobb角相比,差异具有统计学意义;后凸矫正率平均(51.9±9.3)%。末次随访时冠状面Cobb角平均达(37.6±12)°,与术前冠状面Cobb角相比,差异具有统计学意义;矢状面后凸Cobb角平均(33±10)°,与术前矢状面后凸Cobb角相比,差异具有统计学意义。躯干移位经牵引后从平均(12.5±3.8)mm矫形至(6.94±4.6)mm,平均改善65.7%。1例患者牵引过程中Halo松动,予以更换,无其他明显牵引并发症发生。矫形术后无瘫痪、死亡等并发症,所有患者均未出现内固定松动或断裂。[结论]Halo-股骨髁上牵引在治疗重度僵硬型非特发性脊柱侧凸中是一种安全有效的治疗方案,结合单纯一期后路矫形手术,可大幅度提高重度非特发性脊柱侧凸畸形矫正疗效。     

组合可调式Halo-骨盆固定支具的设计及初步临床应用

目的设计新型组合可调式Halo-骨盆固定支具并观察该装置联合截骨术治疗重度僵硬型脊柱畸形的临床疗效。方法回顾性分析2015年2月—2017年6月采用Halo-骨盆固定支具术前牵引联合截骨术治疗的8例重度僵硬型脊柱畸形(特发性侧凸7例,结核性后凸1例)患者的临床资料。记录并观测患者治疗前后脊柱侧凸/后凸Cobb角、躯干偏移距离、躯干高度(T_1～S_1)及身高的改善程度。结果 8例患者均顺利完成手术。7例特发性侧凸患者牵引后及术后Cobb角、躯干高度(T_1～S_1)、躯干偏移距离及身高均较术前显著改善,差异有统计学意义(P 0.05);牵引后及术后Cobb角矫正率分别为29.3%、46.8%。1例结核性后凸患者,牵引后及术后后凸Cobb角及身高均较术前显著改善,牵引后及术后后凸Cobb角矫正率分别为4.9%、34.0%。牵引过程中2例发生盆针皮肤切割伴感染,1例发生颅钉松动脱落,均经对症治疗后痊愈。结论组合可调式Halo-骨盆固定支具可满足重度僵硬型脊柱畸形患者术前脊柱固定和牵引的治疗需求,通过术前缓慢牵引可逐步矫正重度脊柱畸形,是一种简便、安全、有效的辅助治疗手段。     

Halo-头盆环牵引联合Ⅱ期矫形治疗重度僵硬性脊柱侧弯

目的:探讨头盆环牵引联合Ⅱ期矫形在重度僵硬性脊柱侧弯的临床疗效。方法 :2015年1月至2019年5月行头盆环牵引的脊柱侧弯患者共16例,其中男7例,女9例;年龄14~28岁,平均17.6岁;Cobb角90°~140°(108.84±17.93)°;先天性脊柱侧凸10例(分节不良6例,形成障碍3例,混合型1例),特发性脊柱侧凸4例,神经纤维瘤病2例。16例均采用Ⅰ期头盆环牵引联合Ⅱ期手术治疗,其中7例采用自制髂骨穿针导向器进行髂骨穿针,9例采用徒手髂骨穿针。对16例患者手术治疗前后身高、侧凸Cobb角、后凸Cobb角及矫正率进行观察。结果:患者身高由治疗前(144.88±6.32)cm矫正至(154.56±7.87)cm,侧凸Cobb角由(108.84±17.93)°矫正至(42.12±7.29)°,后凸Cobb角由(64.18±16.39)°矫正至(33.81±6.06)°。Ⅰ期术前牵引后身高增加、侧凸及后凸Cobb角平均矫正率分别为(7.06±5.65) cm、(41.50±9.09)%、(30.52±9.66)%;Ⅱ期牵引矫形内固定后身高增加、侧凸及后凸Cobb角平均矫正率分别为(2.63±1.78) cm、(32.47±10.80)%、(15.55±9.47)%(矫正率参照的基准Cobb角是上一期治疗的Cobb角);分期牵引联合手术治疗的身高增加、侧凸及后凸Cobb角平均矫正率分别为(9.69±5.42) cm、(61.09±5.03)%、(46.07±8.60)%。各期治疗前后患者侧凸Cobb角、后凸Cobb角及矫正率差异均有统计学意义(P0.05)。结论:采用头盆环牵引联合Ⅱ期矫形治疗重度僵硬性脊柱侧弯,能够明显矫正畸形,改善外观,且手术并发症少,具有较强的临床可操作性。     

术前大质量Halo-股骨髁上牵引在治疗僵硬型特发性脊柱侧凸中的应用

目的 探讨术前快速大质量Halo-股骨髁上牵引在治疗僵硬型特发性脊柱侧凸中的应用价值.方法 对2003年7月至2006年5月行术前快速大质量Halo-股骨髁上牵引治疗且临床资料完整的16例僵硬型特发性脊柱侧凸患者进行回顾性分析.其中男性4例,女性12例;年龄12～20岁,平均16岁,术前冠状面Cobb角平均111°,胸椎后凸(T_(5～12))平均64°.术前行Halo-双侧股骨髁上牵引,最大质量(可达体质量的1/2)牵引2～3周后,行后路矫形内固定融合术.对术前Bending像、牵引后和术后侧凸纠正率进行比较.结果 随访12～60个月(平均36个月).最大牵引质量平均19 kg,为体质量的35%～56%.1例患者在牵引12 d后出现右侧臂丛神经麻痹,减轻牵引质量后逐渐恢复.矫形术后无瘫痪、死亡等并发症,无呼吸衰竭的发生.术前平卧位Bending像X线片的侧凸纠正率平均18.7%,Halo-股骨髁上牵引后侧凸纠正率平均达31.9%.与Bending像相比,牵引后侧凸纠正率提高了13.2%,差异具有统计学意义(P<0.05).后路矫形术后侧凸矫正率平均为48.6%,胸椎后凸矫正率平均为51.9%.末次随访时冠状面矫正丢失率平均为2.0%,矢状面矫正丢失率平均为5.8%.结论 术前短时间大质量Halo-股骨髁上牵引结合后路广泛松解可改善僵硬型特发性脊柱侧凸畸形矫形率,但应注意与牵引相关的并发症.     

改良Halo-骨盆架在重度僵硬性脊柱侧凸矫形中的应用及牵引能力评价

[目的]探讨改良Halo-骨盆牵引架在重度僵硬性特发性脊柱侧凸矫形过程中的牵引能力,评价该方法的应用价值及主要优点.[方法]对本科2004年1月～2008年3月重度僵硬性特发性脊柱侧凸病例进行回顾性分析.23例患者,男7例,女16例;年龄13～27岁,平均16.8岁.治疗前冠状位主侧凸角为68°～115° (91.8°±12.6°),矢状位胸椎后凸角48°～86°(69.5°13.5°).治疗过程分三期进行.一期:完善相关检查后即安装改良Halo一骨盆架,逐步增加牵引力,直至患者不能耐受止;二期:在持续牵引下行前路松解术,术后继续加大牵引力度至理想效果或患者不能耐受止;三期:进行后路矫形内固定手术并去除头盆环牵引.本组患者平均随访18.5个月,对不同时期脊柱侧凸角及后凸角等矫形情况进行比较分析.[结果]本组患者住院时间26～39 (31.2±4.7) d.一期牵引后侧凸角矫正率30.8%%,后凸角矫正率 21.9%;二期牵引后侧凸角矫正率49.3%,后凸角矫正率37.7%.经后路矫形内固定手术后脊柱畸形进一步改善,侧凸及后凸角矫正率分别为66.4%和54.5%.随访时发现矫形有轻微丢失,但P>0.05.[结论]改良Halo-骨盆架能有效地对重度僵硬性脊柱侧凸进行牵引矫形,该弹性持续牵引增加了患者舒适感和耐受性.结合前路松解、后路椎弓根固定矫形,整个治疗过程能够有效地避免神经系统和呼吸系统并发症的发生,增加矫形效果.     

Halo-股骨髁上牵引对重度脊柱侧凸后路矫形的影响

目的探讨Halo-股骨髁上牵引对重度先天性脊柱侧凸及特发性脊柱侧凸患者后路矫形效果的影响。方法选取60例重度脊柱侧凸患者分为先天性脊柱侧凸组及特发性脊柱侧凸组,每组30例。CS组术前平均冠状面Cobb角、胸椎后凸分别为95．7°及70．2°。IS患者术前平均冠状面Cobb角、胸椎后凸为91．6°及50．6°。平均随访38个月。结果60例患者平均牵引23d,平均牵引重量16kg。IS组患者Halo牵引及后路矫形术后侧凸矫正率分别达39．3％、57．5％,胸椎后凸平均矫正33．7％。CS组Halo牵引及后路矫形术后侧凸矫正率分别达35．3％、45．2％,胸椎后凸平均矫正43．5％。两组患者后路矫形术后侧凸及后凸矫正率差异均有统计学意义（P〈0．05）。4例患者在牵引过程中并发臂丛神经麻痹,神经功能均在2个月内获得完全恢复。结论Halo-股骨髁上牵引可大幅提高脊柱侧凸尤其是特发性脊柱侧凸畸形矫正疗效。     

小切口微创分期手术治疗早发型脊柱侧凸早期疗效观察

目的观察小切口微创分期手术治疗早发型小儿脊柱侧凸的早期疗效和安全性。方法对26例早发型小儿脊柱侧凸进行小切口微创分期手术治疗。其中男8例,女18例,年龄（8.5±1.2）岁。术前侧凸主弯冠状面Cobb角为（98.0°±15.4）°,矢状面后凸Cobb角为（38.8±14.7）°。Ⅰ期采用小切口微创手术,将脊柱侧凸矫正约55%左右,之后每隔6～12个月再进行一次生长矫形,至骨骼发育成熟后作终末矫形内固定,行剃刀背切除并植骨融合。结果所有病例均顺利完成手术,无严重并发症发生。16例完成初次手术,10例完成二次手术。初次小切口矫形术后侧凸主弯冠状面Cobb角为（42.2±10.1）°,平均矫正率56.9%;二次延长术后侧凸主弯冠状面Cobb角为（35.8±6.6）°,平均矫正率34.1%。总矫形率为65.4%。结论对早发型小儿脊柱侧凸行小切口微创分期手术治疗的研究初步证实,该术式可以提高畸形矫形效果,延缓脊柱融合时间,减轻早期融合对脊柱生长发育的影响。     

重度僵硬后凸型脊柱侧凸畸形的手术治疗

目的探讨应用脊柱后路截骨矫形治疗重度僵硬性脊柱侧后凸畸形的治疗效果及临床应用价值。方法 2007年5月至2008年6月采用经后凸顶椎椎弓根Ⅴ形截骨,凸侧采用悬臂梁压棒技术治疗16例重度僵硬性脊柱侧后凸畸形患者,男12例,女4例,年龄14～22岁,平均17.4岁。先天性脊柱侧后凸11例,特发性脊柱侧后凸5例。截骨部位均位于胸椎。结果平均手术时间（226±32）min,术中出血量（1360±265） ml,平均随访28个月（24～36月）,术前主弯侧凸Cobb角83°±11.7°（75°～106°）,后凸角91°±13.2°（82°～102°）,术前C7铅垂线距骶中线距离（1.45±0.26）cm;术后侧凸Cobb角矫正至27.4°±11°（矫正率67%）;后凸Cobb角25.5°±9.5°（矫正率72%）。C7铅垂线距骶中线距离（0.48±0.13） cm。无神经系统并发症发生。结论经后凸顶椎椎弓根V形截骨,凸侧采用悬臂梁压棒技术治疗重度僵硬性脊柱侧后凸畸形是一种安全、可靠的方法,矫形效果满意。     

重度僵硬型脊柱侧凸的一期后路Ponte截骨置钉二期后路矫形术

 目的 探讨一期后路Ponte截骨置钉二期后路矫形在治疗重度僵硬型脊柱侧凸中的疗效及安全性。方法 回顾性分析2010年6月至2012年12月接受一期后路Ponte截骨二期后路矫形治疗的Cobb角大于100°的僵硬型脊柱侧凸患者24例,男9例,女15例;年龄14~30岁,平均（21.4±4.1）岁。术前冠状面主弯Cobb角106°~156°,平均125.8°;后凸角59°~141°,平均100.1°。一期后路Ponte截骨松解、置钉,术后Halo-股骨髁上牵引,再行二期后路置棒矫形融合术。比较术前站立位、后路松解牵引后仰卧位、术后及末次随访的冠状面主弯Cobb角。结果 术前仰卧Bending位主弯侧凸柔韧性为14.8%±7.5%;后路松解牵引后主弯侧凸柔韧性为29.1%±9.9%;较术前平均提高14.3%,差异有统计学意义。后路矫形术后主弯Cobb角平均74.4°±14.5°,矫正率平均41.0%±8.1%;与术前仰卧Bending位和松解牵引后比较矫正率分别提高了26.2%和11.9%,差异有统计学意义。术后随访15~36个月,平均（24.0±5.9）个月。末次随访时主弯Cobb角平均丢失1.4°。术后后凸角平均53.0°±13.7°,较术前（100.1°±23.7°）明显改善,矫正率平均46.1%±11.9%,末次随访时无矫正丢失。牵引中1例发生左侧股骨髁上钉道感染,2例发生左下肢静脉血栓。结论 后路Ponte截骨松解+Halo-股骨髁上牵引能够使重度僵硬型脊柱侧凸患者获得满意的矫正率,但应注意下肢静脉血栓形成的风险。     

应用头颅-骨盆环牵引辅助后路截骨治疗重度脊柱侧后凸畸形的临床效果

目的探讨应用头颅-骨盆环牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形的临床效果。方法回顾分析2014年3月至2018年3月贵州省骨科医院脊柱外科收治的重度脊柱侧后凸畸形患者32例的临床资料。其中男14例,女18例,年龄(17.5±4.8)(14~23)岁。均行Halo骨盆牵引后后路截骨矫形手术治疗。牵引力取患者可承受的极限,牵引时间为(3.2±0.6)(3~4)周,后行后路截骨内固定融合术。对患者治疗前左右侧屈位、牵引后和术后的侧后凸矫正率进行比较。采用SPSS 24.0软件对数据进行统计学处理。结果32例患者均顺利完成手术。行经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)或邻椎截骨12例、Smith-Petersen截骨(Smith-Petersen osteotomy,SPO)或Ponte截骨20例。未见脊髓与神经损伤并发症发生。治疗前脊柱冠状面Cobb角为(136.8±38.0)°(96°~172°),矢状面Cobb角为(90.4±24.0)°(45°~125°)。患者平卧左右侧屈位侧凸矫正率为(8.9±3.2)%,Halo骨盆牵引后侧凸矫正率为(37.6±4.3)%,后路截骨矫形术后侧凸矫正率为(68.7±4.8)%;牵引后矢状面侧凸矫正率为(30.7±5.6)%,后路矫形术后矢状面侧凸矫正率(60.6±4.3)%;各时间点差异均有统计学意义(均P<0.05)。结论应用Halo头颅-骨盆牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形患者,可预测矫形效果,简化手术,降低操作难度,提高畸形矫正率,安全有效。     

Evaluation of deformity and hand function in cerebral palsy patients

Background

A retrospective study of staged surgery for severe rigid scoliosis. The purpose of this study was to evaluate the result of staged surgery in treatment of severe rigid scoliosis and to discuss the indications.

Methods

From 1998 to 2006, 21 cases of severe rigid scoliosis with coronal Cobb angle more than 80° were treated by staged surgeries including anterior release and halo-pelvic traction as first stage surgery and posterior instrumentation and spinal fusion as second stage. Pedicle subtraction osteotomy(PSO) was added in second stage according to spine rigidity. Among the 21 patients, 8 were male and 13 female with an average age of 15.3 years (rang from 4 to 23 years). The mean pre-operative Cobb angle was 110.5° (80°-145°) with a mean spine flexibility of 13%. Radiological parameters at different operative time points were analyzed (mean time of follow-up: 51 months).

Results

External appearance of all patients improved significantly. The average correction rate was 65.2% (ranging from 39.8% to 79.5%) with mean correction loss of 2.23° at the end of follow-up. No decompensation of trunk has been found. Mean distance between the midline of C7 and midsacral line was 1.19 cm ± 0.51. Two patients had neurological complications: one patient had motor deficit and recovered incompletely.

Conclusion

Staged operation and halo-pelvic traction offer a safe and effective way in treatment of severe rigid scoliosis. Patients whose Cobb angle was more than 80° and the flexibility of the spine was less than 20% should be treated in this way, and those whose flexibility of the spine was less than 10% and the Cobb angle remained more than 70° after 1st stage anterior release and halo-pelvic traction should undergo pedicle subtraction osteotomy (PSO) in the second surgery.     

前路松解联合后路矫形固定治疗重度脊柱侧凸

目的：评价前路松解联合后路矫形对重度脊柱侧凸的治疗效果。方法：2000年7月至2007年1月采用前路松解联合后路矫形固定治疗重度脊柱侧凸23例,男12例,女11例;年龄9～18岁,平均15.3岁。其中先天性半椎体脊柱侧凸9例,特发性脊柱侧凸13例,神经纤维瘤病性脊柱侧凸1例。冠状面上Cobb角81°～126°,平均97.4°。结果：术后侧凸Cobb角为10°～55°,平均37.4°,平均矫正率56.2%。身高增加0.5～7.5cm,平均5.2cm。全部病例均获随访,时间6～24个月,平均10个月,2例出现交界区＂附加＂现象,无断棒、脱钩等并发症。结论：脊柱前路松解安全、有效,联合后路矫形内固定治疗重度脊柱侧凸可获得满意治疗效果。     

Is sacral instrumentation mandatory to address pelvic obliquity in neuromuscular thoracolumbar scoliosis due to myelomeningocele?

STUDY DESIGN: Prospective study. OBJECTIVE: To evaluate the functional outcome of two-stage anterior and posterior instrumented fusion without fixation to the sacrum on 11 patients with neuromuscular scoliosis from thoracolumbar myelomeningocele. SUMMARY OF BACKGROUND DATA: To our knowledge, there are no published results of combined anterior and posterior correction and fusion without inclusion of the sacrum in neuromuscular scoliosis from thoracolumbar myelomeningocele. In this article we present our experience and critically evaluate the functional outcome on 11 patients with neuromuscular scoliosis. PATIENTS AND METHODS: From July 1, 1992 through June 30, 1995, 11 consecutive patients with severe thoracolumbar scoliosis were admitted at our hospital. The mean age at operation was 12 years 9 months (range 9 years 9 months to 14 years 6 months). All patients underwent a two-stage anterior and posterior spinal reconstruction. The patients were evaluated before surgery and after surgery. RESULTS: All patients were observed for a mean of 4 years 11 months (range 42-88 months) from the time of second stage procedure. Before treatment the mean scoliosis was 81 degrees (range 55-110 degrees ); this was reduced to a mean of 31 degrees (range 8-70 degrees ), and at the final follow-up the correction had deteriorated slightly to a mean of 35 degrees (range 12-80 degrees ). No patient had increased neurologic deficit or showed other major complication. CONCLUSIONS: Pelvic obliquity in thoracolumbar neuromuscular scoliosis from lumbosacral myelomeningocele spontaneously corrected when the scoliotic deformity is adequately addressed with instrumented fusion without inclusion of the sacrum. The correction obtained remained stable at follow-up. In the absence of a control group we believe that sparing lumbar segments from primary fusion offers these patients a better freedom of mobility.     

One- or two-step instrumentation for thoracolumbar scoliosis due to myelomeningocele?

AIM: This investigation evaluates patients with MMC who underwent a two-stage anterior-posterior correction and stabilisation of thoracolumbar scoliosis due to myelomeningocele. The data were compared with the few reported series of one-stage versus two-stage surgery in the literature. METHOD: From 1.7.1992 to 30.6.1995, 11 consecutive patients with severe thoracolumbar scoliosis due to myelomenigocele were admitted at our hospital. The mean age at operation was 12 years nine months (range nine years nine to 14 years six months). All patients underwent a two-stage anterior and posterior spinal instrumentation. The patients were pre- and postoperatively evaluated. RESULTS: All patients were followed for a mean of 4 years 11 months (range 42 months to 88 months) from the time of the second stage procedure. Preoperatively the mean scoliosis angle was 82 degrees (range 55 degrees to 110 degrees ), this was reduced to a mean of 31 degrees (range 8 degrees - 70 degrees ), at final follow-up, the correction had deteriorated slightly to a mean of 35 degrees (range 12 degrees - 80 degrees ). No patient had increased neurological deficit or showed other major complications, i. e., infection, sepsis due to immunologic disorders at the time of the operation. CONCLUSION: We believe that with the two-stage anterior and posterior instrumentation an effective correction of the scoliosis can be achieved. Compared to other studies this report confirms the low morbidity rate and emphasise the good results of a two staged procedure.     

一期后路全脊椎切除术治疗重度僵硬性胸腰椎畸形的并发症分析

目的 分析一期后路全脊椎切除、椎弓根螺钉固定矫治重度胸腰椎畸形的并发症.方法 2000年2月至2009年2月通过一期后路全脊椎切除治疗重度胸腰椎畸形患者54例,男性23例,女性31例;年龄16～58岁,平均28.3岁.侧凸畸形9例,冠状面主弯Cobb角平均91.7°;侧后凸畸形22例,冠状面主弯Cobb角平均101.5°,后凸角平均69.4°;角状后凸畸形21例,后凸角平均72.2°;圆弧状后凸2例,后凸角平均93.6°.采用主弯区顶椎全脊椎切除、全节段椎弓根螺钉内固定和360°植骨融合术.对临床结果进行评估,统计并分析并发症发生情况.结果 平均切除椎体1.4个,手术时间平均470 min,术中出血量平均4180 ml.随访时间12～66个月,平均26个月.末次随访侧凸畸形平均矫正61.4°(67%);侧后凸畸形中侧凸平均矫正59.7°(56%),后凸平均矫正42.3°(59%);角状后凸平均矫正48.5°(71%);圆弧状后凸平均矫正62.7°(67%).共有17例患者出现21例次并发症(38.9%),其中早期神经系统并发症5例次(9.3%),包括1例完全性脊髓损伤.非神经系统并发症早期11例次(20.4%),后期5例次(9.3%).结论 一期后路全脊椎切除治疗胸腰椎脊柱畸形可以取得较为满意的畸形矫正结果,但其潜在的严重并发症不可忽视.     

Scoliosis associated with lumbar spondylolisthesis. A clinical survey of 190 young patients

A series of 190 patients with lumbar spondylolisthesis treated operatively during the years 1948-80 at the mean age of 15.2 years (8-19 years) and reexamined 4-36 years (mean 11.2 years) later are presented. In 92 of them (48%) scoliosis (more than 5 degrees) in association with olisthesis was seen. The slipping affected the fifth segment in 90 and fourth segment in two patients. The female predominance was characteristic in the scoliotic group. Dysplastic changes of the posterior arc were more often seen in the group of patients with scoliosis than in the nonscoliotic group, and they also presented a more severe grade of slipping and lumbosacral kyphosis. The curve was usually mild and was situated in the lumbar area. Patients with a higher degree of lumbosacral kyphosis and more severe slipping also had a statistically higher degree of lumbar scoliosis. Operative treatment of spondylolisthesis consisted of posterior or posterolateral fusion in situ, but two patients were treated using ventral fusion and three severe cases with removal of loose posterior element. Lumbar scoliosis classified as sciatic type disappeared in 25 out of 39 patients after lumbosacral fusion, suggesting the "sciatic muscle spasm" as an etiologic factor. The torsional type of curve resulting from asymmetrical slipping of the vertebra was also corrected in 19 out of 28 cases after fusion. At follow-up patients with remaining lumbar scoliosis represented more low-back pain than those without any curve. In our opinion lumbosacral fusion is indicated before lumbar curve changes to structural scoliosis in symptomatic patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Radiographic and functional outcome after surgical management of severe scoliosis in skeletally immature patients with muscular dystrophy

OBJECTIVE: Most patients with muscular dystrophy (MD) develop progressive scoliosis after losing ambulatory status, but some cases develop severe scoliosis at a skeletally immature age before losing ambulatory status. Only a few studies have been conducted in skeletally immature patients with severe scoliosis. The purpose of this study was to assess the functional and cosmetic outcome in skeletally immature patients with severe scoliosis. METHODS: Preoperative, immediate postoperative, and final follow-up radiographs were analyzed in 10 consecutive skeletally immature patients with respect to the Cobb angle degree and the pelvic obliquity angle correction, how long the correction was maintained, and the development of the crankshaft phenomenon. In the functional assessment, the ability to sit balanced, according to the Mulcahy method, and the ability to use hands, according to the Rhyu method, were evaluated. Furthermore, the degree of subjective satisfaction was evaluated in these patients. RESULTS: The average age of the patients was 10.4 years, and the average follow-up period was 33 months with minimum 2 years' follow-up. All 10 patients survived and were available at the follow-up. The mean Cobb and pelvic obliquity angles were 80 degrees and 17 degrees at the time of the surgery, 31 degrees and 3.7 degrees immediately after the surgery, and 35 degrees and 4.7 degrees at the time of the final follow-up, respectively. The initial mean Cobb angle correction averaged 61%, with 78% of pelvic obliquity corrected. These corrections were maintained over time in most cases. At the time of the surgery, the mean volume of blood loss was 1111 mL, with an average operation time of 411 minutes. There were no major complications. At the time of the last follow-up, no patient showed development of the crankshaft phenomenon. The average score for the ability to sit balanced improved from 4.4 to 6.6 according to the Mulcahy evaluation method. The scores for hand use were 2.2-2.7. However, the forced vital capacity of the lungs decreased from a preoperative 48% to 46.1%. CONCLUSIONS: These results indicate that even in very young MD patients with severe scoliosis, acceptable curve correction can be achieved and maintained with surgery. The improved pelvic obliquity and scoliosis angle stabilized the spine, freeing the upper extremities and allowing productive activities characteristic of childhood.     

Scoliosis in patients with diastrophic dysplasia: a new classification

STUDY DESIGN: Scoliosis in patients with diastrophic dysplasia was analyzed. OBJECTIVES: To study the natural history of scoliosis and to classify the patients with different types of scoliosis. SUMMARY OF BACKGROUND DATA: Typical findings in diastrophic dysplasia are short-limbed short stature, multiple joint contractures, early degeneration of joints, and spinal deformities. The largest studies have reported scoliosis in 37% to 88% of the patients with this rare skeletal dysplasia. The natural history of the deformity is unknown. METHODS: Of the 130 unselected patients, 98 (75%) who were older than 16 years and/or had undergone surgery at the time of the last radiograph were included in the final analysis. These 98 patients included 37 males and 61 females. Their ages at the first radiograph ranged from newborn to 78 years (average, 21 years). The mean follow-up period was 20 years (range, 2-41 years) for 80 patients. Standard standing anteroposterior and lateral radiographs were taken. The degrees of scoliosis, kyphosis, and lordosis were measured according to the Cobb method. Classification of the scoliosis was based on the patient's age at onset of scoliosis, the rate of progression, the magnitude of the scoliosis at the end of growth, and the curve pattern. RESULTS: Of the 98 patients in this study, 86 (88%) had scoliosis. This difference was highly significant statistically (P < 0.001), as compared with the normal population. The frequency of scoliosis was 90% among females and 84% among males. Scoliosis can be divided further into three subtypes: early progressive (11 patients), idiopathic-like (41 patients), and mild nonprogressive (33 patients). One patient had a congenital scoliosis. CONCLUSIONS: Scoliosis is very common in patients with diastrophic dysplasia. The natural history of scoliosis varies from severe deformity with rapid progression to mild deformity without any progression. The authors suggest that the classification described in this report offers a tool for the predicting natural history of scoliosis in diastrophic dysplasia, and for adjusting the timing of surgery in individual patients.     

Structural vertebral changes in the horizontal plane in idiopathic scoliosis and the long-term corrective effect of spine instrumentation

Summary The rotation and structural changes of the apex vertebra in the horizontal plane as well as of the thoracic cage deformity were quantified by measurements on computed tomography (CT) scans from patients with right convex thoracic idiopathic scoliosis (IS). The CT scans were obtained from 12 patients with moderate scoliosis (mean Cobb angle 25.8°, r 13°–30°) and from 33 with severe scoliosis (mean Cobb angle 46.2°, r 35°–71°). In addition, CT scans of thoracic vertebrae from 15 patients without scoliosis were used as reference material. Ten of the scoliotic cases had had Cotrel-Dubousset instrumentation (CDI) and posterior fusion and had entered a longitudinal study on the effect of operative correction on the re-modelling of the apical vertebra. An increasingly asymmetrical vertebral body, transverse process angle, pedicle width and canal width were found in the groups with scoliosis as compared with the reference material. Vertebral rotation and rib hump index were significantly larger in patients with early and advanced scoliosis than in normal subjects. The modelling angle of the vertebral body, the transverse process angle index and the vertebral rotation in relation to the middle axis of the thoracic cage were significantly greater in patients with severe than with moderate scoliosis. The results of this longitudinal study suggest that the structural changes of the apical vertebra regress 2 years or more after CD instrumentation.     

Lumbar hemivertebra resection

BACKGROUND: A single lumbar hemivertebra can be expected to cause progressive scoliosis. The aim of this study was to evaluate the results of a lumbar hemivertebra resection and short-segment fusion through a combined posterior and anterior approach. METHODS: From 1987 to 2002, a consecutive series of twenty-one patients with congenital scoliosis or kyphoscoliosis due to a lumbar hemivertebra were managed by resection of the hemivertebra through a combined posterior and anterior approach and with the use of a short anterior and posterior convex-side fusion. RESULTS: The mean age at the time of surgery was 3.3 years (range, twelve months to 10.2 years). The mean followup period was 8.6 years. There was a mean improvement of 71.4% in the segmental scoliosis curve from a mean angle of 32.9 degrees before surgery to 9.4 degrees at the time of the latest follow-up assessment, and a mean improvement of 63.9% in the global scoliosis curve from 34.1 degrees to 12.3 degrees. The mean final lordosis was within normal values. CONCLUSIONS: Excision of a lumbar hemivertebra is safe and provides stable correction when combined with a short-segment fusion. Surgery should be performed as early as possible to avert the development of severe local deformities and prevent secondary structural deformities that would require a more extensive fusion later.