A 10-year follow-up of the Harrington operation in congenital scoliosis and scoliosis due to poliomyelitis and neurofibromatosis

From 1972 through 1976 40 patients with congenital scoliosis, scoliosis in neurofibromatosis and scoliosis following poliomyelitis underwent posterior spine fusion using Harrington instrumentation. Follow up was 10 years or more with an average of 12 years. 63 percent of all patients showed a curve of more than 90 degrees before operation. The different types of scolioses revealed characteristical results according to their etiology during long time follow up. Concerning long time reduction of curve the best results were obtained in patients following poliomyelitis. Patients with congenital and neurofibromatous scoliosis showed loss of correction 2 and 5 years postoperatively.     

Adult idiopathic scoliosis treated with Luque or Harrington rods and sublaminar wiring

We reviewed the results of spinal arthrodesis that was performed, with sublaminar wires that were attached to either double L-shaped Luque rods or to a Harrington rod, in forty-two adults who had idiopathic scoliosis. The minimum length of follow-up was two years; the maximum, five years; and the average, three years. The average scoliosis measured 67 degrees preoperatively, was corrected to 37 degrees at operation, and was 44 degrees at the time of follow-up. The final correction averaged 34 per cent. A single Harrington rod and multiple sublaminar wires were used in thirty-one patients. Eighteen of the thirty-one patients had a posterior arthrodesis only and thirteen, a preliminary anterior arthrodesis followed by a posterior arthrodesis. Eleven patients had instrumentation with double L-shaped Luque rods; six of them had posterior arthrodesis only and five, a preliminary anterior arthrodesis followed by a posterior arthrodesis. One patient had neurological deficit that was related to the operation. Three patients had a pseudarthrosis, which was in the lumbar area in all of them. All three patients had had only a posterior operation. No statistically significant difference in the amount of final correction was demonstrated between the subgroups.     

Surgical treatment of adolescent idiopathic scoliosis. A comparative analysis

Three hundred and fifty-two patients had a one-stage posterior spinal arthrodesis between 1960 and 1984 using one of four types of instrumentation: a Harrington distraction rod, Harrington distraction and compression rods, Harrington distraction and compression rods with a device for transverse traction, and a Harrington distraction rod with sublaminar wires. All of the patients were female (age-range, eleven to nineteen years), and all had idiopathic scoliosis with a single right or double thoracic curve. The minimum length of follow-up was two years. No significant difference was found among the four groups relative to the amount of correction that was obtained at operation or maintained two years after operation. An average of 13.5 per cent of correction was lost during follow-up in the patients who were treated with postoperative immobilization, and an average of 27 per cent was lost in the patients who were treated with sublaminar wires without immobilization. The use of a straight Harrington rod reduced normal thoracic kyphosis, the addition of a compression rod corrected hyperkyphosis, and the use of a rod with sublaminar wires corrected thoracic hypokyphosis or thoracic lordosis.     

Management of pseudarthrosis after arthrodesis of the spine for idiopathic scoliosis

Sixty-three first, second, or third-time repairs of one or more pseudarthroses were done in fifty-one patients who had had an arthrodesis for idiopathic scoliosis. Forty-five of the patients were female and six were male. The average age was 30.2 years. The indications for the sixty-three repairs were pain (twenty-five repairs), progression of the curve (sixteen), both pain and progression of the curve (twelve), and radiographic changes only (ten). Failure of the implant was identified before 27 per cent of the sixty-three procedures. The pseudarthroses were diagnosed an average of 2.8 years after the initial arthrodeses. Sixty-eight per cent of the defects were visible on plain radiographs preoperatively and 32 per cent were identified at operation. During the time between the original arthrodeses and the repairs of the pseudarthroses, the scolioses increased by a mean of 7 degrees and the kyphoses, by a mean of 10 degrees. Harrington distraction was the most commonly used instrumentation (twenty-six [41 per cent] of the sixty-three procedures), and autogenous iliac bone was the most commonly used material for the graft (thirty-three [52 per cent] of the procedures).     

Anterior Zielke instrumentation for spinal deformity in adults

Fifty-eight adults who had scoliosis or hyperlordosis had anterior arthrodesis and Zielke instrumentation. Postoperatively, the curve improved 68 per cent in forty-nine patients who had idiopathic scoliosis and 40 per cent in nine patients who had paralytic scoliosis or hyperlordosis or congenital scoliosis. More correction was obtained when a derotator apparatus was used. Only one patient had failure of the instrumentation that necessitated additional surgical treatment. All of the arthrodeses resulted in osseous fusion. No patient who had idiopathic scoliosis lost correction (average follow-up, forty-two months; range, thirty to seventy-eight months). There were no serious complications. Lumbar lordosis decreased an average of 24 per cent compared with the preoperative measurement. This decrease was thought to be related to the correction of vertebral rotation in the curve and to the surgical technique. Use of the Zielke instrumentation resulted in excellent correction, which was not lost postoperatively in the patients who had an idiopathic curve and which was associated with minimum complications.     

Two-stage corrective surgery for congenital deformities of the spine.

Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective.     

Surgical treatment of adult scoliosis. A review of two hundred and twenty-two cases

We evaluated the cases of 222 patients older than twenty years in whom scoliosis was the primary diagnosis. No patient had had prior surgical treatment. The diagnoses were idiopathic scoliosis in 160 patients, paralytic scoliosis in forty-four, and congenital scoliosis in eleven, and there were miscellaneous diagnoses in seven patients. The average age of the patients when first seen was 30.7 years. The indications for operation were pain, progression of the curve, magnitude of the curve, and cardiopulmonary symptoms. Preoperative traction, including halo-femoral traction, did not result in increased correction when compared with the initial supine side-bending roentgenogram. A one-stage fusion was performed in 174 patients and multiple-stage procedures, in forty-eight patients. At an average follow-up of 3.6 years the average loss of correction was 6.2 degrees, 68 per cent of the patients were free of pain, and a solid fusion had been obtained in all but six patients. Complications developed in 53 per cent of the patients, the most common problems being pseudarthrosis, urinary tract infection, wound infection, instrumentation problems, a pulmonary disorder, and loss of lumbar lordosis. Paraplegia occurred in one patient. The over-all mortality rate was 1.4 per cent. Complications increased with age, and the highest mortality rate was in patients with congenital scoliosis who had cor pulmonale.     

The role of Harrington instrumentation and posterior spine fusion in the management of adolescent idiopathic scoliosis

The Harrington instrumentation system was the first widely used, internationally accepted internal fixation system for the correction of idiopathic scoliosis when combined with a spinal arthrodesis. It has been generally available to the orthopedic surgeon for more than 25 years, and therefore its capabilities and limitations have been identified through this long experience. Its implantation requires minimal invasion of the spinal canal and is associated with a low (less than 0.5 per cent) incidence of neurologic complications. It provides predictable correction of spinal deformity with little subsequent loss of correction. When compared with other newer, more complex internal fixation systems for spinal deformities, the Harrington system has a shorter, less difficult "learning curve"; requires less operating time and blood loss to insert; implants a smaller mass of metal; and in some cases costs substantially less for the implant system. The Harrington system has an extremely low incidence of hook dislodgment and pseudoarthrosis formation in single thoracic curves, being reported as near zero for these curves in two recently published series. Conversely, there are some disadvantages to the Harrington system when compared with other types of fixation. It has limited ability to provide sagittal plane control. It does not effectively and predictably derotate the spine. A recent study showed that at an average of 4 years postoperatively, nearly two thirds of the patients had an actual increase in their rib prominence. The pseudoarthrosis rate is high, up to 4 per cent, in the thoracolumbar and lumbar spine. Hook dislodgment approaches 3 per cent when used below the thoracic region. Another disadvantage is the necessity for postoperative external support. As a result, the Harrington system remains an excellent means of treating single and double thoracic idiopathic curves in a safe and predictable manner, while admittedly having limited derotation and sagittal plane control. Other systems that are more sophisticated at segmental fixation of the spine appear to be more appropriate for scoliotic deformities requiring fusion of the thoracolumbar or lumbar spine and those associated with significant sagittal plane deformities.     

Reconstructive surgery in the adult for failed scoliosis fusion

Fifty-nine adult patients were examined who had undergone previous spine surgery for scoliosis but in whom pain (78 per cent), loss of correction (68 per cent), or dyspnea (36 per cent) subsequently developed. Twenty-six patients had idiopathic scoliosis, twenty-five had paralytic scoliosis secondary to poliomyelitis, and eight had scoliosis secondary to miscellaneous etiologies. A one-stage reconstructive procedure was performed in sixteen patients and a two-stage procedure, in forty-three patients. The two-stage procedure consisted of exposure of the spine and multiple osteotomies, followed by two weeks of halofemoral traction to obtain correction. The spine fusion was then extended, using Harrington instrumentation to maintain correction. At an average follow-up of 3.3 years there was reduction of pain in 67 per cent of the patients and a solid fusion in all but two. The complication rate was high (71 per cent), the most important complications being pseudarthrosis, wound infection, urinary tract infections, loss of lumbar lordosis, and pressure sores. The mortality rate was 3.4 per cent. No patient became paraplegic at the initial surgical procedure and early recognition and treatment of pseudarthrosis will reduce the number of patients requiring this salvage operation.     

Combined staged anterior and posterior correction and fusion of the spine in scoliosis following poliomyelitis.

The problems with severe forms of scoliosis following poliomyelitis include the associated muscle imbalance, soft tissue contractures and pelvic obliquity. Such deformities militate against optimal correction and maintenance of that correction and their treatment is often marred by pseudarthroses. Seventeen patients with an average curve of 93 degrees have been treated and followed for up to 38 months. Preliminary traction was used in 8 patients, then a staged anterior and posterior correction and fusion was done, using Dwyer's instrumentation of the major curve in all and a Harrington rod to supplement the posterior fusion in eleven patients. With this technique the major curve was corrected by 80 per cent with an average 2 per cent loss over 18 months. No pseudarthroses were seen when the Harrington rod was used. Great care must be taken if halo-pelvic traction is to be used for patients with pelvic obliquity, for preliminary correction halo-femoral traction will often be adequate. In the more severe forms of paralytic scoliosis a combined staged anterior and posterior correction and fusion should be considered if the aim is maximal correction of the scoliosis and avoidance of pseudarthroses.     

Late results of surgical treatment of infantile idiopathic scoliosis by Harrington's method]

The late results of surgical treatment of infantile scoliosis by the Harrington method have been presented in 43 patients. The patients age at surgical treatment ranged from 11 to 21 years (14.1 years in the average). The patients age at final follow up examination ranged from 18 to 34 years (25.4 years on the average). The curvature angle at operation was 102.1 degrees according to Cobb on the average. 43.7 per cent of curvature was corrected. Although an improvement of posture was present in all the patients, only 51 per cent of the patients, had good posture. After the treatment 81 per cent of the patients worked.     

Surgical treatment of Scheuermann's disease with segmental compression instrumentation

Twenty-one patients with Scheuermann's kyphosis had surgery for progressive kyphotic deformity of 50 degrees or greater. There were six adolescents, with a mean age of 15.6 years (range, 13-17 years) and 15 young adults, with a mean age of 25.4 years (range, 18-40 years). All patients had posterior spine arthrodesis with segmental compression instrumentation. Seven patients with rigid kyphosis had combined anterior and posterior spine arthrodesis. One patient died of superior mesenteric artery syndrome. In the group of 13 patients with posterior arthrodesis only, followup was 4.5 years. The mean preoperative thoracic kyphotic curve of 68.5 degrees improved to 40 degrees at latest review, with an average loss of correction of 5.75 degrees. Junctional kyphosis occurred in two patients with a short arthrodesis: one at the cephalad end and one at the caudal end of the fused kyphotic curve. In the second group of seven patients with combined anterior and posterior arthrodesis, followup was 6 years. The mean preoperative thoracic kyphotic curve of 86.3 degrees improved to 46.4 degrees at latest review, with an average loss of correction of 4.4 degrees. Overall, there was no postoperative neurologic deficit and no pseudarthrosis. Thus, posterior arthrodesis and segmental compression instrumentation seems to be effective for correcting and stabilizing kyphotic deformity in Scheuermann's disease. Despite a long operating time, this technique provided significant correction, avoiding the development of any secondary deformity in most patients. Combined anterior and posterior spine arthrodesis is recommended for rigid, more severe kyphotic deformities.     

Management of neuromuscular spinal deformities with Luque segmental instrumentation

Forty-six patients who had a neuromuscular spinal deformity were treated with arthrodesis and Luque segmental spinal instrumentation and were followed for an average of three years. Twenty-two patients had cerebral palsy and twenty-four had another neuromuscular disease. In thirty-nine patients, the arthrodesis was extended to the sacrum. Eleven patients who had severe scoliosis as well as pelvic obliquity and decompensation of the torso had a combined anterior and posterior arthrodesis; the other thirty-five patients had a one-stage posterior procedure. Preoperatively, the average scoliosis was 74 degrees; this was corrected to 39 degrees at follow-up. Final corrections were similar for scoliosis and were better for pelvic obliquity and decompensation of the torso in patients who had combined anterior and posterior arthrodesis. The results for scoliosis and pelvic obliquity in patients who had a spastic deformity were similar to the results in patients who had a flaccid deformity. Correction of decompensation of the torso was better in patients who had a spastic deformity. Postoperatively, a brace was used in half of the patients in each group; this did not appear to affect the amount of correction in either group, although the result may have been influenced by the selection process. The rate of complications was 48 per cent. Pseudarthrosis occurred in three patients (6.5 per cent). There were no major neurological deficits related to the correction or to the use of sublaminar wires. Three patients died, one in the immediate postoperative period and the other two at eighteen months and four years after the original procedure, due to causes unrelated to the operation.     

One-stage anterior and posterior hemivertebral resection and arthrodesis for congenital scoliosis

Seven children who had congenital scoliosis due to a single, fully segmented lumbar hemivertebra were treated with single-stage anterior and posterior vertebral resection and arthrodesis. The scoliosis averaged 47 degrees preoperatively, 14 degrees postoperatively, and 15 degrees (approximately 70 per cent correction) after an average follow-up of 45.6 months. Four patients had thoracolumbar kyphosis preoperatively, and it remained unchanged at the most recent follow-up examination. Postoperatively, a cast was worn for twelve to sixteen weeks, after which a brace was applied. There were no neurological deficits, infections, deaths, or pseudarthroses. The combined procedure was well tolerated and, in the limited period of follow-up, the congenital scoliosis did not progress.     

Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis.

We evaluated the results of segmental fixation of the spine with Cotrel-Dubousset instrumentation in ninety-five patients who had adolescent idiopathic scoliosis. The instrumentation was used in an attempt to achieve three-dimensional correction of the scoliosis, maintain lumbar lordosis, create thoracic kyphosis, and avoid the need for a postoperative cast or brace. The patients were followed for twenty-four to sixty-four months (average, thirty-five months). Cotrel-Dubousset instrumentation provided an average correction of the coronal curve of 48 per cent at the time of the most recent follow-up. The normal sagittal curves at the thoracolumbar junction and in the lumbar spine were maintained, and the thoracic kyphosis was increased slightly (average, +7 degrees). Apical translation improved an average of 60 per cent, and apical rotation improved an average of 11 per cent. Forced vital capacity improved an average of 21 per cent, and the one-second forced expiratory volume improved an average of 18 per cent. There were no major neurological deficits. A symptomatic pseudarthrosis developed in one patient. Postoperatively, decompensation of the spine developed in five of the first twenty-six patients who had a Type-II or Type-III curve. This complication was avoided in the last twenty-four patients who had a Type-II or Type-III curve by means of a stricter adherence to the definition of a Type-II curve, and reversal of the bend of the rod and the hooks between the caudal neutral and stable vertebrae. The major advantages of Cotrel-Dubousset instrumentation are the stable fixation that is achieved and the preservation of segmental lumbar lordosis.     

Early ambulation following spinal fusion and Harrington instrumentation in idiopathic scoliosis.

Eighty-six patients with idiopathic scoliosis managed by Harrington instrumentation and spinal arthrodesis were ambulated 10 days following surgery. Preoperative reduction of the curves was obtained by Cotrel traction and modified Cotrel localizer cast. Patients were kept immobilized in plaster cast for 7 months following operation. No significant loss of correction was found in these patients ambulated early as compared to a previous group kept recumbent for 3 to 6 months and reported by the authors (DBL). The only exception to this was a patient with double structural curve patterns. A successful surgical program for most cases of idiopathic scoliosis included: (1) Preoperative reduction and balancing of curves by non-skeletal traction and/or correction body cast; (2) Meticulous spinal arthrodesis and employment of Harrington distraction internal fixation; (3) Autogenous iliac bone graft; (4) Ambulation at two weeks following surgery in a well fitting body cast and removal of this cast after 7 months. Deep infection rate was 1 per cent without the use of routine prophylatic antibiotics. One neurological complication resulted from the use of a single distraction rod bridging two curves where the rod was not prebent to allow for kyphosis. There were no pseudarthroses. The average follow-up was 28 months with a range of 18-39 months.     

Results of Harrington instrumentation and fusion in the adult idiopathic scoliosis patient.

Between January 1961 and December 1972, 132 patients over twenty years old with idiopathic scoliosis were surgically treated using Harrington instrumentation and fusion techniques. All patients were seen by us because of curve magnitude or symptoms secondary to scoliosis. The average correction obtained at operation was 48 per cent. Twenty-four patients had early complications. Fifty-two had late complications, the most frequent of which was pseudarthrosis. The majority of patients had significant improvement in symptoms as a result of surgical correction and stabilization.     

Preoperative skeletal traction in scoliosis.

To determine the role of preoperative traction in the treatment of spinal curves, ten patients with curves averaging 81 degrees by the Cobb measurement were studied. Each patient was treated in traction by means of a halo or skull tongs and femoral pins for two to three weeks prior to the surgical correction of the scoliosis with instrumentation. Weights were added to the traction apparatus, 1.8 kilograms a day, to a maximum of 18.1 kilograms. Pretraction supine roentgenograms were compared with supine roentgenograms made at three-day intervals throughout the traction period. Preoperative traction resulted in an average improvement of the curves of 34 degrees, or 41 per cent of the initial curve. Most of the correction was obtained within the first week of traction. Further correction during surgery with Harrington instrumentation yielded 13.5 degrees on the average (16 per cent) so that combined correction averaged 47 degrees, or 57 per cent.     

Natural history of scoliosis in Friedreich's ataxia

Does scoliosis associated with Friedreich's ataxia behave like an idiopathic or a typical neuromuscular scoliosis? Should it be treated like an idiopathic or a neuromuscular curve? Since no precise information to answer these questions could be found in the orthopaedic literature, a retrospective study was undertaken of seventy-eight patients with Friedreich's ataxia who had been followed at our neuromuscular clinic. Fifty-six of these patients were found to have typical Friedreich's ataxia in accordance with the criteria of Geoffroy et al., and their cases were retained for analysis. Their mean age was twenty years (range, eight to thirty-three years). The average length of clinical follow-up was nine years and the average duration of radiographic follow-up of the scoliosis was 3.5 years. A scoliosis of more than 10 degrees was found in all patients and was associated with a hyperkyphosis in 66 per cent. Both sexes were equally affected. Fifty-seven per cent of the curves were double thoracic and lumbar; 14 per cent were thoracolumbar; 7 per cent, double thoracic and thoracolumbar; 7 per cent, thoracic; 4 per cent, lumbar; and 11 per cent, multiple small curves. Of the fifty-six patients whose cases were studied, thirty-six had been followed for at least ten years. Among these thirty-six, there were twenty whose curves were more than 60 degrees and progressed (Group I) and sixteen whose curves were 40 degrees or less and did not progress (Group II).(ABSTRACT TRUNCATED AT 250 WORDS)     

The surgical management of congenital kyphosis and kyphoscoliosis.

STUDY DESIGN: A retrospective study of surgery for congenital kyphosis and kyphoscoliosis. OBJECTIVE: To assess the effectiveness of different types of spine surgery in the management of congenital kyphosis and kyphoscoliosis. SUMMARY OF BACKGROUND DATA: Congenital kyphosis and kyphoscoliosis are much less common than congenital scoliosis but potentially more serious, because these curves can progress rapidly and Type I deformities can lead to spinal cord compression and paraplegia. No one operative procedure can be applied to all types and sizes of deformity. The method of surgical treatment depends on the age of the patient, the type and size of the deformity, and the presence or absence of spinal cord compression causing a neurologic deficit. METHODS: Sixty-five patients with a congenital kyphosis (n = 14) or kyphoscoliosis (n = 51) were treated by five different methods of spine arthrodesis: prophylactic posterior arthrodesis before age of 5 years (n = 11), posterior arthrodesis after age 5 years without instrumentation (n = 26) and with instrumentation (n = 12), combined anterior and posterior arthrodesis without instrumentation (n = 7) and with instrumentation (n = 9). Six patients had preoperative lower limb spastic paraparesis caused by spinal cord compression. The mean age at surgery was 9 years 6 months (range, 11 months to 25 years), and all 65 patients were observed for a minimum of 2 years (mean 6 years 6 months, range 2 to 18 years). Fifty-seven patients reached skeletal maturity. RESULTS: A posterior arthrodesis performed before the age of 5 years resulted in a gradual reduction of the kyphosis by a mean 15 degrees in 9 of the 11 patients, followed up for a mean of 11 years, whose initial kyphosis was less than 55 degrees. Patients treated after the age of 5 years by a posterior arthrodesis followed by cast application had poor correction and a high incidence of pseudarthrosis. This was not significantly improved by the addition of posterior instrumentation. For curves greater than 60 degrees, the most successful results were achieved by an anterior spinal release and arthrodesis with strut graft correction followed by posterior arthrodesis with instrumentation (if possible). CONCLUSION: All patients with a Type I or Type III congenital kyphosis or kyphoscoliosis should be treated by a posterior arthrodesis before the age of 5 years and before the kyphosis exceeds 50 degrees. A kyphosis that does not reduce to less than 50 degrees as measured on the lateral spine radiograph made with the patient supine requires an anterior release and arthrodesis with strut grafting followed by posterior arthrodesis with instrumentation (if possible).