A comparison between spinous process and sublaminar wiring combined with Harrington distraction instrumentation in the management of adolescent idiopathic scoliosis

A study of the efficacy of two techniques of spinal instrumentation on patients with adolescent idiopathic scoliosis was performed. Twenty consecutive patients treated with a single Harrington distraction rod and sublaminar wiring (H-SL) were compared with 20 consecutive patients treated with a single Harrington distraction and spinous process wiring (H-SP). The patients in both groups were similar in age, curve magnitude, curve flexibility, and curve type. The immediate postoperative correction (61% H-SL, 58% H-SP) and follow-up correction (50% H-SL, 49% H-SP) were equivalent. No pseudarthroses were recognized in either group. One patient with H-SL had transient postoperative paresthesias.     

Ventral derotation spondylodesis. A review of 22 cases

Twenty-two patients with major lumbar or thoracolumbar curves were treated with Zielke's modification of the Dwyer instrumentation, termed the "ventral derotation spondylodesis (VDS) system. In 16 patients, this was followed by planned second-stage posterior Harrington instrumentation and fusion. Six patients with adolescent idiopathic scoliosis were treated with VDS instrumentation and fusion alone. In neuromuscular and adult idiopathic scoliosis, a combined approach resulted in excellent curve correction and a high rate of successful fusion. In adolescent idiopathic scoliosis, VDS instrumentation alone resulted in excellent curve correction while permitting a shorter fusion length than conventional posterior Harrington instrumentation.     

The timing of spinal fusion in adolescent idiopathic scoliosis

102 cases of idiopathic adolescent scoliosis seen over a period of 5 years were studied. 59 patients who were treated surgically and followed up for a minimum of 48 months, fell into one of two groups: Group I - those operated on within 3 years following the adolescent growth spurt, and Group II - those who were operated on at or after skeletal maturity. 35 patients were treated by Harrington instrumentation and posterior fusion and 24 by Harrington instrumentation, segmental sublaminar wiring and posterior fusion. In 7 patients anterior release was performed initially. In Group I, the extent of deformity correction and elimination of the rib hump were better, and complications such as neurological deficit, hook dislodgement and implant breakage were encountered less frequently. Harrington instrumentation, segmental sublaminar wiring and posterior fusion gave better results than instrumentation and fusion. Our results suggest that surgical correction should be done within 3 years following growth spurt, i.e. 14 to 16 years of age.     

The comparative results of treatment in idiopathic thoracolumbar and lumbar scoliosis using the Harrington, Dwyer, and Zielke instrumentations

Forty-five patients with idiopathic thoracolumbar or lumbar scoliosis were treated with the Harrington, Dwyer, or Zielke instrumentation and fusion. The Harrington group achieved a 55% correction of the primary curves, while the Dwyer and the Zielke groups achieved 88 and 91%, respectively. Overcorrection of the curves occurred in a total of nine cases in the latter two groups. The Dwyer and Zielke instrumentations enabled better correction of the curves with a shorter fusion. At subsequent follow-up, the 'adding on' phenomenon as a result of the shorter fusion in the Dwyer group was unchanged, while that in the Zielke group became gradually resolved. The Zielke instrumentation appears to be the apparatus of choice for treatment of thoracolumbar and lumbar scoliosis.     

Operative Treatment of Scoliosis with the Harrington Instrumentation Technique

Preliminary results of treatment of scoliosis with the Harrington instrumentation technique in 80 patients are presented. The curve correction at operation averaged 43.4 per cent with the best results being achieved in idiopathic single curves (49.3 per cent). Most of the patients had been treated conservatively for a long time prior to operation, and the curves were rather stiff. The initial loss of correction was 3.2°, and the overall loss at 2 years postoperatively averaged 6.5° in 28 patients. Complications occurred in 22.5 per cent of the patients, most often at the upper hook site. Serious complications were rare. It is concluded that the Harrington instrumentation technique is an effective means of treatment of scoliosis.     

Surgical treatment of late-onset idiopathic thoracic scoliosis. The Leeds procedure

Late-onset idiopathic scoliosis is associated with a rib hump in the thoracic region, and surgery is indicated when this deformity becomes unacceptable. Fifty patients with this deformity were treated by the Leeds procedure, which consists of segmental wiring to a kyphotically-contoured square-ended Harrington rod; this procedure not only derotates the spine but restores the natural thoracic kyphosis, thus avoiding subsequent buckling. All patients were followed up for a minimum of two years. Forty-two of these, who had a pre-operative Cobb angle of less than 60 degrees, were treated by one-stage instrumentation and fusion, while the remaining eight with greater curves underwent preliminary anterior multiple discectomy to provide flexibility with shortening. Postoperative loss of correction was not observed and there were no neurological complications.     

Costectomy as the first stage of surgery for scoliosis

Preliminary costectomy before Harrington instrumentation and fusion for idiopathic scoliosis allows direct excision of the rib prominence and better correction at the second-stage operation. The excised rib fragments are used as grafts, thus avoiding the need for a separate pelvic incision. The management regime and the technique of costectomy are described. The results in 42 children, most suffering from adolescent idiopathic scoliosis and all treated by this method, have been reviewed. Respiratory function in a group of these children has been compared with that of a group treated by Harrington instrumentation alone. Costectomy produced a significantly greater reduction in total lung capacity and peak expiratory flow rate but, providing the preliminary lung function tests were reasonably normal, the cosmetic and psychological effects of costectomy were very rewarding.     

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.     

Spinous process segmental instrumentation for scoliosis

Spinous process segmental instrumentation (SPSI) for spinal fusion was devised in 1983 by Drummond et al. in an attempt to achieve the stability of segmental fixation without the known neurologic risks of passing sublaminar wires. We used SPSI in 75 scoliosis patients. Sixty-one had idiopathic scoliosis, 12 had neurogenic scoliosis, and 2 had congenital scoliosis. There were no deep infections, pseudarthroses, or neurologic complications. Two patients experienced upper hook dislodgement with 10 degrees loss of correction. We concluded that SPSI can achieve the correction of Harrington rod instrumentation and the stability of Luque rod segmental instrumentation, without the neurologic risk of sublaminar wiring.     

Subtransverse process wiring: a new technique of segmental spinal fixation of the thoracic spine or in the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Segmental fixation is the preferred technique for the surgical treatment of adolescent idiopathic scoliosis. Sublaminar wiring is a widely used, strong type of segmental fixation. The most common drawback of the sublaminar wiring is the risk of neurologic injury. The authors have applied subtransverse wiring for 3 years, and the technique seems promising. OBJECTIVES: To show that subtransverse wiring is a technique strong enough to correct scoliosis curves and does not carry neurologic injury risks. SUMMARY OF BACKGROUND DATA: Sublaminar wiring is a commonly used fixation method for posterior fusion in the treatment of scoliosis. Because of its associated risk of neurologic injury, it is mostly recommended for long neuromuscular curves. METHODS: The authors used the subtransverse wiring technique in 12 cases of adolescent idiopathic scoliosis and followed them for an average of 22 months. RESULTS: The average correction rate was 65%, and correction loss at the end of the follow-up period was 5 degrees. No neurologic complications were encountered. CONCLUSIONS: Subtransverse wiring is strong enough to correct scoliotic curves. It requires less operative time and skill and is neurologically safe.     

椎弓根螺钉固定系统对特发性脊柱侧凸矫正效果的影响

目的:探讨经椎弓根螺钉固定对特发性脊柱侧凸矫正效果的影响。方法:66例特发性脊柱侧凸患者分别采用钩-棒、钩-钉-棒或钉-棒固定的方法进行矫正,对各组患者的一般情况、畸形程度、矫正效果和并发症进行分析比较。结果:各组在畸形程度、手术时间以及手术并发症等无显著性差异,椎弓根钉-棒固定组在冠状面和矢状面的矫正率和维持矫正效果均较钩-棒或钩-钉-棒固定组明显提高。结论:在不增加并发症的前提下,椎弓根螺钉固定可以提高特发性脊柱侧凸的手术矫正效果。     

Results of Harrington instrumentation in the treatment for severe scoliosis.

Between July 1963 and December 1974, we surgically treated 207 patients who had severe scoliosis (curves greater than 90 degrees), 196 of whom were eligible for inclusion in this study. No patient was treated preoperatively with a cast or traction. Upon statistical analysis, age and preoperative curve magnitude proved to be significant variables relative to the amount of surgical correction obtained and the maintenance of that correction; sex and etiology of the scoliosis were not shown to affect either surgical outcome or maintenance of correction. A comparative analysis showed our results to be as good as those reported by others using various preoperative regimens of casting or traction or both. Therefore, we find that the preoperative application of traction to patients with severe scoliosis yields no better correction than the use of Harrington instrumentation and fusion alone.     

Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis. Long-term functional and radiographic outcomes

BACKGROUND: Previous studies have shown that the long-term clinical outcome does not correlate with the radiographic outcome in patients treated with Harrington instrumentation for adolescent idiopathic scoliosis. Cotrel-Dubousset instrumentation has been reported to provide better correction radiographically, but it is unclear whether it provides better long-term clinical or functional outcomes. We are not aware of any long-term studies comparing Harrington and Cotrel-Dubousset instrumentation. METHODS: Seventy-eight patients in whom adolescent idiopathic scoliosis was treated with Harrington instrumentation and fifty-seven in whom it was treated with Cotrel-Dubousset instrumentation participated in this study. The mean duration of follow-up was 20.8 years for the Harrington instrumentation group and 13.0 years for the Cotrel-Dubousset instrumentation group. The mean age at the time of follow-up was thirty-six years and twenty-eight years, respectively. Radiographs were made preoperatively and at the two-year and final follow-up examinations. The Scoliosis Research Society questionnaire was completed, a physical examination was performed, and spinal mobility and non-dynamometric trunk strength were measured at the final follow-up visit. RESULTS: The mean preoperative Cobb angle of the thoracic curves was 53 degrees in the Harrington instrumentation group and 55 degrees in the Cotrel-Dubousset instrumentation group. The mean numbers of vertebrae included in the instrumentation were 10.7 and 9.9, respectively. At the two-year follow-up evaluation, the mean postoperative Cobb angles were 38 degrees and 25 degrees, respectively (p < 0.0001). At the final follow-up evaluation, the mean angles were 45 degrees and 32 degrees (p < 0.0001). No significant difference in thoracic kyphosis or lumbar lordosis was observed between the study groups at the final follow-up evaluation. The average score on the Scoliosis Research Society questionnaire was 97 points in both groups. Measurements of non-dynamometric trunk strength corresponded with age and sex-adjusted reference values, on the average, but patients with Cotrel-Dubousset instrumentation performed significantly better in the squatting test (p = 0.010). Abnormal lumbar extension and trunk side-bending were significantly more common in the Harrington instrumentation group (p = 0.050 and p = 0.0061, respectively). Complications were recorded for nine (12%) of the patients treated with Harrington instrumentation and fifteen (26%) of those treated with Cotrel-Dubousset instrumentation (p = 0.027). CONCLUSIONS: Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation. However, complications were more common in the Cotrel-Dubousset instrumentation group.     

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.     

Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring

We retrospectively analyzed the postoperative neurological complications in 137 patients who underwent a posterior spine fusion for scoliosis and had concomitant somatosensory cortical evoked-potential spinal-cord monitoring. The patients were divided into three specific operative groups: group 1, forty-nine patients who had a Harrington rod with segmental wiring (segmental spinal instrumentation); group 2, twenty patients who had Luque segmental spinal instrumentation; and group 3, sixty-eight patients who had a Harrington rod without segmental spinal instrumentation. There were neurological complications in twelve (17 per cent) of the sixty-nine patients in groups 1 and 2. Three patients (4 per cent) had a major injury to the spinal cord and nine patients (13 per cent) had only transient sensory changes. No difference was apparent between group 1 and group 2 in the degree of operative correction of curves or in the incidence of neurological complications. The one neurological complication (1.5 per cent) that occurred in the sixty-eight patients in group 3 was a Brown-Séquard syndrome. The factors related to increased risk for spinal cord injury in groups 1 and 2 included: (1) the passage of sublaminar wires in the thoracic and thoracolumbar spine, (2) intraoperative correction exceeding the preoperative bending correction, and (3) the surgeon's lack of adequate experience with the technique. With spinal cord monitoring we were able to predict the impending major neurological deficits, but the transient (sensory) changes that may be associated with segmental wiring were less reliably predicted.     

Fusion of scoliosis by Harrington distraction rod: Interspinous process and sublaminar wiring compared in 42 cases

Forty-two consecutive patients with scoliosis who between 1981 and 1988 underwent posterior Harrington distraction rod and interspinous process or sublaminar wiring were retrospectively reviewed. No difference was found between the techniques with respect to age, sex, curve pattern, curve magnitude, levels fused, operative time, blood loss, correction, and loss of correction at the 1-year and 2-year follow-up. The interspinous process wiring was superior to the sublaminar wiring as regards ease of technique, early ambulation, few complications, and a more effective means for maintaining the correction without postoperative immobilization.     

Fusion of scoliosis by Harrington distraction rod. Interspinous process and sublaminar wiring compared in 42 cases.

Forty-two consecutive patients with scoliosis who between 1981 and 1988 underwent posterior Harrington distraction rod and interspinous process or sublaminar wiring were retrospectively reviewed. No difference was found between the techniques with respect to age, sex, curve pattern, curve magnitude, levels fused, operative time, blood loss, correction, and loss of correction at the 1-year and 2-year follow-up. The interspinous process wiring was superior to the sublaminar wiring as regards ease of technique, early ambulation, few complications, and a more effective means for maintaining the correction without postoperative immobilization.     

Luque rod instrumentation in the treatment of adolescent idiopathic scoliosis. A comparative study with Harrington instrumentation

Adolescent idiopathic scoliosis in 152 patients was treated by Luque L-rod instrumentation and early mobilisation without external support. This series was compared with a matched group of 156 patients treated by Harrington instrumentation and immobilised in an underarm jacket for nine months. All the operations in both groups were performed by one surgeon and the patients were followed prospectively for more than two years. Correction of the scoliosis in the frontal plane was similar in both groups. However, the normal sagittal contour was better maintained with Luque rods, especially in the thoracolumbar and lumbar regions, and provided less loss of correction than with Harrington rods. Neither method significantly derotated the scoliosis. All the patients with Luque instrumentation developed a solid fusion despite breakage of the sublaminar wires at one or two levels in 4.9%. There were no major neurological complications with either type of instrumentation.     

Surgical treatment of adolescent idiopathic scoliosis: a comparative study of two segmental instrumentation systems

This study compares two different surgical techniques and instrumentation types in the treatment of adolescent idiopathic scoliosis. The charts and radiographs of 116 patients with adolescent idiopathic scoliosis treated by posterior spine fusion with Isola or Cotrel-Dubousset instrumentation were reviewed. Patients were separated into two equivalent groups matched for age, sex, curve type, and curve magnitude. All patients had a minimum of 2 years follow-up. The instrumentation in group 1 consisted of hooks, wires, and pedicle screws. That used in group 2 was limited to hooks and rods. The Mann-Whitney, Wilcoxin, and the paired Student t tests for matched pairs were used for statistical analysis. Patients in group 1 had increased curve correction (66% vs. 52%), apical vertebral translation (63% vs. 30%), and correction of the end vertebral tilt angle (11 degrees vs. 3 degrees) (p < 0.001). The percentage of coronal curve correction in curves larger than 65 degrees also was greater in group 1 (59% vs. 40%). Physiologic sagittal alignment was obtained in 80% of the patients in group 1 and 25% in group 2. No major complication or pseudoarthrosis occurred in either group. This study supports improved correction of curve magnitude, apical translation, and end vertebral tilt angle with the use of multiple anchor types compared with the correction achieved with standard hook-and-rod constructs.     

Patient outcomes after Harrington instrumentation for idiopathic scoliosis: a 15- to 28-year evaluation

STUDY DESIGN: A retrospective study was performed, using the Short Form-36 Health Survey and the Roland and Morris Disability Questionnaire, to investigate patient outcomes after fusion for adolescent idiopathic scoliosis using Harrington rod instrumentation. OBJECTIVE: To evaluate health-related quality of life and low back pain in a long-term follow-up study of surgery for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The commonly accepted surgical treatment for idiopathic evolutive scoliosis is vertebral fusion. It has been suggested that this procedure may cause low back pain and a poor quality of life over the long term. Outcome measures after surgery for adolescent idiopathic scoliosis have focused mainly on objective parameters such as radiographic measures. However, this information has proved to be correlated only weakly with outcomes that are more relevant to patients, such as functional status and symptoms. Until recently, only a few long-term outcome studies have used standardized and validated patient-oriented tools to evaluate surgically treated patients with scoliosis. METHODS: In this study, 70 patients treated with a standard Harrington technique were recontacted and evaluated by means of self-administered questionnaires (Short Form-36 Health Survey and Roland and Morris Disability, clinical examination, and radiographic analysis. Preoperative and follow-up radiographic findings were registered. Relations between radiographic and patient-oriented data were evaluated. RESULTS: A comparison between the current sample and the Italian age-matched normative data for the Short Form-36 Health Survey showed them to have a similar pattern. Findings showed the patient-oriented outcome to be correlated inversely with the extension of vertebral fusion and the preoperative Cobb angle. CONCLUSION: Long-term follow-up evaluation of Harrington rod fusion for adolescent idiopathic scoliosis showed no important impairment of health-related quality of life, as measured by patient-oriented evaluation.