Preoperative evaluation of activity and function in patients with paralytic scoliosis

Preoperative evaluation of patients with paralytic scoliosis should take into account the consequences of surgery on the every day life of the patient. However, the parameters that are customarily used in these operations relate only to very narrow measures such as the angle of scoliosis or kyphosis. The aim of this study was to introduce a set of instruments appropriate for measuring both function and activities in paralytic scoliosis patients. The study took as its starting point the WHO International Classification of Impairments, Disabilities and Handicaps (ICIDH), in which an activity is described at the level of the individual and function at the level of the organ. A consecutive series of 100 paralytic scoliosis patients with 18 different diagnoses were evaluated preoperatively with a set of instruments that had been specially developed at Linköping hospital, in which the variables are classified according to the system used in the ICIDH. The set of instruments included general information and evaluation of activities and function – sitting, balance, weight distribution to sitting surface, angle of scoliosis, reaching, pain estimation, activities of daily living (ADL) Barthel and ADL Klein and Bell, care given, time spent resting, and seating supports). The results showed that patients with paralytic scoliosis constitute a heterogeneous group in activities and function. Even when the patients were grouped into four subgroups according to the Scoliosis Research Society Classification, they remained very heterogeneous. However, reaching, Klein and Bell Activities of Daily Living and pain could only evaluate patients who could understand verbal instructions. In those who could not, assessment relied more heavily on measures of function and level of dependence. It was concluded that the choice of assessment must be guided by the patient’s ability to understand verbal instructions irrespective of his/her disorder. It is important to use the three levels – impairments, disabilities and handicaps – in order to focus on the different outcomes in the two groups with respect to the patient’s total situation.     

Discography in paralytic scoliosis.

Observations are made on the progressive alterations of the intervertebral disc in paralytic scoliosis, demonstrated by discography.     

Development of paralytic scoliosis in myelomeningocele

Among other things the probability of developing a scoliosis in myelomeningocele depends on the patients age, the neurological level of lesion and the localisation of the vertebral arch defect. This study tries to analyse the influence of these factors in 465 patients with MMC and paralytic scoliosis. The results show, that the patients age and the neurological level of lesion are the most important factors for the development of paralytic scoliosis. The statistical evaluation based on the data found permits the determination of regression lines, which allow an estimation of further progression of paralytic scoliosis with respect to the neurological level of lesion and the patients age. At levels of paralysis between Th 3 and Th 12 an average progression of 3.5 degrees per year can be expected. Between L 1 and L 3 the progression rate can be estimated to be 2.5 degrees per year. At levels of paralysis distal to L 3 one can expect to find no significant development of scoliosis. In cases, which exceed the prediction interval, additional intraspinal anomalies, i.e. syringomyelia, must be considered and further examinations including MRI are required.     

麻痹性脊柱侧凸的手术治疗策略

目的:探讨手术治疗麻痹性脊柱侧凸的一些问题.方法:通过对手术治疗的52例患者回顾性分析,就麻痹性脊柱侧凸的发病机理、临床特点及手术方式选择进行讨论.结果:所有病例的脊柱侧凸及骨盆倾斜均得到不同程度的纠正,以钉-棒系统矫正组疗效更佳.结论:手术治疗麻痹性脊柱侧凸时节段性脊柱固定器械(SSI)应为首选,对腰骶的固定及融合要慎重,随着脊柱侧凸畸形的矫正,骨盆倾斜会得到明显的纠正.     

The Milwaukee brace in paralytic scoliosis.

The Milwaukee brace possesses excellent passive properties in addition to the well known dynamic action, and is of definite value in the bracing of paralytic curves in children in whom a fusion should be de-delayed. This application is a temporary but at the same time a long term expedient to allow spine growth prior to surgery.     

Surgical management of paralytic scoliosis in myelomeningocele

A retrospective analysis of 54 patients with paralytic scoliosis due to myelomeningocele, who underwent surgical treatment, was performed. The aim of this study was to compare different surgical techniques and to identify clinical parameters influencing primary and midterm results. Three surgical techniques were used: 1) group I, posterior fusion/instrumentation; 2) group II, anterior fusion/no instrumentation combined with posterior fusion/instrumentation; and 3) group III, anterior and posterior fusion/instrumentation. Average age at surgery was 13.1 years. A preoperative scoliosis angle of 90 degrees [interquartile range (25th-75th percentile) (IQR), 76-106 degrees] was primarily reduced to 38 degrees (IQR, 30-50 degrees). At final follow-up (mean, 3.3 years), correction deteriorated to 44 degrees (IQR, 38-65 degrees). The group III procedure resulted in a better midterm correction of scoliosis compared with group I (P = 0.02). The extension of anterior fusion correlated with primary and midterm correction of scoliosis (P < 0.03). Patients with a thoracic level of paralysis had a higher relative loss of correction compared with patients with a lumbar level (P < 0.06). This finding can be attributed mostly to group I patients (P = 0.011). Hardware complications occurred in 16 patients (30%). Relative loss of correction among these patients was high (P < 0.01) and relative midterm correction low (P = 0.001). We recommend anterior and posterior fusion, each with instrumentation for the treatment of paralytic scoliosis in myelomeningocele. In patients with a thoracic level of paralysis, the two-stage procedure is mandatory to reduce the risk of hardware complications and subsequent major loss of correction.     

Halo轮椅悬吊重力牵引在严重脊柱侧后凸儿童术前的应用价值

目的:探讨术前Halo轮椅悬吊重力牵引在治疗儿童严重脊柱侧后凸中的应用价值。方法:2004年7月至2007年5月,对在我科术前行Halo轮椅悬吊重力牵引治疗且临床资料完整的17例严重脊柱侧后凸畸形儿童进行回顾性分析。其中男性8例,女性9例;年龄4～8岁,平均6.8岁。术前冠状面Cobb角85°～155°,平均116.4°;胸椎后凸Cobb角45°～125°,平均90.2°。患者在后路矫形术前均行Halo轮椅悬吊重力牵引,最大牵引重量为体重的35%～60%,牵引4～15周(平均10.4周)后行后路矫形内固定融合术。对患者术前Bending像、牵引后和术后的侧后凸纠正率进行统计比较。结果:平均最大牵引重量9kg,约占平均体重(16.5kg)的54.5%。1例患者在牵引2周时出现右侧臂丛神经麻痹,减轻牵引重量后逐渐恢复。矫形术后无瘫痪、呼吸衰竭和死亡发生。平卧Bending位X线片上侧凸纠正率平均15.4%,Halo轮椅悬吊重力牵引后侧凸纠正率平均38.4%,后路矫形术后侧凸矫正率为48.3%;胸椎后凸矫正率平均为38.8%。随访18～60个月,平均38个月,末次随访时冠状面矫正丢失率平均为2.3%,矢状面矫正丢失率平均为2.9%。牵引后肺功能及动脉血气分析结果改善明显。结论:术前Halo轮椅悬吊重力牵引可有效改善严重侧后凸儿童的柔韧性,并同时改善患者肺功能,但应注意与牵引相关的并发症。     

Posterior spinal fusion in paralytic scoliosis and myelomeningocele

The Shriners Hospital, Lexington, KY, experience with posterior spinal fusion for scoliosis in 50 patients with myelomeningocele was reviewed. Six patients were fused with Harrington rods and 47 of 50 patients were treated with some form of segmental fixation. The complication rate was 48% (24/50) resulting in 1.48 procedures per patient. The deep infection rate was 8% (4/50) and the pseudarthrosis rate was 16% (8/50). The use of modern segmental instrumentation systems has improved the pseudarthrosis rates for posterior spinal fusion in scoliosis associated with myelomeningocele but not to the point of displacing the current approach of an anterior and posterior spinal fusion.     

Allograft bone in spinal fusion for paralytic scoliosis

To determine the efficacy of allograft bone in spinal surgery, a retrospective study was carried out on thirty-two patients who had had spinal fusion with banked bone from the femoral head between 1977 and 1983. The diagnoses were paralytic and neuromuscular scoliosis. At final follow-up (average, 3.7 years), the infection rate was 9.3 per cent. There were no pseudarthroses, and all patients had well marginated trabecular markings by eighteen months. The rates of complications and of fusion were comparable with or better than those obtained using autogenous bone graft.     

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.     

Anterior and posterior spinal fusion for paralytic scoliosis

Twenty-three patients with paralytic scoliosis were treated with a combination of anterior and posterior spinal instrumentation and fusion. The sequence was anterior surgery first in 19 patients and posterior surgery first in 4. The average age was 14.4 years. Preoperative correction with a halo-hoop apparatus was performed in 12 patients. The average preoperative curve for the group measured 100 degrees, and the average postoperative curve at a mean follow-up time of 21 months was 37 degrees. The mean loss of correction was 8 degrees. Although superior hook dislodgment occurred in 5 patients, no pseudarthrosis or beinding of the fusion mass was documented.     

Preoperative inspiratory muscle training for patients with severe scoliosis and high-risk pulmonary dysfunction in duchenne muscular dystrophy

Severe spinal collapse and pulmonary function deterioration are so common in patients with Duchenne muscular dystrophy (DMD). The limit for scoliosis surgery has been a minimum forced vital capacity (FVC) of about 30% of predicted value. DMD patients with low %FVC who might benefit from scoliosis surgery have not been being offered surgery. Between 2005 and 2007, a total of 17 DMD patients with FVC of <30% at admission underwent scoliosis surgery. %FVC at admission was 22% (range 16–27%). After admission, they were trained with inspiratory muscle training, using a pulmonary trainer (threshold IMT) for 6 weeks prior to surgery and encouraged to continue the training even after surgery and discharge. %FVC increased in all patients and noted 26% (range 22–31%) the day before surgery. The preoperative scoliosis was 97° (range 81°–130°). All patients had posterior spinal fusion and were extubated on the operative day. No patients developed any respiratory complications. No ventilatory support was needed. The mean ICU stay was 0.5 days (range 0–1 day). The postoperative scoliosis was 31° (range 18°–40°). DMD patients with severe scoliosis and FVC considered too low to permit reasonable surgical risk could undergo surgery after inspiratory muscle training, with no major complications.     

青少年特发性脊柱侧凸术前柔韧性评估方法概述

青少年特发性脊柱侧凸矫形手术的目的是：在融合较短脊柱节段的条件下矫正畸形,阻止畸形进展,得到一个在冠状面和矢状面平衡的躯干。术前柔韧性评估在确定脊柱侧凸的结构性特点、选择手术入路、确定融合节段、预测矫形效果等方面有重要意义。虽然柔韧性作为脊柱侧凸术前常规评估的指标已被广泛使用,但仍存在以下问题：柔韧性的定义模糊,导致很多学者对柔韧性一词的误解和误用;