Preoperative Cotrel Traction in Idiopathic Scoliosis

Eighty consecutive patients with idiopathic scoliosis were treated preoperatively with Cotrel traction. Distraction X-rays were taken 2 or 3 days after start of traction and 8-10 days later. In 47 patients equal distraction force was applied in both instances. The force, averaging 28 klb, was measured on the head sling. Cotrel traction reduced the spinal curve 37.5 per cent in the first and 38.9 per cent in the second measurement. The difference is not significant. Preoperative Cotrel traction did not improve the surgical curve correction. Postoperative loss of correction and complication rate was insignificantly reduced compared with the results in a previous study. Cotrel traction does, however, give some indication of the surgical correction achievable.     

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.     

Cotrel Traction, Exercises, Casting in the Treatment of Idiopathic Scoliosis: A Pilot Study and Prospective Randomized Controlled Clinical Trial

A pilot study of ten individuals with adolescent-onset idiopathic scoliosis demonstrated that a week of Cotrel traction and exercises did not improve curve correction obtained by the application of an elongation, derotation, flexion (EDF) cast. There was, however, a significant improvement in lateral bending correction during this period. A prospective, randomized, controlled clinical trial showed that the exercise programme and not the traction was responsible for rendering the spine less rigid.     

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.     

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.     

Cotrel traction, exercises, casting in the treatment of idiopathic scoliosis. A pilot study and prospective randomized controlled clinical trial.

A pilot study of ten individuals with adolescent-onset idiopathic scoliosis demonstrated that a week of Cotrel traction and exercises did not improve curve correction obtained by the application of an elongation, derotation, flexion (EDF) cast. There was, however, a significant improvement on lateral bending correction during this period. A prospective, randomized, controlled clinical trial showed that the exercise programme and not the traction was responsible for rendering the spine less rigid.     

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.     

牵引结合后路手术治疗重度脊柱侧凸的疗效分析

[目的]探讨Halo-股骨髁上牵引结合后路矫形对柔韧性30%～40%的重度脊柱侧凸患者的疗效.[方法]对2000年1月～2006年6月治疗的41例柔韧性30%～40%重度脊柱侧凸患者,按照是否行牵引治疗分为两组.牵引组A组 22例,主侧凸平均Cobb' s角91.2°;对照组B组 19例,主侧凸平均Cobb' s角87.5°.[结果]两组无严重神经系统并发症.A组平均牵引18 d(14～22 d)后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三维矫形术,术后C7～S1偏移值、顶椎偏移矫正A组优于B组.A组主侧凸平均矫正55.2°,B组45.7°,A组优于B组 (P<0.05). A组平均随访40个月, B组平均随访42个月,末次随访两组平均冠状面矫正丢失分别为3°、2.4°,矢状面无丢失,两组均获骨性融合.[结论]对于柔韧性30%～40%的重度脊柱侧凸,术前Halo-股骨髁上牵引可改善肺功能,结合牵引下后路松解矫形术可以获得更好的畸形矫正和躯干平衡,减少术中术后并发症. )后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三维矫形术,术后C_7～S_1偏移值、顶椎偏 矫正A组优于B组.A组主侧凸平均矫正55.2°,B组45.7°,A组优于B组 (P<0.05). A组平均随访40个月, B组平均随访42个月,末次随访两组平均冠状面矫正丢失分别为3°、2.4°,矢状面无丢失,两组均获骨性融合.[结论]对于柔韧性30%～40%的重度脊柱侧凸,术前Halo-股骨髁上牵引可改善肺功能,结合牵引下后路松解矫形术可以获得更好的畸形矫正和躯干平衡,减少术中术后并发症. )后主侧凸平均矫正46%,14例肺功能减退患者均改善.两组均行一期后路松解三     

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.     

Is anterior release effective to increase flexibility in idiopathic thoracic scoliosis? Assessment by traction films

With the advent of thoracoscopy, anterior release procedures in adolescent idiopathic scoliosis (AIS) have come into more frequent use, however, the indication criteria for an anterior release in thoracic AIS are still controversial in the literature. To date, few studies have assessed the influence on spinal flexibility and no study has so far been able to show a beneficial effect on the correction rate as compared to a single posterior procedure. The objective of this study was to evaluate the influence of thoracic disc excision on coronal spinal flexibility. Six patients (5 females, 1 male) with AIS and a mean age of 15.6 years (range 13–20 years) underwent an open anterior thoracic release prior to posterior instrumentation. Cotrel dynamic traction along with radiographs of the whole spine including traction films were conducted pre- and postoperatively and were evaluated retrospectively. The mean preoperative thoracic curve was 89.7° ± 15.4° (range 65°–110°). The flexibility rate in Cotrel traction was 22.8 ± 8.1%. After performance of the anterior release the thoracic curve showed a mean increase of coronal correction by 5.5° ± 5.0° as assessed by traction radiographs. The flexibility index changed by 6.2 ± 5.6%. After posterior instrumentation the thoracic curve was corrected to a mean of 36.5° ± 10.1° (correction rate 59.6%). Disc excision in idiopathic thoracic scoliosis only slightly increased spinal flexibility as assessed by traction films. In our view a posterior release with osteotomy of the concave ribs (concave thoracoplasty, CTP) is more effective in increasing spinal flexibility. According to our clinical experience, an anterior release prior to posterior instrumentation in AIS should only be considered in hyperkyphosis, coronal imbalance or massive curves.     

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.     

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。     

两种矫形方法治疗成人特发性脊柱侧凸的疗效比较

目的:比较单纯后路矫形术和一期前路松解、Halo-股骨髁上牵引加二期后路矫形术治疗成人特发性脊柱侧凸的疗效。方法:选取我院脊柱外科2003年1月～2007年12月收治的有完整影像学资料、Cobb角65°～90°的成人特发性脊柱侧凸患者30例,年龄20～30岁,平均23.4岁。均为初次手术,术前无神经损害。根据不同手术方法分为两组,行单纯后路矫形术的14例患者为A组,行一期前路松解、Halo-股骨髁上牵引及二期后路矫形术的16例患者为B组。两组患者术前侧凸Cobb角、胸椎后凸角、年龄、性别比、侧凸类型相匹配。随访时间为12～72个月,平均40个月。比较两组患者手术时间、出血量、住院时间、并发症情况、侧凸矫正率和冠状面平衡情况。结果:平均手术时间和平均住院时间A组分别为6.7±1.2h和24±18d,B组分别为9.9±1.4h和41±10d,B组均显著长于A组(P<0.05)。所有病例术后均无瘫痪、呼吸衰竭、死亡等并发症发生。术后侧凸矫正率A组为(51.3±11.8)%,B组为(64.5±11.6)%,B组显著大于A组(P<0.05);胸椎后凸角、C7中垂线与骶骨中线的距离A组为20.6°±8.4°、1.32±0.65cm,B组为20.4°±6.7°、1.30±0.70cm,两组比较均无显著性差异(P>0.05)。末次随访时A组侧凸矫正丢失率为(3.5±2.4)%,B组为(2.8±1.5)%,两组无显著性差异(P>0.05)。结论:两种治疗方案治疗中度成人特发性脊柱侧凸均可获得较好的畸形矫正,一期前路松解、Halo-双侧股骨髁上牵引可以增加侧凸Cobb角矫正率,但是存在显著增加手术时间和住院时间等不足。     

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.     

牵引下手术治疗脊柱侧突症

本文介绍了应用自制牵引床,牵引下手术治疗脊柱侧凸60例,其中男23例,女37例,年龄平均15.3岁。术前平均侧凸角是86±18度,术后平均矫正率是64％,无严重神经系统并发症发生。作者认为牵引下后路器械脊柱侧凸矫形术,手术方法简单,安全,既可达到畸形的最大矫正,又能有效地防止神经系统并发症的发生。     

Preoperative halo-gravity traction with and without thoracoscopic anterior release for skeletal dysplasia patients with severe kyphoscoliosis

Purpose

Recent work has shown the safety and efficacy of halo-gravity traction as an operative adjunct. However, there are no reports specifically looking at halo-gravity traction in patients with skeletal dysplasia. Our purpose was to assess the safety and efficacy of traction in children with skeletal dysplasia who present with severe kyphoscoliosis.

Methods

We retrospectively reviewed eight consecutive children with skeletal dysplasia who were treated with halo-gravity traction preoperatively. Six of the patients had a thoracoscopic anterior release prior to the halo-gravity traction. All patients were ambulatory and presented with severe, rigid kyphoscoliosis.

Results

The mean duration of traction was 32 days. There were no neurologic complications with traction or after posterior spinal instrumentation. The majority of kyphoscoliosis correction was with the halo-gravity traction alone: major curve (MC) Cobb angle improved 41 %; C7–center sacral vertical line, 75 %; C7–MC apex, 21 %; and T2–T12 kyphosis, 35 %. Trunk height increased 37 % and thoracic height 44 %. An additional amount of correction was obtained with posterior spinal instrumentation (±fusion), decreasing MC Cobb angle an additional 23 %; C7–apex, 16 %; and T2–T12 kyphosis, 10 %. There was no additional correction of thoracic height. Two years after posterior spinal instrumentation (±fusion), a mild-to-moderate amount of correction was lost: MC Cobb angle decreased 23 %; compensatory Cobb angle, 28 %; C7–CSVL, 24 %; C7–S1, 22 %; regional kyphosis, 31 %; thoracic kyphosis, 29 %; and trunk height, 27 %.

Conclusions

Among children with skeletal dysplasia and severe kyphosis, halo-gravity traction is well tolerated and safe. Most of the corrections in radiographic parameters were achieved with traction alone. Traction improves coronal balance, apical translation, thoracic height, and kyphosis. In this specific population, the potential for neurologic injury during corrective surgery is high. However, preoperative halo-gravity traction provides slow, progressive correction in a safe manner and avoided neurologic injury in these patients. This study did not compare patients without halo-gravity traction to patients with halo-gravity traction, therefore it cannot be concluded that going straight to instrumentation without traction will give a poorer radiographic result.

Level of evidence

IV.

     

Posterior spinal arthrodesis for congenital scoliosis. An analysis of the cases of two hundred and ninety patients, five to nineteen years old

We analyzed the results of posterior arthrodesis of the spine for congenital scoliosis, with or without Harrington instrumentation, in 290 of 323 patients who were operated on between the ages of five and nineteen years and were followed for two years or more. The length of follow-up averaged six years and ranged from two to twenty-eight years. The average curve before surgery was 55 degrees (range, 13 to 155 degrees), the average curve at correction was 38 degrees (range, 5 to 102 degrees), and the average curve at final follow-up was 44 degrees (range, 5 to 103 degrees). Bending of the fusion mass of more than 10 degrees was seen in forty patients; pseudarthrosis, in twenty; and adding-on of vertebrae with an increase in the curve of more than 10 degrees, in seven patients. There were four deaths, only one of them in the last twenty-five years. One was due to intraoperative cardiac arrest; one, to intraoperative overtransfusion; one, to postoperative overtransfusion; and one, to gastrointestinal bleeding eight months postoperatively while the patient was in a Risser jacket. Two patients became paraplegic due to excessive distraction with the Harrington rod, and two others had a partial cranial-nerve lesion due to halo traction. Based on these results, we concluded that posterior arthrodesis of the spine is satisfactory for most patients with congenital scoliosis. The most common problem was bending of the fusion mass in growing children, which occurred in 14 per cent of the patients. Use of Harrington instruments allowed slightly better correction (36 per cent compared with 28 per cent) but was associated with the only cases of paraplegia and infection in the series.     

Surgical management of severe aortic coarctation and interrupted aortic arch in neonates.

Forty-four infants, 2 to 90 days of age, with severe obstructive lesions of the aortic arch, underwent emergency surgical correction between Jan. 1, 1966, and April 1, 1975. The typical clinical presentation was severe congestive heart failure and acidemia. Resection of an aortic coarctation with end-to-end anastomosis was performed in 31 patients. Eight (26 per cent) died after the operation. Since 1969, the mortality rate has been reduced to 14 per cent (3 of 22 patients) even though the incidence of major associated cardiac lesions has remained essentially constant (56 per cent from 1966 through 1969, 64 per cent from 1970 through March, 1975). This suggests that the higher survival rate has resulted from improved surgical techniques and postoperative care. The mortality rate in the infants operated upon during the second and third months of life was twice as high as that in those operated upon before the age of 1 month. Eight patients with Type A interrupted aortic arch were operated upon and 5 survived. Five patients with Type B aortic arch were operated upon and 3 survived.     

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.     

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.