Experimental external fixation combined with percutaneous discectomy in the management of scoliosis

STUDY DESIGN: An assessment of the value of external fixation with or without percutaneous discectomy for the management of scoliosis in young rabbits with induced progressive thoracic scoliosis. OBJECTIVES: To investigate in an experimental setting the effect of external fixation with or without percutaneous discectomy for the management of scoliosis, as a preliminary study to precede clinical consideration. SUMMARY OF BACKGROUND DATA: External fixation of the spine using percutaneous transpedicular screws has been used clinically for cases of traumatic spinal injury, infectious spine, or chronic low back pain caused by a disc lesion. Percutaneous discectomy for the management of scoliosis has been reported. METHODS: Thirty-two young rabbits underwent partial resection of the right lower ribs. Nine rabbits were not treated after production of scoliosis and were followed as controls. At 4-6 weeks after production of scoliosis, in 23 animals, Kirschner wires were inserted percutaneously into the T9-T10 and L1-L2 disc space, and both ends were attached to an external fixator after correction of the scoliosis. In 8 of those 23 animals, percutaneous discectomy was also performed at the apex of the caudal compensatory curvature. RESULTS: In these 23 animals, the initial correction by fixation on of the caudal vertebrae was accompanied by a derotation in the apex. Five animals treated with external fixation only and four treated with combined percutaneous discectomy survived with external fixation until the age of 17 weeks and were followed to the natural cessation of the curve progression, at which the fixation was removed and a final assessment was made. The mean progression of curvature was 15.8 degrees in the group of five animals with external fixation only, and 33.8 degrees in the controls. In the group of four animals treated with supplementary percutaneous discectomy, however, the treated disc space became rigid, and the mean progression of curvature after removal of the fixation was only 5.3 degrees. CONCLUSIONS: The results of the current study suggest the potential for external fixation to allow for derotation and, when combined with percutaneous discectomy, to offer a feasible method of managing scoliosis in the human adolescent. This study was a preliminary experimental study; further experimental studies are planned to develop this novel technique.     

下胸椎侧前方内固定进针点相关问题研究

目的 :探讨下胸椎侧前方入路内固定进针点的问题。方法 :对 40具成人尸体脊柱标本进行观察及测量解剖数据。结果 :以肋凹为进针点参照物 ,以肋凹上缘切线作为X轴 ,肋凹前缘切线作为Y轴来确定进针点位置。结论 :以肋凹作为参照物 ,建立坐标系 ,确定进针点的位置 ,不仅可用于术前估计、术前判断 ,而且对于术中定位也有积极的意义。2 8.75 %的T12 肋凹完全位于椎弓根上 ,手术中应特别注意     

Costoplasty in scoliosis surgery

The rib hump is a protrusion of the apicals ribs of the convex side of the toracic scoliosis and it is due to the torsional deformity that appears in scoliosis. It originates a great cosmetic deformity that although improves with the correction of the scoliosis, it appears again by the costal elasticity. For this reason, in cases of important deformity it is necessary to associate a costoplasty for its definitive improvement. 10 cases of Idiopatic Scoliosis with 75.5 degrees of average and rib hump of 22.1 degrees were analysed. A resection of apicals ribs without stabilization in the same surgical act were done; the correction of the curve was 34.6 degrees (55%) and of the hump 8.1 degrees (64%); there were no important complications and the postoperative evolution was normal. The average follow up was 21,9 months, only in 1 case a slight deterioration of the hump was detected, although in all the cases the ribs recovered. In conclusion, costoplasty breaks the vertebro-bicosto-esternal ring. For that reason it is effective for the improvement of the costal hump without adding morbidity to the correction of the scoliosis.     

Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases

Introduction and importanceLong-level intramedullary astrocytomas complicated with spine scoliosis are rare. Surgical treatment of such tumors becomes more complicated and challenging when spinal scoliosis is present. However, studies describing the treatment of long segmental intramedullary spinal cord astrocytomas complicated with severe spine scoliosis have been rarely reported.Case presentationTwo cases of long-level intramedullary astrocytomas complicated with severe spine scoliosis were surgically treated with one-stage operation of tumor resection and scoliosis correction in this report. Case 1: A 16-year-old boy presented to our hospital with a five-month progressive paresthesia, weakness of the left lower limb, and a long-time abnormal body appearance. MRI showed a T4-T12 intramedullary tumor combined with spinal scoliosis. Case 2: A 14-year-old boy presented at our service with a 6-year history of visible spine scoliosis and a 1-year progressive motor disability of bilateral lower limbs. Spine MRI indicated a long-level abnormal syringomyelia signal from C4 to L1 and there was irregular enhancement after intravenous contrast medium administration at C7-T2 and T9-T12 level.DiscussionWe performed a laminectomy over the whole length of the tumor and corrected the scoliosis with trans-pedicle screws. The patients exhibited a long-time tumor free with largely neurological function preservation. One-stage operation did not generate severe short- or long-term complications. The correction of the scoliosis prevented the progression of the spinal deformity and facilitated the recovery of normal life.ConclusionThis case report demonstrates that the one-stage resection of long-level intramedullary astrocytoma and correction of the complicated scoliosis might be a feasible option.     

Unusual presentation of osteoblastoma in a patient with idiopathic scoliosis after posterior spinal fusion

BACKGROUND CONTEXT: Few studies have described the diagnosis of osteoblastoma of the spine as a cause of scoliosis. These reports have described the tumor in conjunction with initial presentation of painful scoliosis. This case report presents a case of osteoblastoma 9 years removed from diagnosis and fusion of idiopathic scoliosis in the thoracic spine. PURPOSE: To report the late presentation of an osteoblastoma of the thoracic spine 9 years after posterior spinal fusion for scoliosis. STUDY DESIGN: Case report. METHODS: A 25-year-old man presented with thoracolumbar back pain and progressive neurological deficit 9 years after posterior spinal fusion for idiopathic scoliosis. Magnetic resonance imaging of the thoracic spine indicated the presence of a mass in the spinal canal causing cord compression. The patient underwent decompression with resection of the mass which was found to be an aggressive osteoblastoma. RESULTS: The patient enjoyed a full neurological recovery and has subsequently developed a recurrence at 13 months. CONCLUSIONS: We present osteoblastoma as a possible cause of low back pain and neurological deficit postfusion that should be considered in a differential diagnosis.     

Bending of the Cotrel-Dubousset instrumentation after direct trauma: a case report

STUDY DESIGN: Case report. OBJECTIVES: To describe a fracture through the fusion mass of a spine that had been corrected previously with Cotrel-Dubousset rods. These rods had failed in bending after direct trauma. SUMMARY OF BACKGROUND DATA: Nine years after successful treatment of scoliosis with Cotrel-Dubousset instrumentation, the patient was in a motor vehicle accident and sustained a hyperextension spine injury with complete L1-L2 paraplegia and disruption of the fusion mass. The Cotrel-Dubousset instrumentation rods, which failed in bending, could not be corrected in situ, and the angulated segments had to be resected. The spine then became extremely unstable, and the patient consulted the authors for definitive stabilization. RESULTS: The spine was stabilized by attaching the proximal and distal retained Cotrel-Dubousset instrumentation to supplemental rods in a "domino" fashion. Crosslinks were added to improve the torsional stability. Intraoperatively, the fracture was well reduced, and the fixation was stable. A posterolateral fusion was performed with allogenic bone graft. CONCLUSION: Bent Cotrel-Dubousset instrumentation rods are still very strong and may not correct in situ.- If resection is required, the retained portions of Cotrel-Dubousset instrumentation can serve as attachments to restore stable fixation a "domino"technique.     

Nouvelles perspectives en chirurgie du rachis

This paper is based on an invited lecture given at the SICOT 87 meeting in Munich. The topics discussed include: selective spinal arteriography in the management of tumours, which enables definition of the vascular supply of the cord and of the tumour and may facilitate preoperative embolisation; MRI, which allows visualisation of both bone and soft tissue; the pathogenesis of transverse fractures of the upper sacrum; the management of malunion of fractures of the thoracolumbar spine by a three stage procedure, in which an initial posterior approach allows osteotomy and definition of the pedicle, a second anterior procedure for correction of the deformity by appropriate resection of the vertebral body, and a final posterior operation in which internal fixation is carried out using pedicular screws and plates. Operation on extradural tumours of the spine is usually palliative for metastases and aims to decompress the cord by laminectomy, stabilising the spine by osteosynthesis. Total removal of a vertebral body may be needed; percutaneous resection is being used increasingly for lumbar disc resection; the development of the Cotrel-Dubousset system and the use of long transpedicular plates allows better reduction of the deformity in scoliosis.     

一期后路全脊椎切除并内固定矫形治疗胸腰椎疾患

目的 观察一期后路全脊椎切除并内固定矫形治疗胸腰椎疾患的疗效.方法 对17例胸腰椎疾患(6例陈旧性脊柱骨折脱位,4例全脊椎结核,5例脊柱侧后凸畸形,2例全脊椎肿瘤)全脊柱切除的疗效进行回顾性分析.其中14例伴有后凸或侧后凸成角畸形,12例病变节段以下完全或不完全性瘫痪.对所有患者一期经后路行病椎全脊椎切除,环脊髓减压、...     

Surgical repair of pectus excavatum

From 1958 to March 1987 we corrected 704 patients with pectus excavatum. The condition occurred more frequently in boys (544 patients) than girls (160 patients). In the majority of patients (86%), the defect was evident at birth or within the first year of life. Musculoskeletal abnormalities were identified in 133 patients (scoliosis, 107; kyphosis, 4; myopathy, 3; Poland's syndrome, 3; Marfan's syndrome, 2; Pierre Robin syndrome, 2; prune belly syndrome, 2; neurofibromatosis, 3; cerebral palsy, 4; tuberous sclerosis, 1; and congenital diaphragmatic hernia, 2). Sixteen patients had associated congenital heart disease. A family history of chest wall deformity was present in 37% of the cases and a history of scoliosis in 11%. Surgical correction was performed using a uniform technique for bilateral subperichondrial resection of the deformed costal cartilages and sternal osteotomy resecting a wedge of the anterior cortex and fracturing the posterior cortex. Anterior displacement was maintained with silk sutures closing the osteotomy defect. In 28 early cases, the sternum was secured by intramedullary fixation with a Steinman pin. All repairs were completed with a low complication rate (4.4%; pneumothorax, 11; wound infection, 5; wound hematoma, 3; wound dehiscence, 5; pneumonia, 3; seroma, 1; hemoptysis, 1; hemopericardium, 1). Six complications were associated with Steinman pin fixation (hemoptysis, seroma, hemopericardium, pneumothorax, 3). Major recurrence occurred in 17 patients (2.7%) and led to revision in 12. Satisfactory long-term results were achieved in the remaining 687 patients, with follow-up ranging from 2 weeks to 27 years. Mean follow-up was 4.3 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

退变性腰椎侧凸单、双cage置入结合椎弓根螺钉内固定术的生物力学研究

目的 比较单、双椎间融合器(cage)置入法结合短节段内固定的生物力学稳定性,以为临床研究提供参考依据.方法 通过建立退变性腰椎侧凸模型,将12具标本随机分为两组:单cage结合椎弓根螺钉内固定组(实验组),双cage结合椎弓根螺钉内固定组(对照组).两组标本通过脊柱三维运动测试机模拟不同状态下人体前屈、后伸等6个方向的生理运动.运用三维激光扫描仪测定不同载荷下不稳节段的运动范围.结果 正常状态下,两组标本L2～3节段各方向ROM值无统计学差异(P＞0.05),说明两组标本具有可比性;两组标本不稳状态下各方向ROM值相比正常状态均有所增加(P＜0.05或P＜0.01),说明腰椎不稳模型制备成功.行融合术后,两组标本前屈、后伸、屈伸、侧弯、旋转等各方向ROM值较正常状态下均有所减小(P＜0.05或P＜0.01);实验组标本L2-3节段椎间各力向ROM值比对照组略高,但差异无统计学意义(P＞0.05).结论 单cage融合椎弓根螺钉内固定后脊椎的生物力学稳定性与传统双cage融合椎弓根螺钉内固定相似,而且其生物力学特性与完整正常脊柱相近.     

头盆环牵引全脊柱截骨内固定治疗重度脊柱弯曲

[目的]介绍头盆环牵引全脊柱截骨加内固定治疗重度脊柱弯曲的手术方法,并总结185例重度脊柱弯曲的治疗结果。[方法]对重度脊柱侧弯患者,先用头盆环牵引,使重弯变为轻弯,以便置入器械的安装,再在头盆环牵引下进行截骨矫正畸形和内固定手术,术后继续配戴头盆环制动,术后第2d即可下床站立活动,给护理工作带来极大方便。[结果]作者自1983~2003年,采用此法治疗重度脊柱侧弯185例,平均矫正率是70.32%。脊柱截骨断端能达到坚固的骨性融合,矫正率丢失平均在5°以内,术后晚期并发脱钩者4例,均经再次手术固定解决,对矫正效果无影响。1例术后1年并发感染,拆除置入器械后,伤口很快愈合,X线所见植骨愈合良好。1例并发神经根疼痛,而后逐渐减轻,所有病例未见脊髓损伤和神经系统并发症发生。[结论]头盆环牵引加全脊柱截骨是治疗重度脊柱侧弯的有效方法,对那些仅用单纯器械无法安装,置入困难的病例,经头盆环牵引后,内固定器械容易安装,再加上全脊柱截骨,能使弯曲的脊柱进一步伸直,减轻了内固定器械所承受的负荷力,避免了脱钩断棍的发生,为治疗重度脊柱侧弯的有效手段。     

先天性脊柱畸形矫形手术治疗的初步观察

目的：探讨先天性脊柱畸形矫形手术治疗策略。方法：通过回顾性分析本院脊柱外科2002年11月至2003年12月期间治疗的10例先天性脊柱畸形患者的临床资料，确定不同患者不同矫形术式的选择。结果：10例患者手术时平均年龄15．2（1～40）岁，平均后凸角度69°（35°～98°），2例行单纯前路矫形植骨融合内固定手术，1例行单纯半椎体切除术，1例后路原位融合内固定术，6例后路矫形植骨融合内固定术，术后畸形矫正率为32．2％。结论：不同年龄、不同分型以及不同的畸形程度，应选择相应的矫形术式。     

Vascular changes in the chest wall after unilateral resection of the intercostal nerves in the growing rabbit

In young, growing white New Zealand rabbits the third, fourth, and fifth intercostal nerves were resected anteriorly on the right side. Six months later the animals developed structural left convex scoliosis, with a Cobb angle ranging from 15 to 31 degrees. The vascular structure changes of the anterior chest wall were evaluated by measuring surface temperature and fluorescein intensity of the pectoral muscles, and the capillary density of the pectoral and intercostal muscle and periosteal parts of the ribs after angiography. In five normal control rabbits there was neither scoliotic deformity nor significant differences in the examined vascular variables between the right and left sides. In the animals undergoing resection, the temperature of the pectoral muscle on the side of the denervation--the right side--was significantly increased (p less than 0.05), but the difference was not correlated to the degree of scoliosis. The fluorescence index was significantly greater (p less than 0.05) on the right than on the left side, this difference being fairly strongly correlated to the degree of scoliosis. The capillary densities of the costal periosteum and the intercostal and the pectoral muscle were significantly greater (p less than 0.05) on the right than on the left side, and the difference was positively correlated to the degree of scoliosis. The volume density of the periosteum of the ribs was likewise significantly greater on the right. These results demonstrate that unilateral resection of the intercostal nerves significantly increases the vascularity of the structures on the denervated side of the thorax.(ABSTRACT TRUNCATED AT 250 WORDS)     

重度脊柱侧凸的后路手术矫治

目的评价后路矫形内固定术治疗重度脊柱侧凸的疗效。方法重度脊柱侧凸患者16例，进行后路矫形内固定术治疗，术前主弯Cobb角71°-110°（84°±11°），其中矢状面异常患者11例。结果手术时间3．4—5．1（4．1±0．6）h，出血量570—1120（778±178）ml，平均融合节段11（9—13）个椎体，术后主弯Cobb角24°-44°（31°±5°），11例矢状面异常患者重新恢复了胸椎生理性后凸和腰椎生理性前凸，未发生感染、血气胸和神经系统等并发症。终末随访时，主弯Cobb角27°-45°（33°±5°），矫正丢失率为0—13％（7％±5％），固定范围内植骨全部融合，未发生术后失代偿和假关节形成。结论后路矫形内固定术是治疗重度脊柱侧凸安全有效的方法。     

Macroporous calcium phosphate ceramic performance in human spine fusion

With a background of experimental studies on macroporous biphasic calcium phosphate (MBCP) in canine spine fusion, MBCP was investigated in 11- to 18-year-old patients with scoliosis treated by spinal fusion. Twelve cases were chosen for whom enough bone graft was difficult to obtain (severe neurologic scoliosis and osteogenesis imperfecta). MBCP blocks were used in combination with a specific strong fixation (Cotrel-Dubousset instrumentation). Clinical and roentgenogram assessments were performed up to 24 months. In two cases, biopsies were obtained. Histologic, ultrastructural, and microanalysis studies demonstrated the effectiveness of MBCP implants combined with a strong stabilization as bone graft substitutes for spine fusion. Clinical and biologic assessments were normal, and the histologic and ultrastructural evaluation demonstrated the bioactivity and the osteoconduction of this material. Partial resorbability of the MBCP blocks involved lamellar bone formation at the expense of the ceramic.     

Surgical correction of pectus carinatum

Pectus carinatum is an infrequent but eminently correctable chest wall deformity. It is encountered much less frequently than pectus excavatum. In 12 years, from 1973 to 1985, 152 pectus carinatum (16.7%) and 758 pectus excavatum deformities (83.3%) were corrected. It occurs more frequently in boys (119 patients) than girls (33 patients). The majority, 89 cases, were symmetric, while 49 were asymmetric, and 14 were mixed deformities (ipsilateral carinatum, contralateral excavatum). In almost half the patients the deformity was not identified until after the 11th birthday. A family history of chest wall deformities was present in 26%, and of scoliosis in 12%. Associated musculoskeletal abnormalities were identified in 34 patients (scoliosis 23, Poland's syndrome 4, neurofibromatosis 2, Morquio's disease 2, vertebral anomalies 1, hyperlordosis 1, and kyphosis 1). Surgical correction required bilateral resection of the third through seventh costal cartilages in 143 patients, and unilateral resection in nine patients with an isolated abnormality. A single osteotomy was used in 88 patients and a double osteotomy in 53 patients. In 11 cases no osteotomy was required. Mixed deformity with posterior angulation of the sternum was managed by osteotomy and anterior displacement. The remaining cases had sternal osteotomy and fracture of the posterior cortex to correct anterior angulation. The operation was completed with a low complication rate 3.9% (pneumothorax 4, wound infection 1, atelectasis 1, and local tissue necrosis 1). Three patients required revision with additional unilateral lower cartilage resection for persistent malformation of the costal arch. All patients ultimately had a satisfactory result.     

一期后路半椎切除治疗成人半椎畸形

目的探讨一期后路椎弓根螺钉固定、半椎切除、矫形、植骨融合治疗成人半椎畸形的临床疗效。方法 2008-03-2010-07,对11例半椎所致侧后凸畸形患者行一期后路椎弓根螺钉固定、半椎切除、矫形植骨融合术。患者年龄24~38岁,平均27岁,术后随访6个月~2年,平均14个月。通过术前、术后及随访时站立位脊柱正位和侧位X线片测量,评价冠状面及矢状面的矫形效果。结果平均手术时间220 min;术中平均失血量1400 ml。术后所有患者躯干平衡良好,均无感染及严重神经系统并发症发生。术后2周节段侧凸角矫正率85%,后凸角矫正率为80%。末次随访时侧凸及后凸矫形均无明显丢失。结论一期后路椎弓根螺钉固定、半椎切除、矫形植骨融合治疗成人半椎畸形可获得良好的矫形效果,建议半椎畸形患者早期接受手术治疗。     

Neuromuscular scoliosis and pelvic fixation in 2015: Where do we stand?

Neuromuscular scoliosis is a challenging problem to treat in a heterogeneous patient population. When the decision is made for surgery the surgeon must select a technique employed to correct the curve and achieve the goals of surgery, namely a straight spine over a level pelvis. Pre-operatively the surgeon must ask if pelvic fixation is worth the extra complications and infection risk it introduces to an already compromised host. Since the advent of posterior spinal fusion the technology used for instrumentation has changed drastically. However, many of the common problems seen with the unit rod decades ago we are still dealing with today with pedicle screw technology. Screw cut out, pseudoarthrosis, non-union, prominent hardware, wound complications, and infection are all possible complications when extending a spinal fusion construct to the pelvis in a neuromuscular scoliosis patient. Additionally, placing pelvic fixation in a neuromuscular patient results in extra blood loss, greater surgical time, more extensive dissection with creation of a deep dead space, and an incision that extends close to the rectum in patients who are commonly incontinent. Balancing the risk of placing pelvic fixation when the benefit, some may argue, is limited in non-ambulating patients is difficult when the literature is so mottled. Despite frequent advancements in technology issues with neuromuscular scoliosis remain the same and in the next 10 years we must do what we can to make safe neuromuscular spine surgery a reality.     

Surgical treatment of scoliosis associated with Marfan syndrome by using posterior-only instrumentation

Surgical treatment of scoliosis associated with Marfan syndrome poses a challenge to spine surgeons. This retrospective study was undertaken to determine whether posterior-only surgery with instrumented fixation and fusion addresses the correction of scoliosis and maintains curve correction. Twelve consecutive patients with Marfan syndrome were treated between 2002 and 2007 for scoliosis by posterior segmental instrumentation using pedicle screws or hybrid thoracic-hook and lumbar-screw constructs. Their preoperative Cobb angle averaged 66 ± 10° (range: 55-90°). The average operation time was 252 ± 36 min (range: 200-300 min) and the average blood loss was 690 ± 117 ml (range: 550-920 ml). No significant complications were found. All the patients were followed for a minimum of 2 years (range: 2.4-6.8 years). The average Cobb angle was corrected to 23 ± 8° (range: 13-35°) immediately after surgery and 28 ± 9° (range: 14-43°) with a correction rate of 58 ± 13% at final follow-up. The results indicate that posterior-only surgery with instrumented fixation and fusion is effective and safe for the treatment of scoliosis in selected patients with Marfan syndrome.     

腰椎退行性侧凸畸形的手术治疗策略

目的探讨腰椎退行性侧凸畸形的手术策略及疗效。方法回顾性分析自2009-02—2014-02采用责任节段减压、选择性固定融合治疗的93例腰椎退行性侧凸畸形。比较术前及末次随访时腰痛VAS评分、腿痛VAS评分、ODI指数、JOA评分、侧凸Cobb角、前凸Cobb角。结果本组手术时间115~189(147.87±24.51)min,术中出血量210~730(357.33±27.44)ml,术后引流量230~550(441.39±31.39)ml。4例因椎管狭窄及粘连严重术后出现脑脊液漏,经头低足高位治疗,切口均一期愈合。3例切口积血,延期3~5 d愈合。93例均获得随访16~63个月,平均54.1个月。末次随访时患者腰痛VAS评分、腿痛VAS评分、ODI指数、JOA评分、侧凸Cobb角、前凸Cobb角均较术前明显改善,差异有统计学意义(P0.05)。结论责任节段减压、选择性固定融合治疗腰椎退行性侧凸畸形效果良好,但手术既要达到治疗目的,又要减少脊柱结构单元的破坏,更要兼顾术后是否会并发邻近节段退变、侧凸畸形进一步加重等问题。