Evaluation of spinous process wire fixation with Harrington instrumentation for idiopathic scoliosis

A modification of the technique of Harrington instrumentation for idiopathic scoliosis utilizes segmental spinous process wiring. The purpose of this study is to contrast and compare two populations of surgically treated patients with idiopathic scoliosis: one group with a single Harrington distraction rod and the other group with the addition of spinous process wiring. Of 252 consecutive patients between 1971 and 1987, 215 were retrievable, with an average clinical follow-up of 2.2 years. Curves were analyzed by location and patient age. Patients treated with spinous process wires were braced, those without were casted. No significant difference in terms of percent correction with time was evident between the two treatment groups. The complication rate (11.0%) and pseudarthrosis rate (4.0%) were the same in both wired and standard groups. The more rigid adult curves resulted in less correction and greater complications than adolescent curves. Spinous process wiring seemed to protect against upper hook cut-out. There were no deaths or paraplegias. Patients surgically treated with the wire modification enjoyed greater comfort with the removable brace, and curve correction was equal to that obtained in patients treated with the standard technique and post-op casting.     

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.     

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.     

Shear fracture-dislocations of the thoracic and lumbar spine associated with forceful hyperextension (lumberjack paraplegia).

Twelve patients sustained a shear fracture-dislocation of their thoracic or lumbar spines by a hyperextension mechanism of injury. Ten male and two female patients were injured; their average age was 29 years (range, 22 months to 56 years). Ten fracture-dislocations occurred in the thoracic spine, one at the thoracolumbar junction, and one in the lumbar spine. Eleven patients had complete paraplegia, and one had incomplete paraplegia at the time of injury. Dural tears were found in six of the patients. Eleven patients were treated by posterior spinal fusion with instrumentation, and one was treated with a brace. Three patients were treated with Harrington distraction rods alone, six had Harrington distraction rods supplemented with a midline Harrington compression rod or interspinous wiring, and two were treated with Cotrel-Dubousset instrumentation. No patient was lost to follow-up. The average length of follow-up was 3.5 years (range, 1-9 years). Six of the patients treated with Cotrel-Dubousset instrumentation or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring healed anatomically; two patients developed pseudarthroses. None of the patients treated with Harrington distraction rods alone healed in an anatomic position. The use of Harrington distraction rods alone was associated with overdistraction and nonanatomic alignment of the spine. The disruption of the anterior stabilizing structures of the spine associated with hyperextension injuries necessitates the use of instrumentation that can stabilize the spine and prevent overdistraction. This injury can be successfully treated with Cotrel-Dubousset or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring.     

Scoliosis elasticity assessed by manual traction:49 juvenile and adolescent idiopathic cases

We assessed preoperative curve elasticity in 49 consecutive patients with juvenile or adolescent idiopathic scoliosis who were operated on with Harrington distraction rods. Preoperatively, the curve was determined from posteroanterior radiographs taken in the standing position and in the supine position, with traction. In the latter, the radiographs were taken at the moment of maximal traction when one technician applied traction to the ankles and another to the wrists. The scoliotic curve in the 10 patients with juvenile scoliosis averaged 59° and 32° in the standing and supine positions with traction, respectively. Immediately postoperatively, the curve averaged 19°. 39 patients with adolescent scoliosis had a scoliotic curve which averaged 58° in the standing position and 32° in the supine position with traction. The mean postoperative measurement was 21°. These findings suggest that manual traction is a simple and reliable means of predicting the minimal correction of the scoliotic curve to be expected, using Harrington distraction rods.     

Use of a bivalved polypropylene orthosis in the postoperative management of idiopathic scoliosis

Forty-four consecutive patients with idiopathic scoliosis treated by posterior spinal fusion and Harrington rod instrumentation were immobilized after surgery with bivalved polypropylene orthoses. Immediate ambulation was allowed, and the patients wore the orthoses for a mean of 5.9 months. Brace removal was permitted with the patient recumbent for sponge bathing. These patients were followed up for a mean of 2.1 years (range, 1.0-4.3 years). The average final correction for all curves was 45%. The average loss of correction was 2.4 degrees (5.3%). Combined distraction and compression instrumentation was found to improve final correction in all curves by 3 degrees (6.2%) as compared with distraction instrumentation alone. There were no pseudarthroses and no rod breakage. Patients enjoyed the benefits of improved personal hygiene, pleasing cosmetic appearance, and increased life-style flexibility, especially swimming, which was not possible with the conventional Risser plaster cast. Use of the polypropylene orthosis offers significant advantages as compared with previous methods of postoperative management: it not only provides consistently good results but is enthusiastically accepted by patients as well.     

Evaluation of the role of concave rib osteotomies in the correction of thoracic scoliosis

The role of concave rib osteotomies was studied in a series of 25 patients with right thoracic idiopathic scoliosis who underwent Harrington distraction instrumentation and segmental sublaminar wiring of the thoracic curve. Group I had ten patients with rigid curves who had instrumentation, fusion, and segmental concave rib osteotomies. Group II had 15 patients with flexible curves who underwent instrumentation and fusion alone. Preoperative side bending curve reduction averaged 23% in Group I and 49% in Group II. Postoperative correction was similar in both groups with Group I achieving 60% (+/- 10%) overall correction and Group II, 57% (+/- 8%). Group I underwent 56% further reduction from side bending compared with Group II's 12% reduction. It was concluded that if preoperative side bending correction was below 35% of standing curve, curve correction comparable to flexible cases could be achieved through multiple concave rib osteotomies. Neurologic risk was not increased, but there was increased pulmonary morbidity of 30%.     

The simultaneous application of an interspinous compressive wire and Harrington distraction rods in the treatment of fracture-dislocation of the thoracic and lumbar spine

During open reduction of thoracolumbar fracture-dislocation, the normal constraints to distraction and lengthening may be ruptured and allow instrumentation to exert deleterious traction of the spinal cord. An interspinous wire across the unstable segment together with a Harrington rod may be used to prevent potential overdistribution of the spinal cord. Thirty-six patients with fracture-dislocation of the thoracolumbar spine were treated by open reduction with Harrington rods and interspinous wiring. Of 15 patients with a partial cord lesion, four made complete recovery, and nine of the remaining 11 became ambulators. Six patients with a complete paraplegia did not improve; 15 patients remained neurologically intact following the procedure. The compressive wire and Harrington rods act in concert and enable correction of kyphosis and restoration of vertebral and discal height while protecting the cord against traction. The technique is safe and does not add to operative time.     

Spinal surgery in spinal muscular atrophy

Fifteen patients with surgical treatment of spinal muscular atrophy were reviewed. The curve pattern was thoracic in 3, thoracolumbar in 11, and double thoracic and thoracolumbar in 1. Follow-up averaged 31 months. Eleven patients underwent posterior spinal fusion with Harrington instrumentation, with segmental wiring in four, and two had Luque instrumentation. The average age at time of surgery was 14.4 years. The average curve correction was 48%; that with the pelvic obliquity corrected, 63%. Surgery is best done when the curve is approximately 50-60 degrees, and Luque sublaminar wiring of Harrington or Luque rods with no external support appears to be the procedure of choice.     

Posterior fusion for Scheuermann's kyphosis

Ten patients with Scheuermann's kyphosis were surgically treated with posterior spine fusion and Harrington heavy compression-rod instrumentation. This procedure relieved pain and deformity in all ten patients. The average follow-up period was 26.6 months. The average curve before surgery was 71.4 degrees and at follow-up examination was 39.3 degrees. The postoperative correction of kyphosis averaged 32 degrees (45%), with an average loss of correction of 7.8 degrees. Posterior fusion with Harrington heavy compression-rod instrumentation may prove to be the procedure of choice in Scheuermann's kyphosis that is severe but flexible on hyperextension with a curve greater than 65 degrees.     

Contoured Harrington instrumentation in the treatment of unstable spinal fractures. The effect of supplementary sublaminar wires

Twenty-nine patients with major fractures and fracture-dislocations of the thoracic and lumbar spine were treated by spinal fusion and contoured Harrington distraction instrumentation. Two groups of patients were identified. Group I (16 patients) had sublaminar wires. Group II (13 patients) had no wiring. Satisfactory alignment was achieved in all patients. There were several complications in both groups. None of the patients in Group I had postoperative cast immobilization. The addition of sublaminar wiring appears to eliminate the need for rigid external immobilization and is beneficial only for patients who cannot tolerate body casts. This technique is a disadvantage, however, when a short-length fusion is desired.     

Factors influencing the result of posterior spinal fusion in the treatment of adolescent idiopathic scoliosis

Sixty-six consecutive patients with adolescent idiopathic scoliosis treated by posterior spinal fusion using Harrington distraction compression instrumentation were followed for a minimum of 3 years. Initial surgical correction was satisfactory, but during the follow-up period, mean 4.4 years (3-5 years), there was a loss of correction. Several factors (age, sex, the number of vertebrae in the fusions, and the use of cross wires) were important influences on correction. A method of assessing the balance of a posterior spinal fusion is described that is useful when assessing radiographs.     

Comparison of Cotrel-Dubousset and Harrington rod instrumentations in idiopathic scoliosis

An analysis of the efficacy of two techniques of posterior spinal instrumentation in patients with idiopathic scoliosis was performed. Thirty-two consecutive patients treated with Cotrel-Dubousset instrumentation and no external bracing were compared with 30 consecutive patients treated with Harrington rod instrumentation supplemented by Bobechko hooks, sublaminar wires, and postoperative bracing. The groups were similar in age, curve magnitude, and type. Cotrel-Dubousset instrumentation demonstrated significantly improved immediate frontal plane correction. It was also more effective in improving thoracic kyphosis, particularly in patients with preoperative hypokyphosis. Both procedures were performed with similar operative time, blood loss, and minimal complication rates.     

Posterior vertebral instrumentation for correction of scoliosis

One hundred and five patients were treated by instrumentation for various spinal conditions by means of the posterior route. There were 90 patients with scoliosis in this series. Of these, 61 cases (67.7%) were corrected by Harrington distraction rod and segmental wire fixation. The various degrees of deformity in these patients produced the correction figures of 36.4%-42.6% of the original. The complications were eight cases of displacement of the upper hook, two cases of superficial infection, and one case of late infection. There were no cases of neurologic injury. The discussion centers on the importance of the awake test, the estimation of expected correction before surgery, the Harrington distraction rod with segmental wire fixation as an effective method, and the measures to be taken for the prevention of displaced fractures at the site of the upper hook in kyphoscoliosis correction.     

Initial results of the surgical treatment of scoliosis with the Cotrel and Dubousset CD instruments

At the Orthopaedic University Hospital Muenster 50 patients were surgically treated according to the Cotrel and Dubousset technique from June 1985 to October 1986. An outstanding characteristic of this method is the three-dimensional correction of the curve without exclusive application of distraction or transverse forces, bringing about excellent stability. By means of this operation an average preoperative angle of 63.4 degrees could be diminished to 33.9 degrees, meaning a gain of correction of 46.5%. Complications occurred essentially due to insufficient experience with this technique in the first patients operated on. After sufficient training this procedure is as practicable as the Harrington technique.     

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.     

Sublaminar wiring of Harrington distraction rods for unstable thoracolumbar spine fractures

Sublaminar wiring of Harrington distraction rods enhances stability and resistance to pullout and is an effective means of managing unstable thoracolumbar spine fractures. The incidence of distraction rod-related failure and the duration of postoperative immobilization are reduced. Early return to full activity and successful rehabilitation are facilitated by efficient stabilization of the spinal column.     

Harrington-Bobechko instrumentation in the treatment of scoliosis: a preliminary report

A dual hook system devised by Bobechko for use with Harrington and Moe distraction rods to eliminate postoperative orthotic support was employed in the surgical treatment of 57 patients with progressive scoliosis. Mean follow-up time was 33 months (range 15 to 56 months). Average correction was 51%, with an average loss of correction of 8 degrees. Five patients required reinstrumentation, two of whom had dislodgement of both upper hooks during the first postoperative week; the other three had rod breakage which occurred 3 to 20 months after surgery. The results indicate that the dual hook system provides greater security of fixation than a single hook construct, but has the disadvantage of bulkiness, making it prominent in thin patients. Postoperative protection with bracing for 6-9 months continues to be recommended to guard against instrument failure.     

Spinal canal restoration by posterior distraction or anterior decompression in thoracolumbar spinal fractures and its influence on neurological outcome

Summary Thirty consecutive patients who had suffered unstable fractures and dislocations of the thoracolumbar spine mostly associated with neurologic impairment and bony encroachment on the spinal canal were treated either with Harrington distraction rods combined with sublaminar wires or with the Zielke-VDS device. These patients were subsequently assessed for neurologic outcome, spinal canal clearance, sagittal and coronal spinal deformity correction preoperatively and postoperatively with a minimum follow-up of 26 months. In the follow-up evaluation, the patients who underwent surgery with Harrington rods showed an overall improvement of their neurologic function of 90.9%, whereas all patients who underwent the Zielke operation improved. Preoperatively, positive correlations were found between the level of injury and Frankel grades; the cord lesion tended to demonstrate more severe neurologic deficit when compared with cauda equina ones (P < 0.001). Furthermore, dislocation accompanying the injury resulted in a more severe neurological deficit (P < 0.05). Harrington rods and Zielke device offer sufficient initial correction of the frontal spinal deformity but did not significantly either restore or maintain sagittal plane alignment. The Harrington series showed an overallimprovement of the segmental kyphosis of 26% (NS), with a subsequent loss of correction of 7.38% (NS) on the follow-up observation. The Zielke device produced an immediate, much better correction of the segmental posttraumatic kyphosis of 45% (NS), but a loss of correction of 22.9% (NS) was measured in the follow-up evaluation. Correction of the anterior and posterior vertebral height was shown to be better for the Zielke patient group. The coronal deformity was completely corrected equally well by the Harrington and Zielke devices. There was no statistically significant correlation between the degree of bony encroachment of the spinal canal and the initial Frankel grade. Additionally, no statistically significant correlation was found between correction of the sagittal deformity, restoration of anterior and posterior vertebral height, coronal deformity correction, and clearance of the vertebral canal. Concerning neurological status, no patient in either group was worse in the follow-up evaluation. A significant correlation was found between the age of the patient and the neurological improvement favoring young patients (P < 0.001).