Pulmonary function and thoracic deformities in adolescent idiopathic scoliosis 27 years or longer after spinal fusion with Harrington instrument

Background

The aim of this study was to conduct an investigation into spinal fusion with Harrington instrument (HI) in patients with adolescent idiopathic scoliosis (AIS) and to survey pulmonary function and thoracic deformity outcomes many years after surgery.

Evaluation of deformities and pulmonary function in adolescent idiopathic right thoracic scoliosis

Summary Seventy patients with adolescent idiopathic right thoracic scoliosis had full assessment of their pulmonary function using a computerised pulmonary function system. Their mean age at evaluation was 13.8 years. The following measurements were obtained from anteroposterior and lateral standing and antero-posterior supine bending radiographs: lateral curvature, vertebral rotation, kyphosis, maximum sterno-vertebral distance and apical rib-vertebral angles. Using the above measurements, the flexibility of curve, vertebral rotation and rib-vertebral angle asymmetry were calculated. Patients were classified into three groups on the basis of their predicted vital capacity, to determine whether radiological features of deformity can help identify patients with compromised pulmonary function. The mean Cobb angle and vertebral rotation for the 70 patients were 50° (range 35–100°) and 22° (range 1–44°) respectively. The mean flexibility of curve and vertebral rotation were 52% and 49% respectively. Mean thoracic kyphosis was 25%, ranging from -7 to 55%. Of the patients with Cobb angle less than 90%, 71% had vital capacity less than 80% of predicted values, and of these, 18% had marked compromise of vital capacity (less than 60% of predicted values). Mean values of Cobb angle, vertebral rotational flexibility, kyphosis, rib-vertebral angle asymmetry (in standing as well as supine bending radiographs) differed significantly between patients with more than 80% of predicted vital capacity and those with 60% or less of predicted values. Radiological features indicative of better pulmonary function were: rotational flexibility exceeding 55%, rib-vertebral angle asymmetry (standing) less than 25% and kyphosis greater than 15%. Two deformity parameters—that give a better prediction of pulmonary function than the widely used Cobb angle, vertebral rotational flexibility and rib-vertebral angle asymmetry—were identified in this study.     

Evaluation of thoracic factors after scoliosis surgery in patients with both scoliosis and pectus excavatum

Purpose

Pectus excavatum can negatively impact cardiac function during scoliosis surgery. Several authors reported severe hypotension associated with the prone position during scoliosis surgery in children that had both scoliosis and pectus excavatum. However, we could find no studies that evaluated the change in the thoracic factors, such as sternal tilt angle and Haller index after scoliosis surgery in patients with both scoliosis and pectus excavatum. The purpose of this study is to evaluate the change in thoracic factors after surgical treatment for scoliosis associated with pectus excavatum.

Methods

We performed a retrospective review on 20 patients (10 males and 10 females) who underwent surgical treatment for scoliosis associated with pectus excavatum from August 2004 to April 2014 in our hospital. We investigated the scoliosis diagnosis, preoperative and postoperative Cobb and thoracic kyphosis (TK) angles, the change in TK after surgery and thoracic factors, including the AP and transverse diameters of the chest, the sternal tilt angle, and Haller index.

Results

Patient mean age was 13.2 years old (4–27 years old) at surgery. Types of scoliosis were idiopathic in 8 patients, syndromic in 10, and neuromuscular in 2. The mean Cobb angles were 72.1° preoperatively and 19.0° postoperatively. Curve locations were thoracic in 13 patients, thoracolumbar in 4, and lumbar in 3. Surgical treatment of pectus excavatum was performed in 9 patients (45 %) before scoliosis treatment. Mean sternal tilt angles were 11.5° preoperatively and 11.1° postoperatively. Mean Haller indices were 4.8 preoperatively and 5.3 postoperatively. This was especially true for syndromic or neuromuscular scoliosis and thoracolumbar/lumbar curve type patients in which scoliosis surgery tended to worsen the Haller index.

Conclusion

The Haller index increased postoperatively in 11 of 20 patients, which means sternal depression deteriorated after scoliosis surgery in about 50 % of patients. We suggest that surgeons fully assess the thoracic factors in patients with scoliosis and pectus excavatum prior to performing scoliosis surgery and carefully monitor their patient’s general condition during surgery.

     

Excessive thoracic lordosis and loss of pulmonary function in patients with idiopathic scoliosis.

Idiopathic thoracic lordoscoliosis is more common and more productive of respiratory compromise than is kyphoscoliosis. In some patients with idiopathic scoliosis, thoracic lordosis is the predominant component of the disease. Five such patients, all of whom had idiopathic scoliosis with excessive thoracic lordosis, progressive deformity despite Milwaukee brace treatment, and significant compromise of pulmonary function, are presented. Harrington instrumentation (distraction rod only) and spine fusion improved the deformity and respiratory function. The recommended treatment for this type of idiopathic scoliosis is early recognition and prompt surgical correction. The Milwaukee brace should be avoided. Postoperative management must include early ambulation combined with vigorous breathing exercises.     

胸椎侧凸后路凸侧胸廓成形术后胸腔并发症及其预防

目的：探讨青少年特发性胸椎侧凸后路凸侧胸廓成形术的胸腔并发症原因,并提出预防措施。方法：对2003年12月至2007年9月行脊柱侧凸后路矫形内固定术和凸侧胸廓成形术,并有完整资料的胸椎侧凸患者548例进行回顾性分析。其中男167例,女381例;年龄12～38岁,平均16.1岁。术前剃刀背畸形16°～50°,平均35°。结果：凸侧胸廓成形的肋骨切除数平均4.1根。术后剃刀背畸形2°～17°,平均7°。1例（0.2%）术后呼吸困难需间歇性吸氧,29例（5.3%）术中发生壁层胸膜穿孔,其中5例术后胸腔积液,3例气胸。6例（1.1%）患者术中并无明显胸膜穿孔,但术后出现术侧胸腔积液。结论：提高手术技巧,术后严密监测呼吸状态,早期积极处理,可减少凸侧胸廓成形术后胸腔并发症的发生。     

Respiratory impairment and airway closure in patients with untreated idiopathic scoliosis

Fifty patients aged 11 to 78 years with untreated idiopathic scoliosis were studied. An increased frequency of respiratory impairment was found, especially in patients with a severe degree of scoliosis. Seven patients under 60 years were unable to work and all had thoracic curves exceeding 100°. None of the patients between 20 and 65 years of age was engaged in hard work and 22% had a disability pension, all because of respiratory impairment. A tendency to increased shortness of breath was noted with increasing curves as well as age.     

轻中度胸弯型青少年特发性脊柱侧凸患者胸椎后凸角对上胸椎后凸角的影响

目的:探讨轻中度胸弯型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者胸椎后凸角与上胸椎后凸角的关系,并评估其临床意义。方法:选取在我院就诊的轻中度(Cobb角40°~60°)单胸弯型AIS患者50例、双胸弯型AIS患者50例,均摄站立位脊柱全长正位X线片及上肢抱胸体位下的站立位脊柱全长侧位X线片。测量主胸弯Cobb角、上胸椎(T2~T5)后凸角(upper thoracic kyphosis,UTK)及胸椎(T5~T12)后凸角(total kyphosis,TK)。两种弯型患者分别按TK大小分为两组:A组TK<10°,B组10°≤TK≤40°。分别将两种弯型的A组及B组的参数测量结果进行比较,并对相关参数指标进行Spearman相关分析。结果:在单胸弯型AIS患者中,A组UTK平均为6.9°,B组为9.8°,两组比较有统计学意义(P<0.05);单胸弯AIS患者TK与UTK存在显著性正相关(P<0.05)。在双胸弯型AIS患者中,A组的UTK平均为12.0°,B组为11.9°,两组比较无统计学差异(P>0.05),双胸弯型AIS患者的TK与UTK无显著性相关(P>0.05)。结论:双胸弯型AIS患者的TK对UTK无明显影响;而单胸弯型AIS患者的UTK会随着TK的减小而减小,在对单胸弯型AIS患者进行胸椎融合时,应考虑其对术后矢状面形态重建的影响。     

Spinal deformities in patients with muscular dystrophy other than Duchenne. A review of 11 patients having surgical treatment

Eleven patients diagnosed as having muscular dystrophy and who underwent posterior spinal fusion were reviewed: Becker dystrophy in one, limb girdle in two, facioscapulohumeral in one, myopathia unspecified in one, myotonia dystrophica in two, myotonia congenita in one, and hypotonia congenita in three. There were eight females and three males. The curve pattern was thoracic in four, thoracolumbar in three, double thoracic and thoracolumbar in three, and thoracolumbar lordosis in one. Scoliosis was associated with kyphosis in two, with lumbar lordosis in one, and thoracic lordosis in four patients associated with poor vital capacity and shortness of breath. Seven patients had nonoperative treatment, five showing increase of the curve, and two having control of the curve. All patients had posterior spinal fusion with instrumentation with a follow-up of 9-89 months (average, 41 months). Postoperative support was used in all but one. Major complications occurred in four patients: a symptom of vascular obstruction of the duodenum in two, extubation delayed until the 7th day postoperatively in one and pseudarthrosis in one resulting in an increasing curve and refusion. One patient (limb girdle), 6 years after surgery at 21 years died from cardiomyopathy. The second (limb girdle) lost ambulation at age 22 years, 6.6 years after spinal surgery. In conclusion, patients with muscular dystrophies other than Duchenne generally have slowly evolving curves, and the use of an orthosis in the juvenile years controlled the curve until the pubertal growth spurt, when progression occurred. Surgical treatment was successful in stabilizing the deformities.     

Prevalence of scoliosis in children with myelomeningocele in western Sweden.

In a cross-sectional study of the prevalence of scoliosis in patients with myelomeningocele, 131 patients 5-20 years of age were investigated with clinical examination and radiograms. Sixty-nine percent of the myelomeningocele patients had scoliosis, this prevalence being present already at a young age (6 years). The occurrence of scoliosis increased drastically at high levels of dysraphism, being 20% in patients with sacral myelomeningocele but 94% in patients with thoracic MMC level. Between ages 5 and 10, the mean scoliosis increased successively from 15 to 33 degrees. After this age there was no significant further increase. The ambulatory status of the patients was strongly correlated to the scoliosis incidence. Forty-nine percent of the patients had a uni- or bilateral hip dislocation. There was no correlation between the side of the scoliosis convexity and the side of hip dislocation.     

Use of tracheostomy and the mechanical ventilator in acute respiratory failure after thoracic surgery

Of 44 patients with acute respiratory failure after thoracic operations treated by tracheostomy and mechanical ventilation, 31 recovered completely (70.5%), and 32 received mechanical ventilation less than 20 days. Tracheostomy tubes were removed within three weeks in half of the patients. It is suggested that elderly patients with marginal lung function before operation should be supported by respiratory assistance as soon as possible after operation. The methods of clearing the airway and avoiding improper ventilation were recommended. The SC-Ventilator (made in Shanghai) has proved to be efficient for respiratory support.     

Spinal deformities in patients with arthrogryposis. A review of 16 patients

Sixteen patients with arthrogryposis having spinal deformities were reviewed. The age of diagnosis of scoliosis was from birth to 15 years. Many different curve patterns were seen. Five patients had decreased anterior-posterior thoracic diameter associated with decreasing vital capacity. One of them died at age 6 months of bronchopneumonia and one other at 16 years from cardiac arrest during surgery elsewhere. Eight patients had nonoperative treatment with an orthosis, and of these, three are still under orthotic care. For the remaining five, one had improved at the end of the treatment, and four had increased curvatures in the orthosis. Six patients underwent surgery, four from the group treated by bracing, and two having surgery as the primary treatment at this Center. One patient had posterior fusion without instrumentation, four had posterior fusion with instrumentation, and one had posterior instrumentation without fusion. Spinal problems can occur in arthrogryposis patients, are poorly controlled nonoperatively, and frequently require surgical treatment, especially if there is thoracic lordosis.     

同伴教育对稳定期COPD患者长期家庭氧疗依从性的影响

目的探讨同伴教育对稳定期慢性阻塞性肺疾病(COPD)患者长期家庭氧疗依从性的影响。方法将87例COPD患者按纳入顺序编号,采用随机数字表法分为对照组43例与观察组44例。对照组采用COPD氧疗知识的常规健康教育,观察组在此基础上接受同伴教育1年,包括同伴教育者的选择、成立同伴教育者培训小组及同伴教育活动的实施等。连续6个月后评价患者长期家庭氧疗依从性、生活质量评分(SGRQ),统计2年内急性发病再住院率。结果观察组长期家庭氧疗依从性显著高于对照组,肺功能及血气指标显著好于对照组,2年内再住院率显著低于对照组(均P0.05)。结论同伴教育能有效提高COPD患者长期家庭氧疗的依从性,改善肺功能,减少COPD急性发作,从而改善患者生活质量。     

同伴教育对稳定期COPD患者长期家庭氧疗依从性的影响

目的探讨同伴教育对稳定期慢性阻塞性肺疾病（COPD）患者长期家庭氧疗依从性的影响。方法将87例COPD患者按纳入顺序编号,采用随机数字表法分为对照组43例与观察组44例。对照组采用COPD氧疗知识的常规健康教育,观察组在此基础上接受同伴教育1年,包括同伴教育者的选择、成立同伴教育者培训小组及同伴教育活动的实施等。连续6个月后评价患者长期家庭氧疗依从性、生活质量评分（SGRQ）,统计2年内急性发病再住院率。结果观察组长期家庭氧疗依从性显著高于对照组,肺功能及血气指标显著好于对照组,2年内再住院率显著低于对照组（均P〈0.05）。结论同伴教育能有效提高COPD患者长期家庭氧疗的依从性,改善肺功能,减少COPD急性发作,从而改善患者生活质量。     

Pulmonary artery pressure in thoracic scoliosis during and after exercise while breathing air and pure oxygen.

Pulmonary artery catheterisation was carried out in 25 scoliotics aged 13 to 67 years (mean 30.7). Each then performed a progressive exercise test breathing air, and 11 performed a similar test breathing pure oxygen. The mean pulmonary artery pressure (PAP) increased linearly with oxygen uptake (VO2) and with the work rate. The pressure responses have been described in terms of ther intercept and rate of rise of pressure (sPAP/VO2 and sPAP/work rate). sPAP/VO2 was unrelated to the anatomical features of the scoliosis, or to PaO2. It was inversely related to vital capacity, functional residual capacity, and total lung capacity. Inspiration of pure oxygen lowered the resting pressure by a mean of 3.2 mmHg but only decreased sPAP/work rate by 9%. The maximum pressure reached during exercise was diminished by a mean of 5.2 mmHg when pure oxygen was breathed. The mean pressures were shown to fall exponentially after exercise. The time constants were proportional to sPAP/VO2 and to the final pressure reached during exercise. Inspiration of pure oxygen did not effect the time constants but decreased the post-exercise pressure load by lowering the final pressure during exercise.     

胸弯型和胸腰弯/腰弯型青少年特发性脊柱侧凸患者冠状面与矢状面参数的影像学研究

目的:探讨胸弯型和胸腰弯/腰弯型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者冠状面与矢状面参数的变化,分析两种分型矢状面各参数间的相关性.方法:纳入71例胸弯型和64例胸腰弯/腰弯型AIS患者,根据弯弧位置分为两组,并纳入40例正常青少年作为对照组进行对比研究.所有...