The migration of a broken luque rod: a case report

An exceedingly rare complication of Luque segmental spinal instrumentation in spinal fractures is described. A patient was treated for fractures of the eighth and ninth thoracic vertebra associated with traumatic paraplegia using Luque segmental spinal instrumentation. Ten years postoperatively, broken rods and sublaminar wires were found. One of the broken rods migrated caudad penetrating the sacrum and protruding into the pelvic cavity. The rod had projected into the rectum, and was extracted through the wall of the rectum and the anus. This case report emphasizes the importance of careful surgical technique and long-term follow up for patients who had undergone spinal instrumentation surgery.     

Simultaneous correction of pelvic obliquity, frontal plane, and sagittal plane deformities in neuromuscular scoliosis using a unit rod with segmental sublaminar wires: a preliminary report

Ten patients with neuromuscular scoliosis and pelvic obliquity had segmental spinal instrumentation using a unit Luque rod with sublaminar wires and fixation into the pelvis. Nine of the 10 patients also had anterior spinal fusion without instrumentation before the posterior procedure. Average preoperative pelvic obliquity was 42 degrees which was corrected to 6 degrees (82% correction). Average preoperative scoliosis was 92 degrees, which was corrected to 16 degrees (81% correction). Complications included a wound hematoma in one patient and a superficial wound dehiscence in another. There have been no pseudarthroses or hardware failures to date. Excellent correction of the pelvic obliquity and the spinal curve in neuromuscular scoliosis can be obtained with use of a unit rod and without use of anterior instrumentation.     

Spinous process segmental instrumentation for scoliosis

Spinous process segmental instrumentation (SPSI) for spinal fusion was devised in 1983 by Drummond et al. in an attempt to achieve the stability of segmental fixation without the known neurologic risks of passing sublaminar wires. We used SPSI in 75 scoliosis patients. Sixty-one had idiopathic scoliosis, 12 had neurogenic scoliosis, and 2 had congenital scoliosis. There were no deep infections, pseudarthroses, or neurologic complications. Two patients experienced upper hook dislodgement with 10 degrees loss of correction. We concluded that SPSI can achieve the correction of Harrington rod instrumentation and the stability of Luque rod segmental instrumentation, without the neurologic risk of sublaminar wiring.     

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.     

Segmental spinal instrumentation in idiopathic scoliosis. A preliminary report

Eighty-six patients with idiopathic scoliosis who underwent a posterior spinal fusion using sublaminar segmental spinal instrumentation were analyzed retrospectively. There were two operative groups: group 1, 66 patients who had Harrington rod instrumentation and segmental wiring, and group 2, 20 patients who had Luque rod instrumentation. The clinical and radiographic data of the two groups were similar except for the passage of more sublaminar wires and increased intraoperative blood loss in group 2. Twenty intraoperative or postoperative complications occurred in 19 patients (22%) including 14 neurologic complications. Three patients (3%) had major spinal cord injuries, while 11 patients (13%) had transient sensory changes. There was no significant difference in the incidence of neurologic complications between group 1 or group 2. The remaining intraoperative complications were due either to anesthesia, positioning during surgery, or technique (dural tear). Late complications occurred in two patients in group 1 only: one each with rod breakage and hook displacement. Only one patient (1%) has required additional surgery. Our results indicate that although segmental instrumentation can be beneficial in idiopathic scoliosis, the incidence of complications, primarily neurologic, will be higher than expected. The major reason appears to be surgeon inexperience with passage of sublaminar wires. As experience increases, the incidence of complications declines and becomes comparable with conventional Harrington rod instrumentation alone.     

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.     

Intraoperative spinal cord monitoring during descending thoracic and thoracoabdominal aneurysm surgery

BACKGROUND: Postoperative paraplegia is one of the most dreaded complications after descending thoracic and thoracoabdominal aneurysm surgery. In this study, intraoperative monitoring was applied during resection of descending thoracic and thoracoabdominal aneurysms to detect spinal cord ischemia and help prevent paraplegia. METHODS: Fifty-six patients (descending thoracic, 25; thoracoabdominal, 31) were monitored intraoperatively with both motor- (MEP) and somatosensory- (SSEP) evoked potentials. MEPs were elicited with transcranial electrical stimulation and recorded from the spinal epidural space (D wave) or peripheral muscles (myogenic MEP). SSEPs were obtained with median and tibial nerve stimulation. RESULTS: A total of 16 patients (28.6%) showed MEP evidence of spinal cord ischemia, only 4 of whom had delayed congruent SSEP changes. In 13 patients (23.2%), ischemic changes in MEPs were reversed by reimplanting segmental arteries or increasing blood flow or blood pressure. None of these 13 patients suffered acute paraplegia regardless of the status of SSEP at the end of the procedure, but 1 of them developed delayed postoperative paraplegia after multisystem failure. Three patients (5.4%) who had persistent loss of MEPs despite of recovery of SSEPs awoke paraplegic. CONCLUSIONS: The results demonstrate that compared with SSEP, MEP, especially myogenic MEP, is more sensitive and specific in detection of spinal cord ischemia, and that intraoperative monitoring can indeed help prevent paraplegia.     

Two-stage corrective surgery for congenital deformities of the spine.

Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective.     

Sublaminar wiring stabilization to prevent adjacent segment degeneration after lumbar spinal fusion

Introduction  Adjacent segment degeneration (ASD) is a complication of lumbar spinal fusion. There are some reports on the cause of this degeneration but none concerning its prevention. We performed sublaminar wiring stabilization to prevent ASD after posterolateral lumbar spinal fusion with instrumentation. The purpose of this study was to prospectively evaluate the efficacy of this procedure. Patients and methods  Between 2003 and 2004, 54 consecutive patients with lumbar spinal canal stenosis and multilevel instability of the lumbar spine underwent posterior decompression and posterolateral fusion with instrumentation. The mean age at the time of surgery was 66.7 ± 1.3 years, and the mean follow-up period was 40.0 ± 1.1 months, with a minimum of 29 months. Twenty-seven of the patients underwent conventional sublaminar wiring stabilization at the cephalad segment adjacent to the site of fusion to prevent ASD (group A), and the other 27 patients did not (group B). Some items were assessed, including clinical outcome using Japanese Orthopaedic Association (JOA) score, sagittal global lumbar alignment, and segmental motion in flexion–extension radiographs of the cephalad vertebral body adjacent to the site of fusion. Results  There were no significant differences in JOA scores between two groups, but 2 patients in group B underwent subsequent surgery due to ASD. Sagittal lumbar alignment did not change in group A but was significantly decreased in group B. With respect to segmental motion in flexion–extension radiographs, group A showed a significant decrease from 6.9° before surgery to 3.4° after surgery, on the other hand group B showed a significant increase from 5.6° before surgery to 8.4° after surgery. Conclusions  In this study, it was suggested that sublaminar wiring stabilization significantly reduces the range of motion of the adjacent segment and preserves sagittal lumbar alignment, which lead to prevention of ASD. The clinical outcome of the subsequent surgeries is relatively poor, so it is important to prevent ASD by any prevention such as sublaminar wiring stabilization.     

Postoperative neurological deficits in segmental spinal instrumentation. A study using spinal cord monitoring

We retrospectively analyzed the postoperative neurological complications in 137 patients who underwent a posterior spine fusion for scoliosis and had concomitant somatosensory cortical evoked-potential spinal-cord monitoring. The patients were divided into three specific operative groups: group 1, forty-nine patients who had a Harrington rod with segmental wiring (segmental spinal instrumentation); group 2, twenty patients who had Luque segmental spinal instrumentation; and group 3, sixty-eight patients who had a Harrington rod without segmental spinal instrumentation. There were neurological complications in twelve (17 per cent) of the sixty-nine patients in groups 1 and 2. Three patients (4 per cent) had a major injury to the spinal cord and nine patients (13 per cent) had only transient sensory changes. No difference was apparent between group 1 and group 2 in the degree of operative correction of curves or in the incidence of neurological complications. The one neurological complication (1.5 per cent) that occurred in the sixty-eight patients in group 3 was a Brown-Séquard syndrome. The factors related to increased risk for spinal cord injury in groups 1 and 2 included: (1) the passage of sublaminar wires in the thoracic and thoracolumbar spine, (2) intraoperative correction exceeding the preoperative bending correction, and (3) the surgeon's lack of adequate experience with the technique. With spinal cord monitoring we were able to predict the impending major neurological deficits, but the transient (sensory) changes that may be associated with segmental wiring were less reliably predicted.     

Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures.

Fifty-eight patients with severe thoracolumbar burst fractures were treated with bilateral transpedicular decompression, Harrington rod instrumentation, and spine fusion. Spinal realignment and stabilization was achieved by contoured dual Harrington distraction rods supplemented by segmental sublaminal wiring. Posterior element fractures were noted in 25 patients, 9 of whom had associated dural tears. Computed tomography was performed to assess the cross-sectional area of the spinal canal before surgery and after decompression. Patients at initial evaluation averaged greater than 67% spinal canal compromise. After surgery, successful decompression was accomplished in 57 patients. One patient required staged, anterior thoracoabdominal decompression and fibula strut grafting. At follow-up (average, 43 months; range, 25-70 months), neurologic improvement was found in 77% of the patients who initially presented with neurologic deficits. Thirty-four of 40 patients with incomplete paraplegia improved one or more subgroups on the Frankel scale. A solid fusion was attained in all 58 patients. No patient had a significant residual kyphotic deformity. Single-stage bilateral transpedicular decompression and dual Harrington rod instrumentation reliably provides decompression of the spinal canal and restores spinal alignment. The procedure allows early mobilization and provides an environment for solid fusion and maximum neurologic return.     

The effect of Luque-rod instrumentation on the sagittal contour of the lumbosacral spine in adolescent idiopathic scoliosis and the preservation of a physiologic lumbar lordosis.

The changes in the sagittal alignment of the lumbar spine were investigated in 28 patients with adolescent idiopathic scoliosis undergoing long posterior spinal fusion to L4 or L5 with contoured Luque rods and segmental sublaminar wiring. The lumbar lordosis over the instrumented levels was preserved, and there was no compensatory hyperlordosis of vertebral segments distal to the fusion. In situations where long posterior spinal fusions are indicated, instrumentation with contoured Luque rods and segmental sublaminar wiring can preserve the normal sagittal alignment of the lumbosacral spine.     

Rotational dislocation of the thoracolumbar spine. Case report and review of the literature

The authors report a rare case of rotational dislocation of the thoracolumbar spine in a 12-year-old girl with neurofibromatosis Type 1. The patient had progressive spinal kyphoscoliosis with acute-onset paraplegia. She was treated with corrective traction preoperatively, followed by spinal decompression and circumferential spinal fusion without instrumentation. She had complete neurological recovery after a solid fusion of her spine.     

Comparison of novel ultra-high molecular weight polyethylene tape versus conventional metal wire for sublaminar segmental fixation in the treatment of adolescent idiopathic scoliosis

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the surgical outcomes of posterior translational correction and fusion using hybrid instrumentation systems with either sublaminar Nesplon tape or sublaminar metal wire to treat adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Nesplon tape, which consists of a thread of ultra-high molecular weight polyethylene fibers, has advantages over metal wire: (1) its soft and flexible properties avoid neural damage and (2) its flat configuration avoids focal distribution of the stresses to lamina; however, the efficacy of Nesplon tape in the correction of spinal deformity is as yet, still unclear. METHODS: Thirty AIS patients at a single institution underwent posterior correction and fusion using hybrid instrumentation containing hook, pedicle screw, and either sublaminar polyethylene taping (15) or sublaminar metal wiring (15). Patients were evaluated preoperatively, immediately after surgery, and at a 2-year follow-up according to the radiographic changes in curve correction, operating time, intraoperative blood loss, complications, and the Scoliosis Research Society patient questionnaire (SRS-24) score. RESULTS: The average correction rate was 63.0% in the Nesplon tape group and 59.9% in the metal wire group immediately after surgery (P = 0.62). Fusion was obtained in all the patients without significant correction loss in both groups. There was no significant difference in operative time, intraoperative blood loss, and postoperative SRS-24 scores between the 2 groups. Complications were superficial skin infection in a single patient in the Nesplon tape group, and transient sensory disturbance in 1 patient and temporal superior mesenteric artery syndrome in another patient in the metal wire group. CONCLUSIONS: The efficacy of Nesplon tape in correction of deformity is equivalent to that of metal wire, and fusion was completed without significant correction loss. The soft and flexible properties and flat configuration of Nesplon tape make this a safe application for the treatment of AIS with bone fragility or with the fusion areas containing the spinal cord.     

Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele

Twenty-three patients with severe paralytic thoracolumbar scoliosis due to a myelomeningocele were treated by a two-stage procedure. Before operation the mean scoliosis was 98 degrees: after the first-stage procedure, an anterior spinal fusion and correction with Dwyer instrumentation, this was reduced to a mean of 45 degrees. Approximately two weeks later a posterior spinal fusion with Harrington instrumentation was performed, further reducing the scoliosis to a mean of 29 degrees. The pelvic obliquity also was reduced from a mean of 32 degrees to 6 degrees. Although such management carries risks (one patient died of cardiorespiratory failure after the first stage and one patient was made worse), 21 of the 23 patients had improved posture and function.     

TSRH内固定治疗脊柱侧凸

目的　回顾性研究TSRH(TexasScottishRiteHospital)脊柱内固定系统在治疗脊柱侧凸的临床疗效。 方法　对 1998年 1月至 2 0 0 0年 12月手术治疗的 12 9例脊柱侧凸患者 ,总结其侧弯矫形、脊柱平衡、并发症及 3年以上的随访结果。根据手术方法不同 ,共分为 4组。A组 :单纯脊柱后路融合固定术 ;B组 :单纯脊柱前路融合固定术 ;C组 :分期前、后路融合固定术 ;D组 :Ⅰ期前、后路融合固定术。四组患者均应用TSRH内固定系统。手术时平均年龄 14 .2岁 (6～ 5 5岁 ) ,平均随访 34个月。结果　A组 :78例病人行单纯脊柱后路融合TSRH内固定 ,术后平均矫形率为6 3.4 %。随访 38个月 (2 4～ 5 0个月 ) ,平均矫形丢失 7°,矫形丢失率平均 9.5 %。本组并发症发生率为 12 .8% ,包括 3例脱钩 ,3例螺钉断裂 (共 6枚螺钉 ) ,1例术后侧弯失代偿 ,1例术后发生曲轴现象。B组 :2 2例患者行单纯脊柱前路融合、短节段TSRH内固定 ,平均矫形率为 74 .8%。平均随访 36个月 ,平均矫形率丢失 5 %。 2例发生一过性交感神经损伤。术后 6个月内均自然恢复。C组 :17例有 90°以上的侧弯 ,且Bending像上侧弯仍大于 7°的患者行前路松解 ,2～ 3周后再行后路融合TSRH内固定。本组平均手术时间 8.3h ,出血 935ml,输血 6 83ml,平均矫形 33.6°,矫     

Safety of sublaminar wires with Isola instrumentation for the treatment of idiopathic scoliosis

STUDY DESIGN: To investigate the incidence of acute neurologic complications of use of sublaminar wires with third-generation spine instrumentation for the treatment of idiopathic scoliosis. OBJECTIVES: To assess the safety of sublaminar wires in the surgical treatment of idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The use of sublaminar wires in spine deformity for neuromuscular scoliosis and the Luque system has been reported. Use of sublaminar wires is an integral part of the technique in the surgical treatment of spine deformity with Isola instrumentation (AcroMed, Cleveland, OH). To date, the safety of this technique has not been documented. METHODS: The average age of the patients was 37 years (range, 11-74 years). Preoperative diagnosis was adolescent idiopathic scoliosis in 75 patients and adult idiopathic scoliosis in 66. One hundred nine were primary surgeries, and 32 were revision. Detailed evaluation of the curve type, curve magnitude, number of vertebrae instrumented, level of vertebrae wired, postoperative neurologic deficit, and the findings of intraoperative spinal cord monitoring was performed. Wires were always passed just before corrective maneuvers were performed. RESULTS: A total of 1366 wires were placed, 65% (n = 888) in the thoracic region, 22% (n = 300) in the thoracolumbar, and 13% (n = 178) in the lumbar. No permanent change in intraoperative spinal cord monitoring was detected. Stagnara wake-up test was performed in all patients. No patient with adolescent idiopathic scoliosis had neurologic complication. Two adults underwent revision surgery and had transient dysesthesia in the leg, which completely resolved with observation. CONCLUSION: Despite the increasing complexity of spinal instrumentation systems, sublaminar wire placement is a safe and useful adjunct in the surgical treatment of neurologically intact patients with idiopathic scoliosis.     

Anterior and posterior spinal fusion. Staged versus same-day surgery

Seventy-five patients who underwent combined anterior and posterior spinal fusion were compared to evaluate the results and safety of staged vs. continuous anterior and posterior spinal fusion. Thirty-five patients underwent two-stage anterior and posterior spinal fusion. The first stage consisted of anterior release; the second stage, which took place 7-10 days later, consisted of posterior spinal fusion and instrumentation. Forty patients underwent continuous anterior and posterior spinal fusion. This procedure consisted of anterior release followed by immediate posterior spinal fusion and instrumentation. The results show that 1) a continuous procedure is faster than the staged procedure; 2) there is less blood loss; 3) fewer days are spent in the hospital; and 4) better correction of the spinal deformity is achieved. Also, the complications were less frequent and less severe with the continuous procedure. It was concluded that the continuous procedure is safe and efficacious and has several advantages over the staged procedure.     

Neuropathologic changes with experimental spinal instrumentation: transpedicular versus sublaminar fixation.

Fifty-six mature beagles underwent lumbar spine destabilization, followed by fusion using four techniques. Spinal cord neuropathologic analysis was carried out to determine the number of abnormalities within each group. Group I (n = 14) had posterolateral bone grafting without instrumentation. Group IIa (n = 14) had Cotrel-Dubousset (CD) pedicle screws and rods. Group IIb (n = 14) had Steffee pedicle screws and plates. Group III (n = 14) had sublaminar wires and rods. All of the animals remained clinically neurologically normal throughout the 6 months of the study. The incidence of moderate to severe neuropathologic changes was 21% in Group I, 18% in Group II, and 64% in Group III. Thus, a significantly higher percentage of neuropathologic abnormalities occurred with sublaminar instrumentation than with no instrumentation (p = 0.027), or with transpedicular instrumentation (p = 0.027). In this controlled animal study, the theoretical advantage of pedicle screws, which should not violate the spinal canal, over sublaminar devices, which must enter the canal, was confirmed.     

Multilevel somatosensory evoked potentials and cerebrospinal proteins: indicators of spinal cord injury in thoracoabdominal aortic aneurysm surgery.

OBJECTIVE: Multilevel somatosensory evoked potentials (SSEP) and the release of biochemical markers in cerebrospinal fluid (CSF) were investigated to identify patients with spinal cord ischemia during thoracoabdominal aortic repair and/or a vulnerable spinal cord during the postoperative period. METHODS: Thirty-nine consecutive patients undergoing elective aneurysm repair using distal aortic perfusion and cerebrospinal fluid drainage were studied. Continuous SSEP were monitored using nerve stimulation of the right and left posterior tibial nerves with signal recording at the level of both common peroneal nerves, the cervical cord and at the cortical level. CSF concentrations of the markers glial fibrillary acidic protein (GFAp), the light subunit of neurofilament triplet protein (NFL), and S100B were determined at different time points from before surgery until 3 days postoperatively. RESULTS: SSEP indicated spinal cord ischemia in two patients leading to additional intercostal artery reattachments. In one of them the signal loss was permanent and the patient woke up with paraplegia. In the other the signal returned but the patient later developed delayed paraplegia. Three patients without SSEP indications of spinal cord ischemia during surgery later developed delayed paraplegia. The patients with spinal cord symptoms had significant increases, during the postoperative period of CSF biomarkers GFAp (571-fold), NFL (14-fold) and S100B (18-fold) compared to asymptomatic patients. GFAp increased before or in parallel to onset of symptoms in the patients with delayed paraplegia. CONCLUSIONS: Peroperative multilevel SSEP has a high specificity in detecting spinal cord ischemia but does not identify all patients with a postoperative vulnerable spinal cord. Biochemical markers in CSF increase too late for intraoperative monitoring but GFAp is promising for identifying patients at risk for postoperative delayed paraplegia.