Development of paralytic scoliosis in myelomeningocele

Among other things the probability of developing a scoliosis in myelomeningocele depends on the patients age, the neurological level of lesion and the localisation of the vertebral arch defect. This study tries to analyse the influence of these factors in 465 patients with MMC and paralytic scoliosis. The results show, that the patients age and the neurological level of lesion are the most important factors for the development of paralytic scoliosis. The statistical evaluation based on the data found permits the determination of regression lines, which allow an estimation of further progression of paralytic scoliosis with respect to the neurological level of lesion and the patients age. At levels of paralysis between Th 3 and Th 12 an average progression of 3.5 degrees per year can be expected. Between L 1 and L 3 the progression rate can be estimated to be 2.5 degrees per year. At levels of paralysis distal to L 3 one can expect to find no significant development of scoliosis. In cases, which exceed the prediction interval, additional intraspinal anomalies, i.e. syringomyelia, must be considered and further examinations including MRI are required.     

Allograft bone in spinal fusion for paralytic scoliosis

To determine the efficacy of allograft bone in spinal surgery, a retrospective study was carried out on thirty-two patients who had had spinal fusion with banked bone from the femoral head between 1977 and 1983. The diagnoses were paralytic and neuromuscular scoliosis. At final follow-up (average, 3.7 years), the infection rate was 9.3 per cent. There were no pseudarthroses, and all patients had well marginated trabecular markings by eighteen months. The rates of complications and of fusion were comparable with or better than those obtained using autogenous bone graft.     

Anterior and posterior spinal fusion for paralytic scoliosis

Twenty-three patients with paralytic scoliosis were treated with a combination of anterior and posterior spinal instrumentation and fusion. The sequence was anterior surgery first in 19 patients and posterior surgery first in 4. The average age was 14.4 years. Preoperative correction with a halo-hoop apparatus was performed in 12 patients. The average preoperative curve for the group measured 100 degrees, and the average postoperative curve at a mean follow-up time of 21 months was 37 degrees. The mean loss of correction was 8 degrees. Although superior hook dislodgment occurred in 5 patients, no pseudarthrosis or beinding of the fusion mass was documented.     

Surgical management of paralytic scoliosis in myelomeningocele

A retrospective analysis of 54 patients with paralytic scoliosis due to myelomeningocele, who underwent surgical treatment, was performed. The aim of this study was to compare different surgical techniques and to identify clinical parameters influencing primary and midterm results. Three surgical techniques were used: 1) group I, posterior fusion/instrumentation; 2) group II, anterior fusion/no instrumentation combined with posterior fusion/instrumentation; and 3) group III, anterior and posterior fusion/instrumentation. Average age at surgery was 13.1 years. A preoperative scoliosis angle of 90 degrees [interquartile range (25th-75th percentile) (IQR), 76-106 degrees] was primarily reduced to 38 degrees (IQR, 30-50 degrees). At final follow-up (mean, 3.3 years), correction deteriorated to 44 degrees (IQR, 38-65 degrees). The group III procedure resulted in a better midterm correction of scoliosis compared with group I (P = 0.02). The extension of anterior fusion correlated with primary and midterm correction of scoliosis (P < 0.03). Patients with a thoracic level of paralysis had a higher relative loss of correction compared with patients with a lumbar level (P < 0.06). This finding can be attributed mostly to group I patients (P = 0.011). Hardware complications occurred in 16 patients (30%). Relative loss of correction among these patients was high (P < 0.01) and relative midterm correction low (P = 0.001). We recommend anterior and posterior fusion, each with instrumentation for the treatment of paralytic scoliosis in myelomeningocele. In patients with a thoracic level of paralysis, the two-stage procedure is mandatory to reduce the risk of hardware complications and subsequent major loss of correction.     

Activities and functional assessment 1 year after spinal fusion for paralytic scoliosis

The results of spinal fusion in patients with paralytic deformities are usually presented as the correction of the deformity. When evaluating the surgical results in such patients, it is advantageous to classify the patients into subgroups because of the varying dysfunction and disabilities. The aim of this study was to evaluate the effect of spinal fusion in patients with paralytic scoliosis in relation to function in terms of Impairments, activities in terms of Disabilities, and dependence in terms of Handicaps 1 year postoperatively, with emphasis on subgroups. A total of 94 patients with paralytic scoliosis and 18 different diagnoses were evaluated 1 year after surgery. The patients were classified according to whether or not they could understand verbal instructions. The patients were also grouped according to the Scoliosis Research Society classification of diagnoses. A set of instruments was used with the variables classified according to WHO’s International Classification of Impairments, Disabilities, and Handicaps (ICIDH). This consists of the patient’s/relative’s motives for surgery, persistent skin discoloration, ambulating or use of wheelchair, use of a brace, sitting balance, weight distribution on a sitting surface, angle of scoliosis, reaching, pain estimation, activities of daily living (ADL) Klein and Bell, care given, time spent resting, and seating supports. The set of instrument also included a follow-up questionnaire comprising 12 different areas, where the patients/relatives assessed the results of surgery. The study showed that spinal fusion in paralytic scoliosis led to showed improvements in the whole group of patients at the Impairment level in the angle of scoliosis, sitting balance, weight distribution, and reduced number of patients with persistent skin discoloration, and at the Handicap level in reduced time for resting during the day, reduced number of seating supports in the wheelchair, and in the use of a brace. Most of the parameters were unchanged. The results in the subgroups were almost the same as in the whole group, although pain and reaching at the Impairment level, and ADL at the Disability level, could not be measured in the patients who were unable to understand verbal instructions. The subjectively assessed results showed that seating posture was ranked positively irrespective of the motive for surgery. The study showed that the patients with paralytic scoliosis maintained or improved their function and level of independence in terms of Impairment and Handicap 1 year postoperatively. The subjective results assessed by the patients/relatives also showed a positive outcome of surgery. Weight distribution on a seating surface was improved, but still uneven, and with respect to better sitting balance and increasing time sitting in a wheelchair, this can involve a risk for pressure sores and needs further investigation. When introducing outcomes including the Disability level, one must take the importance of homogeneity in the groups into consideration. Received: 9 September 1998 Revised: 21 December 1998 Accepted: 12 January 1999     

Posterior spinal fusion in scoliosis: computer-assisted tomography and biomechanics of the fusion mass

Thirty patients who had posterior vertebral fusion for scoliosis, performed without metallic implants, were examined using computer-assisted tomography to study the configuration of the evolving fusion mass. It was observed that the deposition of bone followed lines of force, according to Wolff's Law. The greatest amounts of bone at the apex of the curve on the concave side indicate that flexion-compression forces are greater at this point. Further, it was observed that usually the fusion mass, seen in section, has a hollow "box-section" shape, which means that a resorption of unstressed central bone occurs. The hypothesis that the torsional forces are the predominant forces acting on the scoliotic spine can explain the characteristic "box-section" of the CT scans obtained.     

Posterior spinal fusion for scoliosis in Ehlers-Danlos syndrome, kyphoscoliosis type

The Ehlers-Danlos syndromes comprise a clinically and genetically heterogeneous group of heritable connective tissue disorders characterized by articular hypermobility, skin extensibility, and tissue fragility. Surgical treatment of scoliosis associated with Ehlers-Danlos syndrome poses a challenge to spine surgeons because of the high risk of major complications. There is a paucity of evidence in the literature on surgical treatment for scoliosis in the Ehlers-Danlos syndrome patient.This article describes 3 adolescent patients diagnosed with Ehlers-Danlos syndrome, kyphoscoliosis type, which was treated by posterior spinal fusion only. After unsuccessful conservative treatment for at least 1 year, the patients underwent posterior spinal surgery for the correction of spinal deformity. A satisfactory correction in the spinal curve was achieved, with no obvious loss of correction during follow-up. No intra- or postoperative major complications were observed.Our experience supports that a satisfactory correction of scoliosis can be achieved by posterior spinal fusion only in patients with Ehlers-Danlos syndrome, kyphoscoliosis type.     

Posterior spinal fusion and instrumentation in the treatment of adolescent idiopathic scoliosis.

Three hundred and nineteen patients with adolescent idiopathic scoliosis were treated by posterior spinal fusion over an eight year period. The changes in preoperative correction and surgical techniques are reviewed. The anaesthetic technique using induced hypotension and the postoperative routine are described. The amount of deformity and its correction at operation and postoperatively is discussed by reference to Cobb angles. The early and late complications are reviewed.     

Anterior only fusion for scoliosis in patients with myelomeningocele.

A series of patients with single major scoliosis curvatures attributable to spina bifida treated by anterior only spinal fusion was studied for 2 years to determine whether the infection rate could be decreased, adequate correction and pelvic balance could be provided, and posterior surgery could be avoided in these patients. Anterior surgery alone was performed for thoracolumbar scoliosis greater than 45 degrees if the compensatory thoracic curve was less than 40 degrees and there was no significant junctional kyphosis. Fourteen patients were treated at a mean age of 11.9 years (range, 7-16 years), with a mean curve of 64 degrees (range, 51 degrees-85 degrees), and motor levels distributed from T10-L4. Thirteen patients had prior neurosurgery for tether, syrinx, or Arnold-Chiari malformation. The spine was fused over a mean of seven vertebrae. A 3/16 inch Texas Scottish Rite Hospital rod was used most commonly (10 patients). Blood loss averaged 1100 cc. The mean curve correction was 57% at 40 months after surgery. Loss of correction occurred primarily by adding on outside the instrumented area. Mean pelvic obliquity was improved from 16 degrees to 9 degrees. There was one superficial infection. Results were good in five patients, fair in four, and poor in five. Failures were attributable to proximal decompensation in two patients who required revision surgery (two), neurologic deterioration in two, and screw pullout in one. Both patients with decompensation had syringomyelia. Both patients with neurologic deterioration had large curves (> 75 degrees). Both patients recovered after rod removal. Retrospectively, by eliminating patients with syrinx or with a curve greater than 75 degrees, all poor results would be eliminated. Anterior only fusion and instrumentation may have significant advantages, but only for selected patients with thoracolumbar curves less than 75 degrees, compensatory curves less than 40 degrees, no increased kyphosis, and no syrinx. Quadriceps function should be monitored. On the basis of this preliminary experience, continued use of this approach using stricter selection seems warranted.     

腰椎后路减压固定融合术治疗退变性腰椎侧凸症

目的：探讨腰椎后路减压、固定融合术治疗症状严重的退变性腰椎侧凸患者的临床效果。方法：同顾性分析2001年1月～2005年10月间行腰椎后路减压矫形内固定植骨融合术治疗的36例退变性腰椎侧凸患者的f临床资料。用日本骨科学会（JOA）29分法对患者术前和随访时的神经功能和生活能力进行评分。计算改善率，并对病程、年龄、术后Cobb角等因素与随访改善率的关系进行统计学分析。结果：术中发生硬膜撕裂1例．修补后未出现脑脊液漏。术后3例出现下肢神经损害症状加重，相应处理后1例完全恢复正常，1例部分恢复，1例无恢复。2例术后切口液化坏死，经清创置管冲洗，切口延迟愈合。无其他严重并发症及闹手术期死亡。27例获得随访，随访时间5～57个月，平均33.2个月，术前JOA评分平均13.3分，末次随访时平均27．0分．改善率平均为87．4％。改善率与病程、年龄、术后Cobb角等因素相关关系不显著。结论：腰椎后路手术治疗退变性腰椎侧凸安全有效，病程、年龄等对术后远期改善率无明显影响。     

Posterior instrumentation and fusion for progressive idiopathic scoliosis

Objectives  

Prevention of progression of an idiopathic scoliosis. Structural improvement of the spinal column and correction of the trunk deformity.     

Posterior spinal instrumentation and fusion of a neuromuscular scoliosis in a patient with autosomal dominant osteopetrosis

STUDY DESIGN: A case report of a patient with autosomal dominant osteopetrosis and neuromuscular scoliosis who required surgical instrumentation and fusion of her spine. OBJECTIVE: To illustrate the surgical technique and long-term outcome in this rare form of spinal deformity. SUMMARY OF BACKGROUND DATA: Osteopetrosis is a group of rare skeletal dysplasias characterized clinically by skeletal osteosclerosis that is classically described in appearance as "marble bone." Despite the ubiquitous involvement of the vertebra, clinical manifestations of spinal involvement are uncommon. We present the case of an osteopetrotic patient with neuromuscular scoliosis who required surgical correction of her progressive deformity. There are no prior reports in the literature concerning operative or nonoperative management of scoliosis in this patient population. METHODS: The surgical technique utilized as well as the patient's response to surgical management of her scoliosis is presented with 5 year follow-up. RESULTS: The patient underwent a successful T4 to L1 posterior spine fusion and instrumentation using Luque rods, sublaminar wires and allograft bone augmentation. At 5 years following her index procedure, she is clinically and radiographically fused. CONCLUSION: Patients with osteopetrosis present unique surgical challenges during surgical correction of spinal deformities. The use of segmental sublaminar wires with 1/4-inch rods and crosslinks afforded stable fixation despite poor bone quality. Allograft bone combined with postoperative bracing resulted in a well-maintained correction and a solid fusion. Five year follow-up and continued radiographic evidence of stable fusion indicate that the presented approach can lead to a successful outcome in the osteopetrotic patient population.