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.     

Scoliosis surgery in neurofibromatosis

Twenty-three patients who were treated by posterior spinal fusion with neurofibromatous scoliosis were reviewed to study the adequacy of spinal fusion, rate of pseudarthrosis, and incidence of complications. Twenty patients achieved a solid fusion with posterior surgery alone. Thirteen patients required one or more posterior augmentation procedures because of progressive deformity. Three patients with dystrophic kyphoscoliosis required an anterior spinal fusion in addition to the posterior fusion to achieve a solid fusion mass. The type of graft material, Harrington instrumentation, and degree of kyphosis or scoliosis had no effect on the rate of pseudarthrosis. Preoperative neuroradiographic evaluation was found to be warranted for all patients with neurofibromatous scoliosis.     

脊柱侧凸后路矫形融合术术后感染的治疗

目的评价清创术后置管冲洗、负压吸引及一期关闭伤口对脊柱侧凸后路矫形融合术术后感染的治疗效果。方法回顾1984年2月～1997年10月924例行脊柱后路矫形融合术的脊柱侧凸病例,发现感染15例,男5例,女10例,年龄11～32岁,平均17.5岁;特发性脊柱侧凸7例,先天性脊柱侧凸8例;内固定系统包括Harrington Luque3例,Harrington8例,CD4例。结果7例诊断为术后早期感染,平均发现时间为术后15d,清创术后除2例内固定物取出外,其余5例均予保留。8例迟发感染,平均发现时间为术后5.5个月,所有病例均予彻底清创,4例内固定物完全取出(其中1例因并发呼吸功能衰竭死亡),2例内固定物部分取出,2例保留。所有病例清创术后均置管持续冲洗及负压吸引,一期关闭伤口。平均置管冲洗2.8周,清创术后静脉使用抗生素19d。14例患者平均随访3.5年,未见感染复发。结论清创术后置管冲洗、负压吸引及一期关闭伤口,是治疗脊柱侧凸后路矫形融合术术后感染的有效方法。保留植入物,对多数病例并不影响对感染的控制。     

Complications of scoliosis surgery in children with myelomeningocele

The purpose of the present study was to evaluate whether the high incidence of complications in scoliosis surgery in myelomeningocele (MMC) could be attributed to the surgical technique and whether improvements were possible. Between 1984 and 1996, 77 patients with MMC and scoliosis were treated surgically. The clinical and radiological follow-up ranged from 1 to 10 years with a mean follow-up of 3.6 years. The mean age at time of surgery was 12 years 8 months. The average preoperative scoliosis measured 90.20° and was corrected by 47%. The first four patients were stabilized with Harrington rods after anterior correction with a Zielke device (group 1). Twenty-five patients were operated only from posterior, using Cotrel-Dubousset (CD) instrumentation (group 2). In 13 patients an anterior release and discectomy was performed prior to CD posterior instrumentation (group 3). In 26 patients (group 4) this was combined with an anterior instrumentation. The 9 patients of group 5 had congenital vertebral malformations which made a special treatment necessary. Complications could be divided into hardware problems, such as implant failure, dislocation or pseudarthrosis, infections, anesthetic, and neurologic complications. Hardware problems were seen in 29% of all patients. More hardware problems were seen with the Harrington rod (75%) and after solitary posterior instrumentation (30%). The occurrence of pseudarthrosis was dependent on the surgical technique, the extent of posterior spondylodesis, and lumbosacral fusion. Patients with hardware problems had a mean loss of correction of 49% compared to 13% in the other patients. Depending on the different surgical techniques a loss of more than 30% was seen in 12–75% of the cases. Early postoperative shunt failure occurred in four cases; delayed failure – after more than 1 year – in three cases. One patient died within 1 day due to an acute hydrocephalus, another died after 21/2 years because of chronic shunt insufficiency with herniation. Wound problems were not dependent on the surgical technique, but on the extent of posterior spondylodesis and the lumbosacral fusion. Based on this analysis we believe our current practice of instrumented anterior and posterior fusion is justified. Further, we are very careful to check shunt function prior to acute correction of spinal deformity. Received: 27 February 1998 Revised: 19 August 1998 Accepted: 15 September 1998     

经前路松解联合后路固定治疗特发性脊柱侧凸

目的:评价经前路松解联合后路矫形对特发性脊柱侧凸的治疗效果。方法:回顾性分析我院收治的51例(男16例,女35例;年龄8～17岁,平均13.2岁)特发性脊柱侧凸行前路松解及后路脊柱畸形矫形植骨融合术患者的临床资料及治疗结果。结果:本组中行前路松解、植骨,阻滞椎间盘平均2.4个。联合后路椎弓根钉(钩)-棒系统内固定,植骨、融合。术后特发性脊柱侧凸Cobb角<90°者额状平面平均矫正率为57%,矢状面后凸平均矫正率为50%;Cobb角>90°者额状平面平均矫正率为71%,矢状面后凸平均矫正率为74%。术后随访10～35个月,平均随访21.6个月,无矫正度的丢失及其他神经系统及血管损伤并发症。结论:脊柱前路松解安全、有效,联合后路相适应内固定系统矫形、植骨治疗特发性脊柱侧凸可获得满意治疗效果。     

Management of adult spinal deformity with combined anterior-posterior arthrodesis and Luque-Galveston instrumentation.

Twenty-five consecutive adult women with nonparalytic spinal deformity were treated with fusion to the sacrum. Two patients were lost to follow-up and one patient died, leaving 22 patients for review. All patients underwent a first-stage anterior spinal fusion without instrumentation followed by a second-stage posterior spinal fusion with Luque-Galveston instrumentation. The average age of the patients was 47 years (range, 25-64 years). The average follow-up was 39 months (range, 24-60 months). Ten patients had had previous surgery in the area of the instrumentation. The main indications were pain (22 patients), loss of sagittal plane balance (17 patients), and progression of the deformity (13 patients). Additional procedures included anterior corpectomies (five patients), anterior and posterior osteotomies (two patients), posterior osteotomies (eight patients), and posterior decompression (five patients). The average curve correction was 27% for thoracic scoliosis and 44% for lumbar scoliosis. Physiologic sagittal plane realignment was obtained in four patients who presented preoperatively with sagittal plane deformities. Pain improvement was reported in 14 of 22 (63%) patients. Nineteen (82%) patients had 34 complications. Pseudarthrosis occurred in nine patients (41%) and was successfully repaired in four; hence the fusion rate was 77% at follow-up. Of the 23 patients, one died from pulmonary embolism, 15 (66%) were in good condition, one (4%) was in fair condition, and seven (30%) were in poor condition. Previous surgery and additional procedures such as vertebrectomies or osteotomies did not adversely affect the outcome. There were no permanent neurologic deficits related to the instrumentation or the passage of sublaminar wires. The Luque-Galveston method provided correction of sagittal plane deformities and flatback syndrome.     

Posterior spinal fusion in paralytic scoliosis and myelomeningocele

The Shriners Hospital, Lexington, KY, experience with posterior spinal fusion for scoliosis in 50 patients with myelomeningocele was reviewed. Six patients were fused with Harrington rods and 47 of 50 patients were treated with some form of segmental fixation. The complication rate was 48% (24/50) resulting in 1.48 procedures per patient. The deep infection rate was 8% (4/50) and the pseudarthrosis rate was 16% (8/50). The use of modern segmental instrumentation systems has improved the pseudarthrosis rates for posterior spinal fusion in scoliosis associated with myelomeningocele but not to the point of displacing the current approach of an anterior and posterior spinal fusion.     

Treatment of Charcot spinal arthropathy following traumatic paraplegia.

Four cases of Charcot's spinal arthropathy in patients with complete traumatic paraplegia were diagnosed an average of 12 years (range, 4-22 years) postinjury. Each patient had previous posterior spinal fusion with Harrington instrumentation. The Charcot joint occurred just below the fusion near the thoracolumbar junction and well below the level of spinal cord injury. All four patients experienced progressive kyphosis, flexion instability, and loss of height. Each underwent a treatment protocol that included anterior fusion with partial resection of the Charcot joint and staged posterior spinal fusion and stabilization with Cotrel-Dubousset (CD) rods. At follow-up evaluation 18-30 months postoperatively, three of four patients showed complete healing with kyphosis correction. One patient developed loosening of his lower hooks at 6 months postoperatively and required posterior revision with ultimate healing. Resection of the involved segments along with two-stage fusion with segmental instrumentation provides excellent management of this difficult problem.     

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     

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.     

各型内固定矫形术治疗脊柱侧凸效果评价

目的评价不同内固定矫形术治疗脊柱侧凸的效果。方法对１９８４～１９９７年用不同手术方法矫治１２５例１００°以内脊柱侧凸患者的治疗和随诊资料进行研究,手术方法包括Ｈａｒｉｎｇｔｏｎ、Ｌｕｑｕｅ、联合ＨａｒｉｎｇｔｏｎＬｕｑｕｅ、ＣＤ、Ｚｉｅｌｋｅ、前路松解加后路手术和俄式手术等,对不同方法的优缺点及各自的矫正情况、身高变化、手术时间、术中输血量、住院时间、术后并发症和矫正度丢失情况及其原因进行比较分析。结果Ｈａｒｉｎｇｔｏｎ法矫正效果比其它方法差而且并发症多;Ｌｕｑｕｅ法费时且有潜在脊髓损伤之忧;ＣＤ法有三维矫正作用,矫正效果好,未见脱钩、断棍;含前路手术的方法远期Ｃｏｂｂ角度丢失少,其中前路松解加后路手术（ＣＤ术）方法简便易行,效果好;俄式手术作为一种探索中的不影响脊柱生长发育的新型脊柱侧凸内固定矫形术,有一定优越性。结论在不进行脊柱融合的新技术发展成熟前,ＣＤ术对生长发育中的青少年脊柱侧凸患者是一种较好的治疗方法     

Adult idiopathic scoliosis treated with Luque or Harrington rods and sublaminar wiring

We reviewed the results of spinal arthrodesis that was performed, with sublaminar wires that were attached to either double L-shaped Luque rods or to a Harrington rod, in forty-two adults who had idiopathic scoliosis. The minimum length of follow-up was two years; the maximum, five years; and the average, three years. The average scoliosis measured 67 degrees preoperatively, was corrected to 37 degrees at operation, and was 44 degrees at the time of follow-up. The final correction averaged 34 per cent. A single Harrington rod and multiple sublaminar wires were used in thirty-one patients. Eighteen of the thirty-one patients had a posterior arthrodesis only and thirteen, a preliminary anterior arthrodesis followed by a posterior arthrodesis. Eleven patients had instrumentation with double L-shaped Luque rods; six of them had posterior arthrodesis only and five, a preliminary anterior arthrodesis followed by a posterior arthrodesis. One patient had neurological deficit that was related to the operation. Three patients had a pseudarthrosis, which was in the lumbar area in all of them. All three patients had had only a posterior operation. No statistically significant difference in the amount of final correction was demonstrated between the subgroups.     

The treatment of scoliosis in cerebral palsy by posterior spinal fusion with Luque-rod segmental instrumentation

Thirty-three patients who had cerebral palsy and scoliosis underwent posterior spinal fusion with Luque-rod segmental instrumentation. The mean curve measured 65 degrees preoperatively and 30 degrees postoperatively. The mean loss of correction was 3 degrees after a mean length of follow-up of forty months. As of the time of writing, pseudarthrosis had not developed in any patient. No patient had a broken rod or an increased neurological deficit. There were no major pulmonary complications. The most common early postoperative complication was wound infection, which occurred in five patients, none of whom required removal of the hardware. We concluded that posterior spinal fusion with Luque-rod segmental instrumentation is an effective method of obtaining and maintaining correction of a spinal curve, with minimum complications, in patients who have cerebral palsy and progressive scoliosis.     

伴有侧凸畸形的腰椎管狭窄症的外科治疗

目的总结后路一期减压、内固定、融合手术治疗伴有腰椎侧凸畸形的腰椎管狭窄症患者的效果。方法自1998年1月-2005年10月,治疗伴有腰椎侧凸畸形的腰椎管狭窄症患者38例,腰椎侧凸畸形角度平均31°,术前 JOA评分平均11分,均采用腰椎后路一期减压、矫形、内固定、融合治疗。结果 32例得到随访,随访时间1-4年,平均2．5年,矫正角度平均13°。矫正角度丧失1°-5°,平均3°。截骨融合率100％。随访时JOA评分平均23分,患者对手术效果满意。结论后路一期减压、内固定、融合手术是治疗伴有腰椎侧凸畸形的腰椎管狭窄症的有效手段。     

Analysis of lumbar lordosis in posterior spine fusions for idiopathic scoliosis

Previous reports are inconclusive regarding changes in the lumbar region after Harrington rod distraction and posterior spinal fusion for idiopathic scoliosis. The purpose of this study was to evaluate the effects of spinal fusion on the lumbar region, particularly the overall lumbar lordosis, the lumbar lordosis in and below the fused segment, the sacro-horizontal angle, and the sagittal plane alignment of the spine. Sixty-six patients under 21 years of age with idiopathic scoliosis who had spine fusion extending to the lumbar vertebrae using only Harrington distraction instrumentation were evaluated. The total lordosis, sacro-horizontal angle, and sagittal plane alignment remained relatively constant. The lordosis within the fusion decreased, and lordosis caudal to the fusion, including the last fused vertebra, increased as the lower hook placement site moved caudally.     

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.     

Ventral derotation spondylodesis. A review of 22 cases

Twenty-two patients with major lumbar or thoracolumbar curves were treated with Zielke's modification of the Dwyer instrumentation, termed the "ventral derotation spondylodesis (VDS) system. In 16 patients, this was followed by planned second-stage posterior Harrington instrumentation and fusion. Six patients with adolescent idiopathic scoliosis were treated with VDS instrumentation and fusion alone. In neuromuscular and adult idiopathic scoliosis, a combined approach resulted in excellent curve correction and a high rate of successful fusion. In adolescent idiopathic scoliosis, VDS instrumentation alone resulted in excellent curve correction while permitting a shorter fusion length than conventional posterior Harrington instrumentation.     

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.     

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.     

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.