Surgical treatment of adult scoliosis. A review of two hundred and twenty-two cases

We evaluated the cases of 222 patients older than twenty years in whom scoliosis was the primary diagnosis. No patient had had prior surgical treatment. The diagnoses were idiopathic scoliosis in 160 patients, paralytic scoliosis in forty-four, and congenital scoliosis in eleven, and there were miscellaneous diagnoses in seven patients. The average age of the patients when first seen was 30.7 years. The indications for operation were pain, progression of the curve, magnitude of the curve, and cardiopulmonary symptoms. Preoperative traction, including halo-femoral traction, did not result in increased correction when compared with the initial supine side-bending roentgenogram. A one-stage fusion was performed in 174 patients and multiple-stage procedures, in forty-eight patients. At an average follow-up of 3.6 years the average loss of correction was 6.2 degrees, 68 per cent of the patients were free of pain, and a solid fusion had been obtained in all but six patients. Complications developed in 53 per cent of the patients, the most common problems being pseudarthrosis, urinary tract infection, wound infection, instrumentation problems, a pulmonary disorder, and loss of lumbar lordosis. Paraplegia occurred in one patient. The over-all mortality rate was 1.4 per cent. Complications increased with age, and the highest mortality rate was in patients with congenital scoliosis who had cor pulmonale.     

Adult idiopathic scoliosis treated by anterior and posterior spinal fusion

Twenty-six adults, ranging in age from nineteen to fifty-eight years old, were treated for idiopathic scoliosis by two-stage anterior and posterior spinal fusion. The goals of the combined procedure were to increase correction of the curve and decrease the rate of pseudarthrosis. Preoperatively, the major curves measured an average of 83 degrees, and on the best side-bend they averaged 59 degrees, a 29 per cent degree of flexibility. At the time of discharge from the hospital the curves had improved to an average of 44 degrees, a correction of the preoperative curve of 39 degrees or 47 per cent. At an average length of follow-up of forty-nine months, the major curves measured an average of 50 degrees, a 41 per cent correction compared with the initial curves. Twenty-three of the major curves were better than when they were measured on the preoperative radiograph of the best side-bend, by an average of 15 degrees, but eight curves were either the same or worse. No patient had pseudarthrosis or permanent neurological injury. It is our conclusion that a two-stage anterior and posterior fusion is of value for the treatment of the adult who has a rigid curve that requires maximum correction to allow the head, shoulders, and torso to be centered over the pelvis. We do not recommend the use of instrumentation for the anterior fusion as this did not increase the correction of the curve in this series of patients.     

Combined staged anterior and posterior correction and fusion of the spine in scoliosis following poliomyelitis.

The problems with severe forms of scoliosis following poliomyelitis include the associated muscle imbalance, soft tissue contractures and pelvic obliquity. Such deformities militate against optimal correction and maintenance of that correction and their treatment is often marred by pseudarthroses. Seventeen patients with an average curve of 93 degrees have been treated and followed for up to 38 months. Preliminary traction was used in 8 patients, then a staged anterior and posterior correction and fusion was done, using Dwyer's instrumentation of the major curve in all and a Harrington rod to supplement the posterior fusion in eleven patients. With this technique the major curve was corrected by 80 per cent with an average 2 per cent loss over 18 months. No pseudarthroses were seen when the Harrington rod was used. Great care must be taken if halo-pelvic traction is to be used for patients with pelvic obliquity, for preliminary correction halo-femoral traction will often be adequate. In the more severe forms of paralytic scoliosis a combined staged anterior and posterior correction and fusion should be considered if the aim is maximal correction of the scoliosis and avoidance of pseudarthroses.     

Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis.

We evaluated the results of segmental fixation of the spine with Cotrel-Dubousset instrumentation in ninety-five patients who had adolescent idiopathic scoliosis. The instrumentation was used in an attempt to achieve three-dimensional correction of the scoliosis, maintain lumbar lordosis, create thoracic kyphosis, and avoid the need for a postoperative cast or brace. The patients were followed for twenty-four to sixty-four months (average, thirty-five months). Cotrel-Dubousset instrumentation provided an average correction of the coronal curve of 48 per cent at the time of the most recent follow-up. The normal sagittal curves at the thoracolumbar junction and in the lumbar spine were maintained, and the thoracic kyphosis was increased slightly (average, +7 degrees). Apical translation improved an average of 60 per cent, and apical rotation improved an average of 11 per cent. Forced vital capacity improved an average of 21 per cent, and the one-second forced expiratory volume improved an average of 18 per cent. There were no major neurological deficits. A symptomatic pseudarthrosis developed in one patient. Postoperatively, decompensation of the spine developed in five of the first twenty-six patients who had a Type-II or Type-III curve. This complication was avoided in the last twenty-four patients who had a Type-II or Type-III curve by means of a stricter adherence to the definition of a Type-II curve, and reversal of the bend of the rod and the hooks between the caudal neutral and stable vertebrae. The major advantages of Cotrel-Dubousset instrumentation are the stable fixation that is achieved and the preservation of segmental lumbar lordosis.     

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.     

Early ambulation following spinal fusion and Harrington instrumentation in idiopathic scoliosis.

Eighty-six patients with idiopathic scoliosis managed by Harrington instrumentation and spinal arthrodesis were ambulated 10 days following surgery. Preoperative reduction of the curves was obtained by Cotrel traction and modified Cotrel localizer cast. Patients were kept immobilized in plaster cast for 7 months following operation. No significant loss of correction was found in these patients ambulated early as compared to a previous group kept recumbent for 3 to 6 months and reported by the authors (DBL). The only exception to this was a patient with double structural curve patterns. A successful surgical program for most cases of idiopathic scoliosis included: (1) Preoperative reduction and balancing of curves by non-skeletal traction and/or correction body cast; (2) Meticulous spinal arthrodesis and employment of Harrington distraction internal fixation; (3) Autogenous iliac bone graft; (4) Ambulation at two weeks following surgery in a well fitting body cast and removal of this cast after 7 months. Deep infection rate was 1 per cent without the use of routine prophylatic antibiotics. One neurological complication resulted from the use of a single distraction rod bridging two curves where the rod was not prebent to allow for kyphosis. There were no pseudarthroses. The average follow-up was 28 months with a range of 18-39 months.     

Halo-pelvic distraction apparatus. An analysis of one hundred and fifty consecutive patients.

One hundred and fifty consecutive patients on whom the halo-pelvic apparatus was used were analyzed. Sixty-six per cent had tuberculous kyphosis or paralytic scoliosis. The apparatus was of great value in holding and correcting spines with tuberculous kyphosis and the results were gratifying, even though the average correction of the kyphos was only 20 per cent. In paralytic scoliosis a 46 per cent correction was obtained, but presently Dwyer and Harrington instrumentation are used for the majority of such cases. The halo-pelvic apparatus was effective in holding and correcting severe congenital curves and kyphoscoliosis secondary to neurofibromatosis, especially when there were signs of cord compression. The complication rate was high early in the series, but has been lowered by strict patient selection and close adherence to specific guidelines in the application of the apparatus. The apparatus should be reserved for severe deformities when other means of correction or stabilization are inadequate.     

Reconstructive surgery in the adult for failed scoliosis fusion

Fifty-nine adult patients were examined who had undergone previous spine surgery for scoliosis but in whom pain (78 per cent), loss of correction (68 per cent), or dyspnea (36 per cent) subsequently developed. Twenty-six patients had idiopathic scoliosis, twenty-five had paralytic scoliosis secondary to poliomyelitis, and eight had scoliosis secondary to miscellaneous etiologies. A one-stage reconstructive procedure was performed in sixteen patients and a two-stage procedure, in forty-three patients. The two-stage procedure consisted of exposure of the spine and multiple osteotomies, followed by two weeks of halofemoral traction to obtain correction. The spine fusion was then extended, using Harrington instrumentation to maintain correction. At an average follow-up of 3.3 years there was reduction of pain in 67 per cent of the patients and a solid fusion in all but two. The complication rate was high (71 per cent), the most important complications being pseudarthrosis, wound infection, urinary tract infections, loss of lumbar lordosis, and pressure sores. The mortality rate was 3.4 per cent. No patient became paraplegic at the initial surgical procedure and early recognition and treatment of pseudarthrosis will reduce the number of patients requiring this salvage operation.     

Anterior Zielke instrumentation for spinal deformity in adults

Fifty-eight adults who had scoliosis or hyperlordosis had anterior arthrodesis and Zielke instrumentation. Postoperatively, the curve improved 68 per cent in forty-nine patients who had idiopathic scoliosis and 40 per cent in nine patients who had paralytic scoliosis or hyperlordosis or congenital scoliosis. More correction was obtained when a derotator apparatus was used. Only one patient had failure of the instrumentation that necessitated additional surgical treatment. All of the arthrodeses resulted in osseous fusion. No patient who had idiopathic scoliosis lost correction (average follow-up, forty-two months; range, thirty to seventy-eight months). There were no serious complications. Lumbar lordosis decreased an average of 24 per cent compared with the preoperative measurement. This decrease was thought to be related to the correction of vertebral rotation in the curve and to the surgical technique. Use of the Zielke instrumentation resulted in excellent correction, which was not lost postoperatively in the patients who had an idiopathic curve and which was associated with minimum complications.     

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.     

Results of Harrington instrumentation in the treatment for severe scoliosis.

Between July 1963 and December 1974, we surgically treated 207 patients who had severe scoliosis (curves greater than 90 degrees), 196 of whom were eligible for inclusion in this study. No patient was treated preoperatively with a cast or traction. Upon statistical analysis, age and preoperative curve magnitude proved to be significant variables relative to the amount of surgical correction obtained and the maintenance of that correction; sex and etiology of the scoliosis were not shown to affect either surgical outcome or maintenance of correction. A comparative analysis showed our results to be as good as those reported by others using various preoperative regimens of casting or traction or both. Therefore, we find that the preoperative application of traction to patients with severe scoliosis yields no better correction than the use of Harrington instrumentation and fusion alone.     

Operative Treatment of Scoliosis with the Harrington Instrumentation Technique

Preliminary results of treatment of scoliosis with the Harrington instrumentation technique in 80 patients are presented. The curve correction at operation averaged 43.4 per cent with the best results being achieved in idiopathic single curves (49.3 per cent). Most of the patients had been treated conservatively for a long time prior to operation, and the curves were rather stiff. The initial loss of correction was 3.2°, and the overall loss at 2 years postoperatively averaged 6.5° in 28 patients. Complications occurred in 22.5 per cent of the patients, most often at the upper hook site. Serious complications were rare. It is concluded that the Harrington instrumentation technique is an effective means of treatment of scoliosis.     

Anterior spine fusion using Zielke instrumentation for adult thoracolumbar and lumbar scoliosis

Analysis of adult patients undergoing anterior spine fusions with Zielke instrumentation between January 1983 and November 1986 was performed. Objectives were to review results of surgical treatment and identify factors affecting results. Charts, 3 foot standing anteroposterior and lateral and supine maximal side bending radiographs were reviewed. Subjective data were obtained by telephone. There were 26 patients, average age 41 years. Average radiographic follow-up was 48 months. Indications were pain and curve progression. Average correction was 63% of the instrumented curve. Average change of lordosis was 8 degrees and kyphosis was 6 degrees. Apical vertebral rotation corrected an average of 37%. Complications were: eight hardware failures, one deep infection, and two psychiatric events. The high-risk groups: curves greater than 60 degrees, patients older than 50 years of age, and rigid curves.     

Surgery of spinal deformity in cerebral palsy. Twelve years in the evolution of scoliosis management

In order to assess the lessons learned from 12 years of surgery on patients with cerebral palsy and spinal deformity, the cases may be divided into three groups classified according to type of posterior spinal fusion, instrumentation, and time period. Group I (1976-1980) included patients who had Harrington rods, usually with Dwyer instrumentation. Group II (1980-1985) consisted of patients with unlinked Luque or wired-in Harrington rods. Group III (1985-1988) comprised patients with a unit Luque rod extending to the pelvis. Most patients were retarded nonwalkers who had total body involvement, pelvic obliquity, and severe thoracolumbar curves (Group I average, 97 degrees; Group II average, 72 degrees; Group III average, 89 degrees). The frontal plane correction at follow-up study averaged 51% in Group I, 47% in Group II, and 76% in Group III. The correction of the pelvic obliquity averaged 71% in Group I, 58% in Group II, and 86% in Group III. The general trend was toward longer fusion, use of the unit 0.625-cm Luque rod, and first-stage anterior discectomy and fusion without anterior instrumentation. The second-stage posterior arthrodesis and fusion is now performed only one week after the first-stage anterior procedure. Skeletal traction has been abandoned. The Luque rod instrumentation without fusion has also been abandoned.     

Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail

In a retrospective study, we attempted to assess progress in the treatment of comminuted fractures of the femoral shaft at Parkland Memorial Hospital from 1978 to 1983. Seventy-nine comminuted femoral-shaft fractures were available for follow-up: thirty-two treated by roller traction, twenty-three treated by cerclage wires and an intramedullary nail, and twenty-four treated by an interlocking intramedullary nail. Using the classification of Winquist and Hansen, Grade-III and IV comminuted fractures accounted for 69 per cent of those treated by roller traction, 68 per cent of those treated by nailing and cerclage wires, and 96 per cent of those treated by an interlocking nail. The frequency of multiple injuries was 38 per cent in the patients treated by roller traction, 39 per cent in those treated by nailing and cerclage wires, and 58 per cent in those treated by an interlocking nail. The average hospitalization times were thirty-one days for roller traction, sixteen days for cerclage wires and an intramedullary nail, and 19.5 days for an interlocking nail. The average length of follow-up was 132 weeks after roller traction, 115 weeks after cerclage wiring and an intramedullary nail, and sixty weeks after insertion of an interlocking nail. All fractures were followed until after union; the average times to union were 18.4 weeks after roller traction, thirty-four weeks after open reduction and intramedullary nailing with cerclage wires, and 13.8 weeks after insertion of an interlocking nail. For the purposes of this study, treatment was assumed to have failed if a change in treatment was necessary, an unplanned reoperation was performed, femoral shortening exceeded 2.5 centimeters, angulation was more than 15 degrees, non-union or a deep infection developed, motion of the knee was less than 70 degrees of flexion, or a refracture occurred. By these criteria, the frequency of failure after roller traction was 66 per cent (secondary to malalignment and shortening); after insertion of an intramedullary nail with cerclage wires, 39 per cent (secondary to unplanned surgery, non-union, shortening, and infection); and after use of an interlocking nail, 4 per cent (secondary to shortening). Currently, at our institution, an interlocking intramedullary nail is the treatment of choice for comminuted femoral-shaft fractures because it encourages early union with maintenance of length and alignment and the results are predictable.     

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.     

Anterior surgery with short fusion using the Zielke procedure for thoracic scoliosis: focus on the correction of compensatory curves

Anterior instrumentation is recommended to correct idiopathic thoracolumbar or lumbar scoliosis through short fusion within the major curve. Only a few reports exist of anterior surgical correction for thoracic scoliosis. This study assessed the results of Zielke instrumentation for thoracic curve and analyzed the three-dimensional correction of deformity, especially correction of the uninstrumented compensatory curve. Seventeen patients, who had undergone selective thoracic correction and fusion using the Zielke procedure to treat thoracic scoliosis, had been followed for at least 3 years. Three-dimensional correction was evaluated radiographically. Furthermore, three-dimensional back deformities were evaluated using a topographic body scanner. Twelve patients with a single thoracic curve and five with a double curve were all female, with a mean age of 14.6 years. The preoperative main thoracic curve was 54.8 degrees +/- 10.5 degrees (range, 40-78 degrees), and it was 23.8 degrees +/- 10.5 degrees (range, 7-40 degrees) at the final follow-up examination (p < 0.0001). The average correction rate of the main curves was 56.6%. By correcting the thoracic curve, the upper and lower compensatory curves were corrected spontaneously without surgical instrumentation, with average correction rates of 45.1% and 50.2%, respectively. The average correction loss of the main curve was 2.3 degrees. The hump angle measured using a topographic body scanner decreased from 12.8 degrees +/- 4.5 degrees to 8.4 degrees +/- 4.3 degrees after surgery (p = 0.0001). Of the three patients in whom the rod broke up, only one showed a correction loss of 10 degrees; however, bony fusion was obtained. Anterior short fusion for thoracic scoliosis appears to offer significant correction, stabilization, and spontaneous correction of the compensatory lumbar curve without limiting lumbar motion.     

垂直悬吊牵引像在重度脊柱侧凸矫形中的应用

目的分析悬吊牵引像在脊柱侧凸矫形中预测上、下固定椎的作用。方法选择2004年7月至2008年7月北京协和医院骨科收治的胸椎侧凸畸形患者27例,男15例,女12例,年龄11～21岁,平均15.5岁。所有患者均采用后路脊柱侧凸矫形植骨融合、钉钩混合固定,随访6～36个月,平均14.7个月。采用标准方法测量术前脊柱正侧位悬吊牵引像,术后及随访正位像的Cobb角、顶椎偏距、悬吊稳定椎等,测量所得结果进行统计学分析。结果 （1）术后胸弯平均Cobb角为43.8°,术后随访平均Cobb角为51.1°,较术前（平均Cobb角84.6°）明显改善（P〈0.01）,平均矫正率为48.2%;（2）悬吊像胸弯Cobb角与术后胸弯Cobb角呈正相关（P〈0.01）;（3）悬吊像顶椎偏距、术后胸弯顶椎偏距与术前顶椎偏距有显著差异（P〈0.01）;（4）悬吊像下平分椎倾斜度与术前站立位下固定椎无显著差异（P〉0.05）,与术后及随访的下固定椎倾斜度有显著差异（P〈0.01）;（5）悬吊像上平分椎倾斜度与术前站立位上固定椎、术后及随访的上固定椎倾斜度有显著差异（P〈0.01）。结论选择悬吊牵引像的稳定椎作为脊柱侧凸矫形中上、下固定椎,术后平衡效果良好。     

Thoracoscopic interventions in deformities of the thoracic spine

AIM OF THE STUDY: We prospectively studied 9 patients with deformities of the thoracic spine who underwent thoracoscopic surgery to critically evaluate the benefits and limitations of thoracoscopy. METHODS: Seven patients with deformities of the thoracic spine (5 scoliosis, 2 kyphosis) underwent a thoracoscopic release and posterior correction and fusion in a single stage. In one case of a crankshaft-phenomenon a thoracoscopic epiphyseodesis und in another case of a posttraumatic kyphosis a thoracoscopic instrumentation and fusion were performed. The average age was 21 years, the follow-up was 18 months with a minimum of 12 months. The perioperative data including complications were collected and a radiographic analysis concerning curve correction was carried out. RESULTS: The scoliotic curves measured preoperatively 84 degrees on average with a Cobb angle of 62 degrees on the traction films and were corrected by 57% to averagely 36 degrees at follow-up. In the two cases of Scheuermann kyphosis a preoperative kyphosis of 94 degrees respectively 82 degrees was corrected to 52 degrees respectively 58 degrees. Between 4 and 5 discs were excised with an average operative time of 160 min and a blood loss of 380 ml. A conversion to open thoracotomy was not necessary in any case. There were no intraoperative neurovascular complications. CONCLUSIONS: Thoracoscopic procedures in deformities of the thoracic spine are technically demanding; however, it is a minimally invasive procedure with a reduced approach-related morbidity compared to open thoracotomy. The indications for a thoracoscopic release are rigid kyphosis and scoliosis with rigid curves between 80 and 90 degrees Cobb angle in which an anterior correction and instrumentation alone is not considered.     

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.